Bill Text: CA SB123 | 2015-2016 | Regular Session | Enrolled
Bill Title: Medi-Cal: school-based administrative activities.
Spectrum: Partisan Bill (Democrat 3-0)
Status: (Vetoed) 2016-11-30 - Last day to consider Governor's veto pursuant to Joint Rule 58.5. [SB123 Detail]
Download: California-2015-SB123-Enrolled.html
BILL NUMBER: SB 123 ENROLLED
BILL TEXT
PASSED THE SENATE AUGUST 29, 2016
PASSED THE ASSEMBLY AUGUST 23, 2016
AMENDED IN ASSEMBLY AUGUST 18, 2016
AMENDED IN ASSEMBLY AUGUST 15, 2016
AMENDED IN ASSEMBLY AUGUST 1, 2016
AMENDED IN ASSEMBLY JUNE 30, 2016
AMENDED IN ASSEMBLY JUNE 16, 2016
AMENDED IN ASSEMBLY MAY 16, 2016
AMENDED IN SENATE MAY 12, 2015
AMENDED IN SENATE APRIL 6, 2015
INTRODUCED BY Senator Liu
(Principal coauthor: Assembly Member Santiago)
(Coauthor: Assembly Member Thurmond)
JANUARY 15, 2015
An act to amend Section 14115.8 of, to amend, repeal, and add
Section 14132.47 of, and to add Sections 14005.272, 14005.273,
14005.274, 14132.471, and 14132.472 to, the Welfare and Institutions
Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
SB 123, Liu. Medi-Cal: school-based administrative activities.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income individuals receive health care services.
The Medi-Cal program is, in part, governed by, and funded pursuant
to, federal Medicaid program provisions. Existing law establishes an
administrative claiming process under which the department is
authorized to contract with local governmental agencies and local
educational consortia for the purpose of obtaining federal matching
funds to assist with the performance of administrative activities
relating to the Medi-Cal program. Existing law defines a local
educational agency for these purposes as a local educational agency
that participates under the process as a subcontractor to the local
educational consortium in its service region.
Existing law provides that specified services provided by local
educational agencies (LEAs) are covered Medi-Cal benefits and
requires the department to perform various activities with respect to
the billing option for services provided by LEAs, including
amendment of the Medicaid state plan to ensure that schools shall be
reimbursed for all eligible services they provide. Existing law
requires the department to file an annual report with the Legislature
that provides information related to these activities, as specified.
Existing law requires the department to regularly consult with the
State Department of Education, school district representatives,
county offices of education, the local educational consortium, and
local educational agencies to assist in formulating those state plan
amendments. Existing law funds these activities by requiring the
department to proportionately reduce federal Medicaid payments
allocable to LEAs, collect the reductions, and deposit them into the
Local Educational Agency Medi-Cal Recovery Fund, as specified.
This bill would additionally require the department to contract
directly with an LEA, if the LEA chooses and the department has
developed a process governing direct contracting, to perform
school-based administrative activities necessary for the proper and
efficient administration of the Medi-Cal program, as specified. The
bill would designate the contracting between the department and
participating local educational agencies, local educational
consortia, and local governmental agencies to perform those
school-based administrative activities as the School-Based
Administrative Claiming process program. The bill would authorize the
department to administer or oversee the administration of a single
statewide random moment time survey, or a reduction in the number of
quarterly random moment time surveys conducted in the state, for the
purposes of the program. The bill would make related legislative
findings and declarations.
This bill would require the department to prepare and post on its
Internet Web site an annual report of the costs of administering the
School-Based Administrative Claiming process program and the LEA
billing option and list local educational agency participation in
each. The bill would also require the department to include in that
report the annual report related to the LEA billing option.
This bill would require the department to enter into an
interagency agreement or memorandum of understanding (MOU) with the
State Department of Education to coordinate the efforts of both
departments with respect to the LEA billing option and the
School-Based Administrative Claiming process program. The bill would
require the department to develop an appeals process, as specified,
to contest an action of the department.
This bill would require the department and the State Department of
Education to establish and jointly administer a School-Based Health
Program and Policy Workgroup, as specified, in order to assist the
department in formulating state plan amendments required to implement
the LEA billing option described above and for the purpose of
advising the department on issues related to the delivery of
school-based Medi-Cal services to students in the state, as
specified. The bill would require the department to consult with the
advisory group in connection with developing the interagency
agreement or MOU described above. The bill would authorize the
department and the State Department of Education to use moneys
collected by the department to fund the LEA Medi-Cal billing option
program activities and amounts withheld from LEAs by agreement with
the department to meet the requirements of the interagency agreement
or MOU described above and to fund staffing requirements for the
workgroup.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. (a) The Legislature finds and declares all of the
following:
(1) Effective cross-agency collaboration is vital to deliver
high-quality school-based health services to California students.
(2) The United States Department of Education and the United
States Department of Health and Human Services, in a key January 2016
policy letter, recognize the critical role that health care coverage
and health services play in ensuring all students are ready and able
to learn, and recommend action steps to better coordinate health and
education services to build strong and sustainable partnerships and
commitments between health and education agencies at the local,
state, and federal levels.
(3) The student success strategic priority in State Superintendent
of Public Instruction Tom Torlakson's 2015 Blueprint 2.0 includes
Section 3.13, which prioritizes the development of infrastructure at
the State Department of Education to improve cross-agency
collaboration in support of student health.
(4) In Report 2014-130 issued on August 20, 2015, the State
Auditor recommended that the State Department of Health Care Services
institute significant structural changes to school-based Medi-Cal
programs in order to improve administration and oversight, increase
federal funding, and cut costs.
(5) Building an effective, transparent infrastructure and
accountability system to fully utilize all available federal Medicaid
funds is a critical component of developing the capacity to deliver
school-based health and mental health programs.
(6) These vital programs must be operated at a level that meets
the benchmark of national best practices in order to meet the needs
of California's most vulnerable children.
(b) It is the intent of the Legislature to ensure effective
coordination between health and education agencies at the state,
county, and local levels to address the achievement gap in our
schools and health and education equity issues in California.
SEC. 2. Section 14005.272 is added to the Welfare and Institutions
Code, to read:
14005.272. (a) The department and the State Department of
Education shall, no later than July 1, 2017, establish and jointly
administer a School-Based Health Program and Policy Workgroup for the
purpose of advising on issues related to the delivery of
school-based Medi-Cal services to students in the state. The director
of the department or his or her designee shall be designated as the
chair and the Superintendent of Public Instruction or his or her
designee shall be designated as the vice chair of the workgroup. The
workgroup shall develop recommendations for an interagency agreement
between the department and the State Department of Education pursuant
to Section 14132.472, and assist the department in formulating the
state plan amendments required by subdivisions (a) and (b) of Section
14115.8. The scope of the workgroup shall include, but not be
limited to, improving the operation of and participation in the
following school-based health programs:
(1) The School-Based Administrative Claiming process program
described in Section 14132.471.
(2) The local educational agency (LEA) Medi-Cal billing option
described in Section 14132.06.
(b) The workgroup shall be representative of the diversity of
California LEAs with respect to size, type, and geographic diversity
and shall include representatives from county offices of education,
urban, suburban, and rural LEAs, and LECs and LGAs described in
Section 14132.471 and from Region IX of the federal Centers for
Medicare and Medicaid Services. The workgroup shall also include
representatives of the LEA Ad Hoc Workgroup described in Section
14132.06 and members with expertise in the school-based health and
mental health programs.
(c) The workgroup shall, no later than January 1, 2018, provide
input to the department and the State Department of Education on the
development and continuing operations of the interagency agreement or
memorandum of understanding described in Section 14132.472. The
recommendations of the workgroup shall identify opportunities for
effective coordination between the state's health and education
systems at the state, regional, and local level, identify ways the
department can maximize its school-based Medicaid program expertise,
recommend an appeals process for the School-Based Administrative
Claiming process program and the LEA billing option, and identify
necessary legislation or state plan amendments to support its
recommendations.
(d) (1) The workgroup shall, on a regular basis, provide input to
the department and the State Department of Education on the degree to
which the process and implementation of the School-Based
Administrative Claiming process program described in Section
14132.471 and the LEA Medi-Cal billing option program described in
Section 14132.06 are meeting the needs of LEAs with respect to
cost-effectiveness, program structure, and operational effectiveness,
including the process of appeals and balancing withheld funds and
actual expenses.
(2) The workgroup shall advise the department and the State
Department of Education on creating consistency across local
educational consortia (LECs), local governmental agencies (LGAs), and
the department with respect to contracts and processes for the
School-Based Administrative Claiming process program described in
Section 14132.471.
(3) The workgroup shall make recommendations that include, but are
not limited to, determining the opportunities for and the benefits,
costs, and feasibility of the following:
(A) Increasing LEA participation and maximizing allowable federal
financial participation in the School-Based Administrative Claiming
process program and the LEA Medi-Cal billing option program.
(B) Increasing contracting options for LEAs participating in the
School-Based Administrative Claiming process program, such as
allowing an LEA to contract with an LEC or LGA outside of the LEA's
region.
(C) Reducing the number of quarterly random moment time surveys.
(D) Identifying areas that may require a state plan amendment.
(E) Integrating and expanding other school-based health and mental
health programs with the School-Based Administrative Claiming
process program and the LEA Medi-Cal billing option program,
including, but not limited to, those being implemented in accordance
with the LEA's local control and accountability plan described in
Section 52060 of the Education Code.
(F) Improving and streamlining the annual school-based Medi-Cal
report described in Section 14005.273.
(e) The workgroup may form technical advisory subcommittees as
necessary that shall report back to the workgroup on the development
of plans and timelines to implement the changes and expanded options
described in this section.
(f) The department shall make available to the workgroup staff any
information on other school-based dental, health, and mental health
programs, including, but not limited to, the mental health programs
described in Section 14700 and school-based health centers that may
receive Medi-Cal funding.
SEC. 3. Section 14005.273 is added to the Welfare and Institutions
Code, to read:
14005.273. Commencing with the 2017-18 state fiscal year, and
annually for each year thereafter, the department shall publish the
following information in a single annual school-based Medi-Cal report
on a section of its Internet Web site:
(a) The costs to the state of operating the School-Based
Administrative Claiming process program described in Section
14132.471 and any related fees passed on to local educational
agencies (LEAs).
(b) A list of all participating LEAs.
(c) The costs and fees being charged to LEAs as reported to the
department by local educational consortia and local governmental
agencies.
(d) Comparisons of costs with other states, summary of department
activities, workgroup recommendations for program improvement,
identifications of barriers to reimbursement and actions taken to
eliminate barriers, and other information in the format required for
the LEA Medi-Cal billing option program report described in Section
14115.8.
(e) The costs of operating the LEA Medi-Cal billing option program
described in Section 14132.06. The report shall also list each local
educational agency participating in the LEA Medi-Cal billing option
program.
SEC. 4. Section 14005.274 is added to the Welfare and Institutions
Code, to read:
14005.274. (a) The department shall develop a process by which a
local educational agency may appeal an action of the department with
respect to the School-Based Administrative Claiming process program
described in Section 14132.471 and the LEA billing option described
in Section 14115.8. The appeals process shall use the Office of
Administrative Hearings and Appeals pursuant to Section 14171 or
another neutral third party acceptable to the department as the
appeals authority and shall require the local educational agency to
pay for the cost of the appeal.
(b) In developing the appeals process described in subdivision
(a), the department shall take into account the recommendations of
the workgroup described in Section 14005.272.
SEC. 5. Section 14115.8 of the Welfare and Institutions Code is
amended to read:
14115.8. (a) (1) The department shall amend the Medicaid state
plan with respect to the billing option for services by local
educational agencies (LEAs), to ensure that schools shall be
reimbursed for all eligible services that they provide that are not
precluded by federal requirements.
(2) The department shall examine methodologies for increasing
school participation in the Medi-Cal billing option for LEAs so that
schools can meet the health care needs of their students.
(3) The department, to the extent possible, shall simplify
claiming processes for LEA billing.
(4) The department shall eliminate and modify state plan and
regulatory requirements that exceed federal requirements when they
are unnecessary.
(b) If a rate study for the LEA Medi-Cal billing option is
completed pursuant to Section 52 of Chapter 171 of the Statutes of
2001, the department, in consultation with the entities named in
subdivision (d) of Section 14005.272, shall implement the
recommendations from the study, to the extent feasible and
appropriate.
(c) Notwithstanding any other law, or any other contrary state
requirement, the department shall take whatever action is necessary
to ensure that, to the extent there is capacity in its certified
match, an LEA shall be reimbursed retroactively for the maximum
period allowed by the federal government for any department change
that results in an increase in reimbursement to local educational
agency providers.
(d) The department may undertake all necessary activities to
recoup matching funds from the federal government for reimbursable
services that have already been provided in the state's public
schools. The department shall prepare and take whatever action is
necessary to implement all regulations, policies, state plan
amendments, and other requirements necessary to achieve this purpose.
(e) The department shall file an annual report with the
Legislature that shall be included in the annual report referenced in
Section 14005.273 and that shall include at least all of the
following:
(1) A copy of the annual comparison required by subdivision (h).
(2) A state-by-state comparison of school-based Medicaid total and
per eligible child claims and federal revenues. The comparison shall
include a review of the most recent two years for which completed
data is available.
(3) A summary of department activities and an explanation of how
each activity contributed toward narrowing the gap between California'
s per eligible student federal fund recovery and the per student
recovery of the top three states.
(4) A listing of all school-based services, activities, and
providers approved for reimbursement by the federal Centers for
Medicare and Medicaid Services in other state plans that are not yet
approved for reimbursement in California's state plan and the service
unit rates approved for reimbursement.
(5) The official recommendations made to the department by the
entities named in subdivision (c) and the action taken by the
department regarding each recommendation.
(6) A one-year timetable for state plan amendments and other
actions necessary to obtain reimbursement for those items listed in
paragraph (4).
(7) Identification of any barriers to local educational agency
reimbursement, including those specified by the entities named in
subdivision (d) of Section 14005.272, that are not imposed by federal
requirements, and a description of the actions that have been, and
will be, taken to eliminate them.
(f) (1) These activities shall be funded and staffed by
proportionately reducing federal Medicaid payments allocable to LEAs
for the provision of benefits funded by the federal Medicaid program
under the billing option for services by LEAs specified in this
section. Moneys collected as a result of the reduction in federal
Medicaid payments allocable to LEAs shall be deposited into the Local
Educational Agency Medi-Cal Recovery Fund, which is hereby
established in the Special Deposit Fund established pursuant to
Section 16370 of the Government Code. These funds shall be used, upon
appropriation by the Legislature, only to support the department to
meet all the requirements of this section. If at any time this
section is repealed, it is the intent of the Legislature that all
funds in the Local Educational Agency Medi-Cal Recovery Fund be
returned proportionally to all LEAs whose federal Medicaid funds were
used to create this fund. The annual amount funded pursuant to this
paragraph shall not exceed one million five hundred thousand dollars
($1,500,000).
(2) Moneys collected under paragraph (1) shall be proportionately
reduced from federal Medicaid payments to all participating LEAs so
that no one LEA loses a disproportionate share of its federal
Medicaid payments.
(3) Moneys collected under paragraph (1) and withheld amounts
agreed to by LEAs as a part of an LEA Medi-Cal billing option program
provider participation agreement administered by the department may
be used by the department and the State Department of Education to
meet the requirements of the interagency agreement or memorandum of
understanding referenced in Section 14132.472 and the staffing needed
to jointly administer and chair the workgroup described in Section
14005.272.
(g) (1) The department may enter into a sole source contract to
comply with the requirements of this section.
(2) The level of additional staff to comply with the requirements
of this section, including, but not limited to, staff for which the
department has contracted for pursuant to paragraph (1), shall be
limited to that level that can be funded with revenues derived
pursuant to subdivision (f).
(h) The activities of the department shall include all of the
following:
(1) An annual comparison of the school-based Medicaid systems in
comparable states.
(2) Efforts to improve communications with the federal government,
the State Department of Education, and local educational agencies.
(3) The development and updating of written guidelines to local
educational agencies regarding best practices to avoid audit
exceptions, as needed.
(4) The establishment and maintenance of a local educational
agency user-friendly, interactive Internet Web site.
(5) Collaboration with the State Department of Education to help
ensure LEA compliance with state and federal Medicaid requirements
and to help improve LEA participation in the Medi-Cal billing option
for LEAs.
SEC. 6. Section 14132.47 of the Welfare and Institutions Code is
amended to read:
14132.47. (a) It is the intent of the Legislature to provide
local governmental agencies the choice of participating in either or
both of the Targeted Case Management (TCM) and Administrative
Claiming process programs at their option, subject to the
requirements of this section and Section 14132.44.
(b) The department may contract with each participating local
governmental agency or each local educational consortium to assist
with the performance of administrative activities necessary for the
proper and efficient administration of the Medi-Cal program, pursuant
to Section 1903a of the federal Social Security Act (42 U.S.C. Sec.
1396b(a)), and this activity shall be known as the Administrative
Claiming process.
(c) (1) Subject to the requirements of paragraph (2) of
subdivision (f), as a condition for participation in the
Administrative Claiming process, each participating local
governmental agency or each local educational consortium shall, for
the purpose of claiming federal Medicaid reimbursement, enter into a
contract with the department and shall certify to the department the
total amount the local governmental agency or each local educational
consortium expended on the allowable administrative activities.
(2) The department shall deny the claim if it determines that the
certification is not adequately supported, or does not otherwise
comply with federal requirements, for purposes of claiming federal
financial participation.
(d) Each participating local governmental agency or local
educational consortium may subcontract with private or public
entities to assist with the performance of administrative activities
necessary for the proper and efficient administration of the Medi-Cal
program under the conditions specified by the department in
regulations.
(e) Each Administrative Claiming process contract shall include a
requirement that each participating local governmental agency or each
local educational consortium submit a claiming plan in a manner that
shall be prescribed by the department in regulations, developed in
consultation with local governmental agencies.
(f) (1) The department shall require that each participating local
governmental agency or each local educational consortium certify to
the department both of the following:
(A) The expenditure of 100 percent of the cost of performing
Administrative Claiming process activities. The funds expended for
this purpose shall be from the local governmental agency's general
fund or the general funds of local educational agencies or from any
other funds allowed under federal law and regulations.
(B) In each fiscal year that its expenditures represent costs that
are eligible for federal financial participation for that fiscal
year. The department shall deny the claim if it determines that the
certification is not adequately supported for purposes of federal
financial participation.
(2) (A) (i) A city that is not a participating local governmental
agency, or any other local public entity, that contracts with a local
governmental agency pursuant to subdivision (d) and that is located
within a county that is a participating local governmental agency
pursuant to this section, may submit certification to the local
governmental agency of amounts expended for Administrative Claiming
services in accordance with Section 433.51 of Title 42 of the Code of
Federal Regulations.
(ii) A city or other local public entity that submits
certification pursuant to this paragraph shall comply with the
requirements of paragraph (1), with other requirements applicable to
local governmental agencies that the department determines, in
regulations, to be applicable, and with all applicable federal
requirements.
(iii) The local governmental agency shall forward the city's or
local public entity's certification to the department for the
purposes of claiming federal financial participation.
(iv) As applicable, the local governmental agency shall obtain and
retain appropriate certifications from the expending city or local
public entity, together with documentation of the underlying
expenditures, as required by the department.
(B) A tribe or tribal organization, as defined in subdivision (n),
that is not participating in Administrative Claiming process
activities as a local governmental agency, may contract with, and
submit to a tribe or tribal organization that is contracting with,
the department pursuant to subdivision (b) amounts expended for
Administrative Claiming process activities that it is certifying in
accordance with Section 433.51 of Title 42 of the Code of Federal
Regulations and other applicable federal law and regulations. The
tribe or tribal organization receiving the certification shall
forward it to the department for purposes of claiming federal
financial participation. The certification shall comply with all of
the requirements for certification set forth in subparagraph (A).
(g) (1) Notwithstanding any other provision of this section, the
state shall be held harmless, in accordance with paragraphs (2) and
(3), from any federal audit disallowance and interest resulting from
payments made to a participating local governmental agency or local
educational consortium pursuant to this section, for the disallowed
claim.
(2) To the extent that a federal audit disallowance and interest
results from a claim or claims for which any participating local
governmental agency or local educational consortium has received
reimbursement for Administrative Claiming process activities, the
department shall recoup from the local governmental agency or local
educational consortium that submitted the disallowed claim, through
offsets or by a direct billing, amounts equal to the amount of the
disallowance and interest, in that fiscal year, for the disallowed
claim. All subsequent claims submitted to the department applicable
to any previously disallowed administrative activity or claim, may be
held in abeyance, with no payment made, until the federal
disallowance issue is resolved.
(3) Notwithstanding paragraph (2), to the extent that a federal
audit disallowance and interest results from a claim or claims for
which the participating local governmental agency or local
educational consortium has received reimbursement for Administrative
Claiming process activities performed by an entity under contract
with, and on behalf of, the participating local governmental agency
or local educational consortium, the department shall be held
harmless by that particular participating local governmental agency
or local educational consortium for 100 percent of the amount of the
federal audit disallowance and interest, for the disallowed claim.
(h) The use of local funds required by this section shall not
create, lead to, or expand the health care funding obligations or
service obligations for current or future years for any participating
local governmental agency or local educational consortium, except as
required by this section or as may be required by federal law.
(i) The department shall deny any claim from a participating local
governmental agency or local educational consortium if the
department determines that the claim is not adequately supported in
accordance with criteria established pursuant to this subdivision and
implementing regulations before it forwards the claim for
reimbursement to the federal Medicaid program. In consultation with
local governmental agencies and local educational consortia, the
department shall adopt regulations that prescribe the requirements
for the submission and payment of claims for administrative
activities performed by each participating local governmental agency
and local educational consortium.
(j) Administrative activities shall be those determined by the
department to be necessary for the proper and efficient
administration of the state's Medicaid plan and shall be defined in
regulation.
(k) If the department denies any claim submitted under this
section, the affected participating local governmental agency or
local educational consortium may, within 30 days after receipt of
written notice of the denial, request that the department reconsider
its action. The participating local governmental agency or local
educational consortium may request a meeting with the director or his
or her designee within 30 days to present its concerns to the
department after the request is filed. If the director or his or her
designee cannot meet, the department shall respond in writing
indicating the specific reasons for which the claim is out of
compliance to the participating local governmental agency or local
educational consortium in response to its appeal. Thereafter, the
decision of the director shall be final.
(l) To the extent consistent with federal law and regulations,
participating local governmental agencies or local educational
consortium may claim the actual costs of nonemergency, nonmedical
transportation of Medi-Cal eligibles to Medi-Cal covered services,
under guidelines established by the department, to the extent that
these costs are actually borne by the participating local
governmental agency or local educational consortium. A local
educational consortium may only claim for nonemergency, nonmedical
transportation of Medi-Cal eligibles for Medi-Cal covered services,
through the Medi-Cal administrative activities program. Medi-Cal
medical transportation services shall be claimed under the local
educational agency Medi-Cal billing option, pursuant to Section
14132.06.
(m) As a condition of participation in the Administrative Claiming
process and in recognition of revenue generated to each
participating local governmental agency and each local educational
consortium in the Administrative Claiming process, each participating
local governmental agency and each local educational consortium
shall pay an annual participation fee through a mechanism agreed to
by the state and local governmental agencies and local educational
consortia, or, if no agreement is reached by August 1 of each year,
directly to the state. The participation fee shall be used to cover
the cost of administering the Administrative Claiming process,
including, but not limited to, claims processing, technical
assistance, and monitoring. The department shall determine and report
staffing requirements upon which projected costs will be based. The
amount of the participation fee shall be based upon the anticipated
salaries, benefits, and operating expenses, to administer the
Administrative Claiming process and other costs related to that
process.
(n) (1) For the purposes of this section, "participating local
governmental agency" means a county, chartered city, Native American
Indian tribe, tribal organization, or subgroup of a Native American
Indian tribe or tribal organization, under contract with the
department pursuant to subdivision (b).
(2) Each
participating Native American Indian tribe, tribal organization, or
subgroup of a Native American Indian tribe or tribal organization may
claim, as a Medi-Cal Administrative Activity, facilitating Medi-Cal
applications, which includes, but is not limited to, using the
California Healthcare Eligibility, Enrollment, and Retention System.
(o) For purposes of this section, "local educational agency" means
a local educational agency, as defined in subdivision (h) of Section
14132.06, that participates under the Administrative Claiming
process as a subcontractor to the local educational consortium in its
service region.
(p) (1) For purposes of this section, "local educational
consortium" means a local agency that is one of the service regions
of the California County Superintendent Educational Services
Association.
(2) Each local educational consortium shall contract with the
department pursuant to paragraph (1) of subdivision (c).
(q) (1) Each participating local educational consortium shall be
responsible for the local educational agencies in its service region
that participate in the Administrative Claiming process. This
responsibility includes, but is not limited to, the preparation and
submission of all administrative claiming plans, training of local
educational agency staff, overseeing the local educational agency
time survey process, and the submission of detailed quarterly
invoices on behalf of any participating local educational agency.
(2) Each participating local educational consortium shall ensure
local educational agency compliance with all requirements of the
Administrative Claiming process established for local governmental
agencies.
(3) Ninety days prior to the initial participation in the
Administrative Claiming process, each local educational consortium
shall notify the department of its intent to participate in the
process, and shall identify each local educational agency that will
be participating as its subcontractor.
(r) (1) Each local educational agency that elects to participate
in the Administrative Claiming process shall submit claims through
its local educational consortium or through the local governmental
agency, but not both.
(2) Each local educational agency participating as a subcontractor
to a local educational consortium shall comply with all requirements
of the Administrative Claiming process established for local
governmental agencies.
(s) A participating local governmental agency or a local
educational consortium may charge an administrative fee to any entity
claiming Administrative Claiming through that agency.
(t) The department shall continue to administer the Administrative
Claiming process in conformity with federal requirements.
(u) The department shall provide technical assistance to all
participating local governmental agencies and local educational
consortia in order to maximize federal financial participation in the
Administrative Claiming process.
(v) (1) Subject to paragraph (2), this section shall be applicable
to Administrative Claiming process activities performed, and to
moneys paid to participating local governmental agencies for those
activities in the 1994-95 fiscal year and thereafter, and to local
educational consortia in the 1998-99 fiscal year and thereafter.
(2) This section shall not be applicable to Administrative
Claiming process activities performed on or after January 1, 2018.
(w) Nothing in this section or Section 14132.44 shall be construed
to prevent any state agency from participating in the Administrative
Claiming process or from contracting with others to engage in these
activities.
(x) This section shall remain in effect only until January 1,
2018, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2018, deletes or extends
that date.
SEC. 7. Section 14132.47 is added to the Welfare and Institutions
Code, to read:
14132.47. (a) It is the intent of the Legislature to provide
local governmental agencies the choice of participating in the
Targeted Case Management (TCM) or the Administrative Claiming process
program, or both, at their option, subject to the requirements of
this section and Section 14132.44.
(b) The department may contract with each participating local
governmental agency to assist with the performance of nonschool-based
administrative activities necessary for the proper and efficient
administration of the Medi-Cal program, pursuant to Section 1903a of
the federal Social Security Act (42 U.S.C. Sec. 1396b(a)), and this
activity shall be known as the Administrative Claiming process.
(c) (1) Subject to the requirements of paragraph (2) of
subdivision (f), as a condition for participation in the
Administrative Claiming process, each participating local
governmental agency shall, for the purpose of claiming federal
Medicaid reimbursement, enter into a contract with the department and
shall certify to the department the total amount the local
governmental agency expended on the allowable administrative
activities.
(2) The department shall deny the claim if the department
determines that the certification is not adequately supported, or
does not otherwise comply with federal requirements, for purposes of
claiming federal financial participation.
(d) Each participating local governmental agency may subcontract
with private or public entities to assist with the performance of
administrative activities necessary for the proper and efficient
administration of the Medi-Cal program under the conditions specified
by the department in regulations.
(e) Each Administrative Claiming process contract shall include a
requirement that each participating local governmental agency submit
a claiming plan in a manner that shall be prescribed by the
department in regulations developed in consultation with local
governmental agencies.
(f) (1) The department shall require that each participating local
governmental agency certify to the department both of the following:
(A) The expenditure of 100 percent of the cost of performing
Administrative Claiming process activities. The funds expended for
this purpose shall be from the local governmental agency's general
fund or from any other funds allowed under federal law and
regulations.
(B) That the agency's expenditures represent costs that are
eligible for federal financial participation for each fiscal year.
The department shall deny the claim if the department determines that
the certification is not adequately supported for purposes of
federal financial participation.
(2) (A) (i) A city that is not a participating local governmental
agency, or any other local public entity, that contracts with a local
governmental agency pursuant to subdivision (d) and that is located
within a county that is a participating local governmental agency
pursuant to this section may submit certification to the local
governmental agency of amounts expended for Administrative Claiming
services in accordance with Section 433.51 of Title 42 of the Code of
Federal Regulations.
(ii) A city or other local public entity that submits
certification pursuant to this paragraph shall comply with the
requirements of paragraph (1), with other requirements applicable to
local governmental agencies that the department determines, in
regulations, to be applicable, and with all applicable federal
requirements.
(iii) The local governmental agency shall forward the city's or
local public entity's certification to the department for the
purposes of claiming federal financial participation.
(iv) As applicable, the local governmental agency shall obtain and
retain appropriate certifications from the expending city or local
public entity together with documentation of the underlying
expenditures, as required by the department.
(B) A tribe or tribal organization, as defined in subdivision (n),
that is not participating in Administrative Claiming process
activities as a local governmental agency may contract with, or
submit to a tribe or tribal organization that is contracting with,
the department pursuant to subdivision (b) amounts expended for
Administrative Claiming process activities that it is certifying in
accordance with Section 433.51 of Title 42 of the Code of Federal
Regulations and other applicable federal law and regulations. The
tribe or tribal organization receiving the certification shall
forward the certification to the department for purposes of claiming
federal financial participation. The certification shall comply with
all of the requirements for certification set forth in subparagraph
(A).
(g) (1) Notwithstanding any other provision of this section, the
state shall be held harmless, in accordance with paragraphs (2) and
(3), from any federal audit disallowance and interest resulting from
payments made to a participating local governmental agency, pursuant
to this section, for the disallowed claim.
(2) To the extent that a federal audit disallowance and interest
results from a claim or claims for which any participating local
governmental agency has received reimbursement for Administrative
Claiming process activities, the department shall recoup from the
local governmental agency that submitted the disallowed claim,
through offsets or by a direct billing, amounts equal to the amount
of the disallowance and interest in that fiscal year for the
disallowed claim. All subsequent claims submitted to the department
applicable to any previously disallowed administrative activity or
claim may be held in abeyance, with no payment made, until the
federal disallowance issue is resolved.
(3) Notwithstanding paragraph (2), to the extent that a federal
audit disallowance and interest results from a claim or claims for
which the participating local governmental agency has received
reimbursement for Administrative Claiming process activities
performed by an entity under contract with, and on behalf of, the
participating local governmental agency, the department shall be held
harmless by that particular participating local governmental agency
for 100 percent of the amount of the federal audit disallowance and
interest for the disallowed claim.
(h) The use of local funds required by this section shall not
create, lead to, or expand the health care funding obligations or
service obligations for current or future years for any participating
local governmental agency, except as required by this section or as
may be required by federal law.
(i) The department shall deny any claim from a participating local
governmental agency if the department determines that the claim is
not adequately supported in accordance with criteria established
pursuant to this subdivision and implementing regulations before the
department forwards the claim for reimbursement to the federal
Medicaid program. In consultation with local governmental agencies,
the department shall adopt regulations that prescribe the
requirements for the submission and payment of claims for
administrative activities performed by each participating local
governmental agency.
(j) Administrative activities shall be those determined by the
department to be necessary for the proper and efficient
administration of the state's Medicaid plan and shall be defined in
regulation.
(k) If the department denies any claim submitted under this
section, the affected participating local governmental agency may,
within 30 days after receipt of written notice of the denial, request
that the department reconsider its action. The participating local
governmental agency may request a meeting with the director or his or
her designee within 30 days to present the agency's concerns to the
department after the request is filed. If the director or his or her
designee cannot meet, the department shall respond in writing to the
participating local governmental agency in response to its appeal,
indicating the specific reasons for which the claim is out of
compliance. The decision of the director shall be final.
(l) To the extent consistent with federal law and regulations,
participating local governmental agencies may claim the actual costs
of nonemergency, nonmedical transportation of Medi-Cal eligibles to
Medi-Cal covered services, under guidelines established by the
department, to the extent that these costs are actually borne by the
participating local governmental agency.
(m) As a condition of participation in the Administrative Claiming
process and in recognition of revenue generated to each
participating local governmental agency in the Administrative
Claiming process, each participating local governmental agency shall
pay an annual participation fee through a mechanism agreed to by the
state and local governmental agencies, or, if no agreement is reached
by August 1 of each year, directly to the state. The participation
fee shall be used to cover the cost of administering the
Administrative Claiming process, including, but not limited to,
claims processing, technical assistance, and monitoring. The
department shall determine and report staffing requirements upon
which projected costs will be based. The amount of the participation
fee shall be based upon the anticipated salaries, benefits, and
operating expenses to administer the Administrative Claiming process
and other costs related to that process.
(n) (1) For the purposes of this section, "participating local
governmental agency" means a county, charter city, Native American
Indian tribe, tribal organization, or subgroup of a Native American
Indian tribe or tribal organization, under contract with the
department pursuant to subdivision (b). A participating local
governmental agency for the purposes of this section does not include
a local educational agency or an agency under contract with the
department for the purpose of claiming reimbursement for school-based
administrative activities related to the Medi-Cal program.
(2) Each participating Native American Indian tribe, tribal
organization, or subgroup of a Native American Indian tribe or tribal
organization may claim, as a Medi-Cal Administrative Activity,
facilitating Medi-Cal applications, which includes, but is not
limited to, using the California Healthcare Eligibility, Enrollment,
and Retention System.
(o) A participating local governmental agency may charge an
administrative fee to any entity claiming Administrative Claiming
through that agency.
(p) The department shall continue to administer the Administrative
Claiming process in conformity with federal requirements.
(q) The department shall provide technical assistance to all
participating local governmental agencies in order to maximize
federal financial participation in the Administrative Claiming
process.
(r) This section shall be applicable to Administrative Claiming
process activities performed and to moneys paid to participating
local governmental agencies for those activities in the 1994-95
fiscal year and thereafter.
(s) Nothing in this section or Section 14132.44 shall be construed
to prevent any state agency from participating in the Administrative
Claiming process or from contracting with others to engage in these
activities.
(t) This section shall be implemented to the extent that federal
financial participation is available and any necessary federal
approvals have been obtained.
(u) The department may seek approval of any state plan amendments
necessary to implement this section.
(v) 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, provider bulletins, or similar
instructions.
(w) This section shall become operative on January 1, 2018.
SEC. 8. Section 14132.471 is added to the Welfare and Institutions
Code, to read:
14132.471. (a) It is the intent of the Legislature to provide
local governmental agencies with the option to participate in the
Targeted Case Management (TCM) program and to provide local
educational agencies with the option to participate in the
Administrative Claiming process program, subject to the requirements
of this section and Section 14132.44.
(b) (1) Beginning no later than July 1, 2018, the department,
based on the input of the workgroup described in Section 14005.272,
may administer, or oversee the administration of, a single statewide
quarterly random moment time survey for the School-Based
Administrative Claiming process program, or a reduction in the number
of random moment time surveys conducted in the state.
(2) The statewide quarterly random moment time survey described in
paragraph (1) shall not apply to the Los Angeles Unified School
District (LAUSD), which shall conduct its own random moment time
survey. Data from the random moment time survey conducted by LAUSD
shall not be included in the statewide random moment time survey
described in paragraph (1).
(c) (1) The department may contract with a participating local
educational consortium or local governmental agency and shall, if a
local educational agency chooses and the department has developed a
process for direct contracting, contract with a local educational
agency to perform school-based administrative activities necessary
for the proper and efficient administration of the Medi-Cal program,
pursuant to Section 1903a of the federal Social Security Act (42
U.S.C. Sec. 1396b(a)). This activity shall be known as the
School-Based Administrative Claiming process.
(2) A local educational agency that contracts with the department
pursuant to paragraph (1) may contract with a participating local
educational consortium or local governmental agency to perform some
or all of the duties imposed on a participant by this section.
(3) For purposes of this section, "participating local educational
agency, local educational consortium, or local governmental agency"
or "participant" means a local educational agency, local educational
consortium, or local governmental agency that contracts with the
department pursuant to paragraph (1).
(d) (1) As a condition of participation in the School-Based
Administrative Claiming process program, each participating local
educational agency, local educational consortium, or local
governmental agency shall, for the purpose of claiming federal
Medicaid reimbursement, enter into a contract with the department and
shall certify to the department, pursuant to subdivision (f), the
total amount the local educational agency expended on the allowable
administrative activities. A local educational agency may certify the
amount expended on allowable administrative activities either
directly to the department or through a local educational consortium
or local governmental agency.
(2) The department shall deny the claim if the department
determines that the certification is not adequately supported, or
otherwise does not comply with federal requirements, for purposes of
claiming federal financial participation.
(e) Each School-Based Administrative Claiming process contract
shall include a requirement for each participating local educational
agency, local educational consortium, or local governmental agency to
submit a claiming plan in a manner that shall be prescribed by the
department in regulations developed in consultation with local
educational agencies, local educational consortia, and local
governmental agencies.
(f) (1) The department shall require each participating local
educational agency, local educational consortium, or local
governmental agency to certify to the department both of the
following:
(A) That the participant claiming federal Medicaid reimbursement
expended funds from its general fund or from any other fund allowed
under federal law and regulations to pay for 100 percent of the cost
of performing School-Based Administrative Claiming process program
activities.
(B) For each fiscal year, that the expenditures of the participant
claiming federal Medicaid reimbursement represent costs that are
eligible for federal financial participation for that fiscal year.
(2) A tribe or tribal organization, as described in subdivision
(n), may contract with, or submit to a tribe or tribal organization
that is contracting with, the department pursuant to subdivision (b)
amounts expended for School-Based Administrative Claiming process
activities that it is certifying in accordance with Section 433.51 of
Title 42 of the Code of Federal Regulations and other applicable
federal law and regulations. The tribe or tribal organization
receiving the certification shall forward the certification to the
department for purposes of claiming federal financial participation.
The certification shall comply with all of the requirements for
certification set forth in subparagraph (A) of paragraph (1).
(g) (1) Notwithstanding any other provision of this section, the
state shall be held harmless, in accordance with paragraphs (2) and
(3), from any federal audit disallowance and interest resulting from
payments made to a participating local educational agency, local
educational consortium, or local governmental agency pursuant to this
section for the disallowed claim.
(2) To the extent that a federal audit disallowance and interest
results from a claim or claims for which a participating local
educational agency, local educational consortium, or local
governmental agency has received reimbursement for School-Based
Administrative Claiming process activities, the department shall
recoup from the participant that submitted the disallowed claim,
through offsets or by a direct billing, amounts equal to the amount
of the disallowance and interest, in that fiscal year, for the
disallowed claim. All subsequent claims submitted to the department
applicable to a previously disallowed administrative activity or
claim may be held in abeyance, with no payment made, until the
federal disallowance issue is resolved.
(3) Notwithstanding paragraph (2), to the extent that a federal
audit disallowance and interest results from a claim or claims for
which the participating local educational agency, local educational
consortium, or local governmental agency has received reimbursement
for School-Based Administrative Claiming process activities performed
by an entity under contract with, and on behalf of, the participant,
the department shall be held harmless by that particular participant
for 100 percent of the amount of the federal audit disallowance and
interest for the disallowed claim.
(h) The use of local funds required by this section shall not
create, lead to, or expand the health care funding obligations or
service obligations for current or future years for a participating
local educational agency, local educational consortium, or local
governmental agency except as required by this section or as may be
required by federal law.
(i) (1) The department shall, in consultation with participating
local educational agency, local educational consortium, or local
governmental agency, adopt regulations that prescribe the
requirements for the submission and payment of claims for
administrative activities performed by each participant.
(2) The department shall deny a claim from a participating local
educational agency, local educational consortium, or local
governmental agency if the department determines that the claim is
not adequately supported in accordance with criteria established
pursuant to this subdivision and implementing regulations before the
department forwards the claim for reimbursement to the federal
Medicaid program.
(j) Administrative activities shall be those determined by the
department to be necessary for the proper and efficient
administration of the state's Medicaid plan and shall be defined in
regulation.
(k) If the department denies a claim submitted under this section,
the affected participating local educational agency, local
educational consortium, or local governmental agency, within 30 days
after receipt of written notice of the denial, may request that the
department reconsider its action. The participant may request a
meeting with the director or his or her designee within 30 days to
present its concerns to the department after the request is filed. If
the director or his or her designee cannot meet, the department
shall respond in writing to the participant in response to its
request for reconsideration, indicating the specific reasons for
which the claim is out of compliance. The participant may appeal the
decision of the director pursuant to the appeals process established
by the department pursuant to Section 14005.274.
( l ) To the extent consistent with federal law and
regulations, participating local educational agencies, local
educational consortia, or local governmental agencies may claim the
actual costs of nonemergency, nonmedical transportation of Medi-Cal
eligibles to Medi-Cal covered services, under guidelines established
by the department, to the extent that these costs are actually borne
by the participants. A participant may only claim for nonemergency,
nonmedical transportation of Medi-Cal eligibles for Medi-Cal covered
services, through the School-Based Administrative Claiming process.
Medi-Cal medical transportation services shall be claimed under the
local educational agency Medi-Cal billing option, pursuant to Section
14132.06.
(m) As a condition of participation in the School-Based
Administrative Claiming process and in recognition of revenue
generated to a participating local educational agency, local
educational consortium, or local governmental agency in the
School-Based Administrative Claiming process, each participant shall
pay an annual participation fee through a mechanism agreed to by the
state and the participant. The participation fee shall be used to
cover the cost of administering the School-Based Administrative
Claiming process. The department shall determine and report staffing
requirements upon which projected costs will be based. The amount of
the participation fee shall be based upon the anticipated salaries,
benefits, and operating expenses to administer the School-Based
Administrative Claiming process and other costs related to that
process.
(n) (1) For the purposes of this section, "participating local
governmental agency" includes a Native American Indian tribe, tribal
organization, or subgroup of a Native American Indian tribe or tribal
organization under contract with the department pursuant to
subdivision (c).
(2) Each participating Native American Indian tribe, tribal
organization, or subgroup of a Native American Indian tribe or tribal
organization may claim, as a Medi-Cal administrative activity,
facilitating Medi-Cal applications, including, but not
limited to, using the California
Healthcare Eligibility, Enrollment, and Retention System.
(o) (1) For purposes of this section, "local educational agency"
includes county offices of education, special education local plan
areas, Healthy Start programs, and local educational agencies, as
defined in subdivision (h) of Section 14132.06, that participate in
the School-Based Administrative Claiming process program as a
contractor with the department.
(2) For purposes of this section, "local educational consortium"
means a local agency that is one of the service regions of the
California County Superintendent Educational Services Association.
(p) (1) Each participating local educational agency, local
educational consortium, or local governmental agency that contracts
with the department pursuant to paragraph (1) of subdivision (c)
shall be responsible for the preparation and submission of all
administrative claiming plans, training of local educational agency
staff, and the submission of detailed quarterly invoices.
(2) A participating local educational consortium shall be
responsible for a local educational agency with which it contracts
that participates in the School-Based Administrative Claiming process
program solely as a subcontractor to the local educational
consortium. This responsibility includes, but is not limited to, the
preparation and submission of all administrative claiming plans,
training of local educational agency staff, overseeing the local
educational agency time survey process, the submission of detailed
quarterly invoices on behalf of any participating local educational
agency, and ensuring that the local educational agency complies with
all requirements of the School-Based Administrative Claiming process
program.
(3) Each participating local educational agency, local educational
consortium, or local governmental agency shall comply with all
requirements of the School-Based Administrative Claiming process
program.
(4) Ninety days prior to the initial participation in the
School-Based Administrative Claiming process program, each local
educational agency, local educational consortium, or local
governmental agency shall notify the department of its intent to
participate in the program.
(q) Each local educational consortium or local governmental agency
that elects to participate in the School-Based Administrative
Claiming process program shall submit claims directly to the
department. A local educational agency that elects to participate in
the School-Based Administrative Claiming process program may submit
claims directly to the department, or to a local educational
consortium or local governmental agency.
(r) The department shall continue to administer the School-Based
Administrative Claiming process program in conformity with federal
requirements.
(s) This section shall be applicable to School-Based
Administrative Claiming process program activities performed on or
after January 1, 2018.
(t) This section and Section 14132.44 shall not be construed to
prevent a state agency from participating in the School-Based
Administrative Claiming process program or from contracting with
others to engage in these activities.
(u) This section shall not be construed to prohibit county offices
of education, local educational consortia, or local governmental
agencies from providing services to local educational agencies to
facilitate participation in school-based health programs on a
fee-for-service basis; however, local governmental agencies and local
educational consortia shall only require local educational agencies
to contract for services that are actually provided and necessary for
the performance of oversight and monitoring responsibilities,
including training regarding random moment time surveys, random
moment time survey study tasks, roster updates, and financial review.
This section shall not be construed to prohibit a county office of
education or a local educational consortium providing services to a
local educational agency from contracting with private or public
entities to assist with the performance of administrative activities
necessary for the proper and efficient administration of the Medi-Cal
program under the conditions specified by the department in
regulations.
(v) This section shall be implemented to the extent that federal
financial participation is available and any necessary federal
approvals have been obtained.
(w) The department may seek approval of any state plan amendments
necessary to implement this section.
(x) 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, provider bulletins, or similar
instructions.
SEC. 9. Section 14132.472 is added to the Welfare and Institutions
Code, to read:
14132.472. (a) By July 1, 2018, the department shall enter into
an interagency agreement or memorandum of understanding (MOU) with
the State Department of Education to coordinate the efforts of both
departments with respect to the School-Based Administrative Claiming
process program described in Section 14132.471 and the local
educational agency (LEA) Medi-Cal billing option (the LEA billing
option) described in Section 14132.06. The interagency agreement or
MOU shall take into consideration the recommendations of the
workgroup established by Section 14005.272 provided pursuant to
subdivision (c) of Section 14005.272.
(b) In developing the interagency agreement or MOU described in
subdivision (a), the department shall do all of the following:
(1) Consult with relevant nonprofit organizations involved in
facilitating information sharing among state Medicaid and education
agencies involved in the administration of Medicaid claiming for
school-based services to identify, and implement if feasible, best
practices that accomplish the coordination of efforts required by
subdivision (a).
(2) Consult with the workgroup established pursuant to Section
14005.272 regarding the role of the State Department of Education on
the impact of the implementation of the School-Based Administrative
Claiming process program and the LEA billing option on operations at
the local level and any changes to the MOU that the workgroup
recommends.
(3) Develop a schedule for the regular ongoing meetings of the
workgroup established pursuant to Section 14005.272 to provide
feedback to the department and the State Department of Education.
(4) Ensure that the MOU components developed in collaboration with
the State Department of Education and with the input of the
workgroup established pursuant to Section 14005.272 are severable.
