BILL NUMBER: AB 2527 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY APRIL 7, 2008
AMENDED IN ASSEMBLY MARCH 25, 2008
INTRODUCED BY Assembly Member Berg
FEBRUARY 21, 2008
An act to amend Sections 14132.44 and 14132.47 of the Welfare and
Institutions Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 2527, as amended, Berg. Medi-Cal: Targeted Case Management and
Administrative Claiming process programs.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income persons receive health care services.
Under existing law, targeted case management (TCM) is a covered
benefit under the Medi-Cal program. Existing law requires a TCM
provider to be a local governmental agency (LGA) under contract with
the department to provide TCM services, and permits a TCM provider to
contract with a nongovernmental entity or the University of
California, or both, to provide TCM services on its behalf under the
conditions specified by the department in regulations.
This bill would, instead, authorize a LGA to contract with any
private or public entity to provide TCM services on its behalf under
the conditions specified by the department in regulations.
Existing law authorizes the department to contract with LGAs or
local education consortiums to assist with the performance of
administrative activities necessary for the proper and efficient
administration of the Medi-Cal program, which is known as the
Administrative Claiming process. Existing law authorizes a LGA to
subcontract with nongovernmental entities, as defined, to assist with
the performance of these administrative activities.
This bill would, instead, authorize a LGA or a local education
consortium to subcontract with any private or public entity to assist
with the performance of the above-described administrative
activities and would make conforming changes.
Existing law requires a local governmental agency that elects to
provide TCM services, and each local governmental agency or local
educational consortium participating in the Administrative Claiming
process, to certify the availability and expenditure of 100% of the
nonfederal share for the provision of either TCM services or the cost
of performing administrating claiming activities, as provided.
This bill would permit, to the extent consistent with federal law,
as to TCM services, a local governmental agency, and, as to
Administrative Claiming process activities, a local governmental
agency or a local educational consortium, to certify appropriate
expenditures made by another state or local public entity, as
provided.
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 14132.44 of the Welfare and Institutions Code
is amended to read:
14132.44. (a) Targeted case management (TCM), pursuant to Section
1915(g) of the Social Security Act as amended by Public Law 99-272
(42 U.S.C. Sec. 1396n(g)), shall be covered as a benefit, effective
January 1, 1995. Nothing in this section shall be construed to
require any local governmental agency to implement TCM.
(b) A TCM provider furnishing TCM services shall be a local
governmental agency under contract with the department to provide TCM
services. Local educational agencies shall not be providers of case
management services under this section.
(c) A TCM provider may contract with any private or public entity
to provide TCM services on its behalf under the conditions specified
by the department in regulations.
(d) Each TCM provider shall have all of the following:
(1) Established procedures for performance monitoring.
(2) A countywide system to prevent duplication of services and to
ensure coordination and continuity of care among providers of case
management services provided to beneficiaries who are eligible to
receive case management services from two or more programs.
(3) A fee mechanism effective January 1, 1995, specific to TCM
services provided, which may vary by program.
(e) A TCM service provider or an entity under contract with a TCM
provider may provide TCM services to one or all of the following
groups of Medi-Cal beneficiaries, which shall be defined in
regulation:
(1) High-risk persons.
(2) Persons who have language or other comprehension barriers.
(3) Persons on probation.
(4) Persons who have exhibited an inability to handle personal,
medical, or other affairs.
(5) Persons abusing alcohol or drugs, or both.
(6) Adults at risk of institutionalization.
(7) Adults at risk of abuse or neglect.
(f) (1) A local governmental agency that elects to provide TCM
services to the groups specified in subdivision (e) shall, for each
fiscal year, for the purpose of obtaining federal medicaid matching
funds, submit an annual cost report as prescribed by the department
that certifies all of the following:
(A) The availability and expenditure of 100 percent of the
nonfederal share for the provision of TCM services from the local
governmental agency's general fund or from any other funds allowed
under federal law and regulation. To the extent consistent with
federal law, a local governmental agency may certify appropriate
expenditures for TCM services that are made by another state or local
public entity. The local governmental agency shall obtain and retain
appropriate certifications from the expending state or local public
entity and retain documentation, as required by the department.
(B) The amount of funds expended on allowable TCM services.
(C) Its expenditures represent costs that are eligible for federal
financial participation.
(D) The costs reflected in the annual cost reports used to
determine TCM rates are developed in compliance with the definitions
contained in the Office of Management and Budget (OMB) Circular A-87.
(E) Case management services provided in accordance with Section
1396n(g) of Title 42 of the United States Code will not duplicate
case management services provided under any home- and community-based
services waiver.
(F) Claims for providing case management services pursuant to this
section will not duplicate claims made to public agencies or private
entities under other program authorities for the same purposes.
(G) The requirements of subdivision (d) have been met.
(2) The department shall deny any claim if it determines that any
certification required by this subdivision is not adequately
supported for purposes of federal financial participation.
(g) Only a local governmental agency may submit TCM service claims
to the department for the performance of TCM services.
(h) During the period from January 1, 1995, through June 30, 1995,
TCM services shall be reimbursed according to the interim mechanism
developed by the state and the Health Care Financing Administration,
which is reflected in the document entitled "Agreement Between the
Health Care Financing Administration and the State of California,
Department of Health Services." For the 1995-96 fiscal year, the
department shall establish an initial rate of reimbursement.
Effective July 1, 1996, and thereafter, TCM services shall be
reimbursed in accordance with regulations that shall be adopted by
the department.
(i) The department, in consultation with local governmental
agencies, and consistent with federal regulations, and the State
Medicaid Manual of the Department of Health and Human Services,
Health Care Financing Administration, shall adopt regulations that
define TCM services, establish the standards under which TCM services
qualify as a Medi-Cal reimbursable service, prescribe the
methodology for determining the rate of reimbursement, and establish
a claims submission and processing system and method to certify local
matching expenditures.
(j) (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 by the federal medicaid program as reimbursement for
claims for providing TCM services pursuant to this section, less the
amounts already remitted to the state pursuant to subdivision (m) for
the disallowed claim.
(2) To the extent that a federal audit disallowance and interest
results from a claim or claims for which any local governmental
agency has received reimbursement for TCM services, the department
shall recoup from the local governmental agency that submitted that
disallowed claim, through offsets or by a direct billing, amounts
equal to the amount of the disallowance and interest, in that fiscal
year, less the amounts already remitted to the state pursuant to
subdivision (m) for the disallowed claim. All subsequent claims
submitted to the department applicable to any previously disallowed
claim, may be held in abeyance, with no payment made, until the
federal disallowance issue is resolved.
(3) Notwithstanding paragraphs (1) and (2), to the extent that a
federal audit disallowance and interest results from a claim or
claims for which the local governmental agency has received
reimbursement for TCM services 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 local
governmental agency for 100 percent of the amount of any such federal
audit disallowance and interest, less the amounts already remitted
to the state pursuant to subdivision (m) for the disallowed claim.
(k) The use of local matching 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 each local
governmental agency, except as required by this section or as may be
required by federal law.
(l) TCM services are services which assist beneficiaries to gain
access to needed medical, social, educational, and other services.
Services provided by TCM providers, and their subcontractors, shall
be defined in regulation, and shall include at least one of the
following:
(1) Assessment.
(2) Plan development.
(3) Linkage and consultation.
(4) Assistance in accessing services.
(5) Periodic review.
(6) Crisis assistance planning.
(m) (1) Each local governmental agency shall contribute to the
department a portion of the agency's general fund that has been made
available due to the coverage of services described in this section
under the Medi-Cal program. The contributed funds shall be reinvested
in health services through the Medi-Cal program. The total
contribution amount shall be equal to 331/3 percent of the amounts
that have been made available under this section, but in no case
shall this contribution exceed twenty million dollars ($20,000,000)
in a fiscal year less the amount contributed pursuant to subdivision
(m) of Section 14132.47. Beginning with the 1994-95 fiscal year, each
local governmental agency's share of the total contribution shall be
determined by claims submitted and approved for payment through
January 1 of the following calendar year. Claims received and
approved for payment after January 1 for dates of service in the
previous fiscal year shall be included in the following year's
calculation. Each local governmental agency's share of the
contribution for the previous fiscal year shall be determined no
later than February 15 and shall be remitted to the state no later
than April 1 of each year. The contribution amount shall be paid from
nonfederal, general fund revenues, and shall be deposited in the
Targeted Case Management Claiming Fund, which is hereby created, for
transfer to the Health Care Deposit Fund.
(2) Moneys received by the department pursuant to this subdivision
are hereby continuously appropriated, notwithstanding Section 13340
of the Government Code, to the department for the support of the
Medi-Cal program, and the funds shall be administered in accordance
with procedures prescribed by the Department of Finance. If not paid
as provided in this section, the department may offset payments due
to each local governmental agency from the state, not related to
payments required to be made pursuant to this section, in order to
recoup these funds for the Targeted Case Management Claiming Fund.
(3) This subdivision shall only apply to claims approved for the
1994-95 to 1997-98 fiscal years, inclusive.
(n) As a condition of participation and in consideration of the
joint effort of the local governmental agencies and the department in
implementing this section and the ongoing need of local governmental
agencies to receive technical support from the department, as well
as assistance in claims processing and program monitoring, the local
governmental agencies shall cover the costs of the administrative
activities performed by the department. Each local governmental
agency shall annually pay a portion of the total costs of
administrative activities performed by the department through a
mechanism agreed to by the department and the local governmental
agencies, or if no agreement is reached by August 1 of each year,
directly to the state. The department shall determine and report the
staffing requirements upon which projected costs will be based.
Projected costs shall include the anticipated salaries, benefits, and
operating expenses necessary to administer targeted case management.
(o) For the purposes of this section a "local governmental agency"
means a county or chartered city.
SEC. 2. 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 1396b(a) of Title 42 of the United States Code, Section
1903a of the federal Social Security Act, and this activity shall be
known as the Administrative Claiming process.
(c) (1) 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 matching funds, enter into a contract with the
department and shall certify to the department the amount of local
governmental agency or each local educational consortium general
funds or any other funds allowed under federal law and regulation
expended on the allowable administrative activities.
(2) The department shall deny the claim if it determines that the
certification is not adequately supported for purposes of 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) The department shall require that each participating local
governmental agency or each local educational consortium certify to
the department both of the following:
(1) The availability and expenditure of 100 percent of the
nonfederal share 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 regulation. To the extent consistent with
federal law, a local governmental agency or local educational
consortium may certify appropriate expenditures for administrative
activities covered under the Administrative Claiming process, which
are made by another state or local public entity. The local
governmental agency or local educati onal consortium shall
obtain and retain appropriate certifications from the expending
state or local public entity and retain documentation, as required by
the department.
(2) 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.
(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, less the amounts
already remitted to the state pursuant to subdivision (m) 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, less the amounts
already remitted to the state pursuant to subdivision (m) 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, less the amounts already
remitted to the state pursuant to subdivision (m) for the disallowed
claim.
(h) The use of local matching 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 government 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) 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) (1) Each participating local governmental agency shall
contribute to the department a portion of the agency's general fund
that has been made available due to the coverage of administrative
activities described in this section under the Medi-Cal program. The
contributed funds shall be reinvested in health services through the
Medi-Cal program. The total contribution amount shall be equal to
331/3 percent of amounts made available under this section, but in no
case shall the contribution exceed twenty million dollars
($20,000,000) a fiscal year less the amount contributed pursuant to
subdivision (m) of Section 14132.44. Beginning with the 1994-95
fiscal year, each local governmental agency's share of the total
contribution shall be determined by claims submitted and approved for
payment through January 1 of the following calendar year. Claims
received and approved for payment after January 1 for dates of
service in the previous fiscal year shall be included in the
following year's calculation. Each local governmental agency's share
of the contribution for the previous fiscal year shall be determined
no later than February 15 and shall be remitted to the state no later
than April 1 of each year. The contribution amount shall be paid
from nonfederal, general fund revenues and shall be deposited in the
Administrative Claiming Fund for transfer to the Health Care Deposit
Fund.
(2) Moneys received by the department pursuant to this subdivision
are hereby continuously appropriated to the department for support
of the Medi-Cal program, and the funds shall be administered in
accordance with procedures prescribed by the Department of Finance.
If not paid as provided in this section, the department may offset
payments due to each participating local governmental agency from the
state, not related to payments required to be made pursuant to this
section in order to recoup these funds for the Administrative
Claiming Fund.
(3) This subdivision shall only apply to claims approved for the
1994-95 to 1997-98 fiscal years, inclusive.
(n) 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.
(o) 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).
(p) 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.
(q) (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).
(r) (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.
(s) (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.
(t) The requirements of subdivision (m) shall not apply to claims
for administrative activities, pursuant to the Administrative
Claiming process, performed by public health programs administered by
the state.
(u) A participating local governmental agency or a local
educational consortium may charge an administrative fee to any entity
claiming Administrative Claiming through that agency.
(v) The department shall continue to administer the Administrative
Claiming process in conformity with federal requirements.
(w) 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.
(x) 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.