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.