Local educational agency: Medi-Cal billing option.

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 the 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 that are provided by a local governmental agency or local educational agency (LEA) . Existing law also provides that specified services provided by LEAs are covered Medi-Cal benefits and are reimbursable on a fee-for-service basis under the LEA Medi-Cal Billing Option. Existing law requires the department to engage in specified activities relating to the LEA Medi-Cal Billing Option, including amending the Medicaid state plan to ensure that schools are reimbursed for all eligible services, consulting with specified entities in formulating state plan amendments, examining methodologies for increasing school participation in the LEA Medi-Cal Billing Option, and conducting an audit of a Medi-Cal Billing Option claim consistent with prescribed requirements, such as generally accepted accounting principles. Existing law requires the department to file an annual report with the Legislature that includes, among other things, a summary of department activities. This bill would require the department to revise the state plan to establish a revised audit process for Medi-Cal Billing Option claims submitted for dates of service on or after January 1, 2024, pursuant to specified requirements and limitations. The bill would require the department to report to the relevant policy committees and post on its internet website any changes made to the state plan pursuant to the requirement to revise the state plan. The bill would require the department to provide technical assistance to the LEA or to complete appeals by the LEA within 180 days if an audit disallows a specified percentage of an LEA's total value of claims. The bill would prohibit an auditor from disallowing certain claims, except as specified. The bill would require the department's summary of activities in the above-described report to also include training for LEAs and a summary of the number of audits conducted of Medi-Cal Billing Option claims, as specified. The bill would require the department to ensure, for those claims, that "medical necessity" for a beneficiary under 21 years of age has a specified meaning. The bill would make other technical, nonsubstantive changes to these provisions.