The Local Educational Agency (LEA) Medi-Cal Billing Option Program provides federal financial participation (FFP) reimbursement to LEAs (school districts, county offices of education, community colleges, and university campuses) for health-related services provided by qualified medical practitioners to students receiving special education services and who are on Medi-Cal. (generally, special education students) and their families.
The LEA Medi-Cal Billing Option Program was established in 1993 in conjunction with the California Department of Education (CDE). It is authorized under California's Welfare and Institutions Code 14132.06. Reimbursement is based upon a "fee-for-service" model. School expenditures for services rendered are reimbursed at 50% of cost.
The purpose of the LEA Billing Option is to:
- Allow LEAs to become Medi-Cal providers and bill the Medi-Cal program for the health services provided by employed or contracted medical professionals.
- Facilitate reinvestment in health and social services for students and their families so that schools can provide comprehensive health services to eligible Medi-Cal students.
- The funds are reimbursement for services rendered and are not considered federal dollars upon receipt by the school and therefore can be used as match to draw down additional federal dollars.
- The funds are restricted in their use, they must supplement existing services, not supplant.
- The fund expenditures are overseen by a interagency collaborative led by the school and must meet the regulations as listed in the California Education Code 8804(g) that are focused on improving student’s health and a variety of other services delineated in the Education Code.
WHO PROVIDES SERVICES
The services are delivered through the LEAs. The LEAs either employ practitioners who provide the services on site, or transports the recipients to local practitioners they contract with. Providers of TCM services are limited to Local Governmental Agencies (counties and chartered cities) under contract with DHCS, as identified in the California State Plan.
LEAs must have an approved provider agreement with DHCS through CDE to be eligible to provide services. However, to participate in the LEA Medi-Cal Billing Option Program LEAs must reinvest the federal reimbursements they receive under this program in health and social services for children and families, and develop and maintain a collaborative committee to assist them in decisions regarding the reinvestment of federal reimbursements.
The LEA program is funded with a combination of local and federal Title XIX (Medicaid) funds. LEAs bill Medi-Cal for the direct medical services they provide to Medi-Cal eligible students. Claims are filed using the traditional Medi-Cal fee-for-service system through the fiscal intermediary for DHCS, Xerox State Healthcare, LLC. LEAs pay for the services and are reimbursed the FFP rate relative to the cost of each individual service from federal funds; therefore, there is no State General Fund expense for this program.
LEAs must annually certify that the public funds expended for LEA services provided are eligible for FFP pursuant to Code of Federal Regulations, Title 42, Section 433.51. DHCS must reconcile the interim Medi-Cal reimbursements to LEAs with the costs to provide the Medi-Cal services. The Cost and Reimbursement Comparison Schedule is used to compare each LEA’s total actual costs for LEA services to interim Medi-Cal reimbursement for the preceding fiscal year.