Frequently Asked Questions (FAQs) for Medi-Cal Title XIX Reimbursement

The Department of Health Care Services (DHCS) created these FAQs to provide additional guidance and clarification to local partners regarding Title XIX reimbursement. DHCS will update this webpage as needed to respond to additional questions.

General Information

1. What is Title XIX?

Section 432 of Title 42 of the Code of Federal Regulations (42 CFR 432) requires Title XIX to be established as a Medicaid program. These regulations define training and describe rates of Federal Financial Participation (FFP) for Medicaid staffing and training costs, among other requirements. DHCS is the Single State Agency responsible for the management of the state's Medicaid (Medi-Cal) program and compliance with all federal statutes and regulations, including those relating to Title XIX reimbursement.

Since Medi-Cal is a federal “reimbursement" program, local partners that provide Medi-Cal services to Medi-Cal members and who meet Medi-Cal program requirements and claim qualified expenditures associated with the administration and provision of services for Medi-Cal members may be eligible to receive reimbursement from the federal government for a portion of the expenditures. The reimbursement local partners receive for their Medi-Cal program expenditures is primarily through Title XIX FFP.

2. What programs are covered under the contract between DHCS and CDPH that are eligible for Title XIX funding?

The MCAH programs eligible for Title XIX funding include the Adolescent Family Life Program (AFLP), Black Infant Health (BIH) Program, Comprehensive Perinatal Services Program (CPSP), Information & Education (I&E) Program, Perinatal Equity Initiative (PEI), and California Home Visiting Program (CHVP).

3. What different rates of Title XIX reimbursement are available?

The federal Centers for Medicare and Medicaid Services (CMS) regulations allow matching for administrative activities that are reimbursable at a non-enhanced rate (50/50) for the majority of expenses necessary for the proper and efficient administration of the Medi-Cal program.

Social Security Act (SSA) Section 1903(a)(2) specifically indicates federal matching at 75 percent is attributable to the compensation and/or training of skilled professional medical personnel (SPMP) and staff directly supporting such personnel of the State agency or any other public agency. This is demonstrated by possession of a medical license, certificate, or other document issued by a recognized National or State medical licensure or certifying organization or a degree in a medical field issued by a college or university certified by a professional medical organization. As defined in federal regulations, “professional education and training" means the completion of a 2-year or longer program leading to an academic degree or certificate in a medically related profession.

4. What happens if a certification or license for a particular classification (e.g., Licensed Vocational Nurse (LVN), etc.) requires less than a 2-year program?  

42 CFR 432.50(d)(1)(ii) states, in pertinent part: “'professional education and training' means the completion of a 2-year or longer program leading to an academic degree or certificate in a medically related profession." (emphasis added). Accordingly, and absent express CMS approval otherwise, the program leading to the degree or certificate must itself be 2 years or longer and post-degree or certificate experience, such as on-the-job training, would not qualify toward the 2-year requirement. 

5. What are the non-federal share requirements?

Local partners must provide qualifying non-federal funds (i.e., local county/city/State funds) to qualify for matching Title XIX reimbursement.

6.  Do Local Health Jurisdictions (LHJ) have to document the client's status as a Medi-Cal member to claim Title XIX Reimbursement?

LHJs must document a client's status to substantiate the member is enrolled in Medi-Cal at the time the service was provided[GA1] . LHJs also need to document when a client has presumptive eligibility.

SPMP Requirements & Analysis

7. What are the rules around the use of SPMPs?

The activities performed by the SPMP must require the use of their professional medical knowledge, training, and/or expertise. A local partner must have a signed Agency Information Form and TXIX SPMP Attestation with the State to verify that requirements are met. SPMP classification includes medical professionals described in Title 42, CFR Sections 432.2 and 432.50, and on the SPMP classifications document.

8. What does an “employer-employee" relationship mean for purposes of Title XIX claiming?

Pursuant to 42 CFR 432.2, SPMPs are public agency employees, such as physicians, dentists, nurses, and other specialized personnel, who have professional education and training in the field of medical care or appropriate medical practice. For example, DHCS directly employs SPMPs, such as physicians and nurses, who provide medical policy guidance and DHCS claim 75% FFP for their work on the Medi-Cal program. In addition to directly employing SPMPs, DHCS also maintains several interagency agreements (IAs) with other state entities, including California Department of Public Health (CDPH), to allow both CDPH to claim enhanced Title XIX funds for some of its SPMP staff as well as to allow local public agencies that have specific, contractual arrangements with CDPH to do the same thing.

Local public agencies that maintain contractual arrangements with the California Department of Public Health (CDPH) must provide explicit assurances to CDPH regarding the establishment and maintenance of a clear employer-employee relationship, as outlined in the Agreement Funding Application (AFA) process. This relationship is essential to meet the requirements of the Interagency Agreement (IA) between CDPH and the California Department of Health Care Services (DHCS). Under the IA, DHCS reimburses CDPH for Maternal, Child, and Adolescent Health (MCAH) program expenditures benefiting Medi-Cal members at the local level, and CDPH, in turn, reimburses local public agencies.

The assurance of an employer-employee relationship is demonstrated through two documents that must be included in the AFA submission:

• Detailed Duty Statement:
  Each employee funded under the IA must have a comprehensive duty statement that specifies their roles, responsibilities, and the scope of work they will perform in the context of the MCAH program. The duty statement ensures clarity about the employee's alignment with program objectives and compliance with both state and federal requirements. It should include:

• Job title and classification.
• Description of tasks and responsibilities related to Medi-Cal services.
• Allocation of time to Medi-Cal activities and other functions, as applicable.
• Supervisory and reporting relationships.

• Organizational Chart:
  An organizational chart must accompany the duty statements, providing a visual representation of the reporting structure and oversight mechanisms within the local public agency. This chart demonstrates:

• The placement of employees within the organization.
• Supervisory relationships to ensure accountability and program oversight.
• Integration of roles funded under the IA into the broader organizational structure.

Ultimately, the “employer-employee" relationship involves an analysis and assessment of what local partners are doing and what expenses they are claiming for both non-SPMP and SPMP staff working on MCAH programs and, as always, local partners must maintain appropriate supporting documentation of the employer-employee relationship and make it available to both CDPH/DHCS upon request in the event of a state or federal audit.

9. If a local partner has a subcontract with an organization as part of their MCAH program, can services provided by the subcontracted organization's staff be eligible for Title XIX funding if provided to Medi-Cal members?

Yes, both staff employed directly with local partners (i.e., on payroll) as well as subcontracted staff may be eligible for Title XIX funding so long as they meet all other applicable federal statutes and regulations around Title XIX claiming and are doing so in a manner consistent with DHCS and CDPH policies. Please note that in the case of subcontracted staff, it is very important that local partners ensure that any costs being claimed for Title XIX funding are for the purpose of providing Medi-Cal members with covered MCAH services, helping to connect Medi-Cal members with MCAH covered services and supports, and/or assisting with bringing additional individuals into the Medi-Cal program (i.e., enrollment related). Lastly, local partners must maintain appropriate, comprehensive supporting documentation of the employer-employee relationship  (i.e., legal or professional association) as well as all other required elements and make it available to CDPH, DHCS, and/or state and federal control agencies upon request or in the event of an audit.

10. What classifications are potentially eligible for enhanced SPMP Title XIX reimbursement (75 percent)?

Per 42 CFR Sections 432.2 and 432.50, and associated state policy, potentially eligible SPMP classifications include the following:

• Physician
• Registered Nurse
• Licensed Vocational Nurse
• Physician Assistant
• Nurse Practitioner
• Dentist
• Dental Hygienist
• Registered Dental Assistant
• Nutritionist (with a Bachelor's degree in nutrition/dietetics and registered with the Commission of Dietetic Registration)
• Licensed Clinical Social Worker (LCSW) with medical specialization or master's degree in social work
• Licensed Clinical Psychologist
• Licensed Audiologist
• Licensed Physical Therapist
• Licensed Occupational Therapist
• Licensed Speech Pathologist
• Licensed Marriage and Family Therapist

Please see the SPMP classifications document.

11. Is the enhanced rate available for support staff?

Yes. Under federal regulations, directly supporting staff are eligible for enhanced FFP. Under this regulation, secretarial, stenographic, and copying personnel and file and records clerks who provide clerical services that directly support the responsibilities of SPMP, who are directly supervised by the SPMP, and who are in an employer-employee relationship with Medi-Cal, as described in question #7. The relationship should be clearly identified on the Agency's Organizational Chart.
 
12. What classifications are not eligible for enhanced SPMP Title XIX reimbursement (75 percent), and would be reimbursed at non-enhanced Title XIX reimbursement (50 percent)?

SPMP includes only professionals in the field of medical care. SPMP does not include non-medical health professionals, such as public administrators, medical budget directors, analysts or senior managers of public assistance or Medicaid programs.
The following are examples of what would not be SPMP classifications, according to federal guidance and state policy:

• Having a Master's degree in Social Work without a LCSW license
• Having a Master's degree in Public Health (MPH)
• Health Education Consultant (HEC)
• Community Health Workers (CHWs)

​13. How do I determine if an activity is eligible for enhanced SPMP Title XIX reimbursement (75 percent)?

For any Title XIX enhanced SPMP claiming (75/25), local county partners should always engage in a two-prong analysis, which includes consideration of both the position classification and activity being performed. To this end, local county partners should ask the following:

• Question #1: Is the position considered to be a potentially eligible SPMP classification?
• If “yes", then you can continue onto question #2.
• EX: Physician, nurse, etc. 
• If “no", the analysis stops here, and you would claim non-enhanced (50/50) Title XIX.
• EX:  Community Health Worker, etc.
• Question #2: Does the specific activity that is being performed require the SPMP's professional medical knowledge, training, and/or expertise?
• If “yes", then you would describe that activity as well as provide and maintain appropriate supporting document for CDPH/DHCS and in the event of an audit.
• EX: Performing maternal depression screenings on pregnant individuals. This requires a particular medical licensure and skill set.
• If “no", then even though the position might be potentially SPMP eligible, the activity would not be and thus you would claim non-enhanced (50/50) Title XIX.
• EX: If a potentially SPMP eligible classification is doing administrative or other work that does not require SPMP knowledge, training and/or expertise, then it would not be eligible for enhanced (75/25) Title XIX claiming.
  

Documentation & Time Studies

14. What is a time study?

Time studies are the primary documentation source for Title XIX claiming and are used to determine the percent of personnel time that is matchable with FFP and non-matchable. To claim Medi-Cal Title XIX funds, local partner staff must document all actual staff time worked in all programs during the time study period.

15. If time studying is required, how should that be done?

Time studies should be conducted for staff utilizing TXIX one month per quarter and account for 100 percent of all personnel time. Local partners must use a time study format approved by CDPH.

16. How long must documentation from a time study be retained?

Local and County partners are responsible for maintaining documentation that allows the contracted State agency and DHCS to verify and substantiate Title XIX claiming for a minimum of three fiscal years.

Specific Programs & Base Medi-Cal Percentage

17. What are allowable versus nonallowable expenses and/or ways to leverage funds to support Maternal, Child, and Adolescent Health (MCAH), Black Infant Health/Perinatal Equity Initiative (BIH/PEI), Adolescent Family Life Program (AFLP), and California Home Visiting Program (CHVP)?

Allowable expenses include the percent of personnel reimbursable activities for all staff and operating expenses, including staff travel and training, hosting a table to encourage participation in Medi-Cal, developing community resource guides to promote covered Medi-Cal health services, etc.

Non-allowable expenses include client events (workshops, graduations, [RK2] [WK3] [RA4] etc.); home visits or portions thereof with members that focus on non-Medi-Cal covered services; outreach, program planning and policy development activities of non-Medi-Cal programs financed by other federal and state programs; and assistance to obtain shelter, housing and transportation to non-Medi-Cal related services, [RK5] [WK6] [EJ7]  etc.

For additional information on additional allowable versus non​allowable expenses, please review the FFP guidance appendices of the CDPH Fiscal Manual.

18. What is the “Base Medi-Cal Percentage" and how does that apply to Title XIX for MCAH, BIH/PEI, AFLP, and CHVP?

The Base Medi-Cal Percentage is the percentage of individuals within the age range of the program who are in enrolled in Medi-Cal compared to non-Medi-Cal members within an LHJ. The percentage is calculated every two years by MCAH Division and must be approved by CMS. It cannot be changed or substituted.  If a claiming unit cannot determine the actual client count, it must use the Base Medi-Cal Percentage.

The “Base Medi-Cal Percentage" applies to Title XIX for MCAH, BIH/PEI, AFLP, and CHVP through time study summaries that use the “Medi-Cal Percentage" to determine percentage of services provided to Medi-Cal members that is eligible for FFP. These summaries are a synopsis of all activities and time spent for all programs for staff persons identified on the MCAH program budget. The summaries determine the percentage of personnel match for operating expenses, amount of MCAH claimable activities, and the amount of Title XIX reimbursable activities based on the “Base Medi-Cal Percentage."

19. Can a staff member claim for Medi-Cal percentages that are higher than the Base Medi-Cal Percentage?

Staff members should calculate the Medi-Cal percentage based upon the actual client count for each billing code whenever possible. When that is not possible, a staff member may use the Base Medi-Cal Percentage, as described above, which may vary for individual billing codes.

To use multiple Medi-Cal percentages for the same staff person, the Agency must:

• Submit with the (AFA), via the Budget Template (I) Justification worksheet, the data source(s) and methodology used for the calculation(s).
• Verify each fiscal year that there were no data changes or shifts in workload. If there are changes, an updated methodology needs to be submitted for the staff member seeking a different Medi-Cal Percentage for review and approval each fiscal year.
• Maintain the methodology, client counts, secondary documentation, and any other substantiating documentation for audit purposes.

​20. How should Title XIX activities be coded for MCAH, BIH/PEI, AFLP, and CHVP?

All Title XIX reimbursable activities are identified by their appropriate FFP Function Code for each activity labeled #1 through #12.

Contact Information

21. If I have additional questions about Title XIX claiming, where can I get more information?

If you have additional questions about Title XIX claiming, DHCS has created a “Title XIX claiming toolkit," which is hosted on DHCS' new Title XIX claiming website.

22. If I have additional questions about Title XIX claiming, who can I contact?

If you have additional questions regarding Title XIX claiming and reimbursement, please email DHCS at Title19ClaimingBD@dhcs.ca.gov.

Glossary of Common Acronyms

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