(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 local governmental agency may contract with the department to provide TCM services. The department shall not contract with local education agencies to provide case management services under this section.
(c) A local governmental agency 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 local governmental agency that provides TCM services 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) Subject to the requirements of federal law and regulations, a local governmental agency or an entity under contract with a local governmental agency 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 reimbursement, submit an annual cost report as prescribed by the department that certifies all of the following:
(A) The expenditure of 100 percent of the costs incurred 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.
(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.
(3) (A) A city that is not a local governmental agency, or any other local public entity that contracts with a local governmental agency pursuant to subdivision (c) and that is located within a county that is a participating local governmental agency pursuant to this section, may submit certification to the local governmental agency of amounts expended for TCM services in accordance with Section 433.51 of Title 42 of the Code of Federal Regulations.
(B) A city or other local public entity that submits certification pursuant to this paragraph shall comply with the requirements of paragraph (1), with other requirements applicable to local governmental agencies that the department determines, in regulations, to be applicable, and with all applicable federal requirements.
(C) The local governmental agency shall forward the city’s or local public entity’s certification to the department for purposes of claiming federal financial participation.
(D) As applicable, the local governmental agency shall obtain and retain appropriate certifications from the expending city or local public entity, together with documentation of the underlying expenditures, as required by the department.
(g) Except as otherwise provided in paragraph (3) of subdivision (f), only a local governmental agency may submit TCM service claims to the department for the performance of TCM services.
(h) 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, Centers for Medicare and Medicaid Services, 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 expenditures.
(i) (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, 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, 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, for the disallowed claim.
(j) The expenditure 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 each local governmental agency, except as required by this section or as may be required by federal law.
(k) Subject to the requirements of federal law and regulations, TCM services are services which assist beneficiaries to gain access to needed medical, social, educational, and other services. Services provided by local governmental agencies, 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.
(l) 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.
(m) For the purposes of this section a “local governmental agency” means a county or chartered city.
(n) Nothing in this section or in Section 14132.47 shall be construed to prevent any state agency from providing TCM services or from contracting with others to provide these services.
(Amended by Stats. 2008, Ch. 464, Sec. 1. Effective January 1, 2009.)
Last modified: October 25, 2018