Updates to the LEA Medi-Cal Billing Program Provider Manual

In the November Medi-Cal update newsletter for LEAs, DHCS announced several updates to the LEA Medi-Cal Billing Option program and corresponding sections in the Provider Manual.

Many of the updates were operational in nature and unrelated to program policy; however, there were a handful of substantial changes including some that appear to be related to the state’s preparation for rolling out non-IEP and non-IFSP billing (previously referred to as free care services). DHCS has noted that the transition to billing for non-IEP and non-IFSP services may take time, particularly to allow for updates to the Provider Manual, the approval of a pending State Plan Amendment, and additional guidance from the Department on program compliance measures.

Of the many updates to the manual, the following are particularly noteworthy for participating school districts (a complete list of changes to the LEA Provider Manual is available here):

  1. “LEAs are no longer required to obtain a 100 percent response rate of requested Other Health Coverage (OHC) information prior to billing Medi-Cal.”
    • While a reference to this requirement has been removed from the Provider Manual (loc ed bil, page 2), the Manual still states that LEAs must request OHC from all parents, bill OHC for all Medi-Cal and non-Medi-Cal students before billing Medi-Cal, and states that if any parent refuses to allow OHC to be billed the LEA cannot bill Medi-Cal for that type of service provided to any student.
    • This update is limited in its actual impact on LEAs until additional language in the Manual is updated to remove all language related to the now-rescinded free care policy which severely restricts schools’ ability to bill for non-IEP and non-IFSP services.
  2. The limitation on billing no more than 24 non-IEP/IFSP services per recipient in a 12 month period has been removed from some sections of the Provider Manual
    • This update is limited in its impact on LEAs as mention of the 24 service limitation is still included in other sections of the Manual (loc ed bil, page 8) and the lifting of this limitation will only impact LEAs once DHCS releases their final guidance to allow non-IEP/non-IFSP billing.
  3. New language included in the Support Cost section of the Manual (loc ed prov, page 10) states, “Withholds are subject to change based on agreement between DHCS and the LEA stakeholders.”
    • Currently, the 1% administrative withhold and combined 2.5% withhold for A&I and the Ad-Hoc Workgroup- both with maximum cap amounts – is codified in the Welfare and Institutions Code (WIC) Section 14115.8.
    • This update allows DHCS by bypass more rigorous processes for increasing withholds in lieu of approval from the LEA Ad-Hoc Workgroup and stakeholders.