A Closer Look At Your School District’s Athletic Teams’ Health Care Obligations
There currently are a variety of regulations and programs (i.e., Medi-Cal, Medicaid, Medicare, Tricare, and other government sponsored health insurance plans) which must be considered and must be coordinated in compliance with § 32221 et seq. of the Education Code. The following is intended to provide you (County, District Superintendents, Charter School Counselors, State Special School Administrators, Presidents, Chancellors, Athletic Directors, Athletic Trainers, Campus Health Center Personnel, and anyone responsible for the processing of claims for injuries under Education Code § 32221) with helpful guidance and clarification of many of the recent changes in State and Federal laws which have a direct impact on Education Code § 32221.
In California, the Medicaid program is known as Medi-Cal and is jointly financed by federal and state funds. It’s our goal to make our clients aware of Medi-Cal benefits for students and athletes who sustain injuries which are covered under the college’s accident insurance program. The college’s accident insurance plan is secondary to all available individual insurance, unless the individual policy is Medi-Cal, Medicaid, Medicare, Tri-care and any other government-sponsored insurance plan.
What does the law say exactly?
The law is very clear that when a beneficiary is eligible for Medi-Cal and another insurance policy, the other insurance policy pays before Medi-Cal and that ‘other insurance policy’, includes the district/college’s accident insurance.
Education Code § 32221 Requirement
Education Code § 32221 requires that athletic team insurance must be provided at the expense of the school districts (1) only in the event that a student does not otherwise have insurance or a reasonable equivalent of health benefits coverage, and (2) only if the student cannot afford such insurance or health benefits coverage. If this is the case, then the school district must pay for the insurance from district or student body funds.
California Education Code § 32221:
California Education Code § 32221 and California Insurance Code § 10493
Mandate protection for medical and hospital expenses resulting from accidental bodily injuries for your athletes and members of athletic teams who are engaged in or are preparing for an athletic event promoted under the sponsorship of the school or community college districts.
California Education Code § 32221:
California Insurance Code § 10493:
We must become knowledgeable about the law
Below are pertinent additional resources and extracts to help guide you on what the law says about our responsibility:
1. The following is an extract from California Code of Regulations § 50769. Department Responsibility – Other Health Care Coverage.
California Code of Regulations § 50769 dictates the responsibilities of the Department regarding other health care coverage: § 50769 (a) On the Medi-Cal card of beneficiaries who have other health care coverage, the Department shall place an indicator code to give notice to providers and beneficiaries that other health care coverage must be utilized prior to billing the Medi-Cal program, and § 50769 (c) when Medi-Cal payment has been made before the other health care coverage has been identified, the Department shall recover payments from the parties having a legal obligation.
2. The following is an extract from California Code, Welfare and Institutions Code – WIC § 14023.7.
Any applicant for coverage under this chapter who at the time of application has any other contractual or legal entitlement to any health care service defined in Section 14053, and who willfully fails at that time to disclose the fact of such other entitlement, or falsely represents that he or she does not have such other entitlement, is guilty of a misdemeanor.
Any person eligible under this chapter who, subsequent to the date of application for such assistance or coverage under this chapter, acquires any other contractual or legal entitlement to any health care service, and willfully fails or refuses to give notice thereof to his county welfare department within 10 days of such acquisition, is guilty of a misdemeanor.
Any person eligible under this chapter who has any other contractual or legal entitlement to any health care service defined in § 14053, and who knowing that he or she must use such entitlement first, obtains any such service under Medi-Cal without first having utilized and exhausted his or her other contractual or legal entitlement thereto or therefor, is guilty of a misdemeanor.
Any applicant shall by virtue of becoming eligible under this chapter to have irrevocably assigned the benefits of any contractual or legal entitlement for health care to the State Director of Health Services to the extent that the services were paid for under this chapter.
California Welfare and Institutions Code § 14023.7 places the responsibility on the provider of services as well. Any provider of service seeking payment for health care services for a person eligible for these services under this chapter shall first seek to obtain payment from any private or public health insurance coverage to which the person is entitled, where the provider is aware of this coverage, and to the extent the coverage extends to these services, prior to submitting a claim to the department for the payment of any unpaid balance for these services.
3. See California Welfare and Institutions § 14124.90.
It is the intent of the Legislature to comply with federal law requiring that when a beneficiary has third-party health coverage or insurance, the State Department of Health Services shall be the payer of last resort.
4. See California Welfare and Institutions § 14014.
Any person receiving health care for which he or she was not eligible on the basis of false declarations as to his or her eligibility or any person making false declarations as to eligibility on behalf of any other person receiving health care for which that other person was not eligible shall be liable for repayment and shall be guilty of a misdemeanor or felony depending on the amount paid on his or her behalf for which he or she was not eligible, as specified in Section 487 of the Penal Code § 14014 (b)(1) Any person who willfully and knowingly counsels or encourages any individual to make false statements or otherwise causes false statements to be made on an application, in order to receive health care services to which the applicant is not entitled, shall be liable to the Medi-Cal program for damages incurred for the cost of services rendered to the applicant.
5. See California Welfare and Institutions § 14107.
Any person, including any applicant or provider as defined in Section 14043.1, or billing agent, who engages in any of the activities identified in subdivision (b) is punishable by imprisonment as set forth in subdivisions (c), (d), and (e), by a fine not exceeding three times the amount of the fraud or improper reimbursement or value of the scheme or artifice, or by both this fine and imprisonment.
What are our obligations under California Code of Education Code § 32221 for beneficiaries of Medi-Cal, etc?
A common practice in student athletics is to have students sign a waiver or release prior to allowing the student-athlete to participate. When a Medi-Cal applicant completes an application for benefits, he/she must sign a Declaration under penalty of perjury, see Figure 1 from the Covered California website.
Education Code § 32221.5 Required Notice Language
A school district that elects to operate an interscholastic athletic team or teams shall include the following statement, printed in boldface type of prominent size, in offers of insurance coverage that are sent to members of school athletic teams:
“Under state law, school districts are required to ensure that all members of school athletic teams have accidental injury insurance that covers medical and hospital expenses. This insurance requirement can be met by the school district offering insurance or other health benefits that cover medical and hospital expenses…”
Assembly Bill No. 2684 Notification
Assembly Bill 2684 (Chapter 108, Statutes of 2006), which enacted Education Code § 32221.5, requires Local Educational Agencies (LEAs) operating interscholastic teams to inform parents via a prescribed statement that students participating in sports activities may qualify to enroll in no-cost or low-cost insurance programs. (Like other school district notices sent to parents, if 15% or more of the pupils enrolled in the school speak a primary language other than English, the notification must be translated into the primary language, pursuant to Education Code § 48985.)
What is being done at the Student Insurance level?
As you know, the federal government is also a paying participant to the Medi-Cal program; hence, we must abide not only by California State law, we must be mindful not to violate the rules and regulations of the Office for Civil Rights, U.S. Department of Health and Human Services as well.
Guidelines for remaining compliant:
Send an annual California Department of Education (EDC) letter with the Education Code § 32221.5 required language.
Provide Student Insurance for athletic team members. Contact Student Insurance for compliant insurance solutions.
Be on the alert and always be aware! It’s a fact that since the ACA (Affordable Care Act) many of the students/athletes enrolled at the community colleges are eligible for Medi-Cal.
When a Medi-Cal applicant completes an application for benefits, ensure he/she signs a Declaration under penalty of perjury.
What is the Risk of Doing Nothing?
- Beware of HIPAA Office of Civil Rights (OCR) Audits.
- Fines and settlements can be hefty. See our citations to Penal Code § 653f, California Welfare and Institutions Code § 14107, and § 14043.1.
- The cost of defending claims and the claims could increase premiums for all.
Suggested Risk Approaches
Insuring your athletes for accident medical insurance is the law. Insuring the student population is a sound business decision. Paying the medical expenses for injuries sustained by a student under the college’s accident insurance policy very often prevents lawsuits which would prove to be far more costly to settle than the cost of the premium for the accident insurance.
- Be mindful of the law. The law is very clear when a beneficiary is eligible for Medi-Cal and another insurance policy (your institution accident insurance is other insurance), the other insurance policy pays before Medi-Cal and that ‘other insurance policy’, includes the district/college’s accident insurance.
- Notify the parents/guardians of athletic team members.
- Inquire about other insurance, and if applicable obtain the information, prior to the beginning of the sports season.
We want all California Community College athletes and students to dedicate themselves to the successful completion of their studies, ensuring they don’t encounter any legal difficulties during their academic career or at any time thereafter as well as, ultimately reducing potential liability to our schools, colleges, and universities.
Student Insurance is happy to assist athletic departments and campus health center personnel with any completion of claim forms and any code regulations.
For more information about these health insurance obligations, or students that may be qualified for no-cost, low-cost, state and federally sponsored programs contact us or Covered California directly.
Marie Rosa Martinelli