(a) Billing shall not exceed a provider's
usual charge made to the general public. Reimbursement for hospital outpatient
departments shall be the provider's usual charge to the general public not to
exceed the maximum rates authorized by this section.
(1) Maximum reimbursement rates, as shown in
the following schedules, include overhead and professional components, except
as otherwise indicated in (g) below. When these segments are billed separately,
the total may not exceed the amounts listed.
(2) Notwithstanding any other provisions of
this section, the Director may negotiate with individual hospital facilities an
all-inclusive per visit rate for hospital outpatient services, provided that
such negotiated rates do not increase overall program
costs.
(b) Occupational
therapy reimbursement shall be made in accordance with Section
51507.1, except that payment shall
not be made for procedure codes X4114 or X4116.
(c) Speech therapy and audiology
reimbursement shall be made in accordance with Section
51507.2, except that payment shall
not be made for procedure code X4306.
(d) Psychology: Reimbursement for psychology
shall be made in accordance with Section
51505.3, except no payment shall
be made for procedure code X9548.
(e) Laboratory: Reimbursement for laboratory
services shall be made in accordance with Section
51529.
(f) Physical therapy reimbursement shall be
made in accordance with Section
51507, except that payment shall
not be made for procedure codes X3932 or X3934.
(g) Physician Services.
(1) Hospital Outpatient Departments.
(A) Services by interns, residents or
hospital compensated physicians.
1.
Reimbursement for services shall be made directly to the hospital.
2. Reimbursement shall not exceed the amounts
payable in accordance with Section
51503(g) plus the
amounts payable under (2).
(B) Services by physicians not compensated by
the hospital.
1. Payment for services may be
made separately to the physician and to the hospital for services provided by
each provider.
2. Reimbursement for
hospital services shall not exceed the amounts payable in (2).
3. Reimbursement for physician services shall
be made in accordance with Section
51503(g), Title
22, California Code of Regulations.
(2) Maximum reimbursement rates for hospital
facilities shall be as follows:
Procedure
Code |
Maximum
Allowance |
Z7500 |
Use of hospital examining or
treatment room |
$23.77 |
Z7502 |
Use of emergency room (Bill only when
used for the treatment of emergency conditions; for nonemergency conditions the
examining room fee is payable.) |
34.58 |
Z7504 |
Use of cast room |
34.58 |
Z7506 |
Use of operating room or cystoscopic
room--first hour |
101.90 |
Z7508 |
first subsequent half
hour |
40.76 |
Z7510 |
second subsequent half
hour |
40.76 |
maximum reimbursement |
224.19 |
Z7512 |
Use of recovery
room |
18.22 |
Z7514 |
Payment for room and board and
general nursing care for stays of less than 24 hours, including ordinary
medication |
40.76 |
Z7612 |
Unlisted services |
By
Report |
(h) Pharmaceutical Services: Billings for
drugs and medical supplies dispensed to outpatients shall be in accordance with
sections
51513, and
51520.
(i) Radiology Services: Reimbursement for
radiology services will not exceed amounts payable by Medi-Cal for the same
services when rendered by physicians in nonhospital settings. If the hospital
and professional components are billed separately, the total payment will not
exceed the amount otherwise payable.
(j) Other Outpatient Services: Payment shall
not exceed the maximum payment under the program for the same services by
individual providers.
(k)
Reimbursement rates payable to hospital outpatient departments qualifying for
outpatient disproportionate share reimbursement shall be the maximum
reimbursement rates authorized in subsections (a) through (j) of this section
augmented by the hospital's disproportionate reimbursement factor, as described
below:
(1) The Department shall develop
annually a disproportionate provider factor for each hospital outpatient
department located within the State and actively participating in the Medi-Cal
program, using, to the extent available, the most recent annual financial
disclosure data administered by the Office of Statewide Health Planning and
Development.
(2) The
disproportionate provider factor shall be the ratio of total Medi-Cal
outpatient gross revenue, including "other" outpatient deductions from
revenues, and revenue-offsetting subsidies, including medically indigent
services program funds, as those deductions are described in the Office of
Statewide Health Planning and Development Quarterly and Financial Disclosure
Report, to total outpatient revenue. For hospitals unable to report the
outpatient component of their "other" deductions from revenue, the Department
shall estimate this amount by multiplying the ratio of other outpatient gross
revenues to other total gross revenues by the total of other deductions from
revenue. The calculation of a hospital's outpatient disproportionate provider
factor shall not take into account any funds received by the hospital pursuant
to Part 4.7, commencing with Section
16900,
of the Welfare and Institutions Code, and shall exclude Medicare and Medi-Cal
contractual allowances.
(3)
Notwithstanding Section
51509(k)(2), the
outpatient disproportionate provider factor for each qualifying children's
hospital shall be no less than the amount that would have been established had
the formula specified in Section
51509(k)(2)
excluded revenue-offsetting subsidies, including medically indigent services
program funds.
(4) Hospital
outpatient departments with disproportionate provider factors exceeding the
mean factor for all hospital outpatient departments specified in Section
51509(k)(1) shall
qualify for outpatient disproportionate share reimbursement. In calculating the
mean disproportionate provider factor, equal weight will be given to each
separately located outpatient department.
(5) Any reimbursement generated by the
disproportionate provider factor of a qualifying hospital outpatient department
shall be directly proportioned to that hospital's disproportionate provider
factor, as defined in Section
51509(k)(2). The
disproportionate provider factors for all qualifying hospital outpatient
departments shall be set at levels which ensure that the estimated aggregate
payments to be made under this Section to all qualifying hospitals do not
exceed the funding available for this purpose.
(6) The maximum reimbursement payable to each
qualifying hospital outpatient department under this section, including any
reimbursement attributable to a disproportionate provider factor developed
pursuant to this Section, shall not exceed the charges billed by that hospital
for any services or items provided to eligible Medi-Cal
beneficiaries.
(l) The
maximum reimbursement rates payable to hospital outpatient departments
qualifying for small and rural hospital outpatient rate increases shall be the
reimbursement rates authorized in subsections (a) through (k) of this section,
augmented by the hospital's rate increase factor as described below:
(1) The Department shall establish and
annually update two separate percentage rate increase factors for hospital
outpatient department services provided by small and rural hospitals, as
defined in Section
1188.855
of the Health and Safety Code, in order to allocate to each eligible hospital
its share of the total funding appropriated for rate increases under this
subsection. One rate increase factor shall be computed for all minimum floor
hospitals, and one rate increase factor shall be computed for all nonminimum
floor hospitals.
(2) The percentage
rate increase factors specified in Section
51509 (
l)(1)
shall be based on the ratio of Medi-Cal's outpatient expenditures for each
small and rural hospital to the total of Medi-Cal's outpatient expenditures for
all small and rural hospitals during the preceding calendar year, provided
that:
(A) The rate increase for minimum floor
hospitals shall be 125 percent of the rate increase for nonminimum floor
hospitals.
(B) Estimated
expenditures attributable to the combined rate increases for minimum floor and
nonminimum floor hospitals shall not exceed the funds appropriated for this
purpose in the annual Budget Act or in any other specific appropriation
measure.
(3) If any
eligible hospital had less than a full year of operation upon which to
determine the ratio of Medi-Cal expenditures as specified in Section
51509 (
l)(2), the
Department shall extrapolate the Medi-Cal paid claims expenditures for that
hospital to estimate a full year's expenditures.
(4) For purposes of this subsection, "minimum
floor hospital" means a hospital for which:
(A) Medi-Cal's expenditures for outpatient
services during the preceding calendar year were less than one-half percent of
Medi-Cal's expenditures for outpatient services rendered by all small and rural
hospitals during that period; and,
(B) Total gross patient revenue from all
sources during the preceding calendar year was less than
$2,500,000.
(5) For
purposes of this subsection, "nonminimum floor hospital" means a hospital for
which:
(A) Medi-Cal's expenditures for
outpatient services during the preceding calendar year were equal to or greater
than one-half percent of Medi-Cal's total expenditures for outpatient services
rendered by all small and rural hospitals during that period, or;
(B) Total gross patient revenue from all
sources during the preceding calendar year was equal to or greater than
$2,500,000.
(6) The
maximum reimbursement rates payable to each hospital outpatient department
under this section, including rates attributable to small and rural hospital
outpatient reimbursement, shall not exceed the charges billed by that hospital
for the services and items rendered.
(m) Except as provided in subsection (n), the
maximum reimbursement rates paid to hospitals for hospital outpatient services
under this section shall be the rates in effect on June 30, 2001, increased by
the following percentages, when the hospital submits a bill in accordance with
applicable requirements of section
51502 using a currently active
hospital outpatient department provider number with respect to services in
which the hospital uses Medi-Cal authorized billing codes:
(1) 30 percent for services provided on or
after July 1, 2001.
(2) 34.33
percent for services provided on or after July 1, 2002.
(3) 38.81 percent for services provided on or
after July 1, 2003.
(4) 43.44
percent for services provided on or after July 1, 2004.
(n) The increases provided for in subsection
(m) are subject to the following exceptions:
(1) The increases shall not apply to
reimbursement for drugs dispensed to outpatients and paid in accordance with
section
51513.
(2) The increases shall not apply to
reimbursement for medical supplies dispensed to outpatients and paid in
accordance with section
51520.
(3) The increases shall not apply to
reimbursement for services that are paid on a cost-basis, which for the purpose
of this paragraph includes, but is not limited to, the following:
(A) Federally qualified health center
services,
(B) Medical items and
equipment that are paid a rate equal to or greater than the provider's
acquisition cost,
(C) Medical items
and equipment that are paid a rate equal to or greater than the manufacturer's
suggested retail price.
(4) The increases for a clinical diagnostic
laboratory test shall not exceed the difference between the rate payable on
June 30, 2001 and the payment rate recognized under title
42 United States Code,
section
1395
l(h) for such
test under Part B of the Medicare Program.
Notes
Cal. Code Regs. Tit. 22, §
51509
1. New
subsection (k) filed 5-24-89 as an emergency exempt from OAL review pursuant to
Welfare and Institutions Code section
14105.97;
operative 5-24-89 (Register 89, No. 21). A Certificate of Compliance must be
transmitted to OAL within 120 days or emergency language will be repealed on
9-21-89. For prior history, see Register 85, No. 52.
2. Certificate
of Compliance as to 5-24-89 order disapproved and new subsection (k) filed
9-29-89 as an emergency; operative 9-29-89 (Register 89, No. 41). A Certificate
of Compliance must be transmitted to OAL within 120 days or emergency language
will be repealed on 1-2-90.
3. Certificate of Compliance as to
9-29-89 order including amendment of subsection (k)(2) filed 10-30-89 (Register
89, No. 45).
4. New subsection (l) filed 6-18-90 as an emergency;
operative 6-18-90 (Register 90, No. 32). A Certificate of Compliance must be
transmitted to OAL by 10-16-90 or emergency language will be repealed by
operation of law on the following day.
5. Certificate of Compliance
as to 6-18-90 order transmitted to OAL 10-3-90 and filed 10-23-90 (Register 90,
No. 49).
6. Amendment of subsections (k) and (k)(2)-(6) and NOTE
filed 7-16-92 as an emergency; operative 7-16-92 (Register 92, No. 29). A
Certificate of Compliance must be transmitted to OAL 11-13-92 or emergency
language will be repealed by operation of law on the following
day.
7. Amendment filed 9-25-92 as an emergency; operative 10-1-92
(Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL
1-25-93 or emergency language will be repealed by operation of law on the
following day.
8. Certificate of Compliance as to 7-16-92 order
transmitted to OAL 11-10-92 and filed 12-22-92 (Register 92, No.
52).
9. Certificate of Compliance as to 9-25-92 order transmitted to
OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).
10. Editorial
correction adding HISTORY 9 (Register 95, No. 25).
11. Amendment of
subsections (g)(1)(A)2. and (g)(1)(B)3. filed 7-21-98 as an emergency;
operative 7-27-98 (Register 98, No. 30). A Certificate of Compliance must be
transmitted to OAL by 11-24-98 or emergency language will be repealed by
operation of law on the following day.
12. Editorial correction of
HISTORY 11 (Register 99, No. 2).
13. Certificate of Compliance as to
7-21-98 order transmitted to OAL 11-23-98 and filed 1-7-99 (Register 99, No.
2).
14. Amendment of subsection (g)(2) and amendment of NOTE filed
3-1-99 as an emergency; operative 3-1-99 (Register 99, No. 10). A Certificate
of Compliance must be transmitted to OAL by 6-29-99 or emergency language will
be repealed by operation of law on the following day.
15.
Reinstatement of section as it existed prior to 3-1-99 emergency amendment by
operation of Government Code section
11346.1(f)
(Register 99, No. 33).
16. Amendment of subsection (g)(2) and
amendment of NOTE filed 8-10-99 as an emergency; operative 8-10-99 (Register
99, No. 33). A Certificate of Compliance must be transmitted to OAL by 12-8-99
or emergency language will be repealed by operation of law on the following
day.
17. Certificate of Compliance as to 8-10-99 order transmitted
to OAL 12-2-99 and filed 1-13-2000 (Register 2000, No. 2).
18.
Amendment of subsections (g)(1)(A)2. and (g)(1)(B)3., new subsection (m) and
amendment of NOTE filed 7-16-2002; operative rates for services provided on or
after 8-1-2000 pursuant to Stats. 2000, c. 52, Items 4260-101-0001 and 0890
(Register 2002, No. 29).
19. Certificate of Compliance as to
7-16-2002 order, including repealer of subsection (m), transmitted to OAL
11-12-2002 and filed 12-24-2002 (Register 2002, No. 52).
20.
Amendment of subsection (a) and new subsections (m)-(n)(4) filed 4-10-2003 as
an emergency; operative 4-10-2003 (Register 2003, No. 15). A Certificate of
Compliance must be transmitted to OAL by 8-8-2003 or emergency language will be
repealed by operation of law on the following day.
21. Certificate
of Compliance as to 4-10-2003 order transmitted to OAL 8-7-2003 and filed
9-15-2003 (Register 2003, No. 38).
Note: Authority cited: Section
1188.877,
Health and Safety Code; and Sections
10725,
14105,
14105.97
and
14124.5,
Welfare and Institutions Code. Reference: Section
1188.877,
Health and Safety Code; Sections
14087.3
and
14132,
Welfare and Institutions Code; Statutes of 1982, Chapter 1594, Section
77; Statutes of 1983, Chapter 323,
Section 149; Statutes of 1984, Chapter
258, Items 4260-106-001 and 890; Statutes of 1984, Chapter 268, Section
66; Statutes of 1985, Chapter 111,
Items 4260-106-001 and 890; Section
14105.97,
Welfare and Institutions Code; Statutes of 1998, Chapter 324, Items
4260-101-0001 and 0890; and Statutes of 2000, Chapter 52, Items
4260-101-0001.
1. New subsection
(k) filed 5-24-89 as an emergency exempt from OAL review pursuant to Welfare
and Institutions Code section
14105.97;
operative 5-24-89 (Register 89, No. 21). A Certificate of Compliance must be
transmitted to OAL within 120 days or emergency language will be repealed on
9-21-89. For prior history, see Register 85, No. 52.
2. Certificate
of Compliance as to 5-24-89 order disapproved and new subsection (k) filed
9-29-89 as an emergency; operative 9-29-89 (Register 89, No. 41). A Certificate
of Compliance must be transmitted to OAL within 120 days or emergency language
will be repealed on 1-2-90.
3. Certificate of Compliance as to
9-29-89 order including amendment of subsection (k)(2) filed 10-30-89 (Register
89, No. 45).
4. New subsection (l) filed 6-18-90 as an emergency;
operative 6-18-90 (Register 90, No. 32). A Certificate of Compliance must be
transmitted to OAL by 10-16-90 or emergency language will be repealed by
operation of law on the following day.
5. Certificate of Compliance
as to 6-18-90 order transmitted to OAL 10-3-90 and filed 10-23-90 (Register 90,
No. 49).
6. Amendment of subsections (k) and (k)(2)-(6) and Note
filed 7-16-92 as an emergency; operative 7-16-92 (Register 92, No. 29). A
Certificate of Compliance must be transmitted to OAL 11-13-92 or emergency
language will be repealed by operation of law on the following day.
7. Amendment filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No.
40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or
emergency language will be repealed by operation of law on the following
day.
8. Certificate of Compliance as to 7-16-92 order transmitted
to OAL 11-10-92 and filed 12-22-92 (Register 92, No. 52).
9.
Certificate of Compliance as to 9-25-92 order transmitted to OAL 1-22-93 and
filed 3-9-93 (Register 93, No. 11).
10. Editorial correction adding
History 9 (Register 95, No. 25).
11. Amendment of subsections
(g)(1)(A)2. and (g)(1)(B)3. filed 7-21-98 as an emergency; operative 7-27-98
(Register 98, No. 30). A Certificate of Compliance must be transmitted to OAL
by 11-24-98 or emergency language will be repealed by operation of law on the
following day.
12. Editorial correction of History 11 (Register 99,
No. 2).
13. Certificate of Compliance as to 7-21-98 order
transmitted to OAL 11-23-98 and filed 1-7-99 (Register 99, No. 2).
14. Amendment of subsection (g)(2) and amendment of Note filed 3-1-99 as an
emergency; operative 3-1-99 (Register 99, No. 10). A Certificate of Compliance
must be transmitted to OAL by 6-29-99 or emergency language will be repealed by
operation of law on the following day.
15. Reinstatement of section
as it existed prior to 3-1-99 emergency amendment by operation of Government
Code section
11346.1(f)
(Register 99, No. 33).
16. Amendment of subsection (g)(2) and
amendment of Note filed 8-10-99 as an emergency; operative 8-10-99 (Register
99, No. 33). A Certificate of Compliance must be transmitted to OAL by 12-8-99
or emergency language will be repealed by operation of law on the following
day.
17. Certificate of Compliance as to 8-10-99 order transmitted
to OAL 12-2-99 and filed 1-13-2000 (Register 2000, No. 2).
18.
Amendment of subsections (g)(1)(A)2. and (g)(1)(B)3., new subsection (m) and
amendment of Note filed 7-16-2002; operative rates for services provided on or
after 8-1-2000 pursuant to
Stats.
2000, c. 52
Items
4260-101-0001 and 0890 (Register 2002, No. 29).
19. Certificate of
Compliance as to 7-16-2002 order, including repealer of subsection (m),
transmitted to OAL 11-12-2002 and filed 12-24-2002 (Register 2002, No.
52).
20. Amendment of subsection (a) and new subsections (m)-(n)(4)
filed 4-10-2003 as an emergency; operative 4-10-2003 (Register 2003, No. 15). A
Certificate of Compliance must be transmitted to OAL by 8-8-2003 or emergency
language will be repealed by operation of law on the following day.
21. Certificate of Compliance as to 4-10-2003 order transmitted to OAL 8-7-2003
and filed 9-15-2003 (Register 2003, No.
38).