Cal. Code Regs. Tit. 22, § 51541 - Hospital Inpatient Services Reimbursement
(a) Except as provided in Welfare and
Institutions Code, Division 9, Part 3, Chapter 8 regarding Prepaid Plans,
reimbursement for hospital inpatient services provided to Medi-Cal
beneficiaries shall be based on either of the following two reimbursement
methodologies:
(1) Negotiated contract
reimbursement. "Negotiated contract reimbursement" means that method of
reimbursement as specified in an executed contract resulting from negotiations,
competitive bidding or any other method the special hospital negotiator, as
defined in Welfare and Institutions Code Section
14082,
or, on or after July 1, 1983, the California Medical Assistance Commission, as
defined in Welfare and Institutions Code Sections
14165
and
14165.5
deems appropriate.
(2) Hospital
reimbursement as otherwise described in this article.
(b) Hospital reimbursement as otherwise
described in this article shall be used to reimburse hospitals for hospital
inpatient services prior to implementation of negotiated contract
reimbursement.
(c) Contracting
Process. The process used for negotiated contract reimbursement will contain
the following steps:
(1) All acute care
hospitals in Health Facilities Planning Areas (HFPA) selected by the special
hospital negotiator in the State of California will be notified by the special
hospital negotiator or, on or after July 1, 1983, the California Medical
Assistance Commission, of the opportunity to contract for the provision of
inpatient services to Medi-Cal beneficiaries. State hospitals and hospitals
owned by the U.S. Government will not be included in the notification
process.
(2) Hospitals which
indicate an interest in contracting with the Medi-Cal Program will be asked to
present their proposal to the special hospital negotiator or, on or after July
1, 1983, the California Medical Assistance Commission.
(3) The special hospital negotiator or, on or
after July 1, 1983, the California Medical Assistance Commission will contract
with a sufficient number of hospitals to assure accessibility of inpatient
hospital services, to Medi-Cal beneficiaries within normal community travel
time or 30 minutes whichever is greater.
(4) The special hospital negotiator will
first evaluate the amount of inpatient hospital services historically rendered
to Medi-Cal patients in each HFPA and will determine the Medi-Cal patients'
needs. Projections of service needs for patients within each HFPA will then be
established. Projected needs will be met by negotiated contract reimbursement
or hospital reimbursement as otherwise described in this article. Hospital
reimbursement, as otherwise described in this article, will be used for those
services and beneficiaries exempt from the Selective Provider Contracting
Program. Hospital capacity projected to be needed in one HFPA may be contracted
for in another HFPA so long as the normal community travel practices are
considered and provided for.
(5)
All affected acute care hospitals in each HFPA will be notified when projected
needs have been met in accordance with paragraphs (3) and (4). Affected
hospitals will be designated as contracting or non-contracting and Medi-Cal
physicians and beneficiaries will be notified that inpatient services, except
as provided for in subsection (6) below, will only be provided in contracting
hospitals. Affected hospitals will not include state hospitals, children's and
charitable research hospitals as defined in Welfare and Institutions Code
Section
14087.2,
hospitals owned or operated by the U.S. Government, and out-of-state
hospitals.
(6) Hospitals designated
as non-contracting will no longer be eligible to receive reimbursement for
services provided to Medi-Cal beneficiaries except under any one of the
following circumstances:
(A) Provision of
inpatient hospital services as defined in Welfare and Institutions Code Section
14087.
(B) Provision of inpatient hospital services
to a Medi-Cal beneficiary where the travel time from a beneficiary's home to a
contract hospital, exceeds the normal practice for the community or 30 minutes,
whichever is greater, and the non-contracting hospital providing services is
closer to the beneficiary's home than a contracting hospital.
(C) Provision of inpatient hospital services
to a Medicare Part A crossover patient by a non-contracting hospital,
subsequent to the exhaustion of Medicare inpatient benefits and, as long as the
beneficiary is in a life threatening or emergency situation which could result
in permanent impairment.
(7) Once designation has occurred in
accordance with paragraph (5), the special hospital negotiator is exempt from
the provisions of paragraphs (1) and (2).
Notes
2. Certificate of Compliance transmitted to OAL 12-30-82 and withdrawn 1-28-83 (Register 83, No. 10).
3. New section refiled 1-28-83 as an emergency; effective upon filing (Register 83, No. 10). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 5-28-83.
4. Certificate of Compliance transmitted to OAL 5-26-83 and filed 6-30-83 (Register 83, No. 27).
Note: Authority cited: Sections 14124.5 and 14082, Welfare and Institutions Code; Section 52, Chapter 328, Statutes of 1982; and Section 87, Chapter 1594, Statutes of 1982. Reference: Sections 14081, 14082, 14082.5, 14086, 14087, 14087.2, 14165 and 14165.5, Welfare and Institutions Code.
2. Certificate of Compliance transmitted to OAL 12-30-82 and withdrawn 1-28-83 (Register 83, No. 10).
3. New section refiled 1-28-83 as an emergency; effective upon filing (Register 83, No. 10). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 5-28-83.
4. Certificate of Compliance transmitted to OAL 5-26-83 and filed 6-30-83 (Register 83, No. 27).
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