Cal. Code Regs. Tit. 22, § 51546 - Reimbursement Limits

(a) For provider fiscal periods beginning on or after the effective date of this Section, reimbursement for in-state hospital inpatient services provided to Medi-Cal program beneficiaries not fully covered by a negotiated contract as allowed in W&I Code Section 14081, shall be the least of the following four items except as stated in (b), (d), (f), (g), and (h) for each provider:

(1) Customary charges.

(2) Allowable costs determined by the Department, in accordance with applicable Medicare standards and principles of cost based reimbursement, as specified in applicable parts of 42 Code of Federal Regulations (CFR), Part 413 and HCFA Publication 15-1.

(3) All-inclusive rate per discharge limitation (ARPDL).

(4) The peer grouping rate per discharge limitation (PGRPDL).

(b) The following adjustment shall be made to items (1) and (4) above:

(1) Providers shall also be reimbursed for disproportionate share payments if applicable.

(2) The least of the four items listed in (a)(1)-(4) above shall be reduced by the amount of third-party liability.

(c) Amounts determined under (a)(3) or (a)(4) above may be increased only by an AA or appeal.

(d) New hospitals and rural hospitals shall be exempt from the provisions of this Article relating to the MIRL and PIRL. New and rural hospitals shall be reimbursed in accordance with the lesser of subsections (a)(1) or (a)(2) above, and subject to any limitations provided for under federal law and/or regulation.

(e) Each provider shall be notified of the ARPDL and PGRPDL at the time of tentative and/or final PIRL settlements. If only a final PIRL settlement is issued, it shall take the place of both the tentative and final PIRL settlement.

(f) Payments for Medicare covered services provided to Medicare/Medi-Cal crossover patients shall not be subject to the limitations specified in this Section. These services shall be reimbursed only for the Medicare deductibles and co-insurance amounts. The deductibles and co-insurance amounts shall not exceed the state reimbursement maximums. State reimbursement maximums shall be the interim rate times charges after consideration of the Medicare payment.

(g) Payment for skilled nursing facility services shall be made in accordance with Section 51511.

(h) Payment for intermediate care facility services shall be made in accordance with Section 51510.

Notes

Cal. Code Regs. Tit. 22, § 51546

1. New section filed 4-23-92; operative 5-25-92 (Register 92, No. 20).
2. Certificate of Compliance as to 8-28-96 order, including new subsections (i) and (j) and amendment of NOTE, transmitted to OAL 1-23-97 and filed 3-10-97 (Register 97, No. 11).
3. Change without regulatory effect amending subsection (c), repealing subsections(i)-(j) and amending NOTE filed 6-12-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 24).

Note: Authority cited: Sections 10725, 14100.1, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14105 and 14106, Welfare and Institutions Code.

1. New section filed 4-23-92; operative 5-25-92 (Register 92, No. 20).
2. Certificate of Compliance as to 8-28-96 order, including new subsections (i) and (j) and amendment of Note, transmitted to OAL 1-23-97 and filed 3-10-97 (Register 97, No. 11).
3. Change without regulatory effect amending subsection (c), repealing subsections(i)-(j) and amending Note filed 6-12-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 24).