Cal. Code Regs. Tit. 22, § 53820 - Maximum Enrollment Levels
(a) The department shall implement the
two-plan model in regions designated by the department, pursuant to section
53800.
(b) For each designated region, the
department shall establish a maximum enrollment level of Medi-Cal beneficiaries
in the mandatory aid categories for the commercial plan under the two-plan
model, which will consider the following factors:
(1) The number of inpatient days qualifying
for DSH supplemental payments as the surrogate measure for services provided by
all safety net providers in the region.
(2) The impact of the enrollment of Medi-Cal
beneficiaries in the commercial plan on supplemental DSH payments, to the
extent that inpatient days provided to members of the commercial plan will be
diverted from safety net providers.
(3) The number of acute inpatient hospital
days attributable to the Medi-Cal beneficiaries not enrolled in prepaid health
plans or PCCM plans.
(4) The acute
inpatient hospital utilization rate for Medi-Cal beneficiaries in the mandatory
aid categories.
(5) The enrollment
levels of both plans of the two-plan model necessary to ensure true beneficiary
choice between plans and among providers within the two plans.
(6) The hospital inpatient care contracts the
commercial plan may have with disproportionate share hospitals.
(7) An agreement between a local initiative
and commercial plan in a designated region regarding local initiative minimum
and commercial plan maximum enrollment levels.
(c) The process for setting the maximum
enrollment level for the commercial plan in any region shall include the
following:
(1) The department shall notify the
Board(s) of Supervisors of each county included within the region of the
proposed maximum enrollment level and the rationale for the proposed
level.
(2) The Board(s) of
Supervisors shall have 30 days to submit written comments to the department on
the proposed maximum enrollment level.
(3) The department shall review and consider
any written comments received from the Board(s) of Supervisors within the 30
day comment period and may adjust the maximum enrollment level, if the
department determines that an adjustment is warranted, or may set the maximum
enrollment level as originally proposed.
(d) The department shall reevaluate the
maximum enrollment level at least every two years and revise the level, if
appropriate.
(e) If the number of
enrollees and the utilization patterns of the commercial plan have
significantly reduced or will significantly reduce DSH supplemental payments in
the region, the department shall require the commercial plan to contract with
disproportionate share hospitals for inpatient care for members.
Notes
2. New article 3 heading, amendment of subsections (a), (b), (b)(2), (b)(6) and (c), and new subsection (e) filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).
3. Repealer of article 3 heading, section heading, section and NOTE and new article 3 heading, section heading, section and NOTE filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
4. New subsection (b)(7) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).
Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 14087.3, 14087.4, 14105.98 and 14201, Welfare and Institutions Code.
2. New article 3 heading, amendment of subsections (a), (b), (b)(2), (b)(6) and (c), and new subsection (e) filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).
3. Repealer of article 3 heading, section heading, section and Note and new article 3 heading, section heading, section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).
4. New subsection (b)(7) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.