CA Welf & Inst Code § 14169.59 (2021)
2021 California Code|Welfare and Institutions Code - WIC|DIVISION 9 - PUBLIC SOCIAL SERVICES|PART 3 - AID AND MEDICAL ASSISTANCE|CHAPTER 7 - Basic Health Care|ARTICLE 5.230 - Medi-Cal Hospital Reimbursement Improvement Act of 2013|Section 14169.59.

14169.59.  (a) The department shall determine during each rebase calculation year the number of subject fiscal years in the next program period.(b) During each rebase calculation year, the department shall retrieve the data, including, but not limited to, the days data source, used to determine the following for the subsequent program period: acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days. The department shall pull data from the most recent base calendar year for which the department determines reliable data is available for all hospitals.(c) (1) During each rebase calculation year, the department shall determine all of the following supplemental payment rates for the subsequent program period, which supplemental payment rates shall be specified in provisional language in the annual Budget Act:(A) The acute psychiatric per diem supplemental rate for each subject fiscal year during the program period.(B) The general acute care per diem supplemental rate for each subject fiscal year during the program period.(C) The high acuity per diem supplemental rate for each subject fiscal year during the program period.(D) The high acuity trauma per diem supplemental rate for each subject fiscal year during the program period.(E) The outpatient supplemental rate for each subject fiscal year during the program period.(F) The subacute supplemental rate for each subject fiscal year during the program period.(G) The transplant per diem supplemental rate for each subject fiscal year during the program period.(2) During each rebase calculation year, the department shall determine all of the following fee rates for the subsequent program period, which fee rates shall be specified in provisional language in the annual Budget Act:(A) The fee-for-service per diem quality assurance fee rate for each subject fiscal year during the program period.(B) The managed care per diem quality assurance fee rate for each subject fiscal year during the program period.(C) The Medi-Cal per diem quality assurance fee rate for each subject fiscal year during the program period.(D) The prepaid health plan hospital managed care per diem quality assurance fee rate for each subject fiscal year during the program period.(E) The prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate for each subject fiscal year during the program period.(d) The department shall determine the rates set forth in subdivision (c) based on the data retrieved pursuant to subdivision (b). Each rate determined by the department shall be the same for all hospitals to which the rate applies. These rates shall be specified in provisional language in the annual Budget Act. The department shall determine the rates in accordance with all of the following:(1) The rates shall meet the requirements of federal law and be established in a manner to obtain federal approval.(2) The department shall consult with the hospital community in determining the rates.(3) The supplemental payments and other Medi-Cal payments for hospital outpatient services furnished by private hospitals for each fiscal year shall equal as close as possible the applicable federal upper payment limit.(4) The supplemental payments and other Medi-Cal payments for hospital inpatient services furnished by private hospitals for each fiscal year shall equal as close as possible the applicable federal upper payment limit.(5) The increased capitation payments to managed health care plans shall result in the maximum payments to the plans permitted by federal law.(6) The quality assurance fee proceeds shall be adequate to make the expenditures described in this article, but shall not be more than necessary to make the expenditures.(7) The relative values of per diem supplemental payment rates to one another for the various categories of patient days shall be generally consistent with the relative values during the first program period under this article.(8) The relative values of per diem fee rates to one another for the various categories of patient days shall be generally consistent with the relative values during the first program period under this article.(9) The rates shall result in supplemental payments and quality assurance fees that are consistent with the purposes of this article.(e) During each rebase calculation year, the director shall determine the amounts and allocation methodology, if any, of direct grants to designated public hospitals and nondesignated public hospitals for each subject fiscal year in a program period, in consultation with the hospital community. The amounts and allocation methodology may include a withholding of direct grants to be used as the nonfederal share for rate range increases. These amounts shall be specified in provisional language in the annual Budget Act.(f) (1) Notwithstanding any other provision in this article, the following shall apply to the first program period under this article:(A) The first program period under this article shall be the period from January 1, 2014, to December 31, 2016, inclusive.(B) The acute psychiatric days shall be those identified in the Final Medi-Cal Utilization Statistics for the 2012–13 state fiscal year as calculated by the department as of December 17, 2012.(C) The days data source shall be the hospital’s Annual Financial Disclosure Report filed with the Office of Statewide Health Planning and Development as of June 6, 2013, for its fiscal year ending during the 2010 calendar year.(D) The general acute care days shall be those identified in the 2010 calendar year, as reflected in the state paid claims file on April 26, 2013.(E) The high acuity days shall be those paid during the 2010 calendar year, as reflected in the state paid claims file prepared by the department on April 26, 2013.(F) The Medi-Cal managed care days shall be those identified in the Final Medi-Cal Utilization Statistics for the 2012–13 fiscal year, as calculated by the department as of December 17, 2012.(G) The outpatient base amount shall be those payments for outpatient services made to a hospital in the 2010 calendar year, as reflected in the state paid claims files prepared by the department on April 26, 2013.(H) The transplant days shall be those identified in the 2010 Patient Discharge Data File Documentation from the Office of Statewide Health Planning and Development accessed on June 28, 2011.(I) With respect to a hospital described in subdivision (f) of Section 14165.50, both of the following shall apply:(i) The hospital shall not be considered a new hospital as defined in Section 14169.51 for the purposes of this article.(ii) To the extent permitted by federal law and other federal requirements, the department shall use the best available and reasonable current estimates or projections made with respect to the hospital for an annual period as the data, including, but not limited to, the days data source and data described as being derived from a state paid claims file, used for all purposes, including, but not limited to, the calculation of supplemental payments and the quality assurance fee. The estimates and projections shall be deemed to reflect paid claims and shall be used for each data element regardless of the time period otherwise applicable to the data element. The data elements include, but are not limited to, acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days.(2) Notwithstanding any other provision in this article, the following shall apply to determine the supplemental payment rates for the first program period:(A) The acute psychiatric per diem supplemental rate shall be nine hundred sixty-five dollars ($965) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, nine hundred seventy dollars ($970) for the subject fiscal quarters in the 2014–15 subject fiscal year, nine hundred seventy-five dollars ($975) for the subject fiscal quarters in the 2015–16 subject fiscal year and nine hundred seventy-five dollars ($975) for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(B) The general acute care per diem supplemental rate shall be eight hundred twenty-four dollars and forty cents ($824.40) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, one thousand one hundred ten dollars and sixty-seven cents ($1,110.67) for the subject fiscal quarters in the 2014–15 subject fiscal year, one thousand three hundred thirty-five dollars and forty-two cents ($1,335.42) for the subject fiscal quarters in the 2015–16 subject fiscal year, and one thousand four hundred forty-one dollars and twenty cents ($1,441.20) for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(C) The high acuity per diem supplemental rate shall be two thousand five hundred dollars ($2,500) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2014–15 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2015–16 subject fiscal year, and two thousand five hundred dollars ($2,500) for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(D) The high acuity trauma per diem supplemental rate shall be two thousand five hundred dollars ($2,500) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2014–15 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2015–16 subject fiscal year, and two thousand five hundred dollars ($2,500) for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(E) The outpatient supplemental rate shall be 119 percent of the outpatient base amount for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, 268 percent of the outpatient base amount for the subject fiscal quarters in the 2014–15 subject fiscal year, 292 percent of the outpatient base amount for the subject fiscal quarters in the 2015–16 subject fiscal year, and 151 percent of the outpatient base amount for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(F) The subacute supplemental rate shall be 50 percent for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, 55 percent for the subject fiscal quarters in the 2014–15 subject fiscal year, 60 percent for the subject fiscal quarters in the 2015–16 subject fiscal year, and 60 percent for the first two subject fiscal quarters in the 2016–17 subject fiscal year of the Medi-Cal subacute payments paid by the department to the hospital during the 2010 calendar year, as reflected in the state paid claims file prepared by the department on April 26, 2013.(G) The transplant per diem supplemental rate shall be two thousand five hundred dollars ($2,500) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2014–15 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2015–16 subject fiscal year, and two thousand five hundred dollars ($2,500) for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(3) Notwithstanding any other provision in this article, the following shall apply to determine the fee rates for the first program period:(A) The fee-for-service per diem quality assurance fee rate shall be three hundred seventy-four dollars and ninety-one cents ($374.91) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, four hundred twenty-five dollars and twenty-two cents ($425.22) for the subject fiscal quarters in the 2014–15 subject fiscal year, four hundred eighty dollars and eleven cents ($480.11) for the subject fiscal quarters in the 2015–16 subject fiscal year, and five hundred forty-two dollars and ten cents ($542.10) for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(B) The managed care per diem quality assurance fee rate shall be one hundred forty-five dollars ($145) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, one hundred forty-five dollars ($145) for the subject fiscal quarters in the 2014–15 subject fiscal year, one hundred seventy dollars ($170) for the subject fiscal quarters in the 2015–16 subject fiscal year, and one hundred seventy dollars ($170) for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(C) The Medi-Cal per diem quality assurance fee rate shall be four hundred fifty-seven dollars and ten cents ($457.10) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, four hundred ninety-seven dollars and eight cents ($497.08) for the subject fiscal quarters in the 2014–15 subject fiscal year, five hundred sixty-eight dollars and fifteen cents ($568.15) for the subject fiscal quarters in the 2015–16 subject fiscal year, and six hundred eighteen dollars and fourteen cents ($618.14) for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(D) The prepaid health plan hospital managed care per diem quality assurance fee rate shall be eighty-one dollars and twenty cents ($81.20) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, eighty-one dollars and twenty cents ($81.20) for the subject fiscal quarters in the 2014–15 subject fiscal year, ninety-five dollars and twenty cents ($95.20) for the subject fiscal quarters in the 2015–16 subject fiscal year, and ninety-five dollars and twenty cents ($95.20) for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(E) The prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate shall be two hundred fifty-five dollars and ninety-seven cents ($255.97) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, two hundred seventy-eight dollars and thirty-seven cents ($278.37) for the subject fiscal quarters in the 2014–15 subject fiscal year, three hundred eighteen dollars and sixteen cents ($318.16) for the subject fiscal quarters in the 2015–16 subject fiscal year, and three hundred forty-six dollars and sixteen cents ($346.16) for the first two subject fiscal quarters in the 2016–17 subject fiscal year.(F) Upon federal approval or conditional federal approval described in Section 14169.63, the director shall have the discretion to revise the fee-for-service per diem quality assurance fee rate, the managed care per diem quality assurance fee rate, the Medi-Cal per diem quality assurance fee rate, the prepaid health plan hospital managed care per diem quality assurance fee rate, or the prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate, based on the funds required to make the payments specified in this article, in consultation with the hospital community.(g) Notwithstanding any other provision in this article, the following shall apply to the second program period under this article:(1) The second program period under this article shall begin on January 1, 2017, and shall end on June 30, 2019.(2) The retrieval date shall occur between October 1, 2016, and December 31, 2016.(3) The base calendar year shall be the 2013 calendar year, or a more recent calendar year for which the department determines reliable data is available.(4) The rebase calculation year shall be the 2015–16 state fiscal year.(5) With respect to a hospital described in subdivision (f) of Section 14165.50, both of the following shall apply:(A) The hospital shall not be considered a new hospital as defined in subdivision (ai) of Section 14169.51 for the purposes of this article.(B) To the extent permitted by federal law or other federal requirements, the department shall use the best available and reasonable current estimates or projections made with respect to the hospital for an annual period as to the data, including, but not limited to, the days data source and data described as being derived from a state paid claims file, used for all purposes, including, but not limited to, the calculation of supplemental payments and the quality assurance fee. The estimates and projections shall be deemed to reflect paid claims and shall be used for each data element regardless of the time period otherwise applicable to the data element. The data elements include, but are not limited to, acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days.(h) Commencing January 2016, the department shall provide a clear narrative description along with fiscal detail in the Medi-Cal estimate package, submitted to the Legislature in January and May of each year, of all of the calculations made by the department pursuant to this section for the second program period and every program period thereafter.(Amended by Stats. 2014, Ch. 442, Sec. 32. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)