California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5 - Application of the Official Medical Fee Schedule (Treatment) › Section 9790.1 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) "Capital
					 outlier factor" means (California fixed loss cost outlier threshold x
					 geographic adjustment factor x large urban add-on x (capital cost-to-charge
					 ratio to total cost-to-charge ratio)). The geographic adjustment factor is
					 specified in the
Federal Register
of August 1, 2000 at Vol.
					 65, page 47126, Table 1a, which document is hereby incorporated by reference
					 and will be made available upon request to the Administrative Director. The
					 "large urban add-on" is indicated by the post-reclassification urban/rural
					 location published in the Payment Impact File at positions 229-235. As stated
					 in Title 42, Code of Federal Regulations, Section
					 412.316(b), as it
					 is in effect on September 29, 2000, the "large urban add-on" is an additional
					 3% of what would otherwise be payable to the health facility.
(b) "California fixed loss cost outlier
					 threshold" means the factor calculated by adjusting the Medicare fixed loss
					 cost outlier threshold for California workers' compensation inpatient
					 admissions. The California fixed loss cost outlier threshold is
					 $14,500.
(c) "Composite factor"
					 means the factor calculated by the administrative director for a health
					 facility by adding the prospective operating costs and the prospective capital
					 costs for the health facility, excluding the DRG weight and any applicable
					 outlier payment, as determined by the federal Health Care Financing
					 Administration for the purpose of determining reimbursement under Medicare.
(1) Prospective capital costs are determined
					 by the following formula:
Capital standard federal payment rate x capital wage
						index x large urban add-on x [1 + capital disproportionate share adjustment
						factor + capital indirect medical education adjustment factor]
The "capital standard federal payment rate" is $382.03 as
						published by HCFA in the
Federal Register
of August 1, 2000,
						at Vol. 65, page 47127, Table 1d, which document is hereby incorporated by
						reference and will be made available upon request to the Administrative
						Director.
The "capital wage index" was published in the Payment
						Impact File at positions 243-252.
The "large urban add-on" is indicated by the
						post-reclassification urban/rural location published in the Payment Impact File
						at positions 229-235. As stated in Title 42, Code of Federal Regulations,
						Section 412.316(b), as it
						is in effect on September 29, 2000, the "large urban add-on" is an additional
						3% of what would otherwise be payable to the health facility.
The "capital disproportionate share adjustment factor"
						was published in the Payment Impact File at positions 117-126.
The "capital indirect medical education adjustment
						factor" (capital IME adjustment) was published in Payment Impact File at
						positions 202-211.
(2)
					 Prospective operating costs are determined by the following formula:
[(Labor-related national standardized amount x operating
						wage index) + nonlabor-related national standardized amount] x [1 + operating
						disproportionate share adjustment factor + operating indirect medical education
						adjustment]
The "labor-related national standardized amount" is
						$2,864.19 for large urban areas and $2,818.85 for other areas, as published by
						the federal Health Care Financing Administration [HCFA] in the
Federal
						Register
of August 1, 2000, at Vol. 65, page 47126, Table 1a, which
						document is hereby incorporated by reference and will be made available upon
						request to the Administrative Director. The "labor-related national
						standardized amount" is $2,894.99 for large urban area sole community hospitals
						and $2,849.16 for other areas sole community hospitals, as published by the
						federal Health Care Financing Administration [HCFA] in the
Federal
						Register
of August 1, 2000, at Vol. 65, page 47127, Table 1e, which
						document is hereby incorporated by reference and will be made available upon
						request to the Administrative Director.
The "operating wage index" was published in the Payment
						Impact File at positions 253-262.
The "nonlabor-related national standardized amount" is
						$1,164.21 for large urban areas and $1,145.78 for other areas, as published by
						HCFA in the
Federal Register
of August 1, 2000, at Vol. 65,
						page 47126, Table 1a, which document is hereby incorporated by reference and
						will be made available upon request to the Administrative Director. The
						"nonlabor-related national standardized amount" is $1,176.73 for large urban
						area sole community hospitals and $1,158.10 for other areas sole community
						hospitals as published by the federal Health Care Financing Administration
						[HCFA] in the
Federal Register
of August 1, 2000, at Vol. 65,
						page 47127, Table 1e, which document is hereby incorporated by reference and
						will be made available upon request to the administrative director.
The "operating disproportionate share adjustment factor"
						was published in the Payment Impact File at positions 127-136.
The "operating indirect medical education adjustment" was
						published in the Payment Impact File at positions 212-221.
(3) A table of composite factors for each
					 health facility in California is contained in Appendix A to Section
					 9792.1.