reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51523 - Home Health Agency Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An approved home health agency shall be
					 reimbursed in accordance with the maximum rates as shown below. However, in no
					 case shall the service billed exceed charges made to the general public for the
					 provision of similar services.
Procedure
								  Code
Per Visit
								  Allowance
Maximum
								  Rates
Z6900
Skilled Nursing
								Services..........................
..........................$74.86
Z6902
Home Health Aide
								Services..........................
..........................$45.75
Z6904
Physical Therapy
								Services..........................
..........................$68.84
Z6906
Occupational Therapy
								Services..........................
..........................$71.36
Z6908
Speech Therapy
								Services..........................
..........................$78.43
Z6910
Medical Social
								Services..........................
..........................$96.22
Z6914
Case Evaluation and Initial Treatment
								Plan..........................
..........................$30.13
Z6916
Monthly Case Evaluation Extension of
								Treatment
								Plan..........................
..........................$15.19
Z6918
Unlisted
								Services..........................
..........................By
								Report
Z6920
Early Discharge
								Visit..........................
..........................$74.86
(b) Each "Per Visit Allowance" billed shall
					 represent a minimum of one hour's service provided to the patient, with the
					 exception of "Home Health Aide Services," which shall represent a minimum of
					 two hours of service provided to the patient.
(c) "Unlisted Services" (Procedure Code
					 Z6918) are payable only upon prior authorization of the Department and shall
					 include:
(1) Services which are provided by
					 the Home Health Agency staff but which are not shown in these rates, except
					 that services rendered by interns or residents-in-training are not separately
					 payable.
(2) Unusual transportation
					 costs may be billed "By Report." All other travel expenses are included in the
					 "Per Visit Allowance" rates.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51524 - In-Home Medical Care Waiver Services and Nursing Facility Waiver Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The method and
					 rate of reimbursement for in-home medical care waiver services and nursing
					 facility waiver services shall be set forth in a written agreement between the
					 provider of services and the Department and may be set on an individual case by
					 case basis.
(b) For beneficiaries
					 receiving in-home care waiver services, the total reimbursement for all
					 Medi-Cal services provided to a beneficiary shall be less than the total cost
					 of services that would be incurred by the Medi-Cal program for the beneficiary
					 in an acute hospital.
(c) For
					 beneficiaries receiving nursing facility waiver services, the total
					 reimbursement for all Medi-Cal services provided each recipient shall be less
					 than the total cost of services that would be incurred by the Medi-Cal program
					 for the beneficiary in the level of Medi-Cal nursing facility care appropriate
					 to that beneficiary's medical needs.
1. New
						section filed 9-1-82 as an emergency; effective upon filing (Register 82, No.
						37). A Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 12-30-82.
2. Certificate of
						Compliance transmitted to OAL 12-30-82 and filed 2-2-83 (Register 83, No.
						6).
3. Editorial correction of NOTE filed 1-15-85 (Register 85, No.
						4).
4. Amendment of section heading, text and NOTE filed 10-20-94;
						operative 10-20-94 (Register 94, No. 42).
5. Editorial correction of
						HISTORY 4 (Register 95, No. 14).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14105,
						  14114
						  and
						  14132,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51525 - Blood and Blood Derivatives

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Payment will be made for reasonable costs subject to
						maximums which may be established by the Director.
1.
						Amendment filed 6-5-67 as an emergency; effective upon filing. Certificate of
						Compliance filed 6-9-67 (Register 67, No. 23).
2. Amendment filed
						9-27-72; designated effective 11-1-72 (Register 72, No. 40).
3. New
						NOTE filed 1-15-85 (Register 85, No. 4).
Note: Authority cited: Sections
						  10725
													14105
						  and 14124.5, Welfare and Institutions Code. Reference: Sections
						  14105, Welfare and Institutions
						  Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51526 - Incontinence Medical Supplies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Manufacturers and principal labelers
					 shall report to the Department, at least annually, their median prices charged
					 for all their Medi-Cal covered products.
(b) The Department shall update the median
					 prices charged within sixty (60) days after receipt from the manufacturer or
					 principal labeler subject to the Department's verification of the accuracy of
					 the median price charged data.
(c)
					 For purposes of reporting the median price charged and calculating the maximum
					 estimated acquisition cost for Incontinence Medical Supplies, the major product
					 categories are:
(1) Disposable Diapers and
					 Briefs
(A) Economy
(1) Infant, large
(2) Infant, extra large
(3) Youth, small
(4) Youth, medium
(5) Youth, large
(6) Adult, small
(7) Adult, medium
(8) Adult, large
(9) Adult, extra large
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51527 - Medical Transportation Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) General Provision.
(1) The reimbursement for medical
					 transportation services shall be in accordance with maximum reimbursement rates
					 as follows: however, billing shall not exceed charges made to the general
					 public.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51528 - Paramedic Ambulance Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 4-20-82 as an emergency; effective upon filing (Register 82, No.
						18).
2. Order of Repeal of 4-20-82 emergency order filed 4-29-82 by
						OAL pursuant to Government Code Section
						11349.6
						(Register 82, No. 18).
3. New section filed 7-6-82 as an emergency;
						effective upon filing (Register 82, No. 28). A Certificate of Compliance must
						be transmitted to OAL within 120 days or emergency language will be repealed on
						11-3-82.
4. Certificate of Compliance as to 7-6-82 order transmitted
						to OAL 11-3-82 and filed 12-3-82 (Register 82, No. 49).
5. Amendment
						of subsection (a) filed 8-1-84 as an emergency; effective upon filing (Register
						84, No. 31). A Certificate of Compliance must be transmitted to OAL within 120
						days or emergency language will be repealed on 11-29-84.
6.
						Certificate of Compliance transmitted to OAL 11-27-84 and filed 12-27-84
						(Register 84, No. 52).
7. Amendment of subsection (a) filed 8-1-85
						as an emergency; effective upon filing (Register 85, No. 32). A Certificate of
						Compliance must be transmitted to OAL within 120 days or emergency language
						will be repealed on 11-29-85.
8. Repealer filed 8-9-85; effective
						thirtieth day thereafter (Register 85, No. 32).
9. Certificate of
						Compliance as to 8-1-85 order transmitted to OAL 11-20-85 and filed 12-27-85
						(Register 85, No. 52).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14105
						  and
						  14136.5,
						  Welfare and Institutions Code; Statutes of 1984, Chapter 258, Items
						  4260-106-001 and 890; and Statutes of 1985, Chapter 111, Items 4260-106-001 and
						  890.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51529 - Pathology Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 This section applies to all laboratory services excluding those performed for
					 hospital inpatients and billed as part of the hospital cost reimbursement
					 billing, and excluding those tests with rates incorporated in section
					 51503(b).
(1) Payment shall be made only for tests
					 performed by standard procedures and techniques commonly employed by clinical
					 laboratories. No payment shall be made to any provider for a laboratory test
					 performed by a laboratory that is not qualified for reimbursement under the
					 Medicare program (Title XVIII) for that test.
(2) Reimbursement for laboratory tests shall
					 be the least of the following:
(A) The amount
					 billed.
(B) The charge to the
					 general public.
(C) 80 percent of
					 the lowest maximum allowance established by the federal Medicare program for
					 the same or similar services.
(3) Reimbursements pursuant to this section
					 shall be made only to a provider who actually performed the pathology services.
					 No provider shall bill the Medi-Cal program for pathology services, including
					 collection and handling services, the provider did not actually perform. For
					 purposes of this section, services shall be deemed to have been performed by
					 the provider if the services are performed by the provider personally, or by an
					 employee of the provider.
(4)
					 Reimbursement for collection and handling of specimens is payable only in
					 accordance with the following:
(A) The
					 specimen is a blood sample.
(B) The
					 specimen is forwarded to an outside laboratory.
(C) The following code is billed:
Code 99000: Handling and/or conveyance of specimen for
						transfer from the physician's office to a laboratory.
Code 99000 includes any or all of the following: Single
						or multiple venipuncture, capillary puncture or arterial puncture with one or
						more tubes, centrifugation and serum separation, freezing, refrigeration,
						preparation for air transportation or other special handling procedures,
						supplies, registration of patient or specimen, and third party
						billing.
(D) Reimbursement
					 shall be made for only one collection and handling procedure per day per
					 provider for each beneficiary.
(E)
					 Reimbursement shall be the least of the following:
1. The amount billed
2. The charge to the general public
3. Medicare's maximum
					 allowance.
(5)
					 Laboratory services necessary for chronic outpatient hemodialysis in renal
					 dialysis centers and community hemodialysis units are payable only when billed
					 by the renal dialysis center or community hemodialysis
					 units.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51531 - Payment for Portable Imaging Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Payment for portable imaging services,
					 when provided at home, in residential care facilities, in intermediate care
					 facilities or in skilled nursing facilities, and done by or under the direction
					 of a physician, may be made when billed by the physician, except when these
					 services are included in the cost payment formula of a skilled nursing
					 facility.
(b) Payment for portable
					 imaging services performed by a portable imaging services provider, in
					 accordance with Sections
					 51193.1 and
					 51311(b), when
					 provided at home, in residential care facilities, in intermediate care
					 facilities or in skilled nursing facilities may be made in accordance with the
					 following:
(1) Payment for portable imaging
					 services shall be reasonable charges not to exceed the charge in the locality
					 for similar services with consideration for customary charges. Services shall
					 be billed by the interpreting physician and/or the portable imaging services
					 provider. In no event shall the charge exceed the charge made to the general
					 public.
(2) Payment for portable
					 imaging services transportation shall include transportation of portable
					 imaging equipment and personnel to the home or skilled nursing facility.
					 Maximum reimbursement rates shall be established pursuant to Welfare and
					 Institutions Code Section
					 14105.23.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51532.2 - Early and Periodic, Screening, Diagnosis, and Treatment (EPSDT) Supplemental Services: Onsite Investigation to Detect the Source of Lead Contamination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement
					 for EPSDT supplemental services identified in Sections
					 51184 and
					 51340 shall be in accordance with
					 the maximum reimbursement rates set forth in this section. However, in no case
					 shall the service billed exceed charges made to the general public for the
					 provision of similar services.
(b)
					 Reimbursement for EPSDT supplemental services for an onsite investigation to
					 detect the source of lead contamination in the home environment of a child
					 diagnosed with high blood lead levels provided in accordance with subsection
					 (d) of Section
					 51340.1 shall be:
Procedure
								Code
Description
Rate
Z5830
Onsite investigation to detect the
								source of lead contamination in the home.
$270.00 per
								investigation
1. New
						section filed 4-13-99 as an emergency; operative 4-13-99 (Register 99, No. 16).
						A Certificate of Compliance must be transmitted to OAL by 8-11-99 or emergency
						language will be repealed by operation of law on the following
						day.
2. New section refiled 8-5-99 as an emergency; operative 8-5-99
						(Register 99, No. 32). A Certificate of Compliance must be transmitted to OAL
						by 12-3-99 or emergency language will be repealed by operation of law on the
						following day.
3. Certificate of Compliance as to 8-5-99 order
						transmitted to OAL 12-1-99 and filed 1-12-2000 (Register 2000, No.
						2).
Note: Authority cited: Sections
						  10725,
						  14105
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14059
						  and
						  14132(v),
						  Welfare and Institutions Code; and
						  42 U.S.C.
						  1396d(r).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51532.3 - EPSDT Supplemental Services Provider -Pediatric Day Health Care Facility Reimbursement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The hourly rate of reimbursement for
					 pediatric day health care EPSDT services shall be $29.41.
(b) Payment for pediatric day health care
					 services shall be limited to:
(1) Labor costs
					 for nursing services and developmental programs authorized in Section
					 51340.1(e)(2)(B),
					 and
(2) Equipment, medications and
					 supplies for emergency purposes.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51534 - Home and Community-Based Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 2-25-83 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 6-25-83.
2. Certificate of
						Compliance including editorial correction transmitted to OAL 6-22-83 and filed
						7-27-83 (Register 83, No. 31).
3. Editorial correction of NOTE filed
						1-15-85 (Register 85, No. 4).
4. Repealer filed 10-20-94; operative
						10-20-94 (Register 94, No. 42).
5. Editorial correction of HISTORY 4
						(Register 95, No. 14).
Note: Authority cited: Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14132(u),
						  Welfare and Institutions Code. Reference: Sections
						  14105,
						  14132(u)
						  and
						  14149,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51535 - Leave of Absence

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Payment may be made to skilled nursing facilities, swing bed facilities,
					 intermediate care facilities, intermediate care facilities for the
					 developmentally disabled, intermediate care facilities for the developmentally
					 disabled/habilitative and intermediate care facilities for the developmentally
					 disabled-nursing, for patients who are on approved leave of absence. Payment
					 for leave of absence shall not exceed the maximum number of days per calendar
					 year indicated below:
(1) Developmentally
					 disabled, developmentally disabled habilitative and developmentally
					 disabled-nursing beneficiaries: 73 days.
(2) Patients in a certified special treatment
					 program for mentally disordered persons, or patients in a mental health
					 therapeutic and rehabilitative program approved and certified by a local mental
					 health director: 30 days.
(3) All
					 other patients: 18 days. Up to 12 additional days of leave per year may be
					 approved when the request for additional days of leave is in accordance with
					 the individual patient care plan and appropriate to the physical and mental
					 well-being of the patient.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51535.1 - Bed Hold for Acute Hospitalization

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Payment shall be made to skilled nursing
					 facilities, swing bed facilities, intermediate care facilities, intermediate
					 care facilities for the developmentally disabled, intermediate care facilities
					 for the developmentally disabled habilitative, and intermediate care facilities
					 for the developmentally disabled-nursing for bed hold days for any beneficiary
					 who exercises the bed hold option provided by Title 22, California Code of
					 Regulations, Sections
					 72520,
					 73504,
					 76506 and
					 76909.1.
(b) Payment for bed hold days shall be
					 limited to a maximum of seven days for each period of acute
					 hospitalization.
(c) The following
					 requirements shall be met:
(1) Acute
					 hospitalization for the beneficiary shall be ordered by the attending
					 physician.
(2) The facility shall
					 hold a bed vacant during the entire bed hold period except when notified, in
					 writing by the attending physician that the patient requires more than seven
					 days of hospitalization. If so notified, the facility is no longer required to
					 hold the bed available and shall not bill Medi-Cal for any remaining days of
					 bed hold.
(3) The day of departure
					 shall be counted as one day of bed hold and the day of return shall be counted
					 as one day of inpatient care.
(4)
					 Bed hold shall be terminated and payment shall not be made on the day of death
					 of the beneficiary.
(5) Facility
					 claims shall identify the inclusive dates of bed hold.
(6) A new treatment authorization request
					 shall be required, as specified in section
					 51335(b)(3), for
					 Medicare-eligible beneficiaries who have returned from a Medicare-qualifying
					 stay in an acute care hospital.
(7)
					 The beneficiary's records maintained in the facility shall show the name and
					 address of the acute care hospital to which the beneficiary has been
					 admitted.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51535.2 - Reimbursement Rates for Personal Care Services Program

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For the individual provider mode for
					 providing personal care services, the reimbursement rate shall be a maximum of
					 $5.50 per hour of service; provided, however, that the reimbursement rate in
					 each county shall not exceed the rate in each county for the individual
					 provider mode of service in the IHSS program pursuant to Article 7 (commencing
					 with Section
					 12300) of Part 3 of Division 9 of
					 the Welfare and Institutions Code, as it existed on September 28,
					 1992.
(b) For the contract mode for
					 providing personal care services pursuant to Welfare and Institutions Code
					 Sections
					 12302
					 and
					 12302.1,
					 the reimbursement rates shall be those specified in the contract between the
					 county and the agency contractor not to exceed the following maximum rates for
					 services provided through State fiscal year 1993-94 as follows:
(1) Butte
$ 9.65
(2) Nevada
$10.34
(3) Riverside
$12.29
(4) San Diego
$10.49
(5) San Francisco
$12.28
(6) San Joaquin
$ 9.50
(7) San Mateo
$12.65
(8) Santa Barbara
$11.76
(9) Santa Clara
$11.11
(10) Santa Cruz
$13.61
(11) Stanislaus
$10.51
(12) Tehama
$11.30
(13) Ventura
$11.04
(c) Nothing in this section is intended to be
					 a limitation on the rights of providers and beneficiaries or on the duties of
					 the Department of Social Services, pursuant to Welfare and Institutions Code
					 Section
					 12302.2
					 subdivision (a). Contributions, premiums and taxes paid pursuant to Welfare and
					 Institutions Code Section
					 12302.2,
					 subdivision (a) shall be in addition to the hourly rates specified in
					 subdivision (a) of this section.
1. New
						section filed 4-14-93 as an emergency; operative 4-14-93. Submitted to OAL for
						printing only pursuant to section
						8, AB 1773 (Chapter 939, Statutes
						of 1992) (Register 93, No. 16).
Note: Authority cited: Section
						  14132.95,
						  Welfare and Institutions Code; Section
						  8, Chapter 939, Statutes of 1922;
						  Section 3, Chapter 7, Statutes of 1993.
						  Reference: Section
						  14132.95,
						  Welfare and Institutions Code; Section
						  1396 d(a)(7) of Title 42, of the
						  United States Code; Article 7 (commencing with Section
						  12300) of Part 3 of Division 9 of
						  the Welfare and Institutions Code; Section
						  440.170(f) of
						  Title 42 of the Code of Federal
						  Regulations.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51535.5 - Local Educational Agency (LEA) Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement to LEA Providers is limited
					 to the specified set of LEA Services defined in Section
					 51190.4 and set forth in Section
					 51360.
(b) LEA Services shall be reimbursable only
					 when provided to an LEA eligible beneficiary, as defined in Section
					 51190.1; by an LEA Practitioner,
					 as defined in Section
					 51190.3; and subject to the
					 limitations of this section.
(c)
					 When a beneficiary is covered by a managed care plan contract the following
					 applies:
(1) If the beneficiary does not have
					 an IEP or an IFSP, the LEA Provider may be reimbursed for LEA Services for
					 which the plan is not capitated under the managed care plan contract;
(2) If the beneficiary has an IEP or an IFSP,
					 the LEA Provider may be reimbursed for LEA Services rendered according to the
					 IEP or IFSP as well as LEA Services for which the plan is not capitated under
					 the managed care plan contract.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51535.6 - Reimbursement for Directly Observed Therapy (DOT)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Reimbursement for providing directly observed therapy
						(DOT), as defined in Section
						51187.1, shall not exceed $19.23
						per encounter. An encounter shall consist of direct visual observation by DOT
						staff of a patient's ingestion of anti-tuberculosis medications. Delivering
						medications without visual confirmation of ingestion does not constitute an
						encounter.
1. New
						section filed 9-11-96; operative 9-11-96 pursuant to Government Code section
						11343.4(d)
						(Register 96, No. 37).
Note: Authority cited: Sections
						  10725,
						  14005.20
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14059
						  and
						  14132,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51535.7 - Targeted Case Management Services Reimbursement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each targeted case management provider of
					 service pursuant to Welfare and Institutions Code, Section
					 14132.44,
					 shall complete and submit to the department, by November 1 of each year, a cost
					 report of the prior year costs of each local program providing targeted case
					 management services in a format specified by the department. Only one cost
					 report shall be submitted for targeted case management services provided to
					 target populations specified in subsections
					 50262.7(a)(1);
					 50262.7(a)(2); 50262.7(a)(3)(A); 50262.7(a)(3)(B), (C) or (D); or
					 50262.7(a)(3)(E).
(b) The cost
					 report shall certify all of the following:
(1)
					 The availability and expenditure of one-hundred (100) percent of the nonfederal
					 share of the cost of providing targeted case management services from the
					 provider's general fund or from any other federally approved source.
(2) The amount of funds expended on allowable
					 targeted case management services.
(3) Targeted case management program
					 expenditures represent costs that are eligible for federal financial
					 participation.
(4) The costs
					 reflected in the annual cost reports used to determine targeted case management
					 rates are developed pursuant to Welfare and Institutions Code, Section
					 14132.44(f)(1)(D).
(5) That targeted case management services
					 provided in accordance with Section
					 1396 n(g) of Title 42 of the
					 United States Code will not duplicate case management services provided under
					 any home- and community-based services waiver.
(6) That claims for providing case management
					 services pursuant to Welfare and Institutions Code, Section
					 14132.44
					 will not duplicate claims made to public agencies or private entitles under
					 other program authorities for the same purposes.
(7) That the provider has complied with all
					 the requirements of Section
					 51271.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51536 - Hospital Inpatient Services Reimbursement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement for hospital inpatient
					 services provided to Medi-Cal program beneficiaries shall be the lesser of the
					 following for each hospital:
(1) Customary
					 charges.
(2) Allowable costs
					 determined in accordance with applicable Medicare standards and principles of
					 reimbursement.
(3) All-inclusive
					 rate per discharge.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51537 - Maximum Allowable Reimbursement Level for Inpatient Hospital Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 8-27-81; effective thirtieth day thereafter (Register 81, No.
						35).
2. Repealer filed 4-23-92; operative 5-25-92 (Register 92, No.
						20).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51538 - Maximum Allowable Rate of Increase for Inpatient Hospital Services. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 10-1-81 as an emergency; designated effective 10-1-81 (Register
						81, No. 42).
2. Certificate of Compliance transmitted to OAL 1-28-82
						and filed 2-26-82 (Register 82, No. 9).
3. Repealer filed 4-23-92;
						operative 5-25-92 (Register 92, No. 20).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51539 - Hospital Reimbursement for Inpatient Hospital Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement to hospitals for inpatient
					 hospital services rendered to Medi-Cal program beneficiaries shall be
					 determined in accordance with Sections
					 51536 and
					 51537, except as modified by this
					 section.
(b) Hospital reimbursement
					 shall, unless exempted from or modified by the provisions of this section, be
					 payable at no more than the 60th percentile rate per discharge of the peer
					 group to which the hospital is assigned by the Department. The peer groups
					 shall be based on a classification of hospitals that combines individual
					 hospitals in a unit on the basis of similar or common characteristics.
(1) The following peer group classifications
					 adapted from the California Health Facilities Commission's report "Hospital
					 Peer Grouping for Efficiency Comparison" (1982) will be used:
(A) University Teaching Hospitals
(B) Large (Non-university) Teaching
					 Hospitals
(C) Large Complex
					 Hospitals
(D) Moderate Sized
					 Hospitals
(E) Small Urban
					 Hospitals
(F) Rural
					 Hospitals
(G) Urban, Skilled
					 Nursing Emphasis Hospitals
(H)
					 Rural, Skilled Nursing Emphasis Hospitals
(I) Alcohol--Drug Rehabilitation
					 Hospitals
(J) Moderate Psychiatric
					 Emphasis Hospitals
(K) Acute
					 Psychiatric Hospitals
(L)
					 Miscellaneous Long-term Psychiatric Hospitals
(M) Miscellaneous Large Skilled Nursing
					 Hospitals
(N) Miscellaneous Large
					 Prepaid Health Plans
(O)
					 Miscellaneous Student Health Centers
(P) Miscellaneous Children's Specialty
					 Hospitals
(Q) Miscellaneous
					 Rehabilitation Hospitals
(R)
					 Miscellaneous Large Rehabilitation Emphasis Hospitals
(S) Miscellaneous Respiratory Specialty
					 Hospitals
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51540 - Hospitals with a Disproportionate Share of Low Income Patients. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
						section filed 1-27-82 as an emergency; effective upon filing (Register 82, No.
						5). A Certificate of Compliance must be received within 120 days or emergency
						language will be repealed on 5-27-82.
2. Certificate of Compliance
						transmitted to OAL 5-26-82 and filed 6-29-82 (Register 82, No.
						27).
3. Repealer filed 4-23-92; operative 5-25-92 (Register 92, No.
						20).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51541 - Hospital Inpatient Services Reimbursement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51542 - Acute Administrative Days

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement for acute administrative
					 days shall be as follows:
(1) On the same
					 basis as specified in section
					 51511(a)(2) for
					 nursing facilities that are distinct parts of acute care hospitals.
(2) For all other acute administrative days,
					 on the same basis as for nursing facilities that are distinct parts of acute
					 care hospitals and offer Level B services.
(3) Not include payment for ancillary items
					 listed in section
					 51511(c). These
					 items and services shall be reimbursed according to the Medi-Cal levels of
					 reimbursement for similar items and services provided to acute care inpatients
					 of the hospital.
(4) Include
					 payment for items as specified in section
					 51511(b).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51543 - Out-of-State Hospital Inpatient Services Reimbursement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Out-of-state hospital inpatient services which have been
						certified for payment at the acute level and which are either of an emergency
						nature or for which prior Medi-Cal authorization has been obtained, shall be
						reimbursed the current statewide per diem average of contract rates for acute
						inpatient hospital services provided by California hospitals with at least 300
						beds or the out-of-state hospital's actual billed charges, whichever is less.
						The term, "current," as used in this paragraph means the most recent per diem
						average as of December 1 of the prior calendar year of the contract rates for
						California hospitals with at least 300 beds that the California Medical
						Assistance Commission has reported to the Legislature pursuant to Welfare and
						Institutions Code Section
						14165.9.
						Therefore, the average per diem contract rate in effect on December 1 in a
						particular calendar year for California contract hospitals with at least 300
						beds shall be the maximum rate paid to out-of-state hospitals for dates of
						service beginning January 1 of the following calendar year.
1. New
						section filed 9-11-87; operative 10-11-87 (Register 87, No. 37).
2.
						Amendment filed 10-1-92 with Secretary of State by Department of Health
						Services; operative 10-1-92. Submitted to OAL for printing only pursuant to
						section 147(c), SB 485,
						(Chapter 722, Statutes of 1992) (Register 92, No. 40).
3.
						Certificate of Compliance as to 10-1-92 order transmitted to OAL 1-2-93 and
						filed 3-12-93 (Register 93, No. 11).
4. Amendment filed 4-21-2009;
						operative 5-21-2009 pursuant to Government Code section
						11343.4
						(Register
						2009,
						No. 17).
Note: Authority cited: Section
						  20, Health and Safety Code; and
						  Sections
						  14105,
						  14105.15
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14086,
						  14105
						  and
						  14105.15,
						  Welfare and Institutions Code; Chandler Regional Medical Center, et al., v.
						  California Department of Health Services; Diana M. BontÃ¡, et al.
						  and Arizona Burn Center, et al., v. California Department of Health Services;
						  Diana M. BontÃ¡, et al. City and County of San Francisco, Case
						  Nos. CGC-01-324400 and CGS-02-408260.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51544 - Hospice Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Hospices shall be reimbursed the lesser of the amount billed or the amounts
					 established under title XVIII of the Social Security Act pursuant to section
					 1902(a)(13),
					 (42 USC
					 1396a(a)(13)) of such Act,
					 for all covered services, as specified in section
					 51349.
(b) With the exception of physician services,
					 as specified in subsection (f), room and board payments as specified in
					 subsection (h) and coinsurance for individuals entitled to Title XVIII hospice
					 benefits as specified in subsection (i), reimbursement for hospice care shall
					 be made at one of four rates for each day a recipient is under the care of the
					 hospice regardless of the amount of services furnished:
(1) Reimbursement for routine home care as
					 defined in Section
					 51180.3, Billing Code number
					 Z7100, shall be made for each day the recipient is at home and not receiving
					 continuous home care.
(2)
					 Reimbursement for continuous home care, as defined in Section
					 51180.4, Billing Code number
					 Z7102, shall be made on an hourly rate basis for each day, or portion thereof,
					 a recipient qualifies for and receives such care. A minimum of eight hours of
					 care must be provided in a 24-hour period in order to qualify for the
					 continuous home care rate.
(3)
					 Reimbursement for respite care as defined in Section
					 51180.5, Billing Code number
					 Z7104, shall be made for each day a recipient qualifies and receives such care.
					 Reimbursement for respite care shall be limited to no more than five
					 consecutive days. Payment for the sixth and consecutive days shall be made at
					 the routine home care rate.
(4)
					 Reimbursement for general inpatient care as defined in Section
					 51180.6, Billing Code number
					 Z7106, shall be made for each day a recipient qualifies and receives such
					 care.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51546 - Reimbursement Limits

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51547 - Methods of Payment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 methods of payment for inpatient hospital services under the MIRL shall include
					 the following:
(1) An ARPD that shall be
					 retrospectively established for each provider's tentative and final settlement
					 fiscal period. The ARPD shall:
(A) Apply to
					 all non-contract Medi-Cal inpatient covered services provided by the provider
					 during its settlement fiscal period. It shall be based upon the statistics
					 included in the providers Medi-Cal cost or audit report.
(B) Be updated annually to reflect
					 reimbursable changes in factor input prices, service intensity, technology,
					 productivity, patient volume, and other items as allowed through the AA and
					 appeals process.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51548 - Overpayments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Interim payment
					 rate adjustments and recovery of overpayments to providers shall be made at
					 tentative or final settlement based upon the application of this Article.
(1) Such overpayments shall be collected and
					 such interim payment rates shall be adjusted whether or not appeals of any
					 audit, MIRL or PIRL for the current or any prior fiscal period have been filed
					 by the provider.
(2) Interim
					 payment rates calculated after the effective date of Article 7.5, Sections
					 51545 through
					 51557, and applied to services
					 provided after the effective date of this regulation, shall comply with
					 Sections 51547 and
					 51548 even if the actual
					 settlement upon which the new interim rate is based, is not subject to this
					 regulation.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51551 - Specific Administrative Adjustment Issues

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) AAs for year-to-year changes in case mix
					 and/or outliers under the ARPD (not the PGRPD) shall be resolved in the
					 following manner:
(1) The case mix adjustment
					 factor (CMAF) shall be calculated using the following steps:
(A) The provider shall supply a listing for
					 every Medi-Cal discharge that occurred during both the settlement fiscal period
					 and the prior fiscal period, sorted in admission date order, and shall include
					 as a minimum:
1. The patient's last name and
					 first initial.
2. Medi-Cal I.D.
					 Number.
3. The admission
					 date.
4. The discharge
					 date.
5. The principal diagnosis
					 code.
6. The total amount of billed
					 charges.
7. The DRG
					 number.
8. The DRG weight. The same
					 set of DRG groups and weights must be used for both settlement fiscal period
					 and prior fiscal period data. If charges for a newborn were billed together
					 with its mother, the newborn(s) and the mother must be listed separately on
					 this listing, each with their own DRG and weight.
9. The sum of the cost weights and the number
					 of Medi-Cal DRG discharges on the list. The number of Medi-Cal DRG discharges
					 on the list must equal or exceed the number of audited Medi-Cal discharges. The
					 listing must include all Medi-Cal patients, which includes newborns that are
					 not counted as Medi-Cal discharges.