California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.71.31 - Methodology for Determining Average Contracted Rate; Default Reimbursement Rate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  The following definitions apply for the purpose of this section:
(1) "Average contracted rate" and ACR mean
				  the claims-volume weighted average of the contracted commercial rates paid by
				  the payor for the same or similar services in the geographic region, in the
				  applicable calendar year, for services most frequently subject to section
				  1371.9 of the Knox-Keene Act. The
				  applicable calendar year is two years prior to the year in which the health
				  care service was rendered. Beginning January 1, 2024, this rate is then
				  adjusted to the date the service was rendered by using the inflation adjustment
				  described in subdivision (a)(2)(B) of section
				  1371.31 of the Knox-Keene
				  Act.
(2) "Default reimbursement
				  rate" means the greater of the average contracted rate or 125 percent of the
				  Medicare rate, payable to a noncontracting individual health professional
				  pursuant to section
				  1371.31 of the Knox-Keene
				  Act.
(3) "Geographic region" has
				  the meaning described in subdivision (a)(6) of section
				  1371.31 of the Knox-Keene Act,
				  whether the default reimbursement rate is based on the Medicare rate or the
				  average contracted rate.
(4)
				  "Medicare rate" means the amount Medicare reimburses on a fee-for service basis
				  for the same or similar health care services in the geographic region in which
				  the health care services were rendered, for the calendar year in which the
				  health care service was rendered, on a "par" basis. "Par" basis means the
				  reimbursement rate paid to health care service providers participating in the
				  Medicare program by accepting Medicare assignment.
(5) "Payor" means a health plan or its
				  delegated entity that has the responsibility for payment of a claim for health
				  care services subject to section
				  1371.9 of the Knox-Keene Act. The
				  term Payor excludes health plans and entities described in subdivision (e) of
				  section 1371.31 of the Knox-Keene
				  Act.
(6) "Services most frequently
				  subject to section
				  1371.9" of the Knox-Keene Act
				  means the health care services that, when added together, comprise at least 80
				  percent of the payor's statewide claims volume for health care services subject
				  to section
				  1371.9 in the applicable calendar
				  year, as defined in subdivision (a)(1) of this section.
(7) "Services subject to section
				  1371.9" of the Knox-Keene Act are
				  nonemergency health care services provided to an enrollee by a noncontracting
				  individual health professional at a contracting health facility where the
				  enrollee received covered health care services, or nonemergency health care
				  services provided to the enrollee by a noncontracting individual health
				  professional as a result of covered health care services received at a
				  contracting health facility.
(8)
				  The definitions in subdivision (f) of section
				  1371.9 of the Knox-Keene Act apply
				  for the purpose of this section.