Section 1820.115 - Rate Setting for Psychiatric Inpatient Hospital Services for Non-Negotiated Rate, Fee-for-Service/Medi-Cal Hospitals(a) Reimbursement rates for acute psychiatric inpatient hospital services for each Fee-for-Service/Medi-Cal hospital with no contract with any MHP shall be determined by the Department. (1) The reimbursement rates in Subsection (a) shall be calculated by the Department prior to the beginning of each fiscal year and shall not be modified for subsequent rate changes among Fee-for-Service/Medi-Cal contract hospitals or the addition of new Fee-for Service/Medi-Cal contract hospitals.(2) One rate per allowable psychiatric accommodation code per non-negotiated rate, Fee-for-Service/Medi-Cal hospital per Rate Region listed in Subsection (i) shall be established and shall be used by all MHPs.(3) The rates shall not be subject to retrospective adjustment to cost.(b) The per diem rate includes routine hospital services and all hospital-based ancillary services.(c) The per diem rate by accommodation code shall equal the weighted average per diem rates by accommodation code negotiated for all Fee-for-Service/Medi-Cal hospitals within the Rate Region listed in Subsection (i) where the non-negotiated rate Fee-for-Service/Medi-Cal hospital is located or, if there are no Fee-for-Service/Medi-Cal hospitals with a negotiated rate by accommodation code within the Rate Region, the weighted average per diem rates by accommodation code negotiated for all Fee-for-Service/Medi-Cal hospitals statewide. The per diem rate shall be based on the following information from each Fee-for-Service/Medi-Cal hospital with a contract in the Rate Region where the non-negotiated rate Fee-for-Service/Medi-Cal hospital is located or statewide, if there are no Fee-for-Service/Medi-Cal hospitals with a negotiated rate by accommodation code within the Rate Region:(1) The latest available fiscal year Medi-Cal paid claims data for Fee-for-Service/Medi-Cal acute psychiatric inpatient hospital services patient days.(2) The negotiated per diem rates by accommodation code for Fee-for-Service/Medi-Cal hospitals for the subsequent fiscal year.(d) Reimbursement for administrative day services shall be the rate established in accordance with Title 22, Section 51542, except for facility-specific reimbursements determined by the Department in accordance with Title 22, Section 51511(a)(2)(B), plus an allowance for hospital-based ancillary services equal to 25 percent of the maximum rate established under Title 22, Section 51542(a)(3).(e) For both acute psychiatric inpatient hospital services and administrative day services, interim reimbursement to the non-negotiated rate Fee-for-Service/Medi-Cal hospital shall be based on the calculated per diem rate less third party liability and patient share of cost.(f) The hospital shall bill its usual and customary charges.(g) At the end of each fiscal year, the Department shall compare, in aggregate, the usual and customary charges to the per diem rate for each hospital. Future claims shall be offset by the amount that the per diem rate exceeds the usual and customary charges for that fiscal year.(h) The per diem rates established by this Section less third party liability and patient share of costs shall be considered to be payment in full for psychiatric inpatient hospital services to a beneficiary.(i) The Rate Regions, including specified border communities, are: (1) Superior -- Butte, Colusa, Del Norte, Glenn, Humboldt, Inyo, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Tehama, and Trinity Counties, and Ashland, Brookings, Cave Junction, Grants Pass, Jacksonville, Klamath Falls, Lakeview, Medford, and Merrill, Oregon.(2) Central Valley -- Alpine, Amador, Calaveras, El Dorado, Fresno, Kings, Madera, Mariposa, Merced, Mono, Placer, Sacramento, San Joaquin, Stanislaus, Sutter, Tulare, Tuolumne, Yolo, and Yuba Counties, and Carson City, Incline Village, Minden, Reno, Sparks, and Zephyr Cove, Nevada.(3) Bay Area -- Alameda, Contra Costa, Marin, Monterey, Napa, San Benito, San Francisco, San Mateo, Santa Clara, Santa Cruz, Solano, and Sonoma Counties.(4) Southern California -- Imperial, Kern, Orange, Riverside, San Bernardino, San Diego, San Luis Obispo, Santa Barbara, and Ventura Counties, and Las Vegas and Henderson, Nevada; and Bullhead City, Kingman, Lake Havasu City, Parker and Yuma, Arizona.(j) The MHP shall not be responsible to reimburse Fee-for-Service/Medi-Cal hospitals that deliver Medicare covered services to a beneficiary for any Medicare coinsurance and deductible payments due to the provider from the Medi-Cal program pursuant to Title 42, United States Code, Section 1396 a(a)(n).Cal. Code Regs. Tit. 9, § 1820.115
1. New section filed 10-31-97 as an emergency; operative 11-1-97 (Register 97, No. 44). A Certificate of Compliance must be transmitted to OAL by 3-2-98 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 3-2-98 as an emergency; operative 3-2-98 (Register 98, No. 10). A Certificate of Compliance must be transmitted to OAL by 6-30-98 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 6-17-98 as an emergency; operative 6-30-98 (Register 98, No. 25). Pursuant to Chapter 324 (Statutes of 1998) Item 4440-103-0001(4), a Certificate of Compliance must be transmitted to OAL by 7-1-99 or emergency language will be repealed by operation of law on the following day.
4. Editorial correction of HISTORY 3 (Register 98, No. 39).
5. Editorial correction extending Certificate of Compliance date to 7-1-2001 pursuant to Chapter 50 (Statutes of 1999) Item 4440-103-0001(4) (Register 99, No. 33). Notwithstanding any other provision of law, emergency regulations adopted pursuant to Welfare and Institutions Code section 14680 to implement the second phase of mental health managed care as provided in this part shall remain in effect until permanent regulations are adopted, or June 30, 2006, whichever occurs first.
6. Editorial correction of HISTORY 5 (Register 2000, No. 42).
7. Editorial correction of HISTORY 5 and repealer and new section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
8. Change without regulatory effect amending subsection (d) and NOTE filed 8-24-2015 pursuant to section 100, title 1, California Code of Regulations (Register 2015, No. 35). Note: Authority cited: Sections 10725, 14680 and 14700, Welfare and Institutions Code. Reference: Sections 14684, 14714 and 14718, Welfare and Institutions Code.
1. New section filed 10-31-97 as an emergency; operative 11-1-97 (Register 97, No. 44). A Certificate of Compliance must be transmitted to OAL by 3-2-98 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 3-2-98 as an emergency; operative 3-2-98 (Register 98, No. 10). A Certificate of Compliance must be transmitted to OAL by 6-30-98 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 6-17-98 as an emergency; operative 6-30-98 (Register 98, No. 25). Pursuant to Chapter 324 (Statutes of 1998) Item 4440-103-0001(4), a Certificate of Compliance must be transmitted to OAL by 7-1-99 or emergency language will be repealed by operation of law on the following day.
4. Editorial correction ofHistory3 (Register 98, No. 39).
5. Editorial correction extending Certificate of Compliance date to 7-1-2001 pursuant to Chapter 50 (Statutes of 1999) Item 4440-103-0001(4) (Register 99, No. 33). Notwithstanding any other provision of law, emergency regulations adopted pursuant to Welfare and Institutions Code section 14680 to implement the second phase of mental health managed care as provided in this part shall remain in effect until permanent regulations are adopted, or June 30, 2006, whichever occurs first.
6. Editorial correction ofHistory5 (Register 2000, No. 42).
7. Editorial correction ofHistory5 and repealer and new section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
8. Change without regulatory effect amending subsection (d) and Note filed 8-24-2015 pursuant to section 100, title 1, California Code of Regulations (Register 2015, No. 35).