Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a) Inpatient hospital services are covered
as specified below:
(1) Hospital care for
newborns and hospitalization for delivery services are covered as follows:
(A) Inpatient delivery services in hospitals
designated as contract hospitals in closed areas or contract/non-contract
hospitals in open areas are covered without authorization up to a maximum of
two consecutive days prior to delivery, beginning at midnight at the beginning
of the day the mother is admitted, if delivery occurs within that two-day
period, and without authorization up to a maximum of two consecutive days
following vaginal delivery, or four consecutive days following delivery by
Cesarean section, beginning at midnight at the end of the day the mother
delivers. Continued medically necessary hospitalization beyond two days prior
to delivery, beyond two days following vaginal delivery, or beyond four days
following delivery by Cesarean section, requires timely submission of a request
for authorization, as defined in Section
51003(b)(3), for
Medi-Cal field office review. Authorization is required for all days of
hospitalization when delivery does not occur within two consecutive days of
admission. Hospitals under the onsite authorization procedure shall obtain
authorizations not later than the first regularly scheduled review day
following admission. Authorizations may be granted for up to a maximum of 30
days. For the purposes of this section, the following definitions shall apply:
1. "Closed areas" means areas in which the
proportion of bed capacity under contract between the Department and the
contracting hospitals exceeds the hospital bed needs of the Medi-Cal population
in that area.
2. "Open areas" means
areas in which the proportion of bed capacity under contract between the
Department and the contracting hospitals does not exceed the hospital bed needs
of the Medi-Cal population in that area.
(B) Hospital care for newborns is covered,
subject to the following:
1. Nursery care for
well newborns during the same hospital admission associated with the delivery
is not separately reimbursable.
2.
Nursery care for sick newborns, who do not require neonatal intensive care, but
who require an acute level of care during the same hospital admission
associated with the delivery, is separately reimbursable under the following
circumstances:
a. For contract hospitals
reimbursed on a per diem basis, timely submission of a request for
authorization for Medi-Cal field office review, as specified in subsection
(a)(1)(A), is required for services provided to the newborn beginning with the
day of the mother's discharge, or as dictated by the terms of the hospital's
contract.
b. For non-contract
hospitals, a separate authorization is required commencing with the onset of
the newborn's illness, whether or not the mother has been
discharged.
3. Nursery
care for a newborn whose mother is ineligible for Medi-Cal and has no other
medical insurance, or whose mother's health coverage does not include coverage
for the newborn, or whose mother is incarcerated, is covered subject to timely
submission of a request for authorization for Medi-Cal field office review, as
specified in Section
51003(b)(3).
Authorization is required for each day of the newborn's hospital
stay.
4. Neonatal intensive care is
covered, commencing with the onset of the newborn's illness and admission to
the Neonatal Intensive Care Unit (NICU), subject to timely submission of a
request for authorization for Medi-Cal field office review, as specified in
Section 51003(b)(3), or
as dictated by the terms of the hospital's contract.
(C) When delivery occurs prior to admission
of the mother to the hospital, inpatient care for both the mother and newborn
is covered without authorization up to a maximum of 48 hours beginning at
midnight at the end of the day the mother delivered. The actual time of vaginal
delivery shall be established based upon the mother's statement, records of
auxiliary personnel involved in the care/transport of the mother, and clinical
assessment by the attending physician.
(D) Emergency inpatient services in hospitals
designated as noncontract hospitals in closed areas are covered as specified in
section 51327(a)(2).
(2) Emergency hospital services shall not
require authorization prior to admission, if hospitalization is for services
that meet the definition of emergency services as defined in section
51541(c)(6)(A)
and are justified as required in section
51056(c).
However, all hospitalization resulting from emergency admissions requires
approval by the Medi-Cal Consultant. Approval shall be obtained by the hospital
on the day of admission or, when the day of admission is not a State working
day, the first State working day thereafter. For those hospitals under the
onsite authorization procedure, the first State working day shall mean the
first regularly scheduled review day. Authorizations may be granted for up to a
maximum of 30 days.
(A) A Medi-Cal beneficiary
who is admitted to a noncontract hospital in a closed area for emergency
inpatient delivery services shall be transported when stable to a contracting
facility for all, or the remainder of, the post-delivery inpatient length of
stay specified in subsection (a)(1)(A), unless:
1. A contract facility is unable to accept
the transfer.
2. The mother's
condition fails to meet the Stable for Transport Guidelines in Section
5.4 of the Manual of Criteria for
Medi-Cal Authorization. If the mother's condition does not stabilize during the
two consecutive days following vaginal delivery, or four consecutive days
following delivery by Cesarean section, the post delivery length of stay at the
noncontract hospital shall be covered, without authorization.
3. A decision for early discharge is made by
the treating physician, in consultation with the mother, as specified in
subsection (b).
(3) All other hospitalization is covered only
if prior authorization is obtained from the Medi-Cal Consultant before the
hospital admission is effected. The Medi-Cal Consultant's authorization shall
be for a specified number of days of hospital care for the diagnosis specified
or the operative procedure contemplated in the authorization request.
Nonemergency services for other unrelated diagnoses or operative procedures
shall not be covered without additional prior authorization by a Medi-Cal
Consultant. Continued necessary hospitalization beyond the specified number of
days shall be covered after approval by the Medi-Cal Consultant has been
obtained by the hospital on or before the last day of the previously approved
period of hospitalization. Hospitals under the onsite authorization procedure
shall obtain authorization not later than the first regularly scheduled review
day thereafter. Days not prior authorized for admission or for extension of
stay are not covered unless otherwise provided for in these regulations.
(A) As a minimum, the authorization request
shall contain the admitting diagnosis or operative procedure contemplated and
acceptable justification of the hospital admission and the estimated length of
hospital stay. The beneficiary's physician, podiatrist or dentist shall certify
to the Department at the time of admission, and recertify not less often than
every two calendar months where such services are furnished over a period of
time, that the beneficiary requires inpatient hospital services.
(B) If a request is approved, the number of
days of hospitalization shall be authorized as determined by the Medi-Cal
Consultant on the basis of medical information submitted.
(C) Under no circumstances shall any one
request for authorization of extensions be approved for more than one month for
acute or one year for long-term care.
(D) Claims for nonemergency hospitalization
shall be accompanied by an approved preadmission authorization request and an
approved extension of hospital stay if the stay extends beyond the period
previously authorized.
(4) For long-term care, the attending
physician must recertify, at 30, 60, and 90 days after initial certification
and every 60 days thereafter, the patient's need for continued care in
accordance with the procedures specified by the Director.
(5) Inpatient hospital services, in an
institution for mental illness or in the psychiatric service of a general
hospital, are covered for persons 65 years of age and over and for persons
under 21 years of age. If the person was receiving such services prior to his
twenty-first birthday and he continues without interruption to require and
receive such services, the services are covered to his twenty-second birthday.
Such inpatient services are subject to the limitations specified in (2) and (3)
above.
(6) Inpatient hospital
services, in an institution for tuberculosis or in the tuberculosis service of
a general hospital, are covered for persons 65 years of age or older.
(7) Inpatient general hospital services for
persons under 65 years of age with a primary diagnosis of mental illness or
tuberculosis are covered. Such inpatient services are subject to the
limitations specified in (2), 3, 5 and (6) above.
(b) Following delivery, an early discharge
follow up visit for the mother and newborn, within 48 hours of discharge, is
covered without authorization when the decision to discharge the mother and
newborn before the time periods specified in subsection (a)(1)(A) is made by
the treating physician in consultation with the mother. When discussing early
discharge with the mother, the treating physician shall disclose the
availability of an early discharge follow up visit. If early discharge is
determined appropriate, the treating physician and mother shall determine,
based on factors such as the transportation needs of the family and
environmental and social risks, whether the postdischarge visit shall occur at
home, in the treating physician's office, or the plan's facility. The early
discharge follow up visit shall:
(1) Be
prescribed by the treating physician.
(2) Be with licensed health care providers
whose scopes of practice include postpartum care and/or newborn care.
(3) Include, at a minimum, parent education,
assistance and training in breast or bottle feeding, and the performance of any
necessary maternal or neonatal physical assessments.
(c) The following inpatient hospital services
are not covered:
(1) Services in an
institution for mental illness for persons 21 through 64 years of age except as
specified in (a)(5) above.
(2)
Services in an institution for tuberculosis for persons under 65 years of
age.
(3) Inpatient hospital
services provided by a hospital which has been designated as noncontracting in
accordance with section
51541(c) except
for the following:
(A) Emergency services and
subsequent inpatient services, in accordance with section
51541(c)(6)(A),
until the patient's condition meets the definition of stable for transport, as
defined in section
51110(c).
(B) Services to a beneficiary who is an
inpatient and whose condition meets the definition of stable for transport as
defined in section
51110(c)
providing the following conditions are met:
1.
A hospital designated as contracting with capacity to provide the necessary
care is unavailable and this finding has been appropriately justified,
and
2. The patient, whose condition
is stable, continues to require acute level of care, and
3. Discharge of the patient, whose condition
is stable, from acute level of care would be life threatening or could result
in permanent impairment.
(C) Services to a beneficiary who is eligible
for Medicare benefits providing the conditions of section
51005 have been met.
(D) Services to a Medicare Part A crossover
patient subsequent to the exhaustion of Medicare inpatient benefits as along as
the beneficiary is in a life threatening or emergency situation which could
result in permanent impairment, until the patient's condition meets the
definition of stable for transport, as defined in section
51110(c).
(E) Services to beneficiaries where the
travel time from a beneficiary's home to a contract hospital, exceeds the
normal practice for the community or 30 minutes, whichever is greater, and the
noncontracting hospital providing services is closer to the beneficiary's home
than a contracting hospital.
(F)
Services to a beneficiary when retroactive authorization has been granted in
accordance with section
51003(b).
(d) There shall also be a periodic medical
review (not less than annually) of all beneficiaries in mental hospitals by a
Medical Review Team as defined in section
50009.2.
1.
Amendment of subsection (a) filed 7-1-75 as an emergency; effective upon filing
(Register 75, No. 27). For prior history, see Register 74, No. 3.
2.
Certificate of Compliance filed 10-24-75 (Register 75, No. 43).
3.
Amendment of subsection (a) filed 10-24-75; effective thirtieth day thereafter
(Register 75, No. 43).
4. Amendment filed 5-22-80; effective
thirtieth day thereafter (Register 80, No. 21).
5. Amendment of
subsections (a)(1) and (a)(2) filed 3-30-81; effective thirtieth day thereafter
(Register 81, No. 14).
6. Amendment of subsection (a) filed 9-11-81;
effective thirtieth day thereafter (Register 81, No. 37).
7.
Amendment of subsection (a)(1) and (2), and new subsection (b)(3) filed 2-3-83
as an emergency; effective upon filing (Register 83, No. 12). A Certificate of
Compliance must be transmitted to OAL within 120 days or emergency language
will be repealed on 6-3-83.
8. Certificate of Compliance transmitted
to OAL 6-3-83 and filed 7-6-83 (Register No. 28).
9. Amendment filed
6-26-87; operative 7-26-87 (Register 87, No. 27).
10. Amendment of
subsection (a)(1)(A) filed 7-12-89; operative 8-11-89 (Register 89, No.
28).
11. Amendment of subsection (a)(1)(A) filed 8-1-91; operative
9-2-91 (Register 91, No. 48).
12. Amendment of section and NOTE
filed 3-13-2000 as an emergency; operative 3-13-2000 (Register 2000, No. 11). A
Certificate of Compliance must be transmitted to OAL by 7-11-2000 or emergency
language will be repealed by operation of law on the following
day.
13. Certificate of Compliance as to 3-13-2000 order transmitted
to OAL 7-5-2000 and filed 8-14-2000 (Register 2000, No.
33).
Note: Authority cited: Sections
14105
and
14124.5,
Welfare and Institutions Code; Section
57(c), Chapter
328, and Section
87(c), Chapter
1594, Statutes of 1982. Reference: Sections
14019,
14081,
14087,
14132,
14132.42,
14133
and
14133.3,
Welfare and Institutions Code.