Current through Register 2024 Notice Reg. No. 12, March 22, 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.
(b) For all health care services subject to
section 1371.9 of the Knox-Keene Act,
payors shall comply with subdivision (e) and do the following:
(1) For health care services most frequently
subject to 1371.9, payors shall use the methodology described in this section
to determine the average contracted rate; or
(2) For health care services that do not fall
under subdivision (b)(1), the payor may, but is not required to, use the
methodology described in this section to determine the average contracted rate.
If the payor uses a different methodology, that different methodology shall be
a reasonable method of determining the average contracted commercial rates paid
by the payor for the same or similar services in the geographic region, in the
applicable calendar year.
(c) Methodology for determining the average
contracted rate.
(1) Except as specified in
subdivision (c)(6), for each health care service procedure code for services
most frequently subject to section
1371.9 of the Knox-Keene Act, the
payor shall calculate the claims volume-weighted mean rate:
Rate = sum of [the allowed amount for the health service
code under each contract x number of claims paid for each allowed amount]/Total
number of claims paid for that code across all commercial contracts. 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.
Example: For hypothetical health care service code Z, and
for a particular combination of the factors described in subdivision (c)(3),
the payor's allowed amounts under its commercial contracts are: Contract A
($10), Contract B ($15), Contract C ($12). During the applicable calendar year,
the payor paid, for code Z, 25 claims under Contract A, 30 claims under
contract B, and 45 claims under contract C. The rate calculation pursuant to
this subdivision (c)(1) is: ($10x25)+($15x30)+($12x45) / (total claims: 100) =
a base ACR rate of $12.40 for health care service code Z. Beginning January 1,
2024, the rate, so calculated, is then adjusted for inflation by the Consumer
Price Index for Medical Care Services, as published by the United States Bureau
of Labor Statistics, as described in subdivision (a)(2)(B) of section
1371.31 of the Knox-Keene
Act.
(2) The payor shall
include the highest and lowest contracted rates when calculating the rate
pursuant to subdivision (c)(1) by ensuring that the "number of claims paid at
that allowed amount" multiplier for each of the payor's highest and lowest
contracted rates is at least 1 (one).
(3) The payor shall calculate a rate
described in subdivision (c)(1) taking into account each combination of these
factors, at a minimum:
(A) Health care service
codes, including but not limited to Current Procedural Terminology (CPT)
codes,
(B) Geographic
region,
(C) Provider type and
specialty,
(D) Facility type,
and,
(E) Information from the
independent dispute resolution process, if any, pursuant to section
1371.30 of the Knox-Keene
Act.
(4) For the purpose
of subdivision (c)(3)(A), the payor shall use unmodified health care service
codes to calculate the average contracted rate, except that the payor shall
calculate separate average contracted rates pursuant to this subdivision (c)
only for CPT code modifiers "26" (professional component) and "TC" (technical
component). For the purpose of this section, a modifier is a code applied to
the service code that makes the service description more specific and may
adjust the reimbursement rate or affect the processing or payment of the code
billed.
(5) When the average
contracted rate is the appropriate default reimbursement rate pursuant to
subdivision (a)(1) of section
1371.31 of the Knox-Keene Act, the
payor may adjust the rate determined under this subdivision (c) when it
reimburses the noncontracting individual health professional, as appropriate.
Appropriate reimbursement shall account for relevant payment modifiers and
other health care service- or claim-specific factors in compliance with the
Knox-Keene Act that affect the amount for reimbursement of health care services
rendered by contracting individual health professionals.
(6) For anesthesia services subject to
section 1371.9 of the Knox-Keene Act:
(A) The payor shall use the anesthesia
conversion factors set forth in the payor's provider contracts instead of an
"allowed amount" to complete the calculation pursuant to subdivision
(c)(1).
(B) The factors that affect
reimbursement pursuant to subdivision (c)(5) of this section shall include the
sum of American Society of Anesthesiologists Relative Value Guide (RVG) base
units, time units, and physical status modifier.
(7) The following claims shall be excluded
from the average contracted rate calculation, except as specified:
(A) Case rates, bundled payments, and global
rates shall be excluded, except that the payor shall include the CPT code in
which a global rate is embedded per the American Medical Association CPT code
description.
(B) Claims paid
pursuant to capitation, risk sharing arrangements, and sub-capitation, except
for fee-for-service payments made by a payor who receives capitation from
another entity.
(C) Denied
claims.
(D) Claims not in final
disposition status, meaning claims for which a final reimbursement amount
pursuant to claims settlement practices required by the Knox Keene Act has not
been determined by the payor, including disputed claims.
(E) Secondary payment rates pursuant to
coordination of benefits clauses.
(d) Payors subject to subdivision (a)(3)(C)
of section
1371.31 of the Knox-Keene Act
shall use a statistically credible database reflecting rates paid to
noncontracting individual health professionals for services provided in a
geographic region to determine an average contracted rate required pursuant to
this section and section
1371.31 of the Knox-Keene Act.
This subdivision (d) applies notwithstanding any other provision of this
section.
(e) Payment of default
reimbursement rate.
(1) Unless otherwise
agreed by the payor and the noncontracting individual health professional, and
except as provided in subdivision (b) of section
1371.31 of the Knox-Keene Act, the
payor shall reimburse the noncontracting individual health professional, for
all services subject to section
1371.9 of the Knox-Keene Act, the
default reimbursement rate.
(2) The
payor shall indicate on claims payment documents the manner by which the payor
satisfied this subdivision (e).
(f) Filing requirements.
(1) Payors shall electronically file with the
department the policies and procedures used to determine the average contracted
rates in compliance with this section by August 15, 2019, and thereafter when
the policies and procedures are amended.
(2) If applicable, the payor shall
demonstrate in its policies and procedures access to and use of a statistically
credible database pursuant to subdivision (d) of this section including the
following information:
(A) Explanation and
justification of the determination that, based on the payor's model, the payor
does not pay a statistically significant number or dollar amount of claims
covered under section
1371.9 of the Knox-Keene
Act;
(B) Information regarding
which database is used for the determination of an ACR;
(C) Certification that the database is
statistically credible; and
(D)
Explanation and justification of the percentile or other methodology used to
determine the average contracted rate, using the database.
(3) For the purpose of subdivision (f)(2), a
statistically credible database shall be a nonprofit database that is
unaffiliated with a payor.
(g) Enforcement. The Director shall have the
civil, criminal, and administrative remedies available under the Knox-Keene
Act, including section
1394.
Note: Authority cited: Sections
1344
and
1371.31,
Health and Safety Code. Reference: Sections
1371.9
and
1371.31,
Health and Safety Code.
Note: Authority cited: Sections
1344
and
1371.31,
Health and Safety Code. Reference: Sections
1371.9
and
1371.31,
Health and Safety Code.