California Code of Regulations
Title 9 - Rehabilitative and Developmental Services
Division 1 - Department of Mental Health
Chapter 11 - Medi-Cal Specialty Mental Health Services
Subchapter 2 - Medi-Cal Psychiatric Inpatient Hospital Services
Article 1 - Fiscal Provisions
Section 1820.115 - Rate Setting for Psychiatric Inpatient Hospital Services for Non-Negotiated Rate, Fee-for-Service/Medi-Cal Hospitals
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(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.
(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:
(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:
(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).
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.
