SECTIONS 14091.3 - California Statutes

WELFARE AND INSTITUTIONS CODE

SECTION 14091.3

14091.3. (a) For purposes of this section, the following
definitions shall apply:
(1) "Medi-Cal managed care plan contracts" means those contracts
entered into with the department by any individual, organization, or
entity pursuant to Article 2.7 (commencing with Section 14087.3),
Article 2.8 (commencing with Section 14087.5), Article 2.91
(commencing with Section 14089), or Article 1 (commencing with
Section 14200) or Article 7 (commencing with Section 14490) of
Chapter 8, or Chapter 8.75 (commencing with Section 14590).
(2) "Medi-Cal managed care health plan" means an individual,
organization, or entity operating under a Medi-Cal managed care plan
contract with the department under this chapter, Chapter 8
(commencing with Section 14200), or Chapter 8.75 (commencing with
Section 14590).
(b) The department shall take all appropriate steps to amend the
Medicaid State Plan, if necessary, to carry out this section. This
section shall be implemented only to the extent that federal
financial participation is available. The department shall adopt
rules and regulations to carry out this section. Until January 1,
2010, any rules and regulations adopted pursuant to this subdivision
may be adopted as emergency regulations in accordance with the
Administrative Procedure Act (Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code).
The adoption of these regulations shall be deemed an emergency and
necessary for the immediate preservation of the public peace, health,
and safety or general welfare. The regulations shall become
effective immediately upon filing with the Secretary of State.
(c) Any hospital that does not have in effect a contract with a
Medi-Cal managed care health plan, as defined in paragraph (2) of
subdivision (a), that establishes payment amounts for services
furnished to a beneficiary enrolled in that plan shall accept as
payment in full, from all these plans, the following amounts:
(1) For outpatient services, the Medi-Cal fee-for-service (FFS)
payment amounts.
(2) For emergency inpatient services, the average per diem
contract rate specified in paragraph (2) of subdivision (b) of
Section 14166.245, except that the payment amount shall not be
reduced by 5 percent. For the purposes of this paragraph, this
payment amount shall apply to all hospitals, including hospitals that
contract with the department under the Medi-Cal Selective Provider
Contracting Program described in Article 2.6 (commencing with Section
14081), and small and rural hospitals specified in Section 124840 of
the Health and Safety Code.
(3) For poststabilization services following an emergency
admission, payment amounts shall be consistent with subdivision (e)
of Section 438.114 of Title 42 of the Code of Federal Regulations.
This paragraph shall only be implemented to the extent that contract
amendment language providing for these payments is approved by CMS.
For purposes of this paragraph, this payment amount shall apply to
all hospitals, including hospitals that contract with the department
under the Medi-Cal Selective Provider Contracting Program pursuant to
Article 2.6 (commencing with Section 14081).
(d) Medi-Cal managed care health plans that, pursuant to the
department's encouragement in All Plan Letter 07003, have been paying
out-of-network hospitals the most recent California Medical
Assistance Commission regional average per diem rate as a temporary
rate for purposes of Section 1932(b)(2)(D) of the Social Security Act
(SSA), which became effective January 1, 2007, shall make
reconciliations and adjustments for all hospital payments made since
January 1, 2007, based upon rates published by the department
pursuant to Section 1932(b)(2)(D) of the SSA and effective January 1,
2007, to June 30, 2008, inclusive, and, if applicable, provide
supplemental payments to hospitals as necessary to make payments that
conform with Section 1932(b)(2)(D) of the SSA. In order to provide
managed care health plans with 60 working days to make any necessary
supplemental payments to hospitals prior to these payments becoming
subject to the payment of interest, Section 1300.71 of Title 28 of
the California Code of Regulations shall not apply to these
supplemental payments until 30 working days following the publication
by the department of the rates.
(e) (1) The department shall provide a written report to the
policy and fiscal committees of the Legislature on October 1, 2009,
and May 1, 2010, on the implementation and impact made by this
section, including the impact of these changes on access to hospitals
by managed care enrollees and on contracting between hospitals and
managed care health plans, including the increase or decrease in the
number of these contracts.
(2) Not later than August 1, 2010, the department shall report to
the Legislature on the implementation of this section. The report
shall include, but not be limited to, information and analyses
addressing managed care enrollee access to hospital services, the
impact of this section on managed care health plan capitation rates,
the impact of this section on the extent of contracting between
managed care health plans and hospitals, and fiscal impact on the
state.
(3) For the purposes of preparing the annual status reports and
the final evaluation report required pursuant to this subdivision,
Medi-Cal managed care health plans shall provide the department with
all data and documentation, including contracts with providers,
including hospitals, as deemed necessary by the department to
evaluate the impact of the implementation of this section. In order
to ensure the confidentiality of managed care health plan proprietary
information, and thereby enable the department to have access to all
of the data necessary to provide the Legislature with accurate and
meaningful information regarding the impact of this section, all
information and documentation provided to the department pursuant to
this section shall be considered proprietary and shall be exempt from
disclosure as official information pursuant to subdivision (k) of
Section 6254 of the Government Code as contained in the California
Public Records Act (Division 7 (commencing with Section 6250) of
Title 1 of the Government Code).
(f) This section shall remain in effect only until January 1,
2012, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2012, deletes or extends
that date.