Welfare and Institutions Code

Part 12 of 35 · provisions 2,201–2,400

This section says the act is to be known as the Welfare and Institutions Code.

Jurisdiction: United States — California
Instrument: Code
Citation: WIC
Version: Undated source snapshot
Language: en
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The Department of the Youth Authority may establish, maintain, or help develop regional centers for counties’ alternative placement options. When a California law mentions “Whittier State School,” it must be read as referring to Fred C. Nelles School for Boys. This section defines “Youth Authority,” “authority,” “the authority,” and “board” for this chapter. This provision states the purpose of the division: to provide protection, care, and assistance to people in need, and to promote welfare through prompt, humane aid and services without discrimination. This section states the purposes of public social services funded by state grants-in-aid to counties.

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Provisions of Welfare and Institutions Code

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14158.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Medical assistance funds must be provided each year through the Budget Act, and the Controller must transfer appropriated state funds from the General Fund to the Health Care Deposit Fund as needed.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14158. Funds for the medical assistance program shall be provided annually by appropriation in the Budget Act. The amount of state funds appropriated shall be transferred in such sums as are needed by the Controller from the General Fund to the Health Care Deposit Fund. (Amended by Stats. 1969, Ch. 21.)
14158.1.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Federal Medicaid-related payments tied to certified public expenditures must be paid to designated public hospitals or their affiliated governmental entities, for expenditures after a new Article 5.4 demonstration project is enacted.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14158.1. Effective for expenditures incurred after enactment of any new demonstration project under Article 5.4 (commencing with Section 14180), any federal financial participation that is available under the federal Medicaid Program, or any related waiver or demonstration project, based on the certified public expenditures of designated public hospitals, as defined in subdivision (d) of Section 14166.1, or the governmental entities with which they are affiliated, shall be paid to designated public hospitals or the governmental entities with which they are affiliated. (Added by Stats. 2010, Ch. 218, Sec. 1. (AB 1653) Effective September 8, 2010.)
14158.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Appropriated funds for these health care programs must cover, but not exceed, the state’s share of payments for medical care, county administration, and fiscal intermediary services.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14158.5. Funds appropriated for purposes of this chapter and Chapter 8 (commencing with Section 14200), shall fully cover and shall not exceed the state’s share of payments under this chapter and Chapter 8 (commencing with Section 14200), for the costs of medical care and services, county administration, and fiscal intermediary services. The state’s share of the costs of medical care and services, county administration, and fiscal intermediary services shall be determined pursuant to a plan approved by the Director of Finance and certified to by the director. (Added by Stats. 1984, Ch. 268, Sec. 56.4. Effective June 30, 1984.)
14159.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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The department must charge certain Medi-Cal and administration costs to the appropriation for the fiscal year when billing is paid, and specified prior-year Health Care Deposit Fund obligations and money are moved into the 2004–05 fiscal year.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14159. Commencing with the 2004–05 fiscal year, expenditures for Medi-Cal services and fiscal intermediary and county administration costs included in the department’s budget shall be charged against the appropriation for the fiscal year in which the billing is paid. Commencing July 1, 2004, all 2002–03 fiscal year and prior accrued obligations of the Health Care Deposit Fund shall become obligations of the 2004–05 fiscal year and all moneys available from the 2002–03 fiscal year and prior appropriations shall be reappropriated to the 2004–05 fiscal year for that purpose. (Added by Stats. 2003, Ch. 230, Sec. 72. Effective August 11, 2003.)
14159.1.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Past county fiscal obligations under Article 5 are preserved, and after June 30, 1971 uncollected county share amounts due the state remain owed by the county.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14159.1. The provisions of Chapter 577 of the Statutes of 1971 in no way eliminate fiscal obligation incurred prior to July 1, 1971, by any county or the state under Article 5 (commencing with Section 14150) of Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code. After June 30, 1971, all uncollected county share amounts under said Article 5 due the state for prior periods remain an obligation of the county to the state. (Added by Stats. 1976, Ch. 504.)
14160.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Money that was mistakenly deposited in the Health Care Deposit Fund must be refunded to the depositor.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14160. Whenever an amount is or was prior to the effective date of this section, erroneously deposited in the Health Care Deposit Fund, including, but not limited to, duplicate payments and payments in excess of the correct amount, the erroneous amount shall be refunded to the depositor. There is hereby appropriated out of the Health Care Deposit Fund amounts sufficient to pay such refunds. (Added by Stats. 1969, Ch. 814.)
14161.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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Medi-Cal carriers and providers must use department-approved accounting and cost-reporting systems and give the department cost information it needs; noncompliance can lead to suspension.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14161. Carriers and providers of Medi-Cal benefits shall be required to utilize uniform accounting and cost-reporting systems as shall be developed and adopted by the department. If any other provision of law provides for uniform accounting and cost-reporting systems for hospitals, the department shall adopt these systems. Carriers and providers of Medi-Cal benefits shall provide cost information to the department as is necessary in order to conduct studies to determine payment for services provided under this chapter, including but not limited to copies of any Medicare cost reports and settlements, and any Medicare audit reports. Failure to comply with the provisions of this section shall be cause for suspension from participation under this chapter. The department shall conduct such studies as necessary to determine payments for services provided under this chapter. (Amended by Stats. 2012, Ch. 728, Sec. 207. (SB 71) Effective January 1, 2013.)
14162.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section requires the State Department of Health Services to include a savings estimate in its annual Medi-Cal budget estimate, and requires the Department of Finance to deposit matching savings into the Critical Needs Health Care Fund starting in 1992.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14162. (a) Beginning in 1991, the State Department of Health Services shall include in the November estimate of Medi-Cal expenditures and the Governor’s Budget an estimate of savings from the prior year which resulted from implementation of Senate Bill 2174 of the 1987–88 Regular Session of the Legislature. (b) Beginning in 1992, the Department of Finance shall, by February 1, deposit an amount equal to the savings level identified in the November estimate of Medi-Cal expenditures into the Critical Needs Health Care Fund, which is hereby created. Funds deposited in the Critical Needs Health Care Fund shall be appropriated by the Legislature for high-priority health expenditures. (Added by Stats. 1988, Ch. 1348, Sec. 15.)
14163.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
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This section creates the Medi-Cal Inpatient Payment Adjustment Fund, defines key terms, and requires public entities/transferor entities to make and pay intergovernmental transfers to the Controller for deposit into the fund.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14163. (a) For purposes of this section, the following definitions shall apply: (1) “Public entity” means a county, a city, a city and county, the State of California, the University of California, a local health care district, a local health authority, or any other political subdivision of the state. (2) “Hospital” means a health facility that is licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code to provide acute inpatient hospital services, and includes all components of the facility. (3) “Disproportionate share hospital” means a hospital providing acute inpatient services to Medi-Cal beneficiaries that meets the criteria for disproportionate share status relating to acute inpatient services set forth in Section 14105.98. (4) “Disproportionate share list” means the annual list of disproportionate share hospitals for acute inpatient services issued by the department pursuant to Section 14105.98. (5) “Fund” means the Medi-Cal Inpatient Payment Adjustment Fund. (6) “Eligible hospital” means, for a particular state fiscal year, a hospital on the disproportionate share list that is eligible to receive payment adjustment amounts under Section 14105.98 with respect to that state fiscal year. (7) “Transfer year” means the particular state fiscal year during which, or with respect to which, public entities are required by this section to make an intergovernmental transfer of funds to the Controller. (8) “Transferor entity” means a public entity that, with respect to a particular transfer year, is required by this section to make an intergovernmental transfer of funds to the Controller. (9) “Transfer amount” means an amount of intergovernmental transfer of funds that this section requires for a particular transferor entity with respect to a particular transfer year. (10) “Intergovernmental transfer” means a transfer of funds from a public entity to the state that is local government financial participation in Medi-Cal pursuant to the terms of this section. (11) “Licensee” means an entity that has been issued a license to operate a hospital by the department. (12) “Annualized Medi-Cal inpatient paid days” means the total number of Medi-Cal acute inpatient hospital days, regardless of dates of service, for which payment was made by or on behalf of the department to a hospital, under present or previous ownership, during the most recent calendar year ending prior to the beginning of a particular transfer year, including all Medi-Cal acute inpatient covered days of care for hospitals that are paid on a different basis than per diem payments. (13) “Medi-Cal acute inpatient hospital day” means any acute inpatient day of service attributable to patients who, for those days, were eligible for medical assistance under the California state plan, including any day of service that is reimbursed on a basis other than per diem payments. (14) “OBRA 1993 payment limitation” means the hospital-specific limitation on the total annual amount of payment adjustments to each eligible hospital under the payment adjustment program that can be made with federal financial participation under Section 1396r-4(g) of Title 42 of the United States Code as implemented pursuant to the Medi-Cal State Plan. (b) The Medi-Cal Inpatient Payment Adjustment Fund is hereby created in the State Treasury. Notwithstanding Section 13340 of the Government Code, the fund shall be continuously appropriated to, and under the administrative control of, the department for the purposes specified in subdivision (d). The fund shall consist of the following: (1) Transfer amounts collected by the Controller under this section, whether submitted by transferor entities pursuant to applicable provisions of this section or obtained by offset pursuant to subdivision (j). (2) Any other intergovernmental transfers deposited in the fund, as permitted by Section 14164 or Article 5.17 (commencing with Section 14165.55). (3) Any interest that accrues with respect to amounts in the fund. (c) Moneys in the fund, which shall not consist of any state general funds, shall be used as the source for the nonfederal share of payments to hospitals pursuant to Section 14105.98. Moneys shall be allocated from the fund by the department and matched by federal funds in accordance with customary Medi-Cal accounting procedures, and used to make payments pursuant to Section 14105.98. (d) Except as otherwise provided in Section 14105.98 or in any law appropriating a specified sum of money to the department for administering this section and Section 14105.98, moneys in the fund shall be used only for the following: (1) Payments to hospitals pursuant to Section 14105.98. (2) Transfers to the Health Care Deposit Fund as follows: (A) In the amount of two hundred thirty-nine million seven hundred fifty-seven thousand six hundred ninety dollars ($239,757,690) for the 1994–95 and 1995–96 fiscal years. (B) In the amount of two hundred twenty-nine million seven hundred fifty-seven thousand six hundred ninety dollars ($229,757,690) for the 1996–97 fiscal year. (C) In the amount of one hundred fifty-four million seven hundred fifty-seven thousand six hundred ninety dollars ($154,757,690) for the 1997–98 fiscal year. (D) In the amount of one hundred fourteen million seven hundred fifty-seven thousand six hundred ninety dollars ($114,757,690) for the 1998–99 fiscal year. (E) (i) In the amount of eighty-four million seven hundred fifty-seven thousand six hundred ninety dollars ($84,757,690) for the 1999–2000 fiscal year. (ii) It is the intent of the Legislature that the economic benefit of any reduction in the amount transferred, or to be transferred, to the Health Care Deposit Fund pursuant to this subdivision for the 1999–2000 fiscal year, as compared to the amount so transferred for the 1998–99 fiscal year, be allocated equally between public and nonpublic disproportionate share hospitals. To implement the reduction in clause (i) the department shall, by June 30, 2000, adjust the calculations in Section 14105.98 in order to allocate the funds in accordance with this clause. (F) In the amount of twenty-nine million seven hundred fifty-seven thousand six hundred ninety dollars ($29,757,690) for the 2000–01 fiscal year and the 2001–02 fiscal year. (G) In the amount of eighty-five million dollars ($85,000,000) for the 2002–03 fiscal year and each fiscal year thereafter. (H) The transfers from the fund shall be made in six equal monthly installments to the Medi-Cal local assistance appropriation item (Item 4260-101-0001 of Section 2.00 of the annual Budget Act) in support of Medi-Cal expenditures. The first installment shall accrue in October of each transfer year, and all other installments shall accrue monthly thereafter from November through March. (3) Transfers to the Health Care Deposit Fund for purposes set forth in Article 5.17 (commencing with Section 14165.55). (e) For the 1991–92 state fiscal year, the department shall determine, no later than 70 days after the enactment of this section, the transferor entities for the 1991–92 transfer year. To make this determination, the department shall utilize the disproportionate share list for the 1991–92 fiscal year issued by the department pursuant to paragraph (1) of subdivision (f) of Section 14105.98. The department shall identify each eligible hospital on the list for which a public entity is the licensee as of July 1, 1991. The public entity that is the licensee of each identified eligible hospital shall be a transferor entity for the 1991–92 transfer year. (f) The department shall determine, no later than 70 days after the enactment of this section, the transfer amounts for the 1991–92 transfer year. The transfer amounts shall be determined as follows: (1) The eligible hospitals for 1991–92 shall be identified. For each hospital, the applicable total per diem payment adjustment amount under Section 14105.98 for the 1991–92 transfer year shall be computed. This amount shall be multiplied by 80 percent of the eligible hospital’s annualized Medi-Cal inpatient paid days as determined from all Medi-Cal paid claims records available through April 1, 1991. The products of these calculations for all eligible hospitals shall be added together to determine an aggregate sum for the 1991–92 transfer year. (2) The eligible hospitals for 1991–92 involving transferor entities as licensees shall be identified. For each hospital, the applicable total per diem payment adjustment amount under Section 14105.98 for the 1991–92 transfer year shall be computed. This amount shall be multiplied by 80 percent of the eligible hospital’s annualized Medi-Cal inpatient paid days as determined from all Medi-Cal paid claims records available through April 1, 1991. The products of these calculations for all eligible hospitals with transferor entities as licensees shall be added together to determine an aggregate sum for the 1991–92 transfer year. (3) The aggregate sum determined under paragraph (1) shall be divided by the aggregate sum determined under paragraph (2), yielding a factor to be utilized in paragraph (4). (4) The factor determined in paragraph (3) shall be multiplied by the amount determined for each hospital under paragraph (2). The product of this calculation for each hospital in paragraph (2) shall be divided by 1.771, yielding a transfer amount for the particular transferor entity for the transfer year. (g) For the 1991–92 transfer year, the department shall notify each transferor entity in writing of its applicable transfer amount or amounts. (h) For the 1992–93 transfer year and subsequent transfer years, transfer amounts shall be determined in the same procedural manner as set forth in subdivision (f), except: (1) The department shall use all of the following: (A) The disproportionate share list applicable to the particular transfer year to determine the eligible hospitals. (B) The payment adjustment amounts calculated under Section 14105.98 for the particular transfer year. These amounts shall take into account any projected or actual increases or decreases in the size of the payment adjustment program as are required under Section 14105.98 for the particular year in question, including any decreases resulting from the application of the OBRA 1993 payment limitation. The department may issue interim, revised, and supplemental transfer requests as necessary and appropriate to address changes in payment adjustment levels that occur under Section 14105.98. All transfer requests, or adjustments thereto, issued to transferor entities by the department shall meet the requirements set forth in subdivision (i). (C) Data regarding annualized Medi-Cal inpatient paid days for the most recent calendar year ending prior to the beginning of the particular transfer year, as determined from all Medi-Cal paid claims records available through April 1 preceding the particular transfer year. (D) The status of public entities as licensees of eligible hospitals as of July 1 of the particular transfer year. (E) For the 1993–94 transfer year and subsequent transfer years, the divisor to be used for purposes of the calculation referred to in paragraph (4) of subdivision (f) shall be determined by the department. The divisor shall be calculated to ensure that the appropriate amount of transfers from transferor entities are received into the fund to satisfy the requirements of Section 14105.98, exclusive of the amounts described in paragraph (2) of this subdivision, and to satisfy the requirements of paragraph (2) of subdivision (d), for the particular transfer year. For the 1993–94 transfer year, the divisor shall be 1.742. (F) The following provisions shall apply for certain transfer amounts relating to nonsupplemental payments under Section 14105.98: (i) For the 1998–99 transfer year, transfer amounts shall be determined as though the payment adjustment amounts arising pursuant to subdivision (ag) of Section 14105.98 were increased by the amounts paid or payable pursuant to subdivision (af) of Section 14105.98. (ii) Any transfer amounts paid by a transferor entity pursuant to subparagraph (C) of paragraph (2) shall serve as credit for the particular transferor entity against an equal amount of its transfer obligation for the 1998–99 transfer year. (iii) For the 1999–2000 transfer year, transfer amounts shall be determined as though the amount to be transferred to the Health Care Deposit Fund, as referred to in paragraph (2) of subdivision (d), were reduced by 28 percent. (2) (A) Except as provided in subparagraphs (B), (C), and (D), for the 1993–94 transfer year and subsequent transfer years, transfer amounts shall be increased for the particular transfer year in the amounts necessary to fund the nonfederal share of the total supplemental payment adjustment amounts of all types that arise under Section 14105.98. These increases shall be paid only by those transferor entities that are licensees of hospitals that are projected to receive some or all of the particular supplemental payments, and the increases shall be paid by the transferor entities on a pro rata basis in connection with the particular supplemental payments. For purposes of this paragraph, supplemental payment adjustment amounts shall be deemed to arise for the particular transfer year as of the date specified in Section 14105.98. Transfer amounts to fund the nonfederal share of the payments shall be paid for the particular transfer year within 20 days after the department notifies the transferor entity in writing of the additional transfer amount to be paid. (B) For the 1995–96 transfer year, the nonfederal share of the secondary supplemental payment adjustments described in paragraph (9) of subdivision (y) of Section 14105.98 shall be funded as follows: (i) Ninety-nine percent of the nonfederal share shall be funded by a transfer from the University of California. (ii) One percent of the nonfederal share shall be funded by transfers from those public entities that are the licensees of the hospitals included in the “other public hospitals” group referred to in clauses (ii) and (iii) of subparagraph (B) of paragraph (9) of subdivision (y) of Section 14105.98. The transfer responsibilities for this 1 percent shall be allocated to the particular public entities on a pro rata basis, based on a formula or formulae customarily used by the department for allocating transfer amounts under this section. The formula or formulae shall take into account, through reallocation of transfer amounts as appropriate, the situation of hospitals whose secondary supplemental payment adjustments are restricted due to the application of the limitation set forth in clause (v) of subparagraph (B) of paragraph (9) of subdivision (y) of Section 14105.98. (iii) All transfer amounts under this subparagraph shall be paid by the particular transferor entities within 30 days after the department notifies the transferor entity in writing of the transfer amount to be paid. (C) For the 1997–98 transfer year, transfer amounts to fund the nonfederal share of the supplemental payment adjustments described in subdivision (af) of Section 14105.98 shall be funded by a transfer from the County of Los Angeles. (D) (i) For the 1998–99 transfer year, transfer amounts to fund the nonfederal share of the supplemental payment adjustment amounts arising under subdivision (ah) of Section 14105.98 shall be increased as set forth in clause (ii). (ii) The transfer amounts otherwise calculated to fund the supplemental payment adjustments referred to in clause (i) shall be increased on a pro rata basis by an amount equal to 28 percent of the amount to be transferred to the Health Care Deposit Fund for the 1999–2000 fiscal year, as referred to in paragraph (2) of subdivision (d). (3) The department shall prepare preliminary analyses and calculations regarding potential transfer amounts, and potential transferor entities shall be notified by the department of estimated transfer amounts as soon as reasonably feasible regarding any particular transfer year. Written notices of transfer amounts shall be issued by the department as soon as possible with respect to each transfer year. All state agencies shall take all necessary steps in order to supply applicable data to the department to accomplish these tasks. The Office of Statewide Health Planning and Development shall provide to the department quarterly access to the edited and unedited confidential patient discharge data files for all Medi-Cal eligible patients. The department shall maintain the confidentiality of that data to the same extent as is required of the Office of Statewide Health Planning and Development. In addition, the Office of Statewide Health Planning and Development shall provide to the department, not later than March 1 of each year, the data specified by the department, as the data existed on the statewide database file as of February 1 of each year, from all of the following: (A) Hospital annual disclosure reports, filed with the Office of Statewide Health Planning and Development pursuant to former Section 443.31 of, or Section 128735 of, the Health and Safety Code, for hospital fiscal years that ended during the calendar year ending 13 months prior to the applicable February 1. (B) Annual reports of hospitals, filed with the Office of Statewide Health Planning and Development pursuant to former Section 439.2 of, or Section 127285 of, the Health and Safety Code, for the calendar year ending 13 months prior to the applicable February 1. (C) Hospital patient discharge data reports, filed with the Office of Statewide Health Planning and Development pursuant to former subdivision (g) of Section 443.31 of, or Section 128735 of, the Health and Safety Code, for the calendar year ending 13 months prior to the applicable February 1. (D) Any other materials on file with the Office of Statewide Health Planning and Development. (4) Transfer amounts calculated by the department may be increased or decreased by a percentage amount consistent with the Medi-Cal state plan. (5) For the 1993–94 fiscal year, the transfer amount that would otherwise be required from the University of California shall be increased by fifteen million dollars ($15,000,000). (6) Notwithstanding any other law, except for subparagraph (D) of paragraph (2), the total amount of transfers required from the transferor entities for any particular transfer year shall not exceed the sum of the following: (A) The amount needed to fund the nonfederal share of all payment adjustment amounts applicable to the particular payment adjustment year as calculated under Section 14105.98. Included in the calculations for this purpose shall be any decreases in the program as a whole, and for individual hospitals, that arise due to the provisions of Section 1396r-4(f) or (g) of Title 42 of the United States Code. (B) The amount needed to fund the transfers to the Health Care Deposit Fund, as referred to in subdivision (d). (7) (A) Except as provided in subparagraphs (B) and (C) and in paragraph (2) of subdivision (j), and except for a prudent reserve not to exceed two million dollars ($2,000,000) in the Medi-Cal Inpatient Payment Adjustment Fund, any amounts in the fund, including interest that accrues with respect to the amounts in the fund, that are not expended, or estimated to be required for expenditure, under Section 14105.98 with respect to a particular transfer year shall be returned on a pro rata basis to the transferor entities for the particular transfer year within 120 days after the department determines that the funds are not needed for an expenditure in connection with the particular transfer year. (B) The department shall determine the interest amounts that have accrued in the fund from its inception through June 30, 1995, and, no later than January 1, 1996, shall distribute these interest amounts to transferor entities: (C) With respect to those particular amounts in the fund resulting solely from the provisions of subparagraph (D) of paragraph (2), the department shall determine by September 30, 1999, whether these particular amounts exceed 28 percent of the amount to be transferred to the Health Care Deposit Fund for the 1999–2000 fiscal year, as referred to in paragraph (2) of subdivision (d). Any excess amount so determined shall be returned to the particular transferor entities on a pro rata basis no later than October 31, 1999. (D) Regarding any funds returned to a transferor entity under subparagraph (A) or (C), or interest amounts distributed to a transferor entity under subparagraph (B), the department shall provide to the transferor entity a written statement that explains the basis for the particular return or distribution of funds and contains the general calculations used by the department in determining the amount of the particular return or distribution of funds. (i) (1) For the 1991–92 transfer year, each transferor entity shall pay its transfer amount or amounts to the Controller, for deposit in the fund, in eight equal installments. (2) (A) Except as provided in subparagraphs (B) and (C), for the 1992–93 transfer year and subsequent transfer years, each transferor entity shall pay its transfer amount or amounts to the Controller, for deposit in the fund, in eight equal installments. However, for the 1997–98 and subsequent transfer years, each transferor entity shall pay its transfer amount or amounts to the Controller, for deposit in the fund, in the form of periodic installments according to a timetable established by the department. The timetable shall be structured to effectuate, on a reasonable basis, the prompt distribution of all nonsupplemental payment adjustments under Section 14105.98, and transfers to the Health Care Deposit Fund under subdivision (d). (B) For the 1994–95 transfer year, each transferor entity shall pay its transfer amount or amounts to the Controller, for deposit in the fund, in five equal installments. (C) For the 1995–96 transfer year, each transferor entity shall pay its transfer amount or amounts to the Controller, for deposit in the fund, in five equal installments. (D) Except as otherwise specifically provided, subparagraphs (A) to (C), inclusive, shall not apply to increases in transfer amounts described in paragraph (2) of subdivision (h) or to additional transfer amounts described in subdivision (o). (E) All requests for transfer payments, or adjustments thereto, issued by the department shall be in writing and shall include (i) an explanation of the basis for the particular transfer request or transfer activity, (ii) a summary description of program funding status for the particular transfer year, and (iii) the general calculations used by the department in connection with the particular transfer request or transfer activity. (3) A transferor entity may use any of the following funds for purposes of meeting its transfer obligations under this section: (A) General funds of the transferor entity. (B) Any other funds permitted by law to be used for these purposes, except that a transferor entity shall not submit to the Controller any federal funds unless those federal funds are authorized by federal law to be used to match other federal funds. In addition, no private donated funds from any health care provider, or from any person or organization affiliated with the health care provider, shall be channeled through a transferor entity or any other public entity to the fund, unless the donated funds will qualify under federal rules as a valid component of the nonfederal share of the Medi-Cal program and will be matched by federal funds. The transferor entity shall be responsible for determining that funds transferred meet the requirements of this subparagraph. (j) (1) If a transferor entity does not submit any transfer amount within the time period specified in this section, the Controller shall offset immediately the amount owed against any funds which otherwise would be payable by the state to the transferor entity. The Controller, however, shall not impose an offset against any particular funds payable to the transferor entity where the offset would violate state or federal law. (2) Where a withhold or a recoupment occurs pursuant to the provisions of paragraph (2) of subdivision (r) of Section 14105.98, the nonfederal portion of the amount in question shall remain in the fund, or shall be redeposited in the fund by the department, as applicable. The department shall then proceed as follows: (A) If the withhold or recoupment was imposed with respect to a hospital whose licensee was a transferor entity for the particular state fiscal year to which the withhold or recoupment related, the nonfederal portion of the amount withheld or recouped shall serve as a credit for the particular transferor entity against an equal amount of transfer obligations under this section, to be applied whenever the transfer obligations next arise. Should no such transfer obligation arise within 180 days, the department shall return the funds in question to the particular transferor entity within 30 days thereafter. (B) For other situations, the withheld or recouped nonfederal portion shall be subject to paragraph (7) of subdivision (h). (k) All transfer amounts received by the Controller or amounts offset by the Controller shall immediately be deposited in the fund. (l) For purposes of this section, the disproportionate share list utilized by the department for a particular transfer year shall be identical to the disproportionate share list utilized by the department for the same state fiscal year for purposes of Section 14105.98. Nothing on a disproportionate share list, once issued by the department, shall be modified for any reason other than mathematical or typographical errors or omissions on the part of the department or the Office of Statewide Health Planning and Development in preparation of the list. (m) Neither the intergovernmental transfers required by this section, nor any elective transfer made pursuant to Section 14164 or Article 5.17 (commencing with Section 14165.55), shall create, lead to, or expand the health care funding or service obligations for current or future years for any transferor entity, except as required of the state by this section or as may be required by federal law, in which case the state shall be held harmless by the transferor entities on a pro rata basis. (n) Except as otherwise permitted by state and federal law, no transfer amount submitted to the Controller under this section, and no offset by the Controller pursuant to subdivision (j), shall be claimed or recognized as an allowable element of cost in Medi-Cal cost reports submitted to the department. (o) Whenever additional transfer amounts are required to fund the nonfederal share of payment adjustment amounts under Section 14105.98 that are distributed after the close of the particular payment adjustment year to which the payment adjustment amounts apply, the additional transfer amounts shall be paid by the parties who were the transferor entities for the particular transfer year that was concurrent with the particular payment adjustment year. The additional transfer amounts shall be calculated under the formula that was in effect during the particular transfer year. For transfer years prior to the 1993–94 transfer year, the percentage of the additional transfer amounts available for transfer to the Health Care Deposit Fund under subdivision (d) shall be the percentage that was in effect during the particular transfer year. These additional transfer amounts shall be paid by transferor entities within 20 days after the department notifies the transferor entity in writing of the additional transfer amount to be paid. (p) (1) Ten million dollars ($10,000,000) of the amount transferred from the Medi-Cal Inpatient Payment Adjustment Fund to the Health Care Deposit Fund due to amounts transferred attributable to years prior to the 1993–94 fiscal year is hereby appropriated without regard to fiscal years to the State Department of Health Care Services to be used to support the development of managed care programs under the department’s plan to expand Medi-Cal managed care. (2) These funds shall be used by the department for both of the following purposes: (A) distributions to counties or other local entities that contract with the department to receive those funds to offset a portion of the costs of forming the local initiative entity and (B) distributions to local initiative entities that contract with the department to receive those funds to offset a portion of the costs of developing the local initiative health delivery system in accordance with the department’s plan to expand Medi-Cal managed care. (3) Entities contracting with the department for any portion of the ten million dollars ($10,000,000) shall meet the objectives of the department’s plan to expand Medi-Cal managed care with regard to traditional and safety net providers. (4) Entities contracting with the department for any portion of the ten million dollars ($10,000,000) may be authorized under those contracts to utilize their funds to provide for reimbursement of the costs of local organizations and entities incurred in participating in the development and operation of a local initiative. (5) To the full extent permitted by state and federal law, these funds shall be distributed by the department for expenditure at the local level in a manner that qualifies for federal financial participation under the Medicaid Program. (q) (1) Any local initiative entity that has performed unanticipated additional work for the purposes identified in subparagraph (B) of paragraph (2) of subdivision (p) resulting in additional costs attributable to the development of its local initiative health delivery system, may file a claim for reimbursement with the department for the additional costs incurred due to delays in start dates through the 1996–97 fiscal year. The claim shall be filed by the local initiative entity not later than 90 days after the effective date of the act adding this subdivision, and shall not seek extra compensation for any sum that is or could have been asserted pursuant to the contract disputes and appeals resolution provisions of the local initiative entity’s respective two-plan model contract. All claims for unanticipated additional incurred costs shall be submitted with adequate supporting documentation including, but not limited to, all of the following: (A) Invoices, receipts, job descriptions, payroll records, work plans, and other materials that identify the unanticipated additional claimed and incurred costs. (B) Documents reflecting mitigation of costs. (C) To the extent lost profits are included in the claim, documentation identifying those profits and the manner of calculation. (D) Documents reflecting the anticipated start date, the actual start date, and reasons for the delay between the dates, if any. (2) In determining any amount to be paid, the department shall do all of the following: (A) Conduct a fiscal analysis of the local initiative entity’s claimed costs. (B) Determine the appropriate amount of payment, after taking into consideration the supporting documentation and the results of any audit. (C) Provide funding for any such payment, as approved by the Department of Finance through the deficiency process. (D) Complete the determination required in subparagraph (B) within six months after receipt of a local initiative entity’s completed claim and supporting documentation. Prior to final determination, there shall be a review and comment period for that local initiative entity. (E) Make reasonable efforts to obtain federal financial participation. In the event federal financial participation is not allowed for this payment, the state’s payment shall be 50 percent of the total amount determined to be payable. (r) Notwithstanding any other law, the Controller may use the moneys in the Medi-Cal Inpatient Payment Adjustment Fund for loans to the General Fund as provided in Sections 16310 and 16381 of the Government Code. However, interest shall be paid on all moneys loaned to the General Fund from the Medi-Cal Inpatient Payment Adjustment Fund. Interest payable shall be computed at a rate determined by the Pooled Money Investment Board to be the current earning rate of the fund from which loaned. This subdivision does not authorize any transfer that will interfere with the carrying out of the object for which the Medi-Cal Inpatient Payment Adjustment Fund was created. (Amended by Stats. 2011, Ch. 20, Sec. 1. (AB 113) Effective April 13, 2011.)
14164.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. )
Verify source ↗

Counties and other state governmental entities may voluntarily transfer funds to the department for Medi-Cal, and the department has discretion to accept them.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5. Fiscal Provisions [14150 - 14164] ( Article 5 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## 14164. (a) In addition to the required intergovernmental transfers set forth in Section 14163, any county, other political subdivision of the state, or governmental entity in the state may elect to transfer funds, subject to subdivision (m) of Section 14163, to the department in support of the Medi-Cal program. Those transfers may consist of cash or loans to the state. The department shall have the discretion to accept or not accept any elective transfer from a county, political subdivision, or other governmental entity, as well as the discretion of whether to deposit the transfer in the Medi-Cal Inpatient Payment Adjustment Fund established pursuant to Section 14163. If the department accepts a transfer pursuant to this section, the department shall obtain federal matching funds to the full extent permitted by federal law. (b) (1) The director may maximize available federal financial participation to provide access to services provided by hospitals that are not reimbursed by certified public expenditure pursuant to Article 5.2 (commencing with Section 14166) by authorizing the use of intergovernmental transfers to fund the nonfederal share of supplemental payments as permitted under Section 433.51 of Title 42 of the Code of Federal Regulations or any other applicable federal Medicaid laws. The transferring entity shall certify to the department that the funds are in compliance with all federal rules and regulations. Any payments funded by intergovernmental transfers shall remain with the hospital and shall not be transferred back to any county, other political subdivision of the state, or governmental entity in the state, except for federal disallowance or withhold recovery efforts by the department. Participation in intergovernmental transfers under this subdivision is voluntary on the part of the transferring entity for purposes of all applicable federal laws. (2) This subdivision shall be implemented only to the extent federal financial participation is not jeopardized. (Amended by Stats. 2013, Ch. 657, Sec. 1. (SB 239) Effective October 8, 2013.)
14165.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
Verify source ↗

The commission is created in the Governor’s office, continues until June 30, 2012, and then dissolves, with its powers moving to Health Care Services.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165. (a) There is hereby created in the Governor’s office the California Medical Assistance Commission, for the purpose of contracting with health care delivery systems for the provision of health care services to recipients under the California Medical Assistance program. (b) Notwithstanding any other provision of law, the commission created pursuant to subdivision (a) shall continue through June 30, 2012, after which, it shall be dissolved and the term of any commissioner serving at that time shall end. (1) Upon dissolution of the commission, all powers, duties, and responsibilities of the commission shall be transferred to the Director of Health Care Services. These powers, duties, and responsibilities shall include, but are not limited to, those exercised in the operation of the selective provider contracting program pursuant to Article 2.6 (commencing with Section 14081). (2) (A) On July 1, 2012, notwithstanding any other law, employees of the California Medical Assistance Commission as of June 30, 2012, excluding commissioners, shall transfer to the State Department of Health Care Services. (B) Employees who transfer pursuant to subparagraph (A) shall be subject to the same conditions of employment under the department as they were under the California Medical Assistance Commission, including retention of their exempt status, until the diagnosis-related groups payment system described in Section 14105.28 replaces the contract-based payment system described in this article. (C) (i) Notwithstanding any other law or rule, persons employed by the department who transferred to the department pursuant to subparagraph (A) shall be eligible to apply for civil service examinations. Persons receiving passing scores shall have their names placed on lists resulting from these examinations, or otherwise gain eligibility for appointment. In evaluating minimum qualifications, related California Medical Assistance Commission experience shall be considered state civil service experience in a class deemed comparable by the State Personnel Board, based on the duties and responsibilities assigned. (ii) On the date the diagnosis-related groups payment system described in Section 14105.28 replaces the contract-based system described in this article, employees who transferred to the department pursuant to subparagraph (A) shall transfer to civil service classifications within the department for which they are eligible. (3) Upon a determination by the Director of Health Care Services that a payment system based on diagnosis-related groups as described in Section 14105.28 that is sufficient to replace the contract-based payment system described in this article has been developed and implemented, the powers, duties, and responsibilities conferred on the commission and transferred to the Director of Health Care Services shall no longer be exercised, excluding all of the following: (A) Stabilization payments made or committed from Sections 14166.14 and 14166.19 for services rendered prior to the director’s determination pursuant to this paragraph. (B) The ability to negotiate and make payments from the Private Hospital Supplemental Fund, established pursuant to Section 14166.12, and the Nondesignated Public Hospital Supplemental Fund, established pursuant to Section 14166.17. (C) The ability to continue to administer and distribute payments for the Construction and Renovation Reimbursement Program, in accordance with Sections 14085 to 14085.57, inclusive. Notwithstanding any other law, maintaining or negotiating a selective provider contract pursuant to Article 2.6 (commencing with Section 14081) or a contract with a county organized health system shall cease to be a requirement for a hospital’s participation in the Construction and Renovation Reimbursement Program. (4) Protections afforded to the negotiations and contracts of the commission by the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code) shall be applicable to the negotiations and contracts conducted or entered into pursuant to this section by the State Department of Health Care Services. (c) Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, or any other provision of law, the State Department of Health Care Services may implement and administer this section by means of provider bulletins or other similar instructions, without taking regulatory action. The authority to implement this section as set forth in this subdivision shall include the authority to give notice by provider bulletin or other similar instruction of a determination made pursuant to paragraph (3) of subdivision (b) and to modify or supersede existing regulations in Title 22 of the California Code of Regulations that conflict with implementation of this section. (Amended by Stats. 2013, Ch. 657, Sec. 2. (SB 239) Effective October 8, 2013.)
14165.1.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
Verify source ↗

The commission must have seven voting members and two ex officio members.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.1. The commission shall be composed of seven voting members and two ex officio members. The voting members shall be selected from persons with experience in management of hospital services, risk management insurance or prepaid health programs, the delivery of health services, the management of county health systems, and a representative of recipients of service. The Directors of the Department of Health Services and the Department of Finance, or their designees, shall serve as ex officio nonvoting members of the commission. (Added by Stats. 1982, Ch. 329, Sec. 11.)
14165.10.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
Verify source ↗

The commission or department may direct independent studies about Medi-Cal coverage, benefits, premiums, eligibility, copayments, and responses to temporary deficits.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.10. The commission or department may direct independent studies, to include, but not be limited to, the following objectives: (a) The development of a method of private medical insurance coverage of the Medi-Cal program as to those Medi-Cal beneficiaries whose medical costs reach a catastrophic level or who become chronically ill. (b) The potential for Medi-Cal payment of medical coverage premiums for the various classifications of Medi-Cal beneficiaries. (c) For each classification of Medi-Cal beneficiaries, the provision of specified medical benefits on the basis of subsidization by the beneficiaries through the payment of premiums. (d) A comparison of Medi-Cal benefits with the medical coverage available to most Californians not covered by Medi-Cal, along with analysis and recommendations concerning alternative benefit packages for Medi-Cal. (e) The determination of whether health care plans providing services to Medi-Cal beneficiaries should offer less than the full range of Medi-Cal benefits. (f) The development of alternative standards for beneficiary eligibility and copayment under Medi-Cal. (g) The development of a method of response to temporary deficits in the Medi-Cal program that will both control expenditures and, to the extent possible, preserve the availability to beneficiaries of essential health services. (Added by Stats. 1983, Ch. 960, Sec. 7.)
14165.11.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
Verify source ↗

The California Medical Assistance Commission may help the Department of Corrections plan and negotiate health care service contracts, including consulting or negotiating directly with providers if both sides agree.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.11. (a) It is the intent of the Legislature that the Department of Corrections operate in the most effective and efficient manner possible when purchasing health care services for inmates. To achieve this goal, it is desirable that the department have the benefit of the experience of the California Medical Assistance Commission in planning and negotiating for the purchase of health care services. (b) The commission may work with the Department of Corrections to assist the department in planning and negotiating contracts for the purchase of health care services. The commission may either consult with the department or negotiate directly with providers on behalf of the department, as mutually agreed upon by the commission and the department. (Added by Stats. 1995, Ch. 749, Sec. 10. Effective October 10, 1995.)
14165.2.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
Verify source ↗

The Governor, Speaker of the Assembly, and Senate Rules Committee must appoint commission members, with one Governor appointee designated as chairperson.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.2. The Governor shall appoint three members of the commission, one of which shall be designated chairperson. The Speaker of the Assembly and the Senate Rules Committee shall each appoint two members of the commission. Of the members first appointed by the Governor, one shall serve for a term of three years, and two for a term of two years. Of the members appointed by the Speaker of the Assembly and the Senate Rules Committee, one appointed by the Speaker of the Assembly and one appointed by the Senate Rules Committee shall serve for a period of three years with the other appointees to serve for a period of two years. Thereafter, all appointments shall be for four-year terms. (Added by Stats. 1982, Ch. 329, Sec. 11.)
14165.3.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
Verify source ↗

The commission must hire an executive director, legal counsel, and other needed staff within available Budget Act funds. Professional staff employees of the commission are exempt from civil service.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.3. The commission shall hire an executive director, legal counsel and such other staff as necessary consistent with funds appropriated in the Budget Act. All professional staff employees of the commission shall be exempt from civil service. (Added by Stats. 1982, Ch. 329, Sec. 11.)
14165.4.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
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The Legislature states that, starting July 1, 1983, the functions, powers, and duties in Article 2.6 are subject to this article’s provisions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.4. It is the intent of the Legislature that beginning July 1, 1983, the functions, powers, and duties contained in Article 2.6 (commencing with Section 14081) become subject to the provisions contained herein. (Amended by Stats. 2010, Ch. 717, Sec. 159. (SB 853) Effective October 19, 2010.)
14165.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
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The executive director must negotiate contract terms, services, and costs within available funds, and the commission reviews all such contracts and may reject a proposed contract within 20 days after the director approves it.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.5. The executive director shall act under the authority of the commission and shall negotiate the terms, services, and costs consistent with funds available. The commission shall serve as a review body for all contracts negotiated by the executive director. The commission may reject any proposed contract within 20 days after approval by the executive director. (Added by Stats. 1982, Ch. 329, Sec. 11.)
14165.50.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.15. Medi-Cal Funding for South Los Angeles [14165.50 - 14165.51] ( Article 5.15 added by Stats. 2010, Ch. 267, Sec. 2. )
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This section requires specified Medi-Cal payments for Martin Luther King, Jr. Community Hospital, including minimum fee-for-service and managed care payment levels, subject to federal law and other listed conditions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.15. Medi-Cal Funding for South Los Angeles [14165.50 - 14165.51] ( Article 5.15 added by Stats. 2010, Ch. 267, Sec. 2. ) ## 14165.50. (a) To facilitate the financial viability of the Martin Luther King, Jr. Community Hospital, a private nonprofit hospital that serves the population of South Los Angeles that was formerly served by the Los Angeles County Martin Luther King, Jr.-Harbor Hospital, Medi-Cal funding shall, at a minimum, be made available, as specified in this section, or pursuant to mechanisms that provide equivalent funding under successor or modified Medi-Cal payment systems. (b) Medi-Cal payment for hospital services provided by the hospital, exclusive of any payments pursuant to the Medi-Cal Hospital Reimbursement Improvement Act of 2013 (Article 5.230 (commencing with Section 14169.50)) or funded by another statewide hospital fee program, and exclusive of the supplemental payments specified in subdivision (d), shall include consideration of the hospital’s projected Medi-Cal costs for providing the services as set forth in this section. (1) (A) Subject to paragraph (2) of subdivision (c), and notwithstanding any other law, Medi-Cal payments made to the hospital on a fee-for-service basis, including payments made pursuant to the methodology authorized under Section 14105.28 or successor or modified methodologies, shall provide compensation that is, at a minimum, equal to 100 percent of the hospital’s projected Medi-Cal costs for each fiscal year. (B) To the extent Medi-Cal supplemental payments are necessary for any fiscal year to meet the applicable minimum reimbursement level, as described in subparagraph (A), the department shall seek federal approval, as necessary, to make the Medi-Cal supplemental payments. (2) (A) To the extent permitted under federal law, except as specified in paragraph (3) of subdivision (b) of Section 14165.51, the department shall require Medi-Cal managed care plans serving Medi-Cal beneficiaries in the County of Los Angeles to pay the hospital amounts determined necessary to meet compensation levels for services provided to Medi-Cal managed care enrollees that are no less than the amount that the hospital would have received on a fee-for-service basis pursuant to paragraph (1). The amounts shall be determined in consultation with the hospital, the County of Los Angeles, and the Medi-Cal managed care plan, and shall be subject to paragraph (2) of subdivision (c). (B) Consistent with federal law, the capitation rates paid to Medi-Cal managed care plans serving Medi-Cal beneficiaries in the County of Los Angeles shall be determined to reflect the obligations described in subparagraph (A). The increased payments to Medi-Cal managed care plans that would be paid consistent with actuarial certification and enrollment in the absence of this paragraph shall not be reduced as a consequence of this paragraph. (C) A Medi-Cal managed care plan receiving the increased payments described in subparagraph (B) shall not impose a fee or retention amount, or reduce other payments to the hospital that would result in a direct or indirect reduction to the amounts required to be paid under subparagraph (A). (3) This subdivision shall not be construed to result in payments that are less than the rates of compensation that would be payable to the hospital for Medi-Cal services without regard to the requirements of paragraphs (1) and (2). (c) If the applicable minimum reimbursement levels required in subdivision (b) result in payments to the hospital that are above the levels of compensation that would have been payable absent that requirement, and to the extent a nonfederal share is necessary with respect to the additional compensation, the following provisions shall apply: (1) (A) For each fiscal year through the 2016–17 fiscal year, General Fund amounts appropriated in the annual Budget Act for the Medi-Cal program shall fund the nonfederal share of the additional payments to the extent that the rates of compensation for inpatient hospital services provided by the hospital that would have been payable in the absence of the requirements of subdivision (b) are less than 77 percent of the hospital’s projected Medi-Cal costs. With respect to the nonfederal share of the additional payments described in paragraph (2) of subdivision (b), however, this subparagraph shall be applicable only for inpatient services provided in conjunction with the implementation of Section 14182, and other mandatory managed care enrollment provisions implemented subsequent to January 1, 2011. (B) For the 2017–18 fiscal year and each fiscal year thereafter, General Fund amounts appropriated in the annual Budget Act for the Medi-Cal program shall fund the nonfederal share of the additional payments to the extent that the rates of compensation for inpatient hospital services provided by the hospital that would have been payable in the absence of the requirements of subdivision (b) are less than 72 percent of the hospital’s projected Medi-Cal costs. With respect to the nonfederal share of the additional payments described in paragraph (2) of subdivision (b), however, this subparagraph shall be applicable only for inpatient services provided in conjunction with the implementation of Section 14182, and other mandatory managed care enrollment provisions implemented subsequent to January 1, 2011. (2) (A) The remaining necessary nonfederal share of the additional payments, after taking into account the General Fund amounts described in paragraph (1), may be funded with public funds that are transferred to the state from the County of Los Angeles, at the county’s election, pursuant to Section 14164. To the extent the county elects not to fund any portion of the remaining necessary nonfederal share, the applicable minimum reimbursement levels required in subdivision (b) shall be reduced accordingly. (B) Public funds transferred to the state for payments to the hospital, as described in this paragraph with respect to a fiscal period, shall be expended solely for the nonfederal share of the payments. Notwithstanding any other law, and except as provided in subdivision (m), the department shall not impose any fee or assessment in connection with the transferred funds or the payments provided for under this section, including, but not limited to, reimbursement for state staffing or administrative costs. (C) If any portion of the funds transferred pursuant to this paragraph is not expended, or not expected to be expended, for the specified rate amounts required in subdivision (b), the unexpended funds shall be returned promptly to the transferring county. (3) This subdivision shall not be construed to reduce the nonfederal share of payments funded by General Fund amounts below the amounts that would be funded without regard to the minimum payment levels required under this section. (d) (1) In addition to payments meeting the applicable minimum reimbursement levels described in subdivision (b), except as specified in paragraph (3) of subdivision (b) of Section 14165.51, the hospital shall be eligible to receive supplemental payments. The supplemental payments shall be provided annually in amounts determined in consultation with the hospital and the County of Los Angeles, and subject to paragraph (3). (2) The department shall seek federal approval, as necessary, to enable the hospital to receive supplemental payments that are in addition to the applicable minimum reimbursement levels required in subdivision (b). The supplemental payments may be provided for under the mechanisms described in Sections 14166.12 and 14301.4 or successor or modified mechanisms, or any other federally permissible payment mechanism. Supplemental payments that are payable through a Medi-Cal managed care plan shall be subject to the same requirements described in subparagraph (C) of paragraph (2) of subdivision (b). (3) If a nonfederal share is necessary to fund the supplemental payments, the County of Los Angeles may voluntarily provide public funds that are transferred to the state pursuant to Section 14164. The county may specify the type of supplemental payment for which it is transferring funds, and any other category relevant to the payment, including, but not limited to, fee-for-service supplemental payment, managed care rate range payment, and payment for services rendered to newly eligible beneficiaries as defined in subdivision (s) of Section 17612.2. (4) Public funds transferred to the state for supplemental payments to the hospital, as described in this subdivision with respect to a fiscal period, shall be expended solely for the nonfederal share of the supplemental payments as specified pursuant to paragraph (3). Notwithstanding any other law, subdivision (o) of Section 14166.12 shall not apply, and the department shall not assess the fee described in subdivision (d) of Section 14301.4, or any other similar fee, except as provided in subdivision (m). If any portion of the funds transferred pursuant to this subdivision is not expended, or not expected to be expended, for the specified supplemental payments, the unexpended funds shall be returned promptly to the transferring county. (e) Notwithstanding any other law, all payments provided for under this section shall be treated as having been paid for purposes of any determination of available room under the federal upper payment limit, as specified in Part 447 of Title 42 of the Code of Federal Regulations, with respect to the applicable class of services and class of health care provider. (f) For purposes of this article, the following definitions shall apply: (1) “Hospital” means a health facility that is certified under Title XVIII and Title XIX of the federal Social Security Act, and is licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code to provide acute inpatient hospital services, and includes all components of the facility, with an inpatient hospital service location on the campus of the Martin Luther King, Jr. Community Hospital. (2) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a comprehensive risk contract with the department to provide covered full-scope health care services to enrolled Medi-Cal beneficiaries pursuant to any provision of this chapter or Chapter 8 (commencing with Section 14200). (g) For purposes of this article, the hospital’s projected Medi-Cal costs shall be based on the cost finding principles applied under subdivision (b) of Section 14166.4, except that the projected costs shall not be multiplied by the federal medical assistance percentage and are not subject to the reimbursement limitations set forth in Article 7.5 (commencing with Section 51536) of Chapter 3 of Subdivision 1 of Division 3 of Title 22 of the California Code of Regulations. The projected Medi-Cal costs shall be determined prior to the start of each fiscal year in consultation with the hospital, using the best available and reasonable current estimates or projections made with respect to the hospital for an annual period, and shall be considered final as of the start of the fiscal year for purposes of the minimum payment levels described in subdivision (b). (h) Notwithstanding any other law, the hospital shall not be eligible to receive payments pursuant to Section 14166.11. This subdivision, however, shall not be construed to preclude the hospital from eligibility for disproportionate share status, or from receipt of any federal Medicaid disproportionate share hospital payments to which it would be entitled, pursuant to the Medi-Cal State Plan. (i) Except as specified in subdivision (h) and paragraph (3) of subdivision (b) of Section 14165.51, this section shall not be construed to preclude the hospital from receiving any other payment for which it is eligible in addition to the payments provided for by this section. (j) Notwithstanding any other law, for purposes of Article 12 (commencing with Section 17612.1) of Chapter 6 of Part 5, the intergovernmental transfers described in this section as reflected in the actual net expenditures for all operating budget units of the County of Los Angeles Department of Health Services shall not be reduced in any manner in the determination of total costs under paragraph (6) of subdivision (b) of Section 17612.5, by application of the imputed other entity intergovernmental transfer amounts or otherwise. (k) Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section by means of all-facility letters, all-county letters, or similar instructions, without taking further regulatory action. This section shall not be construed to preclude the department from adopting regulations. (l) (1) The department shall obtain federal approvals or waivers as necessary to implement this section and to obtain federal matching funds to the maximum extent permitted by federal law. This section shall be implemented only if, and to the extent that, federal financial participation is available and this section does not jeopardize the federal financial participation available for any other state program. (2) This section shall be implemented only if, and to the extent that, any necessary federal approvals are obtained. (m) As part of its voluntary participation to provide the nonfederal share of payments under this section, the County of Los Angeles shall agree to reimburse the state for the nonfederal share of state staffing and administrative costs directly attributable to the cost of administrating the payments and associated intergovernmental transfers pursuant to this section. The costs shall be documented and subject to review by the county. (Amended by Stats. 2024, Ch. 999, Sec. 7. (AB 177) Effective September 30, 2024.)
14165.51.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.15. Medi-Cal Funding for South Los Angeles [14165.50 - 14165.51] ( Article 5.15 added by Stats. 2010, Ch. 267, Sec. 2. )
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The department must set up a Medi-Cal managed care reimbursement method for the hospital by no later than January 1, 2026, and Medi-Cal managed care plans in Los Angeles County must increase payments under that method.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.15. Medi-Cal Funding for South Los Angeles [14165.50 - 14165.51] ( Article 5.15 added by Stats. 2010, Ch. 267, Sec. 2. ) ## 14165.51. (a) (1) For dates of service commencing no later than January 1, 2026, the department shall establish a Medi-Cal managed care directed payment reimbursement methodology in accordance with Section 438.6(c) of Title 42 of the Code of Federal Regulations applicable to the hospital. (2) The directed payment reimbursement methodology shall, at minimum: (A) Provide reimbursement for contracted hospital inpatient services such that aggregate managed care reimbursement to the hospital for hospital inpatient services, exclusive of any payments pursuant to Article 5.230 (commencing with Section 14169.50), is projected by the department to be at least equal to 72 percent of the hospital’s projected Medi-Cal costs for hospital inpatient services associated with the implementation of Section 14182, and other mandatory managed care enrollment provisions implemented subsequent to January 1, 2011. (B) Provide additional reimbursements to the hospital for contracted hospital inpatient and hospital outpatient services in a form and manner that is projected by the department to total twenty-five million dollars ($25,000,000) annually in addition to the amount described in subparagraph (A). (C) Align with the goals and objectives of the department’s comprehensive quality strategy. (D) To the extent appropriate, link payments to value and outcomes, consistent with measures selected by the department consistent with subparagraph (C), in addition to access to and utilization of services. (E) Be developed with consideration of the stability of the hospital’s cash flow. (F) Be developed in consultation with the hospital. (3) (A) The department shall, annually on a prospective basis, make the projections pursuant to subparagraphs (A) and (B) of paragraph (2), and may develop the projections on either an aggregate or individual service level, or both. (B) The department may require Medi-Cal managed care plans and the hospital to submit information regarding contract rates and expected or actual utilization of services, at the times and in the form and manner specified by the department. (C) In the event payments to the hospital at the level set forth in paragraph (2), in combination with any other reimbursement, exceed any federal statutory or regulatory limits on Medicaid reimbursement, the amount of payments that the Medi-Cal managed care plans make shall be reduced to comply with the applicable federal limitation. (D) In establishing the reimbursement methodology pursuant to paragraph (1) and the parameters for Medi-Cal managed care plans in the County of Los Angeles to make increased payments to the hospital pursuant to subdivision (b), the department shall consider strategies that are designed to result in the hospital receiving the payments pursuant to this section as quickly as practicable and on an ongoing or periodic basis that supports the stability of the hospital’s cash flow. (4) To the extent necessary to meet the objectives identified in paragraph (2) or to comply with federal requirements, the department may, in consultation with the hospital, adjust or modify the directed payment reimbursement methodology to meet applicable federal requirements and be consistent with actuarial rate development principles and standards. (b) (1) Medi-Cal managed care plans in the County of Los Angeles shall increase payments to the hospital in accordance with the requirements of the directed payment methodology established by the department pursuant to this section and guidance issued pursuant to subdivision (c). (2) Except as provided in paragraph (3), this section shall not be construed to preclude the hospital from receiving any other payment for which it is eligible in addition to the payments provided for by this section. (3) For any dates of service for which this section is implemented, in whole or in part, and notwithstanding any other law, a Medi-Cal managed care plan shall not be required to make any payments pursuant to Section 14165.50. (c) Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or similar instructions, without taking any further regulatory action. (d) (1) The department shall seek any federal approvals it deems necessary to implement this section. (2) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. (e) (1) The nonfederal share of increases to Medi-Cal managed care plan capitation rates made in accordance with this section shall be funded using General Fund moneys or other state funds appropriated to the department as the state share in the annual Budget Act. (2) Implementation of this section in each applicable fiscal year is subject to an appropriation in the annual Budget Act or another statute for the express purpose of this section. (Added by Stats. 2024, Ch. 999, Sec. 8. (AB 177) Effective September 30, 2024.)
14165.55.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.17. Nondesignated Public Hospital Medi-Cal Rate Stabilization Act [14165.55 - 14165.57] ( Article 5.17 added by Stats. 2011, Ch. 20, Sec. 2. )
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This section defines terms used in the nondesignated public hospital Medi-Cal rate stabilization article.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.17. Nondesignated Public Hospital Medi-Cal Rate Stabilization Act [14165.55 - 14165.57] ( Article 5.17 added by Stats. 2011, Ch. 20, Sec. 2. ) ## 14165.55. For the purposes of this article, the following definitions shall apply: (a) “Bad debt charges” means deductions from revenue for bad debt. (b) “Charity care charges” means deductions from revenue for charity care. (c) “Contract Hospital” means a nondesignated public hospital, which has a Medi-Cal fee-for-service contract negotiated by the California Medical Assistance Commission in effect as of December 31 of the applicable state fiscal year. (d) “Contract Hospital allocation” means the portion of the Nondesignated Public Hospital IGT Pool that is allocated to and transferred to the state by the transferring entity on behalf of the contract hospitals. (e) “Converted hospital” means a private hospital that becomes a designated public hospital or a nondesignated public hospital on or after July 1 of any state fiscal year, a nondesignated public hospital that becomes a private hospital or a designated public hospital on or after July 1 of any state fiscal year, or a designated public hospital that becomes a private hospital or a nondesignated public hospital on or after July 1 of any state fiscal year. A hospital shall be considered a converted hospital only for the fiscal year during which it became a converted hospital. (f) “Intergovernmental transfer (IGT)” means the transfer of public funds by the public entity to the state in accordance with the requirements of this section. (g) “Intergovernmental transfer allocation” or “IGT allocation” means the amount of the Nondesignated Public Hospital IGT Pool allocated to a nondesignated public hospital for a state fiscal year. Each transferring entity may agree to transfer its IGT allocation to the state in order to participate in the Nondesignated Public Hospital Intergovernmental Transfer Program in accordance with this section and Section 14164. (h) “Intergovernmental transfer formula group” or “IGT formula group” means any of the following groups: (1) Contract Hospitals that have an IGT Formula Score of between seven and nine, inclusive. (2) Contract Hospitals that have an IGT Formula Score of between four and six, inclusive. (3) Contract Hospitals that have an IGT Formula Score of between one and three, inclusive. (4) Non-Contract Hospitals that have an IGT Formula Score of between seven and nine, inclusive. (5) Non-Contract Hospitals that have an IGT Formula Score of between four and six, inclusive. (6) Non-Contract Hospitals that have an IGT Formula Score of between one and three, inclusive. (i) “New nondesignated hospital” means a hospital that was not in operation under current or prior ownership as a nondesignated public hospital for any portion of the calendar year prior to July 1 of any state fiscal year. A hospital shall be considered a new hospital only for the fiscal year during which it began operating. (j) “Non-Contract Hospital” means a nondesignated public hospital, which does not have a Medi-Cal fee-for-service contract negotiated by the California Medical Assistance Commission in effect as of December 31 of the applicable state fiscal year. (k) “Non-Contract Hospital allocation” means the portion of the Nondesignated Public Hospital IGT Pool that is allocated to and transferred to the state by the transferring entity on behalf of the Non-Contract Hospitals. (l) “Nondesignated public hospital” means either of the following: (1) A public hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code, is not designated as a specialty hospital in the hospital’s latest annual Office of Statewide Health Planning and Development (OSHPD) financial disclosure report for the hospital, and satisfies the definition in paragraph (25) of subdivision (a) of Section 14105.98, excluding designated public hospitals, as described in subdivision (d) of Section 14166.1 as that section may be amended from time to time. (2) A tax-exempt nonprofit hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code, is not designated as a specialty hospital in the hospital’s latest annual OSHPD financial disclosure report, is a hospital operated, owned, or both by a local health care district, and is affiliated with the health care district hospital owner by means of the district’s status as the nonprofit corporation’s sole corporate member. (m) “Nondesignated Public Hospital Intergovernmental Transfer Pool” or “Nondesignated Public Hospital IGT Pool” means the pool of funds that will be utilized as the state’s share of the aggregate payments funded by the transferring entity’s intergovernmental transfers for a state fiscal year. This amount shall be calculated based on the room under the federal Upper Payment Limit (UPL) in the category of Non-State Government Owned Hospitals (Inpatient) which the department has determined is both attributable to the nondesignated public hospitals and available for the purposes of this article as determined by the department pursuant to Section 14165.56. (n) “Public entity” means the transferring entity, which may be a city, county, special purpose district, or other governmental unit in the state, regardless of whether the unit of government is also a health care provider, except as prohibited by federal law. (o) “Transferring entity” means a public entity that transfers public funds to the state in accordance with subdivision (f) of Section 14165.57 and is a public entity as defined in subdivision (n). (p) “Upper payment limit” or “UPL” means the federal upper payment limit category as defined in Sections 447.272 and 447.321 of Title 42 of the Code of Federal Regulations for the amount of the Medicaid payments for which federal financial participation is available for a class of service and a class of health care providers. (Added by Stats. 2011, Ch. 20, Sec. 2. (AB 113) Effective April 13, 2011.)
14165.56.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.17. Nondesignated Public Hospital Medi-Cal Rate Stabilization Act [14165.55 - 14165.57] ( Article 5.17 added by Stats. 2011, Ch. 20, Sec. 2. )
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The department must set up and run a transfer program for nondesignated public hospitals, and it may make supplemental inpatient fee-for-service payments when permitted by federal approval and available funding rules.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.17. Nondesignated Public Hospital Medi-Cal Rate Stabilization Act [14165.55 - 14165.57] ( Article 5.17 added by Stats. 2011, Ch. 20, Sec. 2. ) ## 14165.56. (a) The department shall establish, implement, and maintain the Nondesignated Public Hospital Intergovernmental Transfer Program to provide supplemental payments to nondesignated public hospitals in a manner that maximizes federal financial participation in the resulting supplemental payments. The department shall develop and implement the program subject to receiving all federal approvals. (b) Upon receiving federal approval, the department shall fully implement this section beginning with the 2010–11 fiscal year. The department shall perform all acts necessary to secure the maximum level of federal financial participation for payments resulting from the Nondesignated Public Hospital IGT Pool. The department shall make every effort to implement this section for the 2010–11 fiscal year so that all allocations will be determined, all intergovernmental transfers will be received by the state, and federal financial participation will be drawn in order for the department to make payments due to each nondesignated public hospital prior to July 1, 2011. (c) By August 1 of each fiscal year, beginning with the 2011–12 fiscal year and every year thereafter, the department shall provide an estimate of the Non-State Government Owned Hospital (Inpatient) UPL associated with the inpatient fee-for-service payments to nondesignated public hospitals in order to establish both the UPL and the available room under the UPL. The department may make supplemental inpatient fee-for-service payments to nondesignated public hospitals using some or all of the shortfall level below the UPL. The amount identified by the department as available for those payments shall be multiplied by 100 percent minus the annual federal medical assistance percentage, as defined in Part 433 of Title 42 of the Code of Federal Regulations and shall be the amount available in the Nondesignated Public Hospital Intergovernmental Transfer Pool. The payments made pursuant to this article may be funded using public entity intergovernmental transfers and associated federal financial participation. (d) Once the department has estimated the UPL and the potential supplemental payment relating to nondesignated public hospitals, the department shall use the IGT allocation formula described in Section 14165.57 to determine the estimated IGT allocation for each nondesignated public hospital from the Nondesignated Public Hospital IGT Pool using the most recent data publicly available from the federal Centers for Medicare and Medicaid Services (CMS), and the federal Health Resources and Services Administration (HRSA). (Amended by Stats. 2012, Ch. 162, Sec. 217. (SB 1171) Effective January 1, 2013.)
14165.57.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.17. Nondesignated Public Hospital Medi-Cal Rate Stabilization Act [14165.55 - 14165.57] ( Article 5.17 added by Stats. 2011, Ch. 20, Sec. 2. )
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This section sets the process for calculating and notifying nondesignated public hospitals about IGT allocations, deadlines for responses, and how supplemental payments are handled.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.17. Nondesignated Public Hospital Medi-Cal Rate Stabilization Act [14165.55 - 14165.57] ( Article 5.17 added by Stats. 2011, Ch. 20, Sec. 2. ) ## 14165.57. (a) The IGT allocation formula shall use data from each nondesignated public hospital’s latest Hospital Annual Financial Disclosure Report on file with OSHPD as of March 1 of each prior fiscal year and shall be as follows: (1) The Nondesignated Public Hospital IGT Pool shall be allocated into two allocations: the Contract Hospitals allocation and the Non-Contract Hospitals allocation. This allocation shall be made to each group, respectively, based upon the ratio of Medi-Cal fee-for-service acute patient days listed in the latest OSHPD Annual Financial Disclosure Report for Contract Hospitals and Non-Contract Hospitals to the total Medi-Cal fee-for-service acute patient days provided by all Contract Hospitals and Non-Contract Hospitals. Medi-Cal fee-for-service acute patient days for converted hospitals and new hospitals will not be included in this allocation. (2) The department shall determine if a nondesignated public hospital provides services in either a federally recognized Health Professional Shortage Area or to a federally recognized Medically Underserved Area or Population. The department shall also determine if the nondesignated public hospital is federally recognized as either a Critical Access Hospital or a Sole Community Provider. If any of these conditions apply, the hospital shall score one point. Otherwise, the hospital shall score zero points. (3) The department shall calculate for each nondesignated public hospital the charity care charges as a percentage of the hospital’s total gross revenue. If the charity care charges are greater than or equal to 3 percent of the total gross revenue, the hospital shall score three points. If the charity care charges are less than 3 percent, but more than or equal to 1 percent, of the total gross revenue, the hospital shall score two points. If the charity care charges are less than 1 percent, but greater than 0 percent, of the total gross revenue, the hospital shall score one point. If charity care charges are less than or equal to 0 percent, of the total gross revenue, the hospital shall score zero points. (4) The department shall calculate for each nondesignated public hospital the bad debt charges as a percentage of the hospital’s other payer’s gross revenue, as disclosed in the Hospital Annual Financial Disclosure Report. If the bad debt charges are greater than or equal to 40 percent of the other gross revenue, the hospital shall score two points. If the bad debt charges are less than 40 percent, but greater than 0 percent, of the other gross revenue, the hospital shall score one point. If the bad debt charges are less than or equal to 0 percent, of the other gross revenue, the hospital shall score zero points. (5) The department shall calculate for each nondesignated public hospital the Medi-Cal charges as a percentage of the hospital’s total gross revenue. If the Medi-Cal charges are greater than or equal to 25 percent of the total gross revenue, the hospital shall score three points. If the Medi-Cal charges are less than 25 percent, but more than or equal to 12 percent, of the total gross revenue, the hospital shall score two points. If the Medi-Cal charges are less than 12 percent, but greater than 0 percent, of the total gross revenue, the hospital shall score one point. If the Medi-Cal charges are less than or equal to 0 percent of total gross revenue, the hospital shall score zero points. (6) The sum of each nondesignated public hospital’s points accumulated pursuant to paragraphs (2) to (5), inclusive, shall constitute the hospital’s IGT Formula Score. The IGT Formula Score for a new hospital or a converted hospital shall be equal to zero. (7) The Contract Hospital allocation shall be allocated among Contract Hospitals and the Non-Contract Hospital allocation shall be allocated among Non-Contract Hospitals to determine preliminary allocations in accordance with the following: (A) Each Contract Hospital that has an IGT Formula Score of between seven and nine, inclusive, shall be allocated three times the amount of the Contract Hospital allocation that is allocated to each Contract Hospital that has a score of one to three, inclusive. (B) Each Contract Hospital that has an IGT Formula Score of between four and six, inclusive, shall be allocated two times the amount of the Contract Hospital allocation that is allocated to each Contract Hospital that has an IGT Formula Score of one to three, inclusive. (C) Each Non-Contract Hospital that has an IGT Formula Score of between seven and nine, inclusive, shall be allocated three times the amount of the Non-Contract Hospital allocation that is allocated to each Non-Contract Hospital that has an IGT Formula Score of one to three, inclusive. (D) Each Non-Contract Hospital that has an IGT Formula Score of between four and six, inclusive, shall be allocated two times the amount of the Non-Contract Hospital allocation that is allocated to each Non-Contract Hospital that has an IGT Formula Score of one to three, inclusive. (E) No amount shall be allocated to a nondesignated public hospital with an IGT Formula Score of zero points. (8) The sum of the preliminary allocation determined under paragraph (7) for all hospitals within each IGT Formula Group shall be reallocated among the hospitals within each IGT Formula Group based on the ratio of each hospital’s staffed acute beds listed in the latest OSHPD Annual Financial Disclosure Report, to the total staffed acute beds of all hospitals in the IGT Formula Group. (b) By no later than September 1 of the 2011–12 fiscal year or as soon thereafter as federal approvals are obtained, and by no later than September 1 of each fiscal year thereafter, the department shall provide each nondesignated public hospital with an estimated IGT allocation notice that includes the calculations and data sources used to calculate the estimated IGT allocation, as described in this section. (c) Each nondesignated public hospital shall have 30 days from receipt of the estimated IGT allocation notice from the department to review the department’s hospital-specific estimated IGT allocation and to notify the department of any data or calculation errors. If the hospital does not respond within 30 days, the information will be deemed accurate. No later than November 30 of each fiscal year, the department shall incorporate all appropriate corrections or data updates for all of the nondesignated public hospitals and then recalculate the IGT allocations using the IGT allocation formula to obtain a final IGT allocation for each nondesignated public hospital. (d) Beginning with the 2011–12 fiscal year, on or before December 1 or as soon thereafter as federal approvals are obtained, and by no later than December 1 of each fiscal year thereafter, the department shall send each nondesignated public hospital a notice of eligibility indicating the final IGT allocation for the nondesignated public hospital. The nondesignated public hospital shall have 20 business days after receipt of the notice to either accept or decline the offer. If a nondesignated public hospital accepts the offer, the nondesignated public hospital may enter into an IGT agreement with the department. If the department receives no response, the offer will be considered declined. (e) Before the later of December 31 of the 2011–12 fiscal year, the date upon which all federal approvals are obtained, and by no later than January 15 of each state fiscal year thereafter, the department shall document all nondesignated public hospital IGT allocation offers that are either accepted or declined. After the department has recorded all IGT allocations as being either accepted or declined, any remaining unsubscribed IGT allocations will be allocated to all the other participating nondesignated public hospitals on a pro rata basis based on the final IGT allocations calculated pursuant to subdivision (b) during January of each fiscal year. The department shall inform each nondesignated public hospital participating in the program of the revised final IGT allocation assigned to that hospital by January 30. At that time, the department shall give each nondesignated public hospital participant five days to accept or decline participation in the program. (f) The state may accept all public funds in the amount of the final IGT allocation from a transferring entity pursuant to this section, provided that any funds from a transferring entity must be permitted by law to be used for these purposes. The transferring entity shall certify to the department that the funds it proposes to transfer satisfy the requirements of this subdivision, and are in compliance with all federal rules and regulations. (g) The state shall deposit the funds received from the transferring entities pursuant to this article into the Medi-Cal Inpatient Payment Adjustment Fund established in accordance with Section 14163. (h) Nondesignated public hospitals participating in the program shall inform the public entity funding the IGT to transfer the appropriate IGT allocation, by February 5 of each fiscal year, to the state according to the time schedule specified in the written agreement specified in subdivision (d). By March 31 of each fiscal year, the department shall make the supplemental payment to the nondesignated public hospital including the associated federal financial participation. The deadlines set forth in this subdivision shall be implemented beginning with the 2011–12 fiscal year or as soon thereafter as federal approvals are obtained. (i) The department shall establish written policies and procedures for transferring entity intergovernmental transfers and payments made to nondesignated public hospitals pursuant to this section. The department shall effectively communicate these policies and procedures to nondesignated public hospitals and the public entities that will be funding the IGTs in order to facilitate a smooth process using local public entity moneys for purposes of drawing down federal financial participation for supplemental payments to nondesignated public hospitals. (j) (1) A nondesignated public hospital participating in the program, as a condition of receiving supplemental payment pursuant to this section, shall reimburse the department for the costs of administering this section. (2) For each fiscal year up to and including the 2025–26 fiscal year, the state shall retain 9 percent of each IGT amount to reimburse the department, or transfer to the General Fund, for the administrative costs of operating the Nondesignated Public Hospital Intergovernmental Transfer Program and for the benefit of Medi-Cal children’s health care programs. (3) (A) Beginning with the 2026–27 fiscal year and every fiscal year thereafter, the state shall retain a percentage of each IGT amount associated with interim supplemental payments such that the total amount retained is equal to the projected administrative cost to the department associated with implementing this section. The department shall project the administrative cost associated with implementing this section each fiscal year in order to determine the percentage of each IGT associated with interim supplemental payments to be retained. That calculation shall account for any excess funds remaining from a prior fiscal year. (B) It is the intent of the Legislature in enacting the changes to this section made by the act that added this paragraph to provide the supplement payment described in this section without any expenditure from the General Fund, beginning with the 2026–27 fiscal year and every fiscal year thereafter. (k) Participation in the intergovernmental transfers under this article is voluntary on the part of the transferring entities for the purpose of all applicable federal laws. (l) (1) The department shall report annually to the Legislature on the Nondesignated Public Hospital Intergovernmental Transfer Program. This report shall include, but not be limited to, the amount of funds available within the UPL, the total amount of IGT allocation funds transferred by public entities, the total amount of federal financial participation received by nondesignated public hospitals, and information on the effectiveness of the IGT allocation formula to distribute available federal matching funds among participating nondesignated public hospitals. (2) The requirement for submitting a report to the Legislature on the Nondesignated Public Hospital Intergovernmental Transfer Program imposed under paragraph (1) is inoperative four years after the date the first report is due. (3) A report to be submitted pursuant to paragraph (1) shall be submitted in compliance with Section 9795 of the Government Code. (m) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this article by means of policy letters or similar instructions, without taking further regulatory action. (Amended by Stats. 2025, Ch. 21, Sec. 110. (AB 116) Effective June 30, 2025.)
14165.6.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
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The commission must direct the planning, development, and negotiation of contract services for specified health care services.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.6. The commission shall direct the planning, development and negotiation of contract services which provide for: (a) The provision of services through a capitation methodology, including, but not limited to, health maintenance organizations, organized county health systems, insurance companies, and independent practice associations. (b) Hospital inpatient or hospital outpatient services. (c) Pilot projects meeting the provisions of Section 14491.5. (d) Health care projects meeting the provisions of Article 2.91 (commencing with Section 14089). (Added by Stats. 1982, Ch. 329, Sec. 11.)
14165.7.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
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The commission must decide by a majority of four votes, including hiring the executive director, and must retain legal counsel to review contracts.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.7. All decisions of the commission shall be by a majority of four votes, including the hiring of the executive director. The commission shall retain an independent office of legal counsel for purposes of contract review. All contracts shall be reviewed by legal counsel. (Added by Stats. 1982, Ch. 329, Sec. 11.)
14165.8.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
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The commission receives an annual salary of $50,000 starting January 1, 2006, and it sets the salary of the executive director and other staff within appropriated funds.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.8. The commission shall be reimbursed at the annual salary of fifty thousand dollars ($50,000), beginning on January 1, 2006. The commission shall set the salary of the executive director and other staff consistent with funds appropriated. The annual compensation provided by this section shall be increased in any fiscal year in which a general salary increase is provided for state employees. The amount of the increase provided by this section shall be comparable to, but shall not exceed, the percentage of the general salary increases provided for state employees during that fiscal year. (Amended by Stats. 2005, Ch. 77, Sec. 38. Effective January 1, 2006.)
14165.9.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
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The commission must report to the Legislature twice each year, on January 1 and May 1.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.9. The commission shall report to the Legislature on January 1 and May 1 of each year. The January report shall include all of the following: (a) The number and type of health service contracts. (b) The persons served, cost per service, and other relevant and statistical information. (c) The projected contract services and estimated costs. (d) The average per diem rate received by contract hospitals, as of December 1 of the preceding year, shall be reported in the following categories: (1) Statewide. (2) By standard consolidated statistical area, as defined by the most recent United States Census. (3) By that portion of the state not included within a standard consolidated statistical area. (4) Statewide by hospitals with 1–99 beds, 100–299 beds, and over 300 beds. (e) The total number of hospitals receiving a net increase, a net decrease, or having a contract rate tied to patient volume during the preceding 12 months. (f) A discussion of the effects of selective contracting on access to, and quality of, services. In preparing this portion of the report, the commission shall solicit comments from representatives of beneficiaries and providers. The May report shall serve as an update of information contained in subdivisions (a) to (c), inclusive, of the January report. (Amended by Stats. 1988, Ch. 873, Sec. 1.)
14165.95.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. )
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The commission must submit an evaluation of its inpatient hospital service procedure to the Legislature by February 1, 1984.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.1. California Medical Assistance Commission [14165 - 14165.11] ( Article 5.1 added by Stats. 1982, Ch. 329, Sec. 11. ) ## 14165.95. On or before February 1, 1984, the commission shall submit to the Legislature an evaluation of its inpatient hospital service procedure, including, but not limited to, the following: (a) The recommended duration of contracts. (b) The effect of the disclosure of executed contracts on the price levels of subsequently negotiated contracts. (c) The conditions under which contractors failing to secure a contract on a first bid should be allowed to rebid. (d) The effectiveness of contract provisions designed to ensure access to hospital services and a high quality of care. (e) The effect of flat per diem rates on the variety of cases treated by contract hospitals. The evaluation provided for by this section shall be accompanied by a recommendation for any relevant legislation deemed necessary by the commission. (Added by Stats. 1983, Ch. 182, Sec. 1.)
14166.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section names the Medi-Cal Hospital/Uninsured Care Demonstration Project Act and explains its purpose: to support hospital funding, federal matching funds, and stable Medi-Cal payments.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166. (a) This article shall be known and may be cited as the “Medi-Cal Hospital/Uninsured Care Demonstration Project Act.” (b) The Legislature finds and declares all of the following: (1) The preservation of the state’s disproportionate share hospitals and the University of California hospitals is of critical importance to the health and welfare of the people of the state. (2) These hospitals, as well as many nondisproportionate district hospitals, are facing unprecedented financial challenges. Many are facing significant budget deficits impeding their ability to continue serving their essential role in the health care delivery system, including providing care to Medi-Cal beneficiaries and uninsured patients. (3) The financial viability of these hospitals has been sustained through funding that has been available for California’s disproportionate share hospital program under Medi-Cal. Without these funds, many of these hospitals would be unable to keep their doors open and others would be forced to curtail services, thereby impacting service to Medi-Cal beneficiaries and other needy individuals. (4) The federal Centers for Medicare and Medicaid Services has indicated in negotiations with the State Department of Health Services that it is changing its approach to federal funding of Medicaid in various respects. For instance, the methodology that many states, including California, have used to fund their disproportionate share hospital programs successfully for more than a decade has become the subject of negative attention by the federal Centers for Medicare and Medicaid Services, which is refusing to approve discretionary waivers and state plan amendments that rely on these funding methods. Accordingly, the State of California has proposed that the funding mechanism for inpatient hospital services under Medi-Cal be modified to secure federal approval and address continued and adequate funding to the University of California and disproportionate share hospitals. To this end, the state has negotiated a waiver from various federal Medicaid requirements that will allow it to implement a demonstration project using modified funding methodologies. The Medi-Cal Hospital/Uninsured Care Demonstration Project is intended to make up to $3.3 billion in additional federal funds available to California safety net hospitals over a five-year period. (5) The methodologies used to fund the Medi-Cal program should maximize the use of federal funds consistent with federal Medicaid law in an effort to access all of the increased federal funding available under the Medi-Cal Hospital/Uninsured Care Demonstration Project. (6) The amount of Medi-Cal funding to the University of California hospitals and disproportionate share hospitals as a whole should not be less than the amount of funding for the 2004-05 fiscal year. Similarly, the amount of Medi-Cal funding for the public disproportionate share hospitals as a group and for the private disproportionate share hospitals as a group should not be less than the amount of funding for the 2004-05 fiscal year. (7) The distributions of Medi-Cal funds should provide a predictable and stable amount of funding for these hospitals in order to allow them to engage in short-term and long-term planning. The distribution methodologies should be fair and equitable, and take into account utilization changes among hospitals. (8) The payments of Medi-Cal funds to these hospitals should be made regularly and periodically throughout the year in order to provide hospitals with necessary cashflow. (Added by Stats. 2005, Ch. 560, Sec. 1. Effective October 5, 2005. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.1.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section defines key terms used in the Medi-Cal hospital care demonstration project article.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.1. For purposes of this article, the following definitions shall apply: (a) “Allowable costs” means those costs recognized as allowable under Medicare reasonable cost principles and additional costs recognized under the demonstration project and successor demonstration project, including those expenditures identified in Appendix D to the Special Terms and Conditions for the demonstration project and successor demonstration project. Allowable costs under this subdivision shall be determined in accordance with the Special Terms and Conditions and implementation documents for the demonstration project and successor demonstration project approved by the federal Centers for Medicare and Medicaid Services. (b) “Base year private DSH hospital” means a nonpublic hospital, nonpublic-converted hospital, or converted hospital, as those terms are defined in paragraphs (26), (27), and (28), respectively, of subdivision (a) of Section 14105.98, that was an eligible hospital under paragraph (3) of subdivision (a) of Section 14105.98 for the 2004–05 state fiscal year. (c) “Demonstration project” means the Medi-Cal Hospital/Uninsured Care Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services, effective for the period of September 1, 2005, through October 31, 2010. (d) “Designated public hospital” means any one of the following hospitals to the extent identified in Attachment C, “Government-operated Hospitals to be Reimbursed on a Certified Public Expenditure Basis,” to the Special Terms and Conditions for the demonstration project and successor demonstration project, as applicable, issued by the federal Centers for Medicare and Medicaid Services: (1) UC Davis Medical Center. (2) UC Irvine Medical Center. (3) UC San Diego Medical Center. (4) UC San Francisco Medical Center. (5) UC Los Angeles Medical Center, including Santa Monica/UCLA Medical Center. (6) LA County Harbor/UCLA Medical Center. (7) LA County Martin Luther King Jr.-Harbor Hospital. (8) LA County Olive View UCLA Medical Center. (9) LA County Rancho Los Amigos National Rehabilitation Center. (10) LA County University of Southern California Medical Center. (11) Alameda Health System. (12) Arrowhead Regional Medical Center. (13) Contra Costa Regional Medical Center. (14) Kern Medical Center. (15) Natividad Medical Center. (16) Riverside County Regional Medical Center. (17) San Francisco General Hospital. (18) San Joaquin General Hospital. (19) San Mateo Medical Center. (20) Santa Clara Valley Medical Center. (21) Tuolumne General Hospital. (22) Ventura County Medical Center. (e) “Federal medical assistance percentage” means the federal medical assistance percentage applicable for federal financial participation purposes for medical services under the Medi-Cal state plan pursuant to Section 1396b(a) of Title 42 of the United States Code. (f) “Nondesignated public hospital” means a public hospital defined in paragraph (25) of subdivision (a) of Section 14105.98, excluding designated public hospitals. (g) “Project year” means the applicable state fiscal year of the Medi-Cal Hospital/Uninsured Care Demonstration Project through October 31, 2010. (h) “Project year private DSH hospital” means a nonpublic hospital, nonpublic-converted hospital, or converted hospital, as those terms are defined in paragraphs (26), (27), and (28), respectively, of subdivision (a) of Section 14105.98, that was an eligible hospital under paragraph (3) of subdivision (a) of Section 14105.98, for the particular project year. (i) “Prior supplemental funds” means the Emergency Services and Supplemental Payments Fund, the Medi-Cal Medical Education Supplemental Payment Fund, the Large Teaching Emphasis Hospital and Children’s Hospital Medi-Cal Medical Education Supplemental Payment Fund, and the Small and Rural Hospital Supplemental Payments Fund, established under Sections 14085.6, 14085.7, 14085.8, and 14085.9, respectively. (j) “Private hospital” means a nonpublic hospital, nonpublic-converted hospital, or converted hospital, as those terms are defined in paragraphs (26) to (28), inclusive, respectively, of subdivision (a) of Section 14105.98. (k) “Safety net care pool” means the federal funds available under the Medi-Cal Hospital/Uninsured Care Demonstration Project and the successor demonstration project to ensure continued government support for the provision of health care services to uninsured populations. (l) “Uninsured” shall have the same meaning as that term has in the Special Terms and Conditions issued by the federal Centers for Medicare and Medicaid Services for the demonstration project and the successor demonstration project. (m) “Successor demonstration project” means the Medicaid demonstration project entitled “California’s Bridge to Reform,” No. 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services, effective for the period of November 1, 2010, through October 31, 2015. (n) “Successor demonstration year” means the demonstration year as identified in the Special Terms and Conditions for the successor demonstration project that corresponds to a specific period of time as follows: (1) Successor demonstration year 6 corresponds to the period of November 1, 2010, through June 30, 2011. (2) Successor demonstration year 7 corresponds to the period of July 1, 2011, through June 30, 2012. (3) Successor demonstration year 8 corresponds to the period of July 1, 2012, through June 30, 2013. (4) Successor demonstration year 9 corresponds to the period of July 1, 2013, through June 30, 2014. (5) Successor demonstration year 10 corresponds to July 1, 2014, through October 31, 2015. (o) “Low Income Health Program” means the county-based elective program to provide benefits for low-income individuals that is authorized by the successor demonstration project and implemented by Part 3.6 (commencing with Section 15909). (p) “Delivery system reform incentive pool” means the separate federal funding pool created within the safety net care pool under the successor demonstration project that is available to support programs of activity to enhance the quality of care and health of patients served by designated public hospitals and nonhospital clinics and other provider types with which they are affiliated, and, under specified conditions and approval of the federal Centers for Medicare and Medicaid Services, to private disproportionate share hospitals and nondesignated public hospitals. (Amended by Stats. 2014, Ch. 46, Sec. 5. (SB 1352) Effective January 1, 2015. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.10.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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Payments to private hospitals under the demonstration project must include the listed payment types, and they are added to any other payments allowed by law.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.10. (a) Payments to private hospitals under the demonstration project shall include, as applicable, all of the following: (1) Payments under selective provider contracts with the department negotiated by the California Medical Assistance Commission in accordance with Article 2.6 (commencing with Section 14081). (2) Disproportionate share hospital replacement payments under Section 14166.11. (3) Supplemental payments under Section 14166.12. (4) Payments to distressed hospitals as negotiated by the California Medical Assistance Commission pursuant to Section 14166.23. (5) Payments of amounts described in Section 14166.14. (b) Payments under subdivision (a) shall be in addition to other payments that may be made in accordance with law. (Amended by Stats. 2006, Ch. 327, Sec. 6. Effective January 1, 2007. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.11.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The department must make and reconcile payments to eligible private hospitals under the Medi-Cal hospital care demonstration project, using specified formulas, lists, and timing rules.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.11. (a) The department shall pay to each project year private DSH hospital the amounts that would have been paid under the disproportionate share hospital program using the formulas and methodology in effect for the 2004–05 fiscal year as more specifically set forth in this section. (b) For each project year, the department shall develop and issue a tentative and final disproportionate share list in accordance with Section 14105.98. (c) For each project year, the department shall perform the computations set forth in paragraphs (1) to (4), inclusive, and (6) to (8), inclusive, of subdivision (am) and paragraphs (1) to (3), inclusive, of subdivision (an) of Section 14105.98, subject to the following: (1) For purposes of these computations, the maximum state disproportionate share hospital allotment for California for each project year shall be the allotment effective during the federal fiscal year beginning during the project year. (2) All references to October 1 shall be deemed to be references to July 1. (3) Notwithstanding any other provision of law, the transfer amounts for the Medi-Cal Inpatient Payment Adjustment Fund to the Health Care Deposit Fund, as provided for pursuant to paragraph (2) of subdivision (d) of Section 14163 shall be deemed to be eighty-five million dollars ($85,000,000) for purposes of the computations under this subdivision. (4) Notwithstanding any other provision of law, the payments made under this section shall be treated as payment adjustments made under Section 14105.98 for purposes of computing the OBRA 1993 payment limitation, as defined in paragraph (24) of subdivision (a) of Section 14105.98, the low-income utilization rate, and all related computations. (5) Subdivision (m) of Section 14105.98 shall apply to payments made under this section. (d) Interim payments shall be made for the first five months of each project year as follows: (1) Interim payments shall be made to each private hospital identified on a tentative disproportionate share list for the project year that was also on the final disproportionate share list for the prior fiscal year. The interim payment amount per month for each of these hospitals shall equal one-twelfth of the total payments, excluding stabilization funds, made to the hospital for the prior fiscal year under this section or under Section 14105.98. The interim payment amount may be adjusted to reflect any changes in the total payment amounts, excluding stabilization funds, projected to be made under this section for the project year. (2) The computation of interim payments described in this subdivision shall be made promptly after the department issues the tentative disproportionate share hospital list for the project year. (3) The first interim payment for a project year shall be made to each hospital no later than 60 days after the issuance of the tentative disproportionate share hospital list for that project year and shall include the interim payment amounts for all prior months in the project year. Subsequent interim payments for a project year shall be made on the last checkwrite of each month made by the Controller until interim payments for the first five months of the project year have been made. (4) The department may recover any interim payments for a project year made under this subdivision to a hospital that is not on the final disproportionate share hospital list for that project year. These interim payments shall be considered an overpayment. The department shall issue a demand for repayment to a hospital at least 30 days prior to taking action to recover the overpayment. After the 30-day period, the department may recover the overpayment using any of the methods set forth in Section 14115.5 or subdivision (c) of Section 14172.5. Any offset shall be subject to Section 14115.5 or subdivision (d) of Section 14172.5. No other provision of Section 14172.5 shall be applicable with respect to the recovery of overpayments under this subdivision. A hospital may appeal the department’s determination of an overpayment under this subdivision pursuant to the appeal procedures set forth in Sections 51016 to 51047, inclusive, of Title 22 of the California Code of Regulations, and seek judicial review of the final administrative decision pursuant to Section 14171, provided that the only issues that may be raised in this appeal are whether the hospital, but for inadvertent error by the department, was on the final disproportionate share list for the project year and whether the department’s computation of the overpayment amount is correct. If the hospital is reinstated on the final disproportionate share list pursuant to Section 14105.98, the department shall promptly refund any amount recovered under this paragraph. (e) Tentative adjusted monthly payments shall be made for the months of December through March of each project year to each private hospital identified on the final disproportionate share hospital list for the project year, computed and paid as follows: (1) An adjusted payment amount shall be computed for each hospital equal to the sum of the total payment adjustment amount for the hospital computed pursuant to subdivision (am) of Section 14105.98, plus the supplemental lump-sum payment adjustment amount computed pursuant to subdivision (an) of Section 14105.98, each as most recently computed by the department, plus any applicable interim estimated stabilization funding pursuant to subdivision (b) of Section 14166.14. (2) A tentative adjusted monthly payment amount shall be computed for each hospital equal to the adjusted payment amount for the hospital, minus the aggregate interim payments made to the hospital for the project year, divided by seven. (3) The computation of tentative adjusted monthly payments described in this subdivision shall be made promptly after the department issues the final disproportionate share hospital list for the project year. (4) The first tentative adjusted monthly payment for a project year shall be made to each hospital by January 15 or within 60 days after the issuance of the final disproportionate share hospital list for the project year, whichever is later, and shall include the tentative adjusted monthly payment amounts for all prior months in the project year for which those payments are due. Subsequent tentative adjusted monthly payments for a project year shall be made on the last checkwrite of each month made by the Controller until tentative adjusted monthly payments for December through March of the project year have been made. (f) Three data corrected payments shall be made on the last checkwrite of the month made by the Controller for the months of April through June of each project year to each private hospital identified on the final disproportionate share hospital list for the project year, computed and paid as follows: (1) An annual data corrected payment amount shall be computed for each hospital equal to the sum of the total payment adjustment amount for the hospital computed pursuant to subdivision (am) of Section 14105.98, plus the supplemental lump-sum payment adjustment amount computed pursuant to subdivision (an) of Section 14105.98, each as most recently computed by the department, plus any interim estimated stabilization funding. The annual data corrected payment amounts shall reflect data corrections, hospital closures, and other revisions made by the department to the adjusted payment amounts computed under paragraph (1) of subdivision (e). (2) A monthly data corrected payment amount shall be computed for each hospital equal to the annual data corrected payment amount for the hospital, minus both the aggregate interim payments made to the hospital for the project year and the aggregate tentative adjusted monthly payments made to the hospital, divided by three. (g) Payment under subdivisions (d), (e), and (f) for a month shall be made only to private hospitals open for patient care through the 15th day of the month. (h) The department shall compute a final adjusted payment amount for each private hospital on the final disproportionate share list for a project year after the completion of the project year and the determination of the amount of stabilization funding available to be paid under this section as follows: (1) An amount shall be computed for each hospital equal to the sum of the total payment adjustment amount for the hospital computed pursuant to subdivision (am) of Section 14105.98, plus the supplemental lump-sum payment adjustment amount computed pursuant to subdivision (an) of Section 14105.98, each as most recently computed by the department. These amounts shall reflect data corrections, hospital closures, and other revisions made by the department to the annual data corrected payment amounts computed under paragraph (1) of subdivision (f) in a manner that ensures that any payments not payable or recouped are redistributed among hospitals eligible for a final adjusted payment amount in accordance with the calculations made pursuant to Section 14105.98. (2) The department shall add to the amount computed for each hospital under paragraph (1) a pro rata share of any stabilization funding to be allocated and paid under this section, allocated based on the amounts computed under paragraph (1). (3) The department shall for each hospital for each project year reconcile the total amount paid to the hospital for that project year under subdivisions (d), (e), and (f) with the amount determined under paragraph (2). The department shall issue a report to each hospital setting forth the result of the reconciliation that shall include the department’s computation, data, and identification of data sources. The department shall pay to the hospital any underpayment determined as a result of this reconciliation and collect from the hospital any overpayment determined as a result of this reconciliation pursuant to paragraph (4) of subdivision (d). (4) A hospital may seek to correct the department’s data and computations under this section in accordance with the processes undertaken by the department to implement Section 14105.98 in effect during the 2004–05 state fiscal year. (i) In accordance with the demonstration project, the following shall apply: (1) Payments under this section shall satisfy the state’s obligation to have a payment adjustment program for disproportionate share hospitals under Section 1923 of the Social Security Act (42 U.S.C. Sec. 1396r-4). (2) Payments under this section and federal financial participation shall not be counted against the state’s allotment of federal funding for Medicaid disproportionate share payment adjustments. (j) (1) For purposes of this subdivision, “federal disproportionate share allotment” means the federal Medicaid disproportionate share hospital allotment specified for California under Section 1396r-4(f) of Title 42 of the United States Code. (2) In the event any hospital, or any party on behalf of a hospital, shall initiate a case or proceeding in any state or federal court in which the hospital seeks any relief of any sort whatsoever, including, but not limited to, monetary relief, injunctive relief, declaratory relief, or a writ, based in whole or in part on a contention that the hospital is entitled to, or should receive any portion of, the federal disproportionate share hospital allotment for any or all of federal fiscal years 2006 to 2010, inclusive, all of the following shall apply: (A) No payments shall be made to the hospital pursuant to this section until the case or proceeding is finally resolved, including the final disposition of all appeals. (B) Any amount computed to be payable to the hospital pursuant to this section for a project year shall be withheld by the department and shall be paid to the hospital only after the case or proceeding is finally resolved, including the final disposition of all appeals, and only if the case or proceeding does not result in any amount being paid or payable to the hospital from the federal disproportionate share hospital allotment for any portion of the project year. (C) The hospital shall become ineligible to receive any amount pursuant to this section for any project year for which it is determined that the hospital is entitled to be paid any portion of the federal disproportionate share hospital allotment. (D) Any amount that would have been payable to the hospital pursuant to this section, but is not paid to the hospital because the hospital has become ineligible to receive payments pursuant to this section shall be returned to the state General Fund. (E) In the event any portion of the federal disproportionate share hospital allotment is applied to payments to any private hospital, the department shall make any additional payments that may be necessary from state funds so that the amount of the disproportionate share hospital payments that are made to designated public hospitals or nondesignated public hospitals is not less than the amount that would have been made if the allotment had not been applied to payments to any private hospital. (F) A hospital’s total project year payment amount determined under this section may be subject to reduction by offset pursuant to Section 14115.5 or 14172.5. (Amended by Stats. 2006, Ch. 327, Sec. 7. Effective January 1, 2007. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.115.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The department must reduce certain disproportionate share hospital replacement payments to private hospitals, with specified reductions for listed fiscal years, and it may use provider bulletins to administer the section.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.115. (a) Due to the state budget deficit and in order to implement changes in the level of funding for health care services, the department shall reduce disproportionate share hospital replacement payments to private hospitals made pursuant to Section 14166.11 as specified in this section. (b) (1) Disproportionate share hospital replacement payments to private hospitals pursuant to Section 14166.11 shall be reduced by 10 percent. The reductions shall be applied to all disproportionate share hospital replacement payments to private hospitals made for the 2009–10 fiscal year, including, but not limited to, interim payments, tentative adjusted monthly payments, data corrected payments, and the final adjusted payment. (2) Disproportionate share hospital replacement payments to private hospitals pursuant to Section 14166.11 shall be reduced in the 2010–11 fiscal year by thirty million dollars ($30,000,000) in General Fund moneys and by the corresponding federal financial participation. To the extent permitted by federal law, the additional room created by this paragraph under the federal upper payment limit shall be used to increase supplemental payments under Article 5.226 (commencing with Section 14168.1) and Article 5.227 (commencing with Section 14168.31). (3) Disproportionate share hospital replacement payments to private hospitals pursuant to Section 14166.11 shall be reduced in the 2011–12 fiscal year by seventy-five million dollars ($75,000,000) in General Fund moneys and by the corresponding federal financial participation. To the extent permitted by federal law, the additional room created by this paragraph under the federal upper payment limit shall be used to increase supplemental payments under legislation extending or creating a new supplemental hospital payment program supported by a fee. (4) Disproportionate share hospital replacement payments to private hospitals pursuant to Section 14166.11 shall be reduced in the 2012–13 fiscal year by ten million five hundred thousand dollars ($10,500,000) in General Fund moneys and by the corresponding federal financial participation. (5) Disproportionate share hospital replacement payments to private hospitals pursuant to Section 14166.11 shall be reduced in the 2013–14 fiscal year by five million two hundred fifty thousand dollars ($5,250,000) in General Fund moneys and by the corresponding federal financial participation. (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement and administer this section by means of provider bulletins, or similar instructions, without taking further regulatory action. (d) The reductions described in this section shall apply only to payments for services when the General Fund share of the payment is paid with funds appropriated to the department in the annual Budget Act. (e) The department shall promptly seek any necessary federal approvals for the implementation of this section. (Amended by Stats. 2011, Ch. 286, Sec. 3. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.12.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section creates the Private Hospital Supplemental Fund and directs state officials to use it to negotiate and pay supplemental Medi-Cal hospital amounts.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.12. (a) The California Medical Assistance Commission shall negotiate payment amounts, in accordance with the selective provider contracting program established pursuant to Article 2.6 (commencing with Section 14081), from the Private Hospital Supplemental Fund established pursuant to subdivision (b) for distribution to private hospitals that satisfy the criteria of subdivision (s). Pursuant to Section 14165, on and after July 1, 2012, the Director of Health Care Services shall exercise the discretion granted to the California Medical Assistance Commission. (b) The Private Hospital Supplemental Fund is hereby established in the State Treasury. For purposes of this section, “fund” means the Private Hospital Supplemental Fund. (c) Notwithstanding Section 13340 of the Government Code, the fund shall be continuously appropriated to the department for the purposes specified in this section. (d) Except as otherwise limited by this section, the fund shall consist of all of the following: (1) One hundred eighteen million four hundred thousand dollars ($118,400,000), which shall be transferred annually from General Fund amounts appropriated in the annual Budget Act for the Medi-Cal program, except as follows: (A) For the 2008–09 fiscal year, this amount shall be reduced by thirteen million six hundred thousand dollars ($13,600,000) and by an amount equal to one-half of the difference between eighteen million three hundred thousand dollars ($18,300,000) and the amount of any reduction in the additional payments for distressed hospitals calculated pursuant to subparagraph (B) of paragraph (3) of subdivision (b) of Section 14166.20. (B) For the 2012–13 fiscal year, this amount shall be reduced by seventeen million five hundred thousand dollars ($17,500,000). (C) For the 2013–14 fiscal year, this amount shall be reduced by eight million seven hundred fifty thousand dollars ($8,750,000). (2) Any additional moneys appropriated to the fund. (3) All stabilization funding transferred to the fund pursuant to paragraph (2) of subdivision (a) of Section 14166.14. (4) Any moneys that any county, other political subdivision of the state, or other governmental entity in the state may elect to transfer to the department for deposit into the fund, as permitted under Section 433.51 of Title 42 of the Code of Federal Regulations or any other applicable federal Medicaid laws. (5) All private moneys donated by private individuals or entities to the department for deposit in the fund as permitted under applicable federal Medicaid laws. (6) Any interest that accrues on amounts in the fund. (e) Any public agency transferring moneys to the fund may, for that purpose, utilize any revenues, grants, or allocations received from the state for health care programs or purposes, unless otherwise prohibited by law. A public agency may also utilize its general funds or any other public moneys or revenues for purposes of transfers to the fund, unless otherwise prohibited by law. (f) The department may accept or not accept moneys offered to the department for deposit in the fund. If the department accepts moneys pursuant to this section, the department shall obtain federal financial participation to the full extent permitted by law. With respect to funds transferred or donated from private individuals or entities, the department shall accept only those funds that are certified by the transferring or donating entity that qualify for federal financial participation under the terms of the Medicaid Voluntary Contribution and Provider-Specific Tax Amendments of 1991 (Public Law 102-234) or Section 433.51 of Title 42 of the Code of Federal Regulations, as applicable. The department may return any funds transferred or donated in error. (g) Moneys in the fund shall be used as the source for the nonfederal share of payments to hospitals under this section. (h) Any funds remaining in the fund at the end of a fiscal year shall be carried forward for use in the following fiscal year. (i) Moneys shall be allocated from the fund by the department and shall be applied to obtain federal financial participation in accordance with customary Medi-Cal accounting procedures for purposes of payments under this section. Distributions from the fund shall be supplemental to any other Medi-Cal reimbursement received by the hospitals, including amounts that hospitals receive under the selective provider contracting program (Article 2.6 (commencing with Section 14081)), and shall not affect provider rates paid under the selective provider contracting program. (j) Each private hospital that was a private hospital during the 2002–03 fiscal year, received payments for the 2002–03 fiscal year from any of the prior supplemental funds, and, during the project year, satisfies the criteria in subdivision (s) to be eligible to negotiate for distributions under any of those sections, shall receive no less from the Private Hospital Supplemental Fund for the project year than 100 percent of the amount the hospital received from the prior supplemental funds for the 2002–03 fiscal year. Each private hospital described in this subdivision shall be eligible for additional payments from the fund pursuant to subdivision (k). (k) All amounts that are in the fund for a project year in excess of the amount necessary to make the payments under subdivision (j) shall be available for negotiation by the California Medical Assistance Commission, along with corresponding federal financial participation, for supplemental payments to private hospitals, which for the project year satisfy the criteria under subdivision (s) to be eligible to negotiate for distributions under any of those sections, and paid for services rendered during the project year pursuant to the selective provider contracting program established under Article 2.6 (commencing with Section 14081). (l) The amount of any stabilization funding transferred to the fund, or the amount of intergovernmental transfers deposited to the fund pursuant to subdivision (o), together with the associated federal reimbursement, with respect to a particular project year, may, in the discretion of the California Medical Assistance Commission, until its dissolution on June 30, 2012, be paid for services furnished in the same project year regardless of when the stabilization funds or intergovernmental transfer funds, and the associated federal reimbursement, become available, provided the payment is consistent with other applicable federal or state law requirements and does not result in a hospital exceeding any applicable reimbursement limitations. On and after July 1, 2012, the Director of Health Care Services shall exercise the discretion granted to the California Medical Assistance Commission by this subdivision. (m) The department shall pay amounts due to a private hospital from the fund for a project year, with the exception of stabilization funding, in up to four installment payments, unless otherwise provided in the hospital’s contract negotiated with the California Medical Assistance Commission, except that hospitals that are not described in subdivision (j) shall not receive the first installment payment. The first payment shall be made as soon as practicable after the issuance of the tentative disproportionate share hospital list for the project year, and in no event later than January 1 of the project year. The second and subsequent payments shall be made after the issuance of the final disproportionate hospital list for the project year, and shall be made only to hospitals that are on the final disproportionate share hospital list for the project year. The second payment shall be made by February 1 of the project year or as soon as practicable after the issuance of the final disproportionate share hospital list for the project year. The third payment, if scheduled, shall be made by April 1 of the project year. The fourth payment, if scheduled, shall be made by June 30 of the project year. This subdivision does not apply to hospitals that are scheduled to receive payments from the fund because they meet the criteria under paragraph (2) of subdivision (s) and do not meet the criteria under paragraph (1), (3), or (4) of subdivision (s), which shall be paid in accordance with the applicable contract or contract amendment negotiated by the California Medical Assistance Commission. (n) The department shall pay stabilization funding transferred to the fund in amounts negotiated by the California Medical Assistance Commission and shall pay the scheduled payments in accordance with the applicable contract or contract amendment. (o) Payments to private hospitals that are eligible to receive payments pursuant to subdivision (s) may be made using funds transferred from governmental entities to the state, at the option of the governmental entity. Any payments funded by intergovernmental transfers shall remain with the private hospital and shall not be transferred back to any unit of government. An amount equal to 25 percent of the amount of any intergovernmental transfer made in the project year that results in a supplemental payment made for the same project year to a project year private DSH hospital designated by the governmental entity that made the intergovernmental transfer shall be deposited in the fund for distribution as determined by the California Medical Assistance Commission. An amount equal to 75 percent shall be deposited in the fund and distributed to the private hospitals designated by the governmental entity. (p) A private hospital that receives payment pursuant to this section for a particular project year shall not submit a notice for the termination of its participation in the selective provider contracting program established pursuant to Article 2.6 (commencing with Section 14081) until the later of the following dates: (1) On or after December 31 of the next project year. (2) The date specified in the hospital’s contract, if applicable. (q) (1) For the 2007–08, 2008–09, and 2009–10 project years, the County of Los Angeles shall make intergovernmental transfers to the state to fund the nonfederal share of increased Medi-Cal payments to those private hospitals that serve the South Los Angeles population formerly served by Los Angeles County Martin Luther King, Jr.-Harbor Hospital. The intergovernmental transfers required under this subdivision shall be funded by county tax revenues and shall total five million dollars ($5,000,000) per project year, except that, in the event that the director determines that any amount is due to the County of Los Angeles under the demonstration project for services rendered during the portion of a project year during which Los Angeles County Martin Luther King, Jr.-Harbor Hospital was operational, the amount of intergovernmental transfers required under this subdivision shall be reduced by a percentage determined by reducing 100 percent by the percentage reduction in Los Angeles County Martin Luther King, Jr.-Harbor Hospital’s baseline, as determined under subdivision (c) of Section 14166.5 for that project year. (2) Notwithstanding subdivision (o), an amount equal to 100 percent of the county’s intergovernmental transfers under this subdivision shall be deposited in the fund and, within 30 days after receipt of the intergovernmental transfer, shall be distributed, together with related federal financial participation, to the private hospitals designated by the county in the amounts designated by the county. The director shall disregard amounts received pursuant to this subdivision in calculating the OBRA 1993 payment limitation, as defined in paragraph (24) of subdivision (a) of Section 14105.98, for purposes of determining the amount of disproportionate share hospital replacement payments due a private hospital under Section 14166.11. (r) (1) The reductions in supplemental payments under this section that result from the reductions in the amounts transferred from the General Fund to the Private Hospital Supplemental Fund for the 2012–13 and 2013–14 fiscal years under subparagraphs (B) and (C) of paragraph (1) of subdivision (d) shall be allocated equally in the aggregate between children’s hospitals eligible for supplemental payments under this section and other hospitals eligible for supplemental payments under this section. When negotiating payment amounts to a hospital under this section for the 2012–13 and 2013–14 fiscal years, the California Medical Assistance Commission, or its successor agency, shall identify both a payment amount that would have been made absent the funding reductions in subparagraphs (B) and (C) of paragraph (1) of subdivision (d) and the payment amount that will be made taking into account the funding reductions under subparagraphs (B) and (C) of paragraph (1) of subdivision (d). For purposes of this subdivision, “children’s hospital” shall have the meaning set forth in paragraph (13) of subdivision (a) of Section 14105.98. (2) This subdivision shall not preclude the department from including some or all of the reductions under this section within the payments made under a new diagnosis-related group payment methodology for the 2012–13 fiscal year or the 2013–14 fiscal year. In the event the department includes some or all of the amounts, including reductions, within the payments made under a new diagnosis-related group payment methodology for the 2012–13 fiscal year or the 2013–14 fiscal year, the department, in implementing the reductions in paragraph (1) of subdivision (d), shall, to the extent feasible, utilize the allocation specified in paragraph (1). (s) In order for a hospital to receive distributions pursuant to Article 2.6 (commencing with Section 14081), the hospital shall satisfy the eligibility criteria in paragraph (1), (2), (3), or (4) of this subdivision. (1) The hospital meets all of the following criteria: (A) The hospital is contracting under Article 2.6 (commencing with Section 14081). (B) The hospital meets the criteria contained in the Medicaid State Plan for disproportionate share hospital status. (C) The hospital is one of the following: (i) A licensed provider of basic emergency services as described in Section 70411 of Title 22 of the California Code of Regulations. (ii) A licensed provider of comprehensive emergency medical services as defined in Section 70451 of Title 22 of the California Code of Regulations. (iii) A children’s hospital, as defined in Section 14087.21, that satisfies clause (i) or (ii), or that jointly provides basic or comprehensive emergency services in conjunction with another licensed hospital. (iv) A hospital owned and operated by a public agency that operates two or more hospitals that qualify under subparagraph (A) or (B) with respect to the particular state fiscal year. (v) A hospital designated by the National Cancer Institute as a comprehensive or clinical cancer research center that primarily treats acutely ill cancer patients and that is exempt from the federal Medicare prospective payment system pursuant to Section 1886(d)(1)(B)(v) of the federal Social Security Act (42 U.S.C. Sec. 1395ww(d)(1)(B)(v)). (D) The hospital is able to demonstrate a purpose for additional funding under the selective provider contracting program including proposals relating to emergency services and other health care services, including infrequent yet high-cost services, such as anti-AB human antitoxin treatment for infant botulism (human botulinum immune globulin (HBIG), commonly referred to as “Baby-BIG”), that are made available, or will be made available, to Medi-Cal beneficiaries. (2) The hospital is contracting under Article 2.6 (commencing with Section 14081) and meets the definition of a university teaching hospital or major, nonuniversity, teaching hospital as set forth on page 51 and as listed on page 57 of the department’s report dated May 1991, entitled “Hospital Peer Grouping.” Payments from the fund shall be used solely for the purposes identified in the contract between the hospital and the state. (3) The hospital is contracting under Article 2.6 (commencing with Section 14081), and meets the definition of any of the following: (A) A large teaching emphasis hospital, as set forth on page 51 and listed on page 57 of the department’s report dated May 1991, entitled “Hospital Peer Grouping,” and also meets the definition of eligible hospital as defined in paragraph (3) of subdivision (a) of Section 14105.98. (B) A children’s hospital pursuant to Section 10727, and also meets the definition of eligible hospital as defined in paragraph (3) of subdivision (a) of Section 14105.98. (C) Notwithstanding the requirement in subparagraph (A) that a hospital must be listed on page 57 of the department’s report dated May 1991, entitled “Hospital Peer Grouping,” any hospital whose license pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code was consolidated during the 1999 calendar year with a large teaching emphasis hospital that is listed on page 57 of the above-described report shall be eligible. All other requirements of paragraph (3) shall continue to apply. (4) The hospital meets all of the following criteria: (A) The hospital is contracting under Article 2.6 (commencing with Section 14081). (B) The hospital satisfies the Medicaid State Plan criteria for disproportionate share hospital status. (C) The hospital is a small and rural hospital as defined in Section 124840 of the Health and Safety Code. (D) The hospital is a licensed provider of standby emergency services as described in Section 70649 of Title 22 of the California Code of Regulations. (E) The hospital is able to demonstrate a purpose for additional funding under the selective provider contracting program with proposals relating to health care services that are made available, or will be made available, to Medi-Cal beneficiaries. (F) The hospital is determined by the California Medical Assistance Commission to be a hospital that provides an important community service that otherwise would not be provided in the community. (Amended by Stats. 2012, Ch. 438, Sec. 21. (AB 1468) Effective September 22, 2012. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.125.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The director must allocate the Private Hospital Supplemental Fund to eligible private hospitals using a consulted methodology, and the methodology should try to keep 2013–14 allocations proportionate to each hospital’s 2011–12 payments, subject to the listed conditions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.125. (a) Effective the first fiscal year in which reimbursement to private hospitals is provided under the diagnosis-related group methodology established pursuant to Section 14105.28, the director shall allocate the Private Hospital Supplemental Fund among eligible private hospitals pursuant to a methodology developed in consultation with the statewide associations representing children’s hospitals and private DSH hospitals. (b) Subject to subdivision (a), for the 2013–14 fiscal year only as a transition, this methodology shall, to the extent possible, ensure that each eligible hospital is allocated funding at a proportionate level of payments it received for the 2011–12 fiscal year, taking into consideration applicable eligibility criteria and the amount of funding available in the Private Hospital Supplemental Fund established in Section 14166.12. (Added by Stats. 2012, Ch. 452, Sec. 1. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.13.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The director must determine a baseline funding amount for certain private DSH hospitals, and the department must calculate an adjusted baseline funding amount using specified Medi-Cal revenue figures and adjustments.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.13. (a) With respect to each project year, the director shall determine a baseline funding amount for each base year private DSH hospital that is also a project year private DSH hospital. A private hospital’s baseline funding amount shall be an amount equal to the total amount paid to the hospital for inpatient hospital services rendered to Medi-Cal beneficiaries during the 2004–05 state fiscal year, including the following Medi-Cal payments, but excluding payments received under the Medi-Cal Specialty Mental Health Services Consolidation Program: (1) Base payments under the selective provider contracting program as provided for under Article 2.6 (commencing with Section 14081), or under the Medi-Cal state plan cost reimbursement system for inpatient hospital services for noncontracting hospitals. (2) Emergency Services and Supplemental Payments Fund payments as provided for under Section 14085.6. (3) Medi-Cal Medical Education Supplemental Payment Fund payments and Large Teaching Emphasis Hospital and Children’s Hospital Medi-Cal Medical Education Supplemental Payment Fund payments as provided for under Sections 14085.7 and 14085.8, respectively. (4) Small and Rural Hospital Supplemental Payments Fund payments as provided for under Section 14085.9. (5) Disproportionate share hospital payment adjustments as provided for under Section 14105.98. (6) Administrative day payments as provided for under Section 51542 of Title 22 of the California Code of Regulations. (b) The aggregate project year private DSH hospital baseline funding amount shall be the sum of all baseline funding amounts determined under subdivision (a). (c) With respect to each project year beginning after the 2005–06 project year, an aggregate project year private DSH hospital adjusted baseline funding amount shall be determined as follows: (1) The department shall determine the aggregate total Medi-Cal revenue, using amounts determined under subdivision (a), for inpatient hospital services rendered during the 2004–05 fiscal year for project year private DSH hospitals, less the total amount of disproportionate share hospital payments identified in paragraph (5) of subdivision (a) for those hospitals. (2) The department shall determine the aggregate total Medi-Cal revenue paid or payable for inpatient hospital services rendered during the fiscal year immediately preceding the project year for which the private hospital adjusted baseline funding amount is being calculated for project year private DSH hospitals. The aggregate total revenue for services rendered in the relevant preceding fiscal year shall include the payments described in paragraphs (1) and (6) of subdivision (a), and all other payments made to project year private DSH hospitals under this article, excluding disproportionate share hospital replacement payments made under Section 14166.11, stabilization funding under Section 14166.14, and distressed hospital funding under Section 14166.23 and paragraph (3) of subdivision (b) of Section 14166.20. (3) The department shall: (A) Calculate the difference between the amount determined under paragraph (1) and the amount determined under paragraph (2). (B) Determine the percentage increase or decrease by dividing the difference in subparagraph (A) by the amount in paragraph (1). (C) Apply the percentage in subparagraph (B) to the amount determined under paragraph (1). (4) The aggregate private DSH hospital adjusted baseline funding amount is the amount determined in paragraph (1), plus the amount determined in subparagraph (C), plus the amount in paragraph (5) of subdivision (a). (d) If, with respect to any project year, the difference between the percentage adjustment in subparagraph (B) of paragraph (3) of subdivision (c) of this section is greater than five percentage points more than the aggregate percentage adjustment for designated public hospitals, excluding the percentage adjustment for any designated public hospital that was not in operation for the full project year, determined under subparagraph (B) of paragraph (3) of subdivision (c) of Section 14166.5, then the aggregate percentage adjustment for private DSH hospitals shall be reduced in the amount necessary to reduce the difference to five percentage points. (Amended by Stats. 2007, Ch. 518, Sec. 5. Effective January 1, 2008. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.14.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section divides stabilization funding among hospital-related purposes, including shortfalls, a supplemental fund, pro rata distributions, and some transfers or retained amounts.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.14. The amount of any stabilization funding payable to the project year private DSH hospitals under Section 14166.20 for a project year, which amount shall not include the amount of stabilization funding paid or payable to hospitals prior to the computation of the stabilization funding under Section 14166.20, plus any amount payable to project year private DSH hospitals under paragraph (1) of subdivision (b) of Section 14166.21, shall be allocated as follows: (a) (1) To fund any shortfall due under Section 14166.11. (2) An amount shall be transferred to the Private Hospital Supplemental Fund established pursuant to Section 14166.12, as may be necessary so that the amount for the Private Hospital Supplemental Fund for the project year, including all funds previously transferred to, or deposited in, the Private Hospital Supplemental Fund for the project year, is not less than the Private Hospital Supplemental Fund base amount determined pursuant to subdivision (j) of Section 14166.12. (3) The amounts paid or transferred under paragraphs (1) and (2) shall be reduced pro rata if there is not sufficient funding described under paragraphs (1) and (2). (b) Of the stabilization funding remaining, after allocations pursuant to subdivision (a), that are payable to project year private DSH hospitals, 66.4 percent shall be allocated and distributed among those hospitals pro rata based on the amounts determined in accordance with Section 14166.11, and 33.6 percent shall be transferred to the Private Hospital Supplemental Fund. (c) (1) Notwithstanding any other law, the stabilization funding payable to project year private DSH hospitals under Section 14166.20 for a project year as determined under this section that has not been paid, or specifically committed for payment, to hospitals prior to January 1, 2012, may be utilized by the director to make payments to hospitals that received underpayments pursuant to Section 14166.11 due to improper peer group classifications for the 2005–06 and 2006–07 payment adjustment years. (2) The balance after payments made pursuant to paragraph (1), if any, of the stabilization funding payable to project year private DSH hospitals under Section 14166.20 shall not be paid to the project year private DSH hospitals pursuant to Section 14166.20. The funds that would otherwise be paid from the Private Hospital Supplemental Fund shall be transferred to the General Fund, and funds that would otherwise be drawn from the General Fund for payments to the private DSH hospitals pursuant to Section 14166.20 shall be retained in the General Fund. (Amended by Stats. 2012, Ch. 23, Sec. 91. (AB 1467) Effective June 27, 2012. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.15.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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Payments to nondesignated public hospitals must include specified payment types, and those payments are additional to other payments allowed by law.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.15. (a) Payments to nondesignated public hospitals under the demonstration project shall include, as applicable, the following: (1) Payments under selective provider contracts with the department negotiated by the California Medical Assistance Commission in accordance with Article 2.6 (commencing with Section 14081). (2) Disproportionate share hospital payments under Section 14166.16. (3) Supplemental payments under Section 14166.17. (4) Payments to distressed hospitals as negotiated by the California Medical Assistance Commission pursuant to Section 14166.23. (5) Payment of amounts described in Section 14166.19. (b) Payments under subdivision (a) shall be in addition to other payments that may be made in accordance with law. (Added by Stats. 2005, Ch. 560, Sec. 1. Effective October 5, 2005. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.151.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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Nondesignated public hospitals can receive certain safety net care pool payments only if they comply with reporting, certification, and reimbursement rules.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.151. (a) It is the intent of the Legislature to allow for a voluntary process for nondesignated public hospitals to claim reimbursement from the safety net care pool in the successor demonstration project based on their public structure, to the extent that there is funding available for nondesignated public hospitals in that pool, as allowed by the federal government, which shall be allocated equally between the state and the nondesignated public hospital, so that for every dollar of certified public expenditure used by the nondesignated public hospital, the nondesignated public hospital shall voluntarily allow the state to use a corresponding certified public expenditure amount for claiming purposes. (b) (1) Beginning with services provided on or after July 1, 2013, nondesignated public hospitals shall be eligible to receive safety net care pool payments for uncompensated care costs to the extent that additional federal funding is made available pursuant to the Special Terms and Conditions for the safety net care pool uncompensated care limit of the successor demonstration project and if they comply with the requirements set forth in this section. (2) The amount of funds that may be claimed pursuant to paragraph (1) shall not exceed the additional federal funding made available under the safety net care pool for nondesignated public hospital uncompensated care costs, and shall not reduce the amounts of federal funding for safety net care pool uncompensated care costs that would otherwise be made available to designated public hospitals in the absence of this paragraph, including the amounts available under the Special Terms and Conditions in effect as of July 1, 2013, and amounts available pursuant to Section 15916. (3) (A) Notwithstanding paragraph (2), if the designated public hospitals do not have sufficient certified public expenditures to claim the full amount of federal funding made available to the designated public hospitals as referenced in paragraph (2), including consideration of the potential for the designated public hospitals to have sufficient certified public expenditures in a subsequent year, the department may authorize the funding to be claimed by the nondesignated public hospitals. (B) The department may determine whether designated public hospitals do not have sufficient certified public expenditures to claim the full amount of federal funding pursuant to subparagraph (B) no sooner than after the submission of the cost reporting information required pursuant to Section 14166.8 for the applicable successor demonstration year. (C) If the department makes the determination identified in subparagraph (B) based on as-filed cost reporting information submitted prior to a final audit, the department shall make the determination in consultation with the designated public hospitals and shall apply an audit cushion of at least 5 percent to the as-filed cost information. If the department makes the determination identified in subparagraph (B) based on audited cost reporting information, no audit cushion shall be applied. (c) Beginning in the 2013–14 fiscal year, within five months after the end of a successor demonstration year, nondesignated public hospitals shall submit to the department all of the following reports: (1) The hospital’s Medicare or Medicaid cost report for the successor demonstration year. (2) Other cost reporting and statistical data necessary for the determination of amounts due to the hospital under the successor demonstration project, as requested by the department. (d) For each successor demonstration year, the reports shall identify all of the costs incurred in providing hospital services to uninsured individuals. (e) A nondesignated public hospital, or the governmental entity with which it is affiliated, that operates nonhospital clinics or provides physician, nonphysician practitioner, or other health care services that are not identified as hospital services under the Special Terms and Conditions for the successor demonstration project, shall report and certify all of the uncompensated uninsured costs of the services furnished. (f) Reports submitted under this section shall include all allowable costs. (g) The appropriate public official shall certify to all of the following: (1) The accuracy of the reports required under this section. (2) That the expenditures to meet the reported costs comply with Section 433.51 of Title 42 of the Code of Federal Regulations. (3) That the sources of funds used to make the expenditures certified under this section do not include impermissible provider taxes or donations, as defined under Section 1396b(w) of Title 42 of the United States Code, or other federal funds. For this purpose, federal funds do not include delivery system reform incentive pool payments or patient care revenue received as payment for services rendered under programs such as nondesignated state health programs, the Low Income Health Program, Medicare, or Medicaid. (h) The certification of public expenditures made pursuant to this section shall be based on a schedule established by the department in accordance with federal requirements. (1) The director may require nondesignated public hospitals to submit quarterly estimates of anticipated expenditures, if these estimates are necessary to obtain interim payments of federal Medicaid funds. (2) All reported expenditures shall be subject to reconciliation to allowable costs, as determined in accordance with applicable implementing documents for the successor demonstration project. (i) The timeframes for data submission and reporting periods may be adjusted as necessary in accordance with federal requirements. (j) (1) Beginning in the 2013–14 fiscal year, safety net care pool payments for uncompensated care shall be allocated to nondesignated public hospitals as follows: (A) The department shall determine the maximum amount of safety net care pool payments for uncompensated care that is available to nondesignated public hospitals for the successor demonstration year pursuant to this section. This determination shall be made solely with respect to allowable uncompensated care costs incurred by nondesignated public hospitals and reported pursuant to subdivisions (c) to (i), inclusive. (B) The department shall establish, in consultation with the nondesignated public hospitals, an allocation methodology to determine the amount of safety net care pool payments to be made to the nondesignated public hospitals. The allocation methodology shall be implemented when the director issues a declaration stating that the methodology complies with all applicable federal requirements for federal financial participation. (2) A safety net care pool payment amount may be paid to a nondesignated public hospital, or governmental entity with which it is affiliated, pursuant to this section independent of the amount of uncompensated uninsured costs that is certified as public expenditures pursuant to subdivisions (c) to (i), inclusive, provided that, in accordance with the Special Terms and Conditions for the successor demonstration project, the recipient hospital shall not return any portion of the funds received to any unit of government, excluding amounts recovered by the state or federal government. (3) Nondesignated public hospitals, or governmental entities with which they are affiliated, shall receive the amount established pursuant to this subdivision, less the 50 percent retained by the state pursuant to subdivision (l), in quarterly interim payments during the successor demonstration year. The determination of the interim payments shall be made on an interim basis prior to the start of each successor demonstration year. The department shall use the cost and statistical data that is in subdivisions (c) to (i), inclusive. (k) (1) No later than April 1 following the end of the relevant reporting period for the successor demonstration year, the department shall undertake an interim reconciliation of the payment amount established pursuant to subdivision (j) for nondesignated public hospitals using Medicare and other cost, payment, and statistical data submitted by the hospitals for the successor demonstration year, and shall adjust payments to the hospitals accordingly. (2) All payments to nondesignated public hospitals are subject to a final reconciliation that is subject to final audits of all applicable Medicare and other cost, payment, discharge, and statistical data for the successor demonstration year. (l) The process for supplemental payments made in subdivisions (j) and (k) is a voluntary process the implementation of which is limited by this subdivision. The department may submit for federal approval a proposed amendment to the successor demonstration project to implement this section. (1) If a nondesignated public hospital voluntarily agrees to participate in a process that, up to the amount of safety net care pool funds available, allows the certified public expenditures for uncompensated care under this section to be allocated equally between the state and the nondesignated public hospital, so that for every dollar of certified public expenditure used by the nondesignated public hospital, the nondesignated public hospital shall voluntarily allow the state to use a corresponding certified public expenditure amount for claiming purposes. Participation in the safety net care pool under this section is voluntary on the part of the nondesignated public hospital for the purposes of all applicable federal laws. If a nondesignated public hospital does not voluntarily agree to participate in this process, it shall not be eligible to receive safety net care pool funds. (2) If the budget neutrality requirements established under Section XI of the Special Terms and Conditions of the successor demonstration project are exceeded, payments made under this section shall be reduced or refunded to achieve budget neutrality before any other payments under the successor demonstration project are made. The state’s share of the federal financial participation shall be reduced after the provider’s share has been exhausted. (3) Notwithstanding any other provision of law, upon the receipt of a notice of disallowance or deferral from the federal government related to any certified public expenditures for uncompensated care incurred by the nondesignated public hospital that are used for federal claiming under the safety net care pool pursuant to the successor demonstration project after this section is implemented, and subject to the processes set forth in this section, the department and the nondesignated public hospitals shall each be responsible for one-half of the repayment of the federal portion of any federal disallowance or deferral for the applicable successor demonstration year, up to the amount claimed and allocated pursuant to this section for that particular year beginning with the 2013–14 fiscal year. (4) This section shall be implemented only to the extent other federal financial participation is not jeopardized. (m) Eligible providers, as a condition of receiving supplemental reimbursement pursuant to this section, shall enter into, and maintain, an agreement with the department for the purposes of implementing this section and reimbursing the department for the costs of administering this section, including, but not limited to, the state personnel costs. No General Fund moneys shall be expended for the implementation and administration of this section. (Amended by Stats. 2013, Ch. 672, Sec. 2. (AB 498) Effective January 1, 2014. Section initially operative January 1, 2014, pursuant to this amendment's removal of the condition formerly in subd. (f). Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.16.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The department must calculate and pay hospital payment adjustments for eligible nondesignated public hospitals, issue payment lists, make scheduled interim and later payments, and reconcile any overpayments or underpayments.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.16. (a) The department shall pay to each nondesignated public hospital that is an eligible hospital for the project year, as determined under Section 14105.98, disproportionate share hospital payment adjustments as more specifically set forth in this section. (b) For each project year, the department shall develop and issue a tentative and final disproportionate share list in accordance with Section 14105.98. (c) (1) The department shall compute, for each nondesignated public hospital that is an eligible disproportionate share hospital for the project year, the payment adjustment amounts as determined under paragraphs (1) to (4), inclusive, and (6) to (8), inclusive, of subdivision (am) of Section 14105.98, and the supplemental payment adjustment amounts as determined under paragraphs (1) to (3), inclusive, of subdivision (an) of Section 14105.98. (2) The department shall perform the computations set forth in Section 14163 to determine the hospital’s transfer amount as though that section were still in effect. (3) The disproportionate share hospital payment amount for each nondesignated public hospital for each project year shall be the sum of the amounts computed under paragraph (1) less the amount determined for the hospital under paragraph (2). (4) For purposes of the computations under this subdivision, the federal disproportionate share hospital allotment for California for each project year shall be the allotment effective during the federal fiscal year beginning during the project year. (5) Notwithstanding any other provision of law, the transfer amounts from the Medi-Cal Inpatient Payment Adjustment Fund to the Health Care Deposit Fund, as provided for pursuant to paragraph (2) of subdivision (d) of Section 14163, shall be deemed to be eighty-five million dollars ($85,000,000) for purposes of the computations under this subdivision. (6) Subdivision (m) of Section 14105.98 shall apply to payments made under this section. (7) The federal share of the payment amounts determined under this subdivision and paid pursuant to this section, excluding the stabilization funding amounts allocated and paid pursuant to paragraph (2) of subdivision (i), shall be drawn from the allotment of federal funds for Medicaid disproportionate share hospital payment adjustments for California specified under Section 1396r-4(f) of Title 42 of the United States Code. (d) To the extent necessary to compute and determine compliance with the hospital-specific disproportionate share hospital payment limitations described in paragraph (3) of subdivision (c) of Section 14166.3, nondesignated public hospitals shall comply with subdivisions (a), (b), and (d) of Section 14166.8. (e) Two interim payments shall be made for the first portion of the project year, on October 1 and December 1 of each project year, as follows: (1) The interim payments shall be made to each nondesignated public hospital identified on a tentative disproportionate share list for the project year that was also on the final disproportionate share list for the prior fiscal year. The interim payment amount for each hospital shall be paid in two equal amounts on October 1 and December 1 of each project year, which combined shall equal five-twelfths of the total payments, excluding stabilization funds, made to the hospital for the prior fiscal year under this section, except that for the 2005–06 project year, the combined amount shall equal the amount that was payable to the hospital for the 2004–05 fiscal year under Section 14105.98, less the transfer amount assessed with respect to the hospital under Section 14163 for the same fiscal year, multiplied by five-twelfths. The interim payment amount may be adjusted to reflect any changes in the total payment amounts, excluding stabilization funds, projected to be made under this section for the project year. (2) The computation of interim payments described in this subdivision shall be made promptly after the department issues the tentative disproportionate share hospital list for the project year. (3) The first interim payment to each hospital for a project year shall be made no later than 60 days after the issuance of the tentative disproportionate share hospital list for the project year and shall include the interim payment amounts for all prior months in the project year. Subsequent interim payments for a project year shall be made on the last checkwrite of each month made by the Controller until interim payments for the first five months of the project year have been made. (4) The department may recover any interim payments made under this subdivision for a project year to a hospital that is not on the final disproportionate share hospital list for the project year. These interim payments shall be considered an overpayment. The department shall issue a demand for repayment to a hospital at least 30 days prior to taking action to recover the overpayment. After the 30-day period, the department may recover the overpayment using any of the methods set forth in Section 14115.5 or subdivision (c) of Section 14172.5. Any offset shall be subject to Section 14115.5 or subdivision (d) of Section 14172.5. No other provision of Section 14172.5 shall be applicable with respect to the recovery of overpayments under this subdivision. A hospital may appeal the department’s determination of an overpayment under this subdivision pursuant to the appeal procedures set forth in Sections 51016 to 51047, inclusive, of Title 22 of the California Code of Regulations, and seek judicial review of the final administrative decision pursuant to Section 14171, provided that the only issues that may be raised in the appeal are whether the hospital, but for inadvertent error by the department, was on the final disproportionate share list for the project year and whether the department’s computation of the overpayment amount is correct. If the hospital is reinstated on the final disproportionate share list pursuant to Section 14105.98, the department shall promptly refund any amount recovered under this paragraph. (f) Tentative adjusted monthly payments shall be made for December through March of each project year to each nondesignated public hospital identified on the final disproportionate share hospital list for the project year, computed and paid as follows: (1) An adjusted payment amount shall be computed for each hospital equal to the sum of the total payment adjustment amount for the hospital computed pursuant to subdivision (am) of Section 14105.98, plus the supplemental lump-sum payment adjustment amount computed pursuant to subdivision (an) of Section 14105.98, less the amount computed pursuant to Section 14163, each as most recently computed by the department as described in subdivision (c). (2) A tentative adjusted monthly payment amount shall be computed for each hospital equal to the adjusted payment amount for the hospital, minus the aggregate interim payments made to the hospital for the project year, divided by seven. (3) The computation of tentative adjusted monthly payments described in this subdivision shall be made promptly after the department issues the final disproportionate share hospital list for the project year. (4) The first tentative adjusted monthly payment to each hospital for a project year shall be made by January 15 or within 60 days after the issuance of the final disproportionate share hospital list for the project year, whichever is later, and shall include the tentative adjusted monthly payment amounts for all prior months in the project year for which those payments are due. Subsequent tentative adjusted monthly payments for a project year shall be made on the last checkwrite of each month made by the Controller until tentative adjusted monthly payments for December through March of the project year have been made. (g) Three data corrected payments shall be made on the last checkwrite of the month made by the Controller for the months of April through June of each project year to each nondesignated public hospital identified on the final disproportionate share hospital list for the project year, computed and paid as follows: (1) An annual data corrected payment amount shall be computed for each hospital equal to the sum of the total payment adjustment amount for the hospital computed pursuant to subdivision (am) of Section 14105.98, plus the supplemental lump-sum payment adjustment amount computed pursuant to subdivision (an) of Section 14105.98, less the amount computed pursuant to Section 14163, each as most recently computed by the department as described in subdivision (c). The annual data corrected payment amounts shall reflect data corrections, hospital closures, and other revisions made by the department to the adjusted payment amounts computed under paragraph (1) of subdivision (d). (2) A monthly data corrected payment amount shall be computed for each hospital equal to the annual data corrected payment amount for the hospital, minus both the aggregate interim payments made to the hospital for the project year and the aggregate tentative adjusted monthly payments made to the hospital, divided by three. (h) Payment under subdivisions (e), (f), and (g) for a month shall be made only to hospitals open for patient care through the 15th day of the month. (i) The department shall compute a final adjusted payment amount for each nondesignated public hospital on the final disproportionate share list for a project year after the completion of the project year and the determination of the amount of stabilization funding available to be paid under this section as follows: (1) An amount shall be computed for each hospital equal to the sum of the total payment adjustment amount for the hospital computed pursuant to subdivision (am) of Section 14105.98, plus the supplemental lump-sum payment adjustment amount computed pursuant to subdivision (an) of Section 14105.98, less the amount computed pursuant to Section 14163, each as most recently computed by the department as described in subdivision (c). These amounts shall reflect data corrections, hospital closures, and other revisions made by the department to the annual data corrected payment amounts computed under paragraph (1) of subdivision (e) in a manner that ensures that any payments not payable or recouped are redistributed among hospitals eligible for a final adjusted payment amount in accordance with the calculations made pursuant to Section 14105.98. (2) The department shall add to the amount computed for each hospital under paragraph (1) a pro rata share of any stabilization funding to be allocated and paid under this section allocated based on the amounts computed under paragraph (1). The federal share of any stabilization funding allocated and paid under this section shall not be drawn from the allotment of federal funding for Medicaid disproportionate share hospital payment adjustments for California specified under Section 1396r-4(f) of Title 42 of the United States Code. (3) The department shall for each hospital for each project year reconcile the total amount computed for the hospital for the project year under subdivisions (c), (d), and (e) with the amount determined under paragraph (2). The department shall issue a report to each hospital setting forth the result of the reconciliation that shall include the department’s computation, data, and identification of data sources. The department shall pay to the hospital any underpayment determined as a result of this reconciliation and collect from the hospital any overpayment determined as a result of this reconciliation. (4) A hospital may seek to correct the department’s data and computations under this section in accordance with the processes undertaken by the department to implement Section 14105.98 in effect during the 2004–05 fiscal year. (Amended by Stats. 2006, Ch. 327, Sec. 11. Effective January 1, 2007. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.17.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section creates and funds the Nondesignated Public Hospital Supplemental Fund, directs how the department and the California Medical Assistance Commission use it, and sets eligibility and payment rules for nondesignated public hospitals.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.17. (a) The California Medical Assistance Commission shall negotiate payment amounts in accordance with the selective provider contracting program established pursuant to Article 2.6 (commencing with Section 14081) from the Nondesignated Public Hospital Supplemental Fund established pursuant to subdivision (b) for distribution to nondesignated public hospitals that satisfy the criteria of subdivision (o). Pursuant to Section 14165, on and after July 1, 2012, the Director of Health Care Services shall exercise the discretion granted to the California Medical Assistance Commission. (b) (1) The Nondesignated Public Hospital Supplemental Fund is hereby established in the State Treasury. For purposes of this section, “fund” means the Nondesignated Public Hospital Supplemental Fund. (2) Effective December 31, 2028, the Nondesignated Public Hospital Supplemental Fund in the State Treasury, created pursuant to this section, is hereby abolished. All moneys remaining in the fund or moneys designated to be deposited to the fund shall be transferred to the General Fund. (c) Notwithstanding Section 13340 of the Government Code, the fund shall be continuously appropriated to the department for the purposes specified in this section. (d) Except as otherwise limited by this section, the fund shall consist of all of the following: (1) One million nine hundred thousand dollars ($1,900,000), which shall be transferred annually from General Fund amounts appropriated in the annual Budget Act for the fund. (2) Any additional moneys appropriated to the fund. (3) All stabilization funding transferred to the fund. (4) All private moneys donated by private individuals or entities to the department for deposit in the fund as permitted under applicable federal Medicaid laws. (5) Any interest that accrues on amounts in the fund. (e) The department may accept or not accept moneys offered to the department for deposit in the fund. If the department accepts moneys pursuant to this section, the department shall obtain federal financial participation to the full extent permitted by law. With respect to funds transferred or donated from private individuals or entities, the department shall accept only those funds that are certified by the transferring or donating entity as qualifying for federal financial participation under the terms of the Medicaid Voluntary Contribution and Provider-Specific Tax Amendments of 1991 (Public Law 102-234) or Section 433.51 of Title 42 of the Code of Federal Regulations, as applicable. The department may return any funds transferred or donated in error. (f) Moneys in the funds shall be used as the source for the nonfederal share of payments to hospitals under this section. (g) Any funds remaining in the fund at the end of a fiscal year shall be carried forward for use in the following fiscal year. (h) Moneys shall be allocated from the fund by the department and shall be applied to obtain federal financial participation in accordance with customary Medi-Cal accounting procedures for purposes of payments under this section. Distributions from the fund shall be supplemental to any other Medi-Cal reimbursement received by the hospitals, including amounts that hospitals receive under the selective provider contracts negotiated under Article 2.6 (commencing with Section 14081), and shall not affect provider rates paid under the selective provider contracting program. (i) Each nondesignated public hospital that was a nondesignated public hospital during the 2002–03 fiscal year, received payments for the 2002–03 fiscal year from any of the prior supplemental funds, and, during the project year satisfies the criteria in subdivision (o) to be eligible to negotiate for distributions under any of those sections shall receive no less from the Nondesignated Public Hospital Supplemental Fund for the project year than 100 percent of the amount the hospital received from the prior supplemental funds for the 2002–03 fiscal year, minus the total amount of intergovernmental transfers made by or on behalf of the hospital pursuant to subdivision (o) for the same fiscal year. Each hospital described in this subdivision shall be eligible for additional payments from the fund pursuant to subdivision (j). (j) (1) For each fiscal year up to and including the 2024–25 fiscal year, all amounts that are in the fund for a project year in excess of the amount necessary to make the payments under subdivision (i) shall be available for negotiation by the California Medical Assistance Commission, along with corresponding federal financial participation, for supplemental payments to nondesignated public hospitals that for the project year satisfy the criteria under subdivision (o) to be eligible to negotiate for distributions under any of those sections, and paid for services rendered during the project year pursuant to the selective provider contracting program under Article 2.6 (commencing with Section 14081). (2) For the 2025–26 fiscal year, all amounts that are in the fund for a project year in excess of the amount necessary to make the payments under subdivision (i) shall be available for supplemental payments to nondesignated public hospitals, as follows: (A) Additional supplemental payments shall be made to nondesignated public hospitals that meet the criteria for supplemental payments pursuant to paragraph (1) such that the payments under this subparagraph together with the payments under subdivision (i) to those hospitals are equal to the amounts transferred to the fund pursuant to paragraph (1) of subdivision (d) plus the applicable amount of federal financial participation that is available for the nonfederal share of payments described in paragraph (1) of subdivision (d). (B) All remaining amounts in the fund, including any funds that have been carried forward pursuant to subdivision (g), shall be used for supplemental payments to nondesignated public hospitals pursuant to a methodology developed by the department that is based on all Medi-Cal inpatient days, as described in Section 1396r-4(b)(2) of Title 42 of the United States Code, in the numerator of the Medi-Cal inpatient utilization rate for each hospital, as determined in the most recent final calculation of the Medi-Cal inpatient utilization rate pursuant to paragraph (4) of subdivision (f) of Section 14105.98 as of July 1, 2025. (k) The amount of any stabilization funding transferred to the fund with respect to a project year may in the discretion of the California Medical Assistance Commission, until its dissolution on June 30, 2012, to be paid for services furnished in the same project year regardless of when the stabilization funds become available, provided the payment is consistent with other applicable federal or state legal requirements and does not result in a hospital exceeding any applicable reimbursement limitations. On and after July 1, 2012, the Director of Health Care Services shall exercise the discretion granted to the California Medical Assistance Commission by this subdivision. (l) The department shall pay amounts due to a nondesignated hospital from the fund for a project year, with the exception of stabilization funding, in up to four installment payments, unless otherwise provided in the hospital’s contract negotiated with the California Medical Assistance Commission, except that hospitals that are not described in subdivision (i) shall not receive the first installment payment. The first payment shall be made as soon as practicable after the issuance of the tentative disproportionate share hospital list for the project year, and in no event later than January 1 of the project year. The second and subsequent payments shall be made after the issuance of the final disproportionate hospital list for the project year, and shall be made only to hospitals that are on the final disproportionate share hospital list for the project year. The second payment shall be made by February 1 of the project year or as soon as practicable after the issuance of the final disproportionate share hospital list for the project year. The third payment, if scheduled, shall be made by April 1 of the project year. The fourth payment, if scheduled, shall be made by June 30 of the project year. This subdivision does not apply to hospitals that are scheduled to receive payments from the fund because they meet the criteria under paragraph (2) of subdivision (o) but do not meet the criteria under paragraph (1), (3), or (4) of subdivision (o). (m) The department shall pay stabilization funding transferred to the fund in amounts negotiated by the California Medical Assistance Commission and paid in accordance with the applicable contract or contract amendment. (n) A nondesignated public hospital that receives payment pursuant to this section for a particular project year shall not submit a notice for the termination of its participation in the selective provider contracting program established pursuant to Article 2.6 (commencing with Section 14081) until the later of the following dates: (1) On or after December 31 of the next project year. (2) The date specified in the hospital’s contract, if applicable. (o) In order for a hospital to receive distributions pursuant to Article 2.6 (commencing with Section 14081), the hospital shall satisfy the eligibility criteria in paragraph (1), (2), (3), or (4) of this subdivision. (1) The hospital meets all of the following criteria: (A) The hospital is contracting under Article 2.6 (commencing with Section 14081). (B) The hospital meets the criteria contained in the Medicaid State Plan for disproportionate share hospital status. (C) The hospital is one of the following: (i) A licensed provider of basic emergency services as described in Section 70411 of Title 22 of the California Code of Regulations. (ii) A licensed provider of comprehensive emergency medical services as defined in Section 70451 of Title 22 of the California Code of Regulations. (iii) A children’s hospital, as defined in Section 14087.21, that satisfies clause (i) or (ii), or that jointly provides basic or comprehensive emergency services in conjunction with another licensed hospital. (iv) A hospital owned and operated by a public agency that operates two or more hospitals that qualify under subparagraph (A) or (B) with respect to the particular state fiscal year. (v) A hospital designated by the National Cancer Institute as a comprehensive or clinical cancer research center that primarily treats acutely ill cancer patients and that is exempt from the federal Medicare prospective payment system pursuant to Section 1886(d)(1)(B)(v) of the federal Social Security Act (42 U.S.C. Sec. 1395ww(d)(1)(B)(v)). (D) (1) The hospital is able to demonstrate a purpose for additional funding under the selective provider contracting program including proposals relating to emergency services and other health care services, including infrequent yet high-cost services, such as anti-AB human antitoxin treatment for infant botulism (human botulinum immune globulin (HBIG), commonly referred to as “Baby-BIG”), that are made available, or will be made available, to Medi-Cal beneficiaries. (2) The hospital is contracting under Article 2.6 (commencing with Section 14081) and meets the definition of a university teaching hospital or major, nonuniversity, teaching hospital as set forth on page 51 and as listed on page 57 of the department’s report dated May 1991, entitled “Hospital Peer Grouping.” Payments from the fund shall be used solely for the purposes identified in the contract between the hospital and the state. (3) The hospital is contracting under Article 2.6 (commencing with Section 14081) and meets the definition of any of the following: (A) A large teaching emphasis hospital, as set forth on page 51 and listed on page 57 of the department’s report dated May 1991, entitled “Hospital Peer Grouping,” and also meets the definition of eligible hospital as defined in paragraph (3) of subdivision (a) of Section 14105.98. (B) A children’s hospital pursuant to Section 10727, and also meets the definition of eligible hospital as defined in paragraph (3) of subdivision (a) of Section 14105.98. (C) Notwithstanding the requirement in subparagraph (A) of paragraph (3) that a hospital must be listed on page 57 of the department’s report dated May 1991, entitled “Hospital Peer Grouping,” any hospital whose license pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code was consolidated during the 1999 calendar year with a large teaching emphasis hospital that is listed on page 57 of the above-described report shall be eligible. All other requirements of paragraph (3) shall continue to apply. (4) The hospital meets all of the following criteria: (A) The hospital is contracting under Article 2.6 (commencing with Section 14081). (B) The hospital satisfies the Medicaid State Plan criteria for disproportionate share hospital status. (C) The hospital is a small and rural hospital as defined in Section 124840 of the Health and Safety Code. (D) The hospital is a licensed provider of standby emergency services as described in Section 70649 of Title 22 of the California Code of Regulations. (E) The hospital is able to demonstrate a purpose for additional funding under the selective provider contracting program with proposals relating to health care services that are made available, or will be made available, to Medi-Cal beneficiaries. (F) The hospital is determined by the California Medical Assistance Commission to be a hospital that provides an important community service that otherwise would not be provided in the community. (p) This section shall become inoperative on June 30, 2026, and, as of July 1, 2030, is repealed. The department may conduct any necessary and remaining duties related to this section even after the section becomes inoperative. (Amended by Stats. 2025, Ch. 21, Sec. 111. (AB 116) Effective June 30, 2025. Inoperative June 30, 2026, by its own provisions. Repealed as of July 1, 2030, by its own provisions.)
14166.18.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The director must set a baseline funding amount for each qualifying nondesignated public hospital, and the department must calculate adjusted baseline funding amounts using specified revenue and payment figures.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.18. (a) With respect to each project year, the director shall determine a baseline funding amount for each nondesignated public hospital that was an eligible hospital under paragraph (3) of subdivision (a) of Section 14105.98 for both the 2004–05 fiscal year and the project year. A hospital’s baseline funding amount shall be an amount equal to the total amount paid to the hospital for inpatient hospital services rendered to Medi-Cal beneficiaries during the 2004–05 fiscal year, including the following Medi-Cal payments, but excluding payments received under the Medi-Cal Specialty Mental Health Services Consolidation Program: (1) Base payments under the selective provider contracting program as provided for under Article 2.6 (commencing with Section 14081) or the Medi-Cal state plan cost reimbursement system for inpatient hospital services for noncontracting hospitals. (2) Emergency Services and Supplemental Payments Fund payments as provided for under Section 14085.6. (3) Medi-Cal Medical Education Supplemental Payment Fund payments and Large Teaching Emphasis Hospital and Children’s Hospital Medi-Cal Medical Education Supplemental Payment Fund payments as provided for under Sections 14085.7 and 14085.8, respectively. (4) Small and Rural Hospital Supplemental Payments Fund payments as provided for under Section 14085.9. (5) Disproportionate share hospital payment adjustments as provided for under Section 14105.98. (6) Administrative day payments as provided for under Section 51542 of Title 22 of the California Code of Regulations. (b) The baseline funding amount for each nondesignated public hospital shall reflect a reduction for the total amount of intergovernmental transfers made pursuant to Sections 14085.6, 14085.7, 14085.8, 14085.9, and 14163 for the 2004–05 state fiscal year by the nondesignated public hospital, or on its behalf by the governmental entity with which it is affiliated. (c) The aggregate nondesignated public hospital baseline funding amount shall be the sum of all baseline funding amounts determined under subdivision (a), as adjusted by subdivision (b). (d) With respect to each project year beginning after the 2005–06 project year, an aggregate nondesignated public hospital adjusted baseline funding amount shall be determined as follows: (1) The department shall determine the aggregate total Medi-Cal revenue, using amounts determined under subdivision (a), as adjusted by subdivision (b), but excluding the reductions for the amount of intergovernmental transfers made pursuant to Section 14163, with respect to inpatient hospital services rendered during the 2004–05 fiscal year, for nondesignated public hospitals that were eligible hospitals under paragraph (3) of subdivision (a) of Section 14105.98 for the project year, less the total amount of disproportionate share hospital payments identified in paragraph (5) of subdivision (a) for those hospitals. (2) The department shall determine the aggregate total Medi-Cal revenue paid or payable for inpatient hospital services rendered during the fiscal year preceding the project year for which the nondesignated public hospital adjusted baseline funding amount is being calculated for the nondesignated public hospitals described in paragraph (1). The aggregate total revenue for services rendered in the particular preceding fiscal year shall include the payments that are described under paragraphs (1) and (6) of subdivision (a), and all other payments made to nondesignated public hospitals under this article, excluding disproportionate share hospital payments pursuant to Section 14166.16, stabilization funding pursuant to Section 14166.19, and distressed hospital funding pursuant to Section 14166.23 and paragraph (3) of subdivision (b) of Section 14166.20. (3) The department shall: (A) Calculate the difference between the amount determined under paragraph (1) and the amount determined under paragraph (2). (B) Determine the percentage increase or decrease by dividing the difference in subparagraph (A) by the amount in paragraph (1). (C) Apply the percentage determined in subparagraph (B) to the amount that results from both of the following: (i) Aggregating the nondesignated public hospital baseline funding amounts determined under subdivision (a), as adjusted by subdivision (b), but excluding the reductions for the amount of intergovernmental transfers made pursuant to Section 14163. (ii) Subtracting from the amount in clause (i) the total amount of disproportionate share hospital payments in paragraph (5) of subdivision (a) for those hospitals. (D) The aggregate nondesignated public hospital adjusted baseline funding amount is the amount determined in subdivision (c), plus the resulting product determined in subparagraph (C). (Amended by Stats. 2007, Ch. 130, Sec. 250. Effective January 1, 2008. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.19.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section directs how certain stabilization funding for nondesignated public hospitals must be divided, including a minimum transfer to a supplemental fund and a later transfer of some funds to the General Fund.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.19. The amount of any stabilization funding payable to the nondesignated public hospitals under paragraph (4) of subdivision (b) of Section 14166.20 for a project year, which amount shall not include the amount of stabilization funding paid or payable to hospitals prior to the computation of the stabilization funding under Section 14166.20, shall be allocated in the following priority: (a) An amount shall be transferred to the Nondesignated Public Hospital Supplemental Fund, as may be necessary so that the amount for the Nondesignated Public Hospital Supplemental Fund for the project year, including all funds previously transferred to, or deposited in, the Nondesignated Public Hospital Supplemental Fund for the project year, is not less than one million nine hundred thousand dollars ($1,900,000). (b) Of the remaining stabilization funding payable to nondesignated public hospitals, 75 percent shall be allocated, distributed, and paid in accordance with Section 14166.16, and 25 percent shall be transferred to the Nondesignated Public Hospital Supplemental Fund. (c) Notwithstanding any other law, the amount of any stabilization funding payable to nondesignated public hospitals under Section 14166.20 for a project year as determined under this section that has not been paid, or specifically committed for payment, to nondesignated public hospitals before January 1, 2012, shall not be paid pursuant to Section 14166.20. The funds that would otherwise be paid from the Nondesignated Public Hospital Supplemental Fund shall be transferred to the General Fund, and funds that would otherwise be drawn from the General Fund for payments to the nondesignated public hospitals pursuant to Section 14166.20 shall be retained in the General Fund. (Amended by Stats. 2012, Ch. 23, Sec. 98. (AB 1467) Effective June 27, 2012. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.2.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section sets out how the department and director must administer the demonstration project, make certain hospital payments, and report or file declarations and plan amendments.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.2. (a) The demonstration project, and the successor demonstration project, as applicable, shall be implemented and administered pursuant to this article. (b) (1) The director may modify any process or methodology specified in this article to the extent necessary to comply with federal law or the terms of the demonstration project or the successor demonstration project, as applicable, but only if the modification results in the equitable distribution of funding, consistent with this article, among the hospitals affected by the modification. If the director, after consulting with affected hospitals, determines that an equitable distribution cannot be achieved, the director shall execute a declaration stating that this determination has been made. The director shall retain the declaration and provide a copy, within five working days of the execution of the declaration, to the fiscal and appropriate policy committees of the Legislature. This article shall become inoperative on the date that the director executes a declaration pursuant to this subdivision, and as of January 1 of the following year shall be repealed. (2) In addition to the requirements specified in paragraph (1), the director shall post the declaration on the department’s Internet Web site and the director shall send the declaration to the Secretary of State and the Legislative Counsel. (c) The director shall administer the demonstration project, the successor demonstration project, and related Medi-Cal payment programs in a manner that attempts to maximize available payment of federal financial participation, consistent with federal law, the applicable Special Terms and Conditions for the demonstration project and successor demonstration project issued by the federal Centers for Medicare and Medicaid Services, and this article. (d) As permitted by the federal Centers for Medicare and Medicaid Services, this article shall be effective with regard to services rendered throughout the term of the demonstration project, and retroactively, with regard to services rendered on or after July 1, 2005, but prior to the implementation of the demonstration project, and with regard to services rendered throughout the term of the successor demonstration project. (e) In the administration of this article, the state shall continue to make payments to hospitals that meet the eligibility requirements for participation in the supplemental reimbursement program for hospital facility construction, renovation, or replacement pursuant to Section 14085.5 and shall continue to make inpatient hospital payments not covered by the contract. These payments shall not duplicate any other payments made under this article. (f) The department shall continue to operate the selective provider contracting program in accordance with Article 2.6 (commencing with Section 14081) in a manner consistent with this article. A designated public hospital participating in the certified public expenditure process shall maintain a selective provider contracting program contract. These contracts shall continue to be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code. (g) (1) In the event of a final judicial determination made by any state or federal court that is not appealed in any action by any party or a final determination by the administrator of the federal Centers for Medicare and Medicaid Services that federal financial participation is not available with respect to any payment made under any of the methodologies implemented pursuant to this article because the methodology is invalid, unlawful, or is contrary to any provision of federal law or regulation, the director may modify the process or methodology to comply with law, but only if the modification results in the equitable distribution of demonstration project funding, consistent with this article, among the hospitals affected by the modification. If the director, after consulting with affected hospitals, determines that an equitable distribution cannot be achieved, the director shall execute a declaration stating that this determination has been made. The director shall retain the declaration and provide a copy, within five working days of the execution of the declaration, to the fiscal and appropriate policy committees of the Legislature. This article shall become inoperative on the date that the director executes a declaration pursuant to this subdivision, and as of January 1 of the following year shall be repealed. (2) In addition to the requirements specified in paragraph (1), the director shall post the declaration on the department’s Internet Web site and the director shall send the declaration to the Secretary of State and the Legislative Counsel. (h) (1) The department may adopt regulations to implement this article. These regulations may initially be adopted as emergency regulations in accordance with the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code). For purposes of this article, the adoption of regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health, and safety or general welfare. Any emergency regulations adopted pursuant to this section shall not remain in effect subsequent to 24 months after the effective date of this article. (2) As an alternative, and notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, or any other provision of law, the department may implement and administer this article by means of provider bulletins, manuals, or other similar instructions, without taking regulatory action. The department shall notify the fiscal and appropriate policy committees of the Legislature of its intent to issue a provider bulletin, manual, or other similar instruction, at least five days prior to issuance. In addition, the department shall provide a copy of any provider bulletin, manual, or other similar instruction issued under this paragraph to the fiscal and appropriate policy committees of the Legislature. The department shall consult with interested parties and appropriate stakeholders, regarding the implementation and ongoing administration of this article. (i) To the extent necessary to implement this article, the department shall submit, by September 30, 2005, to the federal Centers for Medicare and Medicaid Services proposed amendments to the Medi-Cal state plan, including, but not limited to, proposals to modify inpatient hospital payments to designated public hospitals, modify the disproportionate share hospital payment program, and provide for supplemental Medi-Cal reimbursement for certain physician and nonphysician professional services. The department shall, subsequent to September 30, 2005, submit any additional proposed amendments to the Medi-Cal state plan that may be required by the federal Centers for Medicare and Medicaid Services, to the extent necessary to implement this article. (j) Each designated public hospital shall implement a comprehensive process to offer individuals who receive services at the hospital the opportunity to apply for the Medi-Cal program, the Healthy Families Program, or any other public health coverage program for which the individual may be eligible, and shall refer the individual to those programs, as appropriate. (k) In any judicial challenge of the provisions of this article, nothing shall create an obligation on the part of the state to fund any payment from state funds due to the absence or shortfall of federal funding. (l) Any reference in this article to the “Medicare cost report” shall be deemed a reference to the Medi-Cal cost report to the extent that report is approved by the federal Centers for Medicare and Medicaid Services for any of the uses described in this article. (Amended by Stats. 2011, Ch. 86, Sec. 2. (AB 1066) Effective July 15, 2011. Repealed on date prescribed in subd. (b) or (g) or in Section 14166.26. Note: Termination clauses affect Article 5.2, commencing with Section 14166.)
14166.20.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section sets how stabilization funding is calculated, allocated, and paid to hospitals for project years through October 31, 2010.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.20. (a) With respect to each project year through October 31, 2010, the total amount of stabilization funding shall be the sum of the following: (1) (A) Federal Medicaid funds available in the Health Care Support Fund, established pursuant to Section 14166.21, reduced by the amount necessary to meet the baseline funding amount, or the adjusted baseline funding amount, as appropriate, for project years after the 2005–06 project year for each designated public hospital, project year private DSH hospitals in the aggregate, and nondesignated public hospitals in the aggregate as determined in Sections 14166.5, 14166.13, and 14166.18, respectively, taking into account all other payments to each hospital under this article. This amount shall be not less than zero. (B) For purposes of subparagraph (A), federal Medicaid funds available in the Health Care Support Fund shall not include health care coverage initiative amounts identified under paragraph (2) of subdivision (e) of Section 14166.9. (C) The federal financial participation amount arising from the certified public expenditures that has been paid to designated public hospitals, or the governmental entities with which they are affiliated, pursuant to subdivision (g) of Section 14166.221, shall be disregarded for purposes of this section. (2) The state general funds that were made available due to the receipt of federal funding for previously state-funded programs through the safety net care pool and any federal Medicaid hospital reimbursements resulting from these expenditures, unless otherwise recognized under paragraph (1), to the extent those funds are in excess of the amount necessary to meet the baseline funding amount, or the adjusted baseline funding amount, as appropriate, for project years after the 2005–06 project year for each designated public hospital, for project year private DSH hospitals in the aggregate, and for nondesignated public hospitals in the aggregate, as determined in Sections 14166.5, 14166.13, and 14166.18, respectively. (3) To the extent not included in paragraph (1) or (2), the amount of the increase in state General Fund expenditures for Medi-Cal inpatient hospital services for the project year for project year private DSH hospitals and nondesignated public hospitals, including amounts expended in accordance with paragraph (1) of subdivision (c) of Section 14166.23, that exceeds the expenditure amount for the same purpose and the same hospitals necessary to provide the aggregate baseline funding amounts applicable to the project determined pursuant to Sections 14166.13 and 14166.18, and any direct grants to designated public hospitals for services under the demonstration project. (4) To the extent not included in paragraph (2), federal Medicaid funds received by the state as a result of the General Fund expenditures described in paragraph (3). (5) The federal Medicaid funds received by the state as a result of federal financial participation with respect to Medi-Cal payments for inpatient hospital services made to project year private DSH hospitals and to nondesignated public hospitals for services rendered during the project year, the state share of which was derived from intergovernmental transfers or certified public expenditures of any public entity that does not own or operate a public hospital. (6) Federal safety net care pool funds claimed and received for inpatient hospital services rendered under the health care coverage initiative identified under paragraph (3) of subdivision (e) of Section 14166.9. (b) With respect to the 2005–06, 2006–07, and subsequent project years through October 31, 2010, the stabilization funding determined under subdivision (a) shall be allocated as follows: (1) Eight million dollars ($8,000,000) shall be paid to San Mateo Medical Center. All or a portion of this amount may be paid as disproportionate share hospital payments in addition to the hospital’s allocation that would otherwise be determined under Section 14166.6. The amount provided for in this paragraph shall be disregarded in the application of the limitations described in paragraph (3) of subdivision (a) of Section 14166.6, and in paragraph (1) of subdivision (a) of Section 14166.7. (2) (A) Ninety-six million two hundred twenty-eight thousand dollars ($96,228,000) shall be allocated to designated public hospitals to be paid in accordance with Section 14166.75. (B) Forty-two million two hundred twenty-eight thousand dollars ($42,228,000) shall be allocated to private DSH hospitals to be paid in accordance with Section 14166.14. (C) Five hundred forty-four thousand dollars ($544,000) shall be allocated to nondesignated public hospitals to be paid in accordance with Section 14166.17. (D) In the event that stabilization funding is less than one hundred forty-seven million dollars ($147,000,000), the amounts allocated to designated public hospitals, private DSH hospitals, and nondesignated public hospitals under this paragraph shall be reduced proportionately. (3) (A) An amount equal to the lesser of 10 percent of the total amount determined under subdivision (a) or twenty-three million five hundred thousand dollars ($23,500,000), but at least fifteen million three hundred thousand dollars ($15,300,000), shall be made available for additional payments to distressed hospitals that participate in the selective provider contracting program under Article 2.6 (commencing with Section 14081), including designated public hospitals, in amounts to be determined by the California Medical Assistance Commission. The additional payments to designated public hospitals shall be negotiated by the California Medical Assistance Commission, but shall be paid by the department in the form of a direct grant rather than as Medi-Cal payments. (B) Notwithstanding subparagraph (A) and solely for the 2006–07 fiscal year, if the amount that otherwise would be made available for additional payments to distressed hospitals under subparagraph (A) is equal to or greater than eighteen million three hundred thousand dollars ($18,300,000), that amount shall be reduced by eighteen million three hundred thousand dollars ($18,300,000) and the state’s obligation to make these payments shall be reduced by this amount. In the event the amount that otherwise would be made available under subparagraph (A) is less than eighteen million three hundred thousand dollars ($18,300,000), but greater than or equal to the minimum amount of fifteen million three hundred thousand dollars ($15,300,000), then the amount available under this paragraph shall be zero and the state’s obligation to make these payments shall be zero. (C) Notwithstanding subparagraph (A) and solely for the 2008–09 and 2009–10 fiscal years, the amount to be made available shall be reduced by fifteen million three hundred thousand dollars ($15,300,000) in each of the two years. The funds generated from this reduction shall be retained in the General Fund. (4) An amount equal to 0.64 percent of the total amount determined under subdivision (a), to nondesignated public hospitals to be paid in accordance with Section 14166.19. (5) The amount remaining after subtracting the amount determined in paragraphs (1) and (2), subparagraph (A) of paragraph (3), and paragraph (4), without taking into account subparagraphs (B) and (C) of paragraph (3), shall be allocated as follows: (A) Sixty percent to designated public hospitals to be paid in accordance with Section 14166.75. (B) Forty percent to project year private DSH hospitals to be paid in accordance with Section 14166.14. (c) By April 1 of the year following the project year for which the payment is made, and after taking into account final amounts otherwise paid or payable to hospitals under this article, the director shall calculate in accordance with subdivision (a), allocate in accordance with subdivision (b), and pay to hospitals in accordance with Sections 14166.75, 14166.14, and 14166.19, as applicable, the stabilization funding. (d) For purposes of determining amounts paid or payable to hospitals under subdivision (c), the department shall apply the following: (1) In determining amounts paid or payable to designated public hospitals that are based on allowable costs incurred by the hospital, or the governmental entity with which it is affiliated, the following shall apply: (A) If the final payment amount is based on the hospital’s Medicare cost report, the department shall rely on the cost report filed with the Medicare fiscal intermediary for the project year for which the calculation is made, reduced by a percentage that represents the average percentage change from total reported costs to final costs for the three most recent cost reporting periods for which final determinations have been made, taking into account all administrative and judicial appeals. Protested amounts shall not be considered in determining the average percentage change unless the same or similar costs are included in the project year cost report. (B) If the final payment amount is based on costs not included in subparagraph (A), the reported costs as of the date the determination is made under subdivision (c), shall be reduced by 10 percent. (C) In addition to adjustments required in subparagraphs (A) and (B), the department shall adjust amounts paid or payable to designated public hospitals by any applicable deferrals or disallowances identified by the federal Centers for Medicare and Medicaid Services as of the date the determination is made under subdivision (c) not otherwise reflected in subparagraphs (A) and (B). (2) Amounts paid or payable to project year private DSH hospitals and nondesignated public hospitals shall be determined by the most recently available Medi-Cal paid claims data increased by a percentage to reflect an estimate of amounts remaining unpaid. (e) The department shall consult with hospital representatives regarding the appropriate calculation of stabilization funding before stabilization funds are paid to hospitals. The calculation may be comprised of multiple steps involving interim computations and assumptions as may be necessary to determine the total amount of stabilization funding under subdivision (a) and the allocations under subdivision (b). No later than 30 days after this consultation, the department shall establish a final determination of stabilization funding that shall not be modified for any reason other than mathematical errors or mathematical omissions on the part of the department. (f) The department shall distribute 75 percent of the estimated stabilization funding on an interim basis throughout the project year. (g) The allocation and payment of stabilization funding shall not reduce the amount otherwise paid or payable to a hospital under this article or any other provision of law, unless the reduction is required by the demonstration project’s Special Terms and Conditions or by federal law. (h) It is the intent of the Legislature that the amendments made to Section 14166.12 and to this section by the act that added this subdivision in the 2007–08 Regular Session shall not be construed to amend or otherwise alter the ongoing structure of the department’s Medicaid Demonstration Project and Waiver approved by the federal Centers for Medicare and Medicaid Services to begin on September 1, 2005. (i) The provisions of this section shall only apply with respect to the demonstration project term, and shall not apply with respect to the successor demonstration project term. (Amended by Stats. 2012, Ch. 162, Sec. 220. (SB 1171) Effective January 1, 2013. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.21.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The Health Care Support Fund is created in the State Treasury and must be continuously appropriated to the department; the fund also includes accrued interest.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.21. (a) The Health Care Support Fund is hereby established in the State Treasury. Notwithstanding Section 13340 of the Government Code, the fund shall be continuously appropriated to the department for the purposes specified in this article. The fund shall include any interest that accrues on amounts in the fund. (b) During the term of the demonstration project, amounts in the Health Care Support Fund shall be paid in the following order of priority: (1) To hospitals for services rendered to Medi-Cal beneficiaries and the uninsured in an amount necessary to meet the aggregate baseline funding amount, or the adjusted aggregate baseline funding amount for project years after the 2005-06 project year, as specified in subdivision (d) of Section 14166.5, subdivision (b) of Section 14166.13, and Section 14166.18, taking into account all other payments to each hospital under this article, except payments made from the Distressed Hospital Fund pursuant to Section 14166.23 and payments made to distressed hospitals pursuant to paragraph (3) of subdivision (b) of Section 14166.20. If the amount in the Health Care Support Fund is inadequate to provide full aggregate baseline funding, or adjusted aggregate baseline funding, to all designated public hospitals, project year private DSH hospitals, and nondesignated public hospitals, each group’s payments shall be reduced pro rata. (2) To the extent necessary to maximize federal funding under the demonstration project and consistent with Section 14166.22, the department may claim safety net care pool funds based on health care expenditures incurred by the department for uncompensated medical care costs of medical services provided to uninsured individuals, as approved by the federal Centers for Medicare and Medicaid Services. (3) Stabilization funding, allocated and paid in accordance with Sections 14166.75, 14166.14, and 14166.19, and paragraph (3) of subdivision (b) of Section 14166.20. (4) Any amounts remaining after final reconciliation of all amounts due at the end of a project year shall remain available for payments in accordance with this section in the next project year. (c) Subdivision (b) shall not apply to federal safety net care pool funds claimed and received for services rendered under the health care coverage initiative identified under paragraph (2) of subdivision (e) of Section 14166.9, which shall be paid in accordance with Part 3.5 (commencing with Section 15900) and under paragraphs 43 and 44 of the Special Terms and Conditions for the demonstration project. (d) During the term of the successor demonstration project, amounts in the Health Care Support Fund shall be paid as follows: (1) To the department consistent with Section 14166.22, with respect to amounts claimed by the department based on health care expenditures incurred by the state for uncompensated medical care costs of medical services provided to uninsured individuals, or expenditures incurred by the state for uncompensated costs of state-funded workforce development programs, as approved by the federal Centers for Medicare and Medicaid Services. (2) To designated public hospitals and the governmental entities with which they are affiliated pursuant to Section 14166.71, with respect to amounts claimed based on certified public expenditures as reported pursuant to Section 14166.8. (3) Any amounts remaining after final reconciliation of all amounts due at the end of a successor demonstration year shall remain available for payments in accordance with this section in the next successor demonstration year, as authorized by the Special Terms and Conditions for the successor demonstration project. (Amended by Stats. 2011, Ch. 86, Sec. 16. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.22.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The department may claim federal reimbursement for certain expenditures, if needed to maximize federal funds and allowed by the demonstration project conditions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.22. (a) To the extent required to maximize available federal funds under the demonstration project and to the extent authorized by the Special Terms and Conditions for the demonstration project, the department may claim federal reimbursement for expenditures, consistent with the equitable distribution established under this article, in the following priority order: (1) The medically indigent adults long-term care program. (2) The Genetically Handicapped Persons Program established pursuant to Article 1 (commencing with Section 125125) of Chapter 2 of Part 5 of Division 106 of the Health and Safety Code. (3) The Breast and Cervical Cancer Treatment Program established pursuant to Article 1.5 (commencing with Section 104160) of Chapter 2 of Part 1 of Division 103 of the Health and Safety Code. (4) The California Children’s Services Program established pursuant to Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code. (b) Notwithstanding any other law, the federal reimbursement received as a result of a claim made pursuant to subdivision (a) shall be used to create General Fund savings solely for the department for use in support of safety net hospitals under the demonstration project. (c) The federal reimbursement received as a result of a claim made pursuant to subdivision (a) is hereby appropriated to the department for the program in which the claimed expenditures were made. (d) An amount of General Fund moneys appropriated to the department for programs specified in subdivision (a) equal to the amount of federal reimbursement identified pursuant to subdivision (c) is hereby reappropriated to the Health Care Deposit Fund to be used for the purposes set forth in this article. (Amended by Stats. 2015, Ch. 303, Sec. 621. (AB 731) Effective January 1, 2016. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.221.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The department is directed to maximize federal Medi-Cal reimbursement, may claim specified federal funding, and must make certain notifications and fund deposits.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.221. (a) It is the intent of the Legislature for the department to maximize the receipt of federal funds for California’s Medi-Cal program, including this demonstration project, by identifying state resources which will enable the state to obtain additional federal reimbursement during this unprecedented fiscal crisis. It is further the intent of the Legislature that any program identified by the department for the purposes specified in this section shall not be modified or altered in any manner unless subsequent statutory authority is expressly provided by the Legislature. (b) Notwithstanding Section 14166.22, in order to maximize federal claiming under the demonstration project, the department shall have broad discretion to claim federal reimbursement consistent with all applicable federal claiming rules for the following expenditures in an order of priority determined by the department: (1) Expenditures in programs funded in whole or in part by realignment funds under Chapter 6 (commencing with Section 17600) of Part 5, including, but not limited to, the County Medical Services Program. (2) Expenditures in programs funded in whole or in part by the County Mental Health Services Act. (3) Other public expenditures, to the extent the department determines the expenditures to be appropriate for claiming under the demonstration project. (4) Expenditures in any programs referenced in subdivision (a) of Section 14166.22 or other state-only funded programs as the department, in its discretion, determines should be used for the purposes of this section. These programs may include programs administered by other state agencies or departments. (c) The department shall have discretion to claim under this section for any and all additional demonstration project funding made available pursuant to any amendments to the demonstration project made on or after October 1, 2008, or pursuant to any federal laws that increase the amount of available funding, including, but not limited to, the federal American Recovery and Reinvestment Act of 2009 (Public Law 111-5). This additional funding shall include federal funds made available due to an increase in the federal medical assistance percentage in addition to any other increase in the amount of federal funding. (d) Any amounts received in the 2008–09, 2009–10, and 2010–11 fiscal years from the federal government pursuant to additional demonstration project funding as specified in this section shall be deposited in the Federal Trust Fund. Notwithstanding Section 28.00 of the Budget Act of 2009, the Department of Finance may authorize expenditure of these funds in a manner consistent with federal law and that offsets General Fund expenditures otherwise authorized in the Budget Act of 2009 for the Medi-Cal program, and as appropriated in Item 4260-101-0001, or for the Health Care Support Fund. For any adjustments made under the authority provided for by this section, the Department of Finance shall provide notification in writing to the Chairperson of the Joint Legislative Budget Committee not less than 30 days prior to the effective date of the adjustment, or not sooner than whatever lesser time the Chairperson of the Joint Legislative Budget Committee, or his or her designee, may in each instance determine. The notification to the chairperson of the joint committee shall include, at a minimum, the amounts of the proposed appropriation adjustments, a description of any assumptions used in making the adjustments, the relevant federal authority, and any other clarifying description as relevant. (e) If the federal Centers for Medicare and Medicaid Services or any federal or state court issues a ruling that any or all federal dollars obtained by claiming for expenditures from any particular program referenced in subdivision (b) cannot be used to increase state revenues, the department may discontinue use of those expenditures for claiming under this section and substitute other expenditures from other programs referenced in subdivision (b) at its discretion. (f) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section by means of a provider bulletin, or other similar instruction, without taking regulatory action. The department shall also provide notification to the Joint Legislative Budget Committee within five working days if that action is taken in order to inform the Legislature that the action is being implemented. (g) (1) A portion of the additional federal funding described in subdivision (c) shall be allocated to the designated public hospitals and shall be identical in amount to the fee proceeds retained by the state under Section 14167.5. (2) Funding under this subdivision shall be made available to the designated public hospitals in increments that reflect the quarters of the subject federal fiscal year for which payments are made to private hospitals from the Hospital Quality Assurance Revenue Fund established pursuant to Section 14167.35. (3) The department shall claim the federal funds made available to the designated public hospitals under this subdivision upon receipt of the necessary expenditure reports and certifications from the designated public hospitals, or the governmental entities with which they are affiliated, and distribute those funds pursuant to Section 14167.5 so that receipt of the federal funds by the designated public hospitals is aligned with the payment schedule set forth in subdivision (c) of Section 14167.9. (h) The department shall implement subdivision (g) of this section and subdivision (e) of Section 14167.5 only if and to the extent that all of the following are satisfied: (1) The state has determined, after consultation with the designated public hospitals, that the designated public hospitals, or the governmental entities with which they are affiliated, have incurred sufficient expenditures during the 2009 and 2010 project years, or that portion of the 2011 project year to the extent federal funds are available under Section 15900 or under an extension of the demonstration project, so that each designated public hospital receives the total amount, taking into account grant funds under Section 14167.5 and payments under this section, that it would have received for each installment under subdivision (c) of Section 14167.9 had subdivision (e) of Section 14167.5 not been implemented. (2) The implementation of subdivision (g) of this section and subdivision (e) of Section 14167.5 does not result in the receipt by any designated public hospital, or the governmental entity with which it is affiliated, of less than what would otherwise be paid to that hospital or entity pursuant to Part 3.5 (commencing with Section 15900), the sections referred to in Section 14166.35, or Article 5.21 (commencing with Section 14167.1). (3) In determining the amount retained by the state under subdivision (e) of Section 14167.5 and made available to the designated public hospitals in subdivision (g), the department makes adjustments to the reported expenditures for possible audit disallowances, consistent with the type of adjustments applied in prior project years to reduce the likelihood of a federal recoupment. (4) The department is satisfied that the expenditures claimed under paragraph (3) of subdivision (g) represent valid expenditures for the purposes of federal financial participation under the Special Terms and Conditions for the demonstration project based on federal law and guidance provided by the federal Centers for Medicare and Medicaid Services. (5) Notwithstanding subdivision (b), the department has claimed federal reimbursement for the state-only expenditures in the programs referenced in subdivision (a) of Section 14166.22 and in the programs authorized by paragraph (4) of subdivision (b) of Section 14166.221, to the maximum extent authorized under the Special Terms and Conditions for the demonstration project. (6) Federal financial participation is available and implementation of these provisions does not jeopardize the federal financial participation for other programs. (Amended by Stats. 2010, Ch. 218, Sec. 3. (AB 1653) Effective September 8, 2010. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.225.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The director must reduce safety net care pool payments, and the department must or may increase federal claiming to offset the reduction under stated limits.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.225. (a) In order to implement changes in the level of funding for health care services, the director shall reduce safety net care pool payments as specified in this section. (b) Notwithstanding the provisions of this article, safety net care pool payments made to the designated public hospitals and the South Los Angeles Medical Services Preservation Fund, for services rendered on or after July 1, 2009, through and including June 30, 2010, shall be reduced by 10 percent, but in no event shall the total amount of the reduction exceed fifty-four million two-hundred thousand dollars ($54,200,000). (c) (1) Notwithstanding Section 14166.22 and any other provision of this article, the department shall increase federal claiming from the safety net care pool for the state-funded programs listed in subdivision (a) of Section 14166.22 above the amount necessary to maintain stabilization funding to private hospitals, nondesignated public hospitals, and distressed hospitals pursuant to Section 14166.20, by an amount equivalent to the reduction made pursuant to subdivision (b), but only to the extent that the state-only funded programs have sufficient costs available for the claiming of federal funds from the safety net care pool. (2) If necessary to reach the full amount of the reduction set forth in subdivision (b), the department may increase federal claiming from the safety net care pool for the state-funded programs listed in subdivision (a) of Section 14166.22 for fiscal years prior to the 2009–10 fiscal year, but only to the extent that the state-only funded programs have sufficient costs available in fiscal years prior to the 2009–10 fiscal year that were not previously the basis for claiming federal funds. (d) The General Fund savings generated pursuant to subdivision (c) shall be made available to the General Fund and shall not be subject to the provisions of subdivisions (b) and (d) of Section 14166.22. (e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section by means of a provider bulletin, or other similar instruction, without taking regulatory action. (Amended by Stats. 2009, 4th Ex. Sess., Ch. 5, Sec. 48. Effective July 28, 2009. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.23.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section creates the Distressed Hospital Fund and sets rules for how money enters it, how it may be used, and how payments to distressed hospitals are handled.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.23. (a) For purposes of this section, “distressed hospitals” are hospitals that participate in selective providers contracting under Article 2.6 (commencing with Section 14081) and that meet all of the following requirements, as determined by the California Medical Assistance Commission in its discretion: (1) The hospital serves a substantial volume of Medi-Cal patients measured either as a percentage of the hospital’s overall volume or by the total volume of Medi-Cal services furnished by the hospital. (2) The hospital is a critical component of the Medi-Cal program’s health care delivery system, such that the Medi-Cal health care delivery system would be significantly disrupted if the hospital reduced its Medi-Cal services or no longer participated in the Medi-Cal program. (3) The hospital is facing a significant financial hardship that may impair its ability to continue its range of services for the Medi-Cal program. (b) The Distressed Hospital Fund is hereby created in the State Treasury. (c) Notwithstanding Section 13340 of the Government Code, the fund shall be continuously appropriated to the department for the purposes specified in this section. (d) Except as otherwise limited by this section, the fund shall consist of all of the following: (1) The amounts transferred to the fund pursuant to subdivision (e). (2) Any additional amounts appropriated to the fund by the Legislature. (3) Any interest that accrues on amounts in the fund. (e) The following amounts shall be transferred to the fund from the prior supplemental funds at the beginning of each project year. (1) Twenty percent of the amount in the prior supplemental funds on the effective date of this article, less any and all payments for services rendered prior to July 1, 2005, but paid after July 1, 2005. (2) Interest that accrued on the prior supplemental funds during the prior project year. (3) Notwithstanding paragraph (1), solely for the 2009–10 fiscal year, the amount of funds transferred shall be reduced by six million one hundred and ninety-one thousand dollars ($6,191,000). The funds generated from this reduction shall be transferred to the General Fund. (f) No distributions, payments, transfers, or disbursements shall be made from the prior supplemental funds except as set forth in this section. (g) Moneys in the fund shall be used as the source for the nonfederal share of payments to hospitals under this section. (h) Except as otherwise provided in subdivision (j), moneys shall be applied to obtain federal financial participation to the extent available in accordance with customary Medi-Cal accounting procedures for purposes of payments under this section. Distributions from the fund shall be supplemental to any other Medi-Cal reimbursement received by the hospitals, including amounts that hospitals receive under the selective provider contracting program, and shall not affect provider rates paid under the selective provider contracting program. (i) Subject to subdivision (j), all amounts that are in the fund shall be available for negotiation by the California Medical Assistance Commission, along with corresponding federal financial participation, for additional payments to distressed hospitals. These amounts shall be paid under contracts entered into by the department and negotiated by the California Medical Assistance Commission pursuant to Article 2.6 (commencing with Section 14081), provided that any amounts payable to a designated public hospital shall be paid in the form of a direct grant of state general funds pursuant to a contract negotiated by the California Medical Assistance Commission. The commission shall not consider the lack of federal financial participation in direct grants to designated public hospitals in determining which hospital may receive funding under this section. (j) After April 1, 2007, and each April 1 thereafter, in the event that funding under this article is insufficient to meet the adjusted aggregate baseline funding amounts for a particular project year, as determined in subdivision (d) of Section 14166.5, and in Sections 14166.13 and 14166.18, funds under this section shall first be available for use under contracts negotiated by the California Medical Assistance Commission for hospitals contracting under the selective provider contracting program under Article 2.6 (commencing with Section 14081) in an effort to address the insufficiency, to the extent funds under this section are available on or after April 1 for the particular project year. (k) Any funds remaining in the fund at the end of a fiscal year shall be carried forward for use in the following fiscal year. (Amended by Stats. 2009, 4th Ex. Sess., Ch. 5, Sec. 49. Effective July 28, 2009. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.24.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section delays final payment determinations for certain designated public hospitals, allows appeals and judicial review of overpayment decisions, and sets consultation and repayment rules for disallowances, deferrals, and federal reimbursement issues.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.24. (a) Any determination of the amount due a designated public hospital that is based in whole or in part on costs reported to or audited by a Medicare fiscal intermediary shall not be deemed final for purposes of this article unless the hospital has received a final determination of Medicare payment for the cost reporting for Medicare purposes. Designated public hospitals shall be entitled to pursue all administrative and judicial review available under the Medicare Program and any final determination shall be incorporated into the department’s final determination of payment due the hospital under this article. (b) If as a result of an audit performed by the department or any state or federal agency, the department determines that any hospital has been overpaid under the demonstration project or the successor demonstration project, the department shall recoup the overpayment in accordance with Section 14172.5 or 14115.5. The hospital may appeal the overpayment determinations and any related audit determination in accordance with the appeal procedures set forth in Sections 51016 to 51047, inclusive, of Title 22 of the California Code of Regulations. The hospital may seek judicial review of the final administrative decision as set forth in Section 14171. (c) The department shall promptly consult with the affected governmental entity regarding a dispute between a designated public hospital and the department regarding the validity of the hospital’s certified public expenditures. If the department determines that the hospital’s certification is valid, the department shall submit the claim to obtain federal reimbursement for the certified expenditure in question. (d) (1) Upon receipt of a notice of disallowance or deferral from the federal government related to the certified public expenditures or intergovernmental transfers of any governmental entity participating in the demonstration project, the department shall promptly notify the affected governmental entity. The governmental entity that certified the public expenditure shall be the entity responsible for the federal portion of that expenditure. (2) The department and the affected governmental entity shall promptly consult regarding the proposed disallowance or deferral. (3) After consulting with the governmental entity, the department shall determine whether the disallowance or response to a deferral should be filed with the federal government. If the department determines the appeal or response has merit, the department shall timely appeal. If necessary, the department may request an extension of the deadline to file an appeal or response to a deferral. The affected governmental entity may provide the department with the legal and factual basis for the appeal or response. (e) Notwithstanding any other provision of law, if the department has exercised the authority set forth in subdivision (g) of Section 14166.221 and subdivision (e) of Section 14167.5, then all of the following shall occur: (1) (A) The state shall be solely responsible for the repayment of the federal portion of any federal disallowance associated with any certified public expenditures for the 2009, 2010, and 2011 project years through October 31, 2010, and paragraph (1) of subdivision (d) of Section 14166.24 shall be disregarded, up to the total amount of the grant funds retained by the state under subdivision (e) of Section 14167.5. (B) If the hospitals have additional certified public expenditures for which federal funds have not been received but for which federal funds could have been received under the demonstration project had additional federal funds been available, including federal funds made available under an extension of the demonstration project, the state shall first be allowed to respond to a deferral or disallowance based on the certified public expenditures of designated public hospitals, or the governmental entities with which they are affiliated, by substituting the additional certified public expenditures for those deferred or disallowed. (2) The department shall not recoup any overpayment from a designated public hospital, or a governmental entity with which it is affiliated, with respect to payments under this article for the 2009, 2010, and 2011 project years through October 31, 2010, until the state has repaid all federal funds due up to the amount of the grant funds retained by the state under subdivision (e) of Section 14167.5. (Amended by Stats. 2011, Ch. 86, Sec. 17. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.25.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section creates a fund for South Los Angeles hospital-related services, requires a county assurance not to cut ongoing health services funding as a condition of receiving distributions, and limits when fund money may be used.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.25. (a) The Legislature finds and declares all of the following: (1) In light of the closure of Los Angeles County Martin Luther King, Jr.-Harbor Hospital, there is a need to ensure adequate funding for continued health care services to the uninsured population of South Los Angeles, including, but not limited to, the Cities of Compton, Lynwood, South Gate, and Huntington Park, the southern and central portions of the Cities of Los Angeles, Inglewood, Gardena, and surrounding unincorporated communities. (2) The state, the County of Los Angeles, and all health care providers in the South Los Angeles community must work together to meet the health care needs of the community until the critical hospital services previously provided by Los Angeles County Martin Luther King, Jr.-Harbor Hospital can be restored at this location. (3) The Medi-Cal Hospital/Uninsured Care Demonstration Project provides a critical source of funding for services to low-income communities throughout the state that are provided by California’s safety net hospital systems. (4) The special funding provided in this section is predicated on the express intent of the County of Los Angeles to restore hospital services on the hospital campus, to be operated by either a private or public entity. The county has undertaken a specific plan to do so as quickly as possible. (5) The Legislature anticipates that demonstration project funds will be available to help fund the reopened hospital. The nature and amount of that funding cannot be determined until the new structure and operation of the hospital is known. (6) As an interim response to the specific circumstances caused by the closure of this hospital, and until hospital services can be restored at this location, a special fund will be created to receive demonstration project funding to be available to the County of Los Angeles for expenditures to preserve health care services for the uninsured population of South Los Angeles, as defined above. (b) The South Los Angeles Medical Services Preservation Fund is hereby created in the State Treasury. Notwithstanding Section 13340 of the Government Code, the fund shall be continuously appropriated to the department for the purposes specified in this section. (c) Subject to the conditions in this section, a maximum amount of one hundred million dollars ($100,000,000) of the safety net care pool funds claimed and received by the state that are based on the certified public expenditures of the County of Los Angeles or its designated public hospitals shall be transferred to the South Los Angeles Medical Services Preservation Fund for each of the three project years, 2007–08, 2008–09, and 2009–10. (1) In the event that the director determines that any amount is due to the County of Los Angeles under the demonstration project for services rendered during the portion of a project year during which Los Angeles County Martin Luther King, Jr.-Harbor Hospital was operational, the amount deposited in the fund under this subdivision shall be reduced by a percentage determined by reducing 100 percent by the percentage reduction in the hospital’s baseline as determined under subdivision (c) of Section 14166.5 for that project year. (2) If, in the aggregate, the federal medical assistance percentage of the certified public expenditures reported by the County of Los Angeles and its designated public hospitals under Section 14166.8, excluding those certified public expenditures reported under paragraph (1) of subdivision (b) of Section 14166.8, in any project year do not exceed the amounts paid or payable to the county and its designated public hospitals in the aggregate under Section 14166.6, excluding disproportionate share payments funded with intergovernmental transfers, Section 14166.7, and subdivision (d) for the same project year, then the amount deposited in the fund under subdivision (c) shall be reduced by the amount of excess payments over the federal medical assistance percentage of certified public expenditures. (d) Moneys in the South Los Angeles Medical Services Preservation Fund shall be distributed to the County of Los Angeles in amounts equal to the costs incurred by the county, including indirect costs associated with adequately maintaining the hospital building so that it can be reopened, in providing, or compensating other providers for, health services rendered to the uninsured population of South Los Angeles, including all of the following: (1) Services provided in the multiservice ambulatory care center operating on the former Los Angeles County Martin Luther King, Jr.-Harbor Hospital campus. (2) Services rendered to patients in beds at other designated public hospitals operated by the County of Los Angeles that have been opened specifically for the purpose of serving patients that would have been served by the former Los Angeles County Martin Luther King, Jr.-Harbor Hospital. (3) Services rendered in the county-operated health center and the comprehensive health center formerly operated under Los Angeles County Martin Luther King, Jr.-Harbor Hospital. (4) Services rendered to the uninsured by other public or private health care providers for which the County of Los Angeles has agreed to pay under a contract with the provider as a result of the downsizing or closure of Los Angeles County Martin Luther King, Jr.-Harbor Hospital. (e) As a condition for receiving distributions from the South Los Angeles Medical Services Preservation Fund in any project year, the County of Los Angeles shall assure the director that it will not reduce the county’s ongoing, systemwide financial contribution to the county department of health services during that project year for health care services to the uninsured. (f) No funds shall be available from the South Los Angeles Medical Services Preservation Fund for services rendered when a hospital on the former Los Angeles County Martin Luther King, Jr.-Harbor Hospital campus is certified for Medi-Cal participation. (g) If the full amount of the South Los Angeles Medical Services Preservation Fund for any project year is not distributed to the County of Los Angeles, based on the cost of services identified in subdivision (d) that were rendered during that project year, any remaining amounts shall revert to the Health Care Support Fund established pursuant to Section 14166.21. (h) To the extent that the County of Los Angeles receives distributions from the South Los Angeles Medical Services Preservation Fund based on the cost of services rendered by county-operated providers, or based on payments made to private providers for services rendered to the uninsured population of South Los Angeles, the costs of the services rendered shall not be considered for purposes of any of the following determinations with respect to either the county or the private provider: (1) Medi-Cal payments under the selective provider contracting program under Article 2.6 (commencing with Section 14081), including payments to distressed hospitals under Section 14166.23. (2) Baseline amounts, or adjustments thereto, under Section 14166.5, 14166.13, or 14166.18. (3) Any other payment under Medi-Cal or other health care program. (i) This section shall be implemented only to the extent that the director determines that it will not result in the loss of federal funds under the demonstration project. (Amended by Stats. 2009, Ch. 140, Sec. 213. (AB 1164) Effective January 1, 2010. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.252.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The director may set allocation amounts for a partial-year extension of a demonstration project, but only if federal CMS extension requirements are followed.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.252. (a) In the event of a partial year extension of a demonstration project pursuant to this article, the director shall have discretion to determine allocations for the extension period on either an annual or partial year basis, consistent with any requirements in the letter from the federal Centers for Medicare and Medicaid Services granting the extension. (b) This section shall be implemented only to the extent federal financial participation is available and is not jeopardized. (Added by Stats. 2010, Ch. 714, Sec. 4. (SB 208) Effective October 19, 2010. Conditionally inoperative as provided in Section 14166.25 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.253.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The director may request temporary extensions in certain CMS-related circumstances, and the department must continue and apply specified payment methods, use interim payments only as allowed, give conflict notice, and may use informal guidance instead of regulations until July 1, 2016.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.253. (a) If the department has not received adequate assurances from the federal Centers for Medicare and Medicaid Services (CMS) before November 1, 2015, that the department’s application for a subsequent demonstration project, as defined in subdivision (x) of Section 17612.2 and as submitted pursuant to Section 17612.8, is likely to be approved with an effective date of November 1, 2015, the director may request one or more temporary extensions, as necessary to continue the operation of, and the authorities provided under, the federal Medicaid demonstration project titled “California Bridge to Reform Demonstration” (waiver number 11-W-00193/9), until the approved effective date of the subsequent demonstration project. (b) To the extent permitted under the terms of any approved temporary extension obtained by the department pursuant to subdivision (a), an approved subsequent demonstration project, or as otherwise permitted under federal Medicaid law, the department shall, after consulting with the affected designated public hospitals, extend and apply the payment methodologies and allocations described in this article and in effect during the successor demonstration project, on a state fiscal year, annual, partial year, or other basis, consistent with any applicable implementing provisions of the Medi-Cal state plan and requirements imposed by the CMS. The department may make payments on an interim basis and subject to reconciliation to amounts payable under the payment and allocation methodologies applicable to any approved temporary extension obtained by the department pursuant to subdivision (a) or approved subsequent demonstration project. (c) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not jeopardized. (d) Until July 1, 2016, in the event of a conflict between the terms of any federally approved extension obtained by the department pursuant to subdivision (a) and this article, the terms of the federally approved temporary extension shall control, and the department shall provide notice of the conflict to the appropriate policy and fiscal committees of the Legislature. (e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions without taking regulatory action until July 1, 2016. (Added by Stats. 2015, Ch. 759, Sec. 1. (SB 36) Effective October 10, 2015. Conditionally inoperative as provided in Section 14166.25 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.26.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The director must retain and provide the declaration, post it on the department website, and send it to the Secretary of State and the Legislative Counsel. The article becomes inoperative when the director executes the declaration and is repealed six months later, unless repealed earlier under another section.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.26. (a) Unless this article is repealed pursuant to subdivision (b) or (g) of Section 14166.2, this article shall become inoperative on the date that the director executes a declaration, which shall be retained by the director and provided to the fiscal and appropriate policy committees of the Legislature, stating that the federal demonstration project or the successor demonstration project provided for in this article has been terminated by the federal Centers for Medicare and Medicaid Services, and shall, six months after the date the declaration is executed, be repealed. (b) In addition to the requirements specified in subdivision (a), the director shall post the declaration on the department’s Internet Web site and the director shall send the declaration to the Secretary of State and the Legislative Counsel. (Amended by Stats. 2011, Ch. 86, Sec. 18. (AB 1066) Effective July 15, 2011. Repealed on date prescribed by this section's own provisions or by subd. (b) or (g) of Section 14166.2. Note: Termination clause affects Article 5.2, commencing with Section 14166.)
14166.3.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section limits how certain Medi-Cal disproportionate share hospital payment adjustments are made and who may receive them during the demonstration project terms.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.3. (a) During the demonstration project and successor demonstration project terms, payment adjustments to disproportionate share hospitals shall not be made pursuant to Section 14105.98. Payment adjustments to disproportionate share hospitals shall be made solely in accordance with this article. (b) Except as otherwise provided in this article, the department shall continue to make all eligibility determinations and perform all payment adjustment amount computations under the disproportionate share hospital payment adjustment program pursuant to Section 14105.98 and pursuant to the disproportionate share hospital provisions of the Medicaid state plan in effect as of the 2004–05 state fiscal year. For purposes of these determinations and computations, services that are rendered under the Health Care Coverage Initiative authorized pursuant to Part 3.5 (commencing with Section 15900) or the Low Income Health Program authorized pursuant to Part 3.6 (commencing with Section 15909) shall be included. (c) (1) Notwithstanding Section 14105.98, the federal disproportionate share hospital allotment specified for California under Section 1396r-4(f) of Title 42 of the United States Code for each of federal fiscal years 2006 to 2015, inclusive, and federal fiscal year 2016 with respect to the pro rata portion of the allotment that will apply during successor demonstration year 10 pursuant to paragraph (2), shall be distributed solely among the following hospitals: (A) Eligible hospitals, as determined pursuant to Section 14105.98 for each project year and successor demonstration year in which the particular federal fiscal year commences, which meet the definition of a public hospital as specified in paragraph (25) of subdivision (a) of Section 14105.98. (B) Hospitals that are licensed to the University of California, which meet the requirements set forth in Section 1396r-4(d) of Title 42 of the United States Code. (2) The federal disproportionate share hospital allotment for each of the federal fiscal years 2006 to 2015, inclusive, shall be aligned with the project year or successor demonstration year in which the applicable federal fiscal year commences. The payment adjustment year, as used within the meaning of paragraph (6) of subdivision (a) of Section 14105.98, shall be the corresponding project year or successor demonstration year. With respect to successor demonstration year 10, the period of July 1, 2015, through October 31, 2015, shall be aligned with a pro rata portion of the federal disproportionate share hospital allotment for federal fiscal year 2016. (3) Uncompensated Medi-Cal and uninsured costs as reported pursuant to Section 14166.8, shall be used by the department as the basis for determining the hospital-specific disproportionate share hospital payment limits required by Section 1396r-4(g) of Title 42 of the United States Code for the hospitals described in paragraph (1). (4) The distribution of the federal disproportionate share hospital allotment to hospitals described in paragraph (1) shall satisfy the state’s payment obligations, if any, with respect to those hospitals under Section 1396r-4 of Title 42 of the United States Code. (d) Eligible hospitals, as determined pursuant to Section 14105.98 for each project year and each successor demonstration year, which are nonpublic hospitals, nonpublic-converted hospitals, and converted hospitals, as those terms are defined in paragraphs (26), (27), and (28), respectively, of subdivision (a) of Section 14105.98, shall receive Medi-Cal disproportionate share hospital replacement payment adjustments pursuant to Section 14166.11 and other provisions of this chapter. The payment adjustments so provided shall satisfy the state’s payment obligations, if any, with respect to those hospitals under Section 1396r-4 of Title 42 of the United States Code. The federal share of these payments shall not be claimed from the federal disproportionate share hospital allotment described in subdivision (c). (e) The nonfederal share of payments described in subdivisions (c) and (d) shall be derived from the following sources: (1) With respect to the payments described in paragraph (1) of subdivision (c) that are made to designated public hospitals, the nonfederal share shall consist of certified public expenditures described in subparagraphs (A) and (C) of paragraph (2) of subdivision (a) of Section 14166.9, and intergovernmental transfer amounts described in paragraph (2) of subdivision (d) of Section 14166.6. (2) With respect to the payments described in paragraph (1) of subdivision (c) that are made to nondesignated public hospitals, the nonfederal share shall consist solely of state General Fund appropriations. (3) With respect to the payments described in subdivision (d), the nonfederal share shall consist of state General Fund appropriations. (f) (1) During the terms of the demonstration project and successor demonstration project, for the 2005–06 state fiscal year and any subsequent state fiscal years, no public entity shall be obligated to make any intergovernmental transfer pursuant to Section 14163, and all transfer amount determinations for those state fiscal years shall be suspended. However, during the demonstration project and successor demonstration project terms, intergovernmental transfers shall be made with respect to the disproportionate share hospital payment adjustments made in accordance with paragraph (2) of subdivision (d) of Section 14166.6, or paragraph (2) of subdivision (d) of Section 14166.61, as applicable. (2) During the terms of the demonstration project and successor demonstration project, for the 2005–06 state fiscal year and any subsequent state fiscal years, transfer amounts from the Medi-Cal Inpatient Payment Adjustment Fund to the Health Care Deposit Fund, as provided for pursuant to paragraph (2) of subdivision (d) of Section 14163, are hereby reduced to zero. Unless otherwise specified in this article, this paragraph shall be disregarded for purposes of the calculations made under Section 14105.98 during the demonstration project and successor demonstration project. (Amended by Stats. 2011, Ch. 86, Sec. 3. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.35.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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Designated public hospitals are eligible to receive specified Medi-Cal-related payments and other funding for project years and successor demonstration years.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.35. (a) For each project year through October 31, 2010, designated public hospitals shall be eligible to receive the following: (1) Payments for Medi-Cal inpatient hospital services and supplemental payments for physician and nonphysician practitioner services, as specified in Section 14166.4. (2) Disproportionate share hospital payment adjustments, as specified in Section 14166.6. (3) Safety net care pool funding, as specified in Section 14166.7. (4) Stabilization funding, as specified in Section 14166.75. (5) Grants to distressed hospitals as negotiated by the California Medical Assistance Commission pursuant to Section 14166.23. (b) For each successor demonstration year, designated public hospitals shall be eligible to receive the following: (1) Payments for Medi-Cal inpatient hospital services and supplemental payments for physician and nonphysician practitioner services, as specified in Section 14166.4. (2) Disproportionate share hospital payment adjustments, as specified in Section 14166.61. (3) Safety net care pool funding, as specified in Section 14166.71. (4) Delivery system reform incentive pool payments, as specified in Section 14166.77. (5) Grants to distressed hospitals as negotiated by the California Medical Assistance Commission to the extent the funding is available pursuant to Section 14166.23 or any other provisions of this article. (c) Payments under this section shall be in addition to other payments that may be made in accordance with law. (Amended by Stats. 2011, Ch. 86, Sec. 4. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.4.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section sets how designated public hospitals are paid for Medi-Cal inpatient and related services, and requires the department to reconcile and adjust payments.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.4. (a) Notwithstanding Article 2.6 (commencing with Section 14081), and any other provision of law, fee-for-service payments to the designated public hospitals for inpatient services to Medi-Cal beneficiaries shall be governed by this section. Each of the designated public hospitals shall receive as payment for inpatient hospital services provided to Medi-Cal beneficiaries during any project year or successor demonstration year, the hospital’s allowable costs incurred in providing those services, multiplied by the federal medical assistance percentage. These costs shall be determined, certified, and claimed in accordance with Sections 14166.8 and 14166.9. All Medicaid federal financial participation received by the state for the certified public expenditures of the hospital, or the governmental entity with which the hospital is affiliated, for inpatient hospital services rendered to Medi-Cal beneficiaries shall be paid to the hospital. (b) With respect to each project year and successor demonstration year, each of the designated public hospitals shall receive an interim payment for each day of inpatient hospital services rendered to Medi-Cal beneficiaries based upon claims filed by the hospital in accordance with the claiming process set forth in Division 3 (commencing with Section 50000) of Title 22 of the California Code of Regulations. The interim per diem payment amount shall be based on estimated costs, which shall be derived from statistical data from the following sources and which shall be multiplied by the federal medical assistance percentage: (1) For allowable costs reflected in the Medicare cost report, the cost report most recently audited by the hospital’s Medicare fiscal intermediary adjusted by a trend factor to reflect increased costs, as approved by the federal Centers for Medicare and Medicaid Services for the demonstration project. (2) For allowable costs not reflected in the Medicare cost report, each hospital shall provide hospital-specific cost data requested by the department. The department shall adjust the data by a trend factor as necessary to reflect project year allowable costs. (c) Until the department commences making payments pursuant to subdivision (b), the department may continue to make fee-for-service, per diem payments to the designated public hospitals, pursuant to the selective provider contracting program in accordance with Article 2.6 (commencing with Section 14081), for services rendered on and after July 1, 2005, for a period of 120 days following the award of this demonstration. Per diem payments shall be adjusted retroactively to the amounts determined under the payment methodology prescribed in this article. (d) No later than April 1 following the end of the relevant reporting period for the project year or successor demonstration year, the department shall undertake an interim reconciliation of payments made pursuant to subdivisions (a) to (c), inclusive, based on Medicare and other cost and statistical data submitted by the hospital for the year and shall adjust payments to the hospital accordingly. (e) (1) The designated public hospitals shall receive supplemental reimbursement for the costs incurred for physician and nonphysician practitioner services provided to Medi-Cal beneficiaries who are patients of the hospital, to the extent that those services are not claimed as inpatient hospital services by the hospital and the costs of those services are not otherwise recognized under subdivision (a). (2) Expenditures made by the designated public hospital, or a governmental entity with which it is affiliated, for the services identified in paragraph (1) shall be reduced by any payments received pursuant to Article 7 (commencing with Section 51501) of Title 22 of the California Code of Regulations. The remainder shall be certified by the appropriate public official and claimed by the department in accordance with Sections 14166.8 and 14166.9. These expenditures may include any of the following: (A) Compensation to physicians or nonphysician practitioners pursuant to contracts with the designated public hospital. (B) Salaries and related costs for employed physicians and nonphysician practitioners. (C) The costs of interns, residents, and related teaching physician and supervision costs. (D) Administrative costs associated with the services described in subparagraphs (A) to (C), inclusive, including billing costs. (3) Designated public hospitals shall receive federal funding based on the expenditures identified and certified in paragraph (2). All federal financial participation received by the department for the certified public expenditures identified in paragraph (2) shall be paid to the designated public hospital, or a governmental entity with which it is affiliated. (4) To the extent that the supplemental reimbursement received under this subdivision relates to services provided to hospital inpatients, the reimbursement shall be applied in determining whether the designated public hospital has received full baseline payments for purposes of paragraph (1) of subdivision (b) of Section 14166.21. (5) Supplemental reimbursement under this subdivision may be distributed as part of the interim payments under subdivision (b), on a per-visit basis, on a per-procedure basis, or on any other federally permissible basis. (6) The department shall submit for federal approval, by September 30, 2005, a proposed amendment to the Medi-Cal state plan to implement this subdivision, retroactive to July 1, 2005, to the extent permitted by the federal Centers for Medicare and Medicaid Services. If necessary to obtain federal approval, the department may limit the application of this subdivision to costs determined allowable by the federal Centers for Medicare and Medicaid Services. If federal approval is not obtained, this subdivision shall not be implemented. (Amended by Stats. 2011, Ch. 86, Sec. 5. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The director must set baseline funding amounts for each designated public hospital, and the department must calculate adjusted baseline funding amounts for later project years through October 31, 2010.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.5. (a) With respect to each project year through October 31, 2010, the director shall determine a baseline funding amount for each designated public hospital. A hospital’s baseline funding amount shall be an amount equal to the total amount paid to the hospital for inpatient hospital services rendered to Medi-Cal beneficiaries during the 2004–05 fiscal year, including the following Medi-Cal payments, but excluding payments received under the Medi-Cal Specialty Mental Health Services Consolidation Program: (1) Base payments under the selective provider contracting program as provided for under Article 2.6 (commencing with Section 14081). (2) Emergency Services and Supplemental Payments Fund payments as provided for under Section 14085.6. (3) Medi-Cal Medical Education Supplemental Payment Fund payments and Large Teaching Emphasis Hospital and Children’s Hospital Medi-Cal Medical Education Supplemental Payment Fund payments as provided for under Sections 14085.7 and 14085.8, respectively. (4) Disproportionate share hospital payment adjustments as provided for under Section 14105.98. (5) Administrative day payments as provided for under Section 51542 of Title 22 of the California Code of Regulations. (b) The baseline funding amount for each designated public hospital shall reflect a reduction for the total amount of intergovernmental transfers made pursuant to Sections 14085.6, 14085.7, 14085.8, 14085.9, and 14163 for the 2004–05 state fiscal year by the designated public hospital, or the governmental entity with which it is affiliated. (c) With respect to each project year beginning after the 2005–06 project year through October 31, 2010, the department shall determine an adjusted baseline funding amount for each designated public hospital to reflect any increase or decrease in volume. The adjustment for designated public hospitals shall be calculated as follows: (1) Applying the cost-finding methodology approved under the demonstration project, and applying accounting and reporting practices consistent with those applied in paragraph (2), the department shall determine the total allowable costs incurred by the hospital, or the governmental entity with which it is affiliated, in rendering hospital services that would be recognized under the demonstration project to Medi-Cal beneficiaries and the uninsured during the 2004–05 state fiscal year. (2) Applying the cost-finding methodology approved under the demonstration project, and applying accounting and reporting practices consistent with those applied in paragraph (1), the department shall determine the total allowable costs incurred by the hospital, or the governmental entity with which it is affiliated, in rendering hospital services under the demonstration project to Medi-Cal beneficiaries and the uninsured during the state fiscal year preceding the project year for which the volume adjustment is being calculated. (3) The department shall: (A) Calculate the difference between the amount determined under paragraph (1) and the amount determined under paragraph (2). (B) Determine the percentage increase or decrease by dividing the difference in subparagraph (A) by the amount in paragraph (1). (C) Apply the percentage determined in subparagraph (B) to that amount that results from the hospital’s baseline funding amount determined under subdivision (a) as adjusted by subdivision (b), except for the reduction for the amount of intergovernmental transfers made pursuant to Section 14163, minus the amount of disproportionate share hospital payments in paragraph (4) of subdivision (a). (4) The designated public hospital’s adjusted baseline for the project year is the amount determined for the hospital in subdivision (a) as adjusted by subdivision (b), plus the amount in subparagraph (C) of paragraph (3). (5) Notwithstanding paragraphs (3) and (4), when, as determined by the department, in consultation with the designated public hospital, there has been a material reduction in patient services at the designated public hospital during the project year, and the reduction has resulted in a diminution of access for Medi-Cal and uninsured patients and a related reduction in total costs at the designated public hospital of at least 20 percent, the department may utilize current or adjusted data that are reflective of the diminution of access, even if the data are not annual data, to determine the hospital’s adjusted baseline amount. (d) The aggregate designated public hospital baseline funding amount for each project year through October 31, 2010, shall be the sum of all baseline funding amounts determined under subdivisions (a) and (b), as adjusted in subdivision (c), as appropriate, for all designated public hospitals. (e) (1) If, with respect to any project year, the difference between the percentage adjustment in subparagraph (B) of paragraph (3) of subdivision (c) of this section, computed in the aggregate for designated public hospitals, excluding the percentage adjustment for any designated public hospital that was not in operation for the full project year, is greater than five percentage points more than the aggregate percentage adjustment for private DSH hospitals determined under subparagraph (B) of paragraph (3) of subdivision (c) of Section 14166.13, then the aggregate percentage adjustment for designated public hospitals shall be reduced in the amount necessary to reduce the difference to five percentage points. The reduction required by the previous sentence shall be allocated among designated public hospitals pro rata based on the relationship between each hospital’s percentage determined under subparagraph (B) of paragraph (3) of subdivision (c) of this section and the aggregate percentage for designated public hospitals. (2) Notwithstanding paragraph (1), the department may apply the adjustments set forth in paragraph (5) of subdivision (c). (f) The provisions of this section shall apply only with respect to the demonstration project term, and shall not apply with respect to the successor demonstration project term. All references to baseline funding amounts and adjusted baseline funding amounts with respect to designated public hospitals shall be disregarded for purposes of successor demonstration year determinations. (Amended by Stats. 2011, Ch. 86, Sec. 6. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.6.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section sets how designated public hospitals receive federal disproportionate share hospital payments and requires the department to calculate, distribute, and reconcile those payments under specified limits.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.6. (a) For the 2005–06 project year and subsequent project years through October 31, 2010, each designated public hospital described in subdivision (c) of Section 14166.3 shall be eligible to receive an allocation of federal Medicaid funding from the applicable federal disproportionate share hospital allotment pursuant to this section. The department shall establish the allocations in a manner that maximizes federal Medicaid funding to the state during the term of the demonstration project, and shall consider, at a minimum, all of the following factors, taking into account all other payments to each hospital under this article: (1) The optimal use of intergovernmental transfer-funded payments described in subdivision (d). (2) Each hospital’s pro rata share of the applicable aggregate designated public hospital baseline funding amount described in subdivision (d) of Section 14166.5. (3) That the allocation under this section, in combination with the federal share of certified public expenditures for Medicaid inpatient hospital services for the project year determined under subdivision (a) of Section 14166.4, any supplemental reimbursement for professional services rendered to hospital inpatients determined for the project year under subdivision (e) of Section 14166.4, and the distribution of safety net care pool funds from the Health Care Support Fund determined under subdivision (a) of Section 14166.7, shall not exceed the baseline funding amount or adjusted baseline funding amount, as appropriate, for the hospital. (4) Minimizing the need to redistribute federal funds that are based on the certified public expenditures of designated public hospitals as described in subdivision (c). (b) Each designated public hospital shall receive its allocation of federal disproportionate share hospital payments in one or both of the following forms: (1) Distributions from the Demonstration Disproportionate Share Hospital Fund established pursuant to subdivision (d) of Section 14166.9, consisting of federal funds claimed and received by the department, pursuant to subparagraphs (A) and (C) of paragraph (2) of subdivision (a) of Section 14166.9 based on designated public hospitals’ certified public expenditures up to 100 percent of uncompensated Medi-Cal and uninsured costs. (2) Intergovernmental transfer-funded payments, as described in subdivision (d). For purposes of determining whether the hospital has received its allocation of federal disproportionate share hospital payments established under this section, only the federal share of intergovernmental transfer-funded payments shall be considered. (c) The distributions described in paragraph (1) of subdivision (b) may be made to a designated public hospital independent of the amount of uncompensated Medi-Cal and uninsured costs certified as public expenditures by that hospital pursuant to Section 14166.8, provided that, in accordance with the Special Terms and Conditions for the demonstration project, the recipient hospital does not return any portion of the funds received to any unit of government, excluding amounts recovered by the state or federal government. (d) Designated public hospitals that meet the requirement of Section 1396r-4(b)(1)(A) of Title 42 of the United States Code regarding the Medicaid inpatient utilization rate or Section 1396r-4(b)(1)(B) of Title 42 of the United States Code regarding the low-income utilization rate, may receive intergovernmental transfer-funded disproportionate share hospital payments as follows: (1) The department shall establish the amount of the hospital’s intergovernmental transfer-funded disproportionate share hospital payment. The total amount of that payment, consisting of the federal and nonfederal components, shall in no case exceed that amount equal to 75 percent of the hospital’s uncompensated Medi-Cal and uninsured costs of hospital services, determined in accordance with the Special Terms and Conditions for the demonstration project. (2) A transfer amount shall be determined for each hospital that is subject to this subdivision, equal to the nonfederal share of the payment amount established for the hospital pursuant to paragraph (1). The transfer amount so determined shall be paid by the hospital, or the public entity with which the hospital is affiliated, and deposited into the Medi-Cal Inpatient Payment Adjustment Fund established pursuant to subdivision (b) of Section 14163. The sources of funds utilized for the transfer amount shall not include impermissible provider taxes or donations as defined under Section 1396b(w) of Title 42 of the United States Code or other federal funds. For this purpose, federal funds do not include patient care revenue received as payment for services rendered under programs such as Medicare or Medicaid. (3) The department shall pay the amounts established pursuant to paragraph (1) to each hospital using the transfer amounts deposited pursuant to paragraph (2) as the nonfederal share of those payments. The total intergovernmental transfer-funded payment amount, consisting of the federal and nonfederal share, paid to a hospital shall be retained by the hospital in accordance with the Special Terms and Conditions for the demonstration project. (e) The total federal disproportionate share hospital funds allocated under this section to designated public hospitals with respect to each project year, in combination with the federal share of disproportionate share hospital payment adjustments made to nondesignated public hospitals pursuant to Section 14166.16 for the same project year, shall not exceed the applicable federal disproportionate share hospital allotment. (f) (1) Each designated public hospital shall receive quarterly interim payments of its disproportionate share hospital allocation during the project year. The determinations set forth in subdivisions (a) to (e), inclusive, shall be made on an interim basis prior to the start of each project year, except that, with respect to the 2005–06 project year, the interim determinations shall be made prior to January 1, 2006. The department shall use the same cost and statistical data used in determining the interim payments for Medi-Cal inpatient hospital services under Section 14166.4, and available payments and uncompensated and uninsured cost data, including data from the Medi-Cal paid claims file and the hospital’s books and records, for the corresponding period. (2) Prior to the distribution of payments in accordance with paragraph (1) and with subdivision (g) to a designated public hospital that is part of a hospital system containing multiple designated public hospitals licensed to the same governmental entity, the department shall consult with the applicable governmental entity. The department shall implement any adjustments to the payment distributions for the hospitals in that hospital system as requested by the governmental entity if the net effect of the requested adjustments for those hospitals is zero. These payment redistributions shall recognize the level of care provided to Medi-Cal and uninsured patients and shall maintain the viability and effectiveness of the hospital system. The adjustments made pursuant to this paragraph with respect to an affected hospital shall be disregarded in the application of the limitations described in paragraph (3) of subdivision (a), and in paragraph (1) of subdivision (a) of Section 14166.7. (g) No later than April 1 following the end of the relevant reporting period for the project year, the department shall undertake an interim reconciliation of payments based on Medicare and other cost, payment, and statistical data submitted by the hospital for the project year, and shall adjust payments to the hospital accordingly. (h) Each designated public hospital shall receive its disproportionate share hospital allocation, as computed pursuant to subdivisions (a) to (e), inclusive, subject to final audits of all applicable Medicare and other cost, payment, and statistical data for the project year. (i) The provisions of this section shall apply only with respect to the demonstration project term, and shall not apply with respect to the successor demonstration project term. (Amended by Stats. 2011, Ch. 86, Sec. 7. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.61.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section sets how the department allocates and pays federal disproportionate share hospital funding to designated public hospitals, including Kern Medical Center, and how payments are later reconciled and adjusted.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.61. (a) For successor demonstration year 6 and subsequent successor demonstration years, each designated public hospital described in subdivision (c) of Section 14166.3 shall be eligible to receive an allocation of federal Medicaid funding from the applicable federal disproportionate share hospital allotment pursuant to this section. The department shall establish the allocations and claim the federal funding in a manner that maximizes federal Medicaid funding to the state during the term of the successor demonstration project, and shall consider, at a minimum, all of the following factors: (1) The optimal use of intergovernmental transfer-funded payments described in subdivision (d). (2) Minimizing the need to redistribute federal funds that are based on the certified public expenditures of designated public hospitals as described in paragraph (1) of subdivision (c). (b) Disproportionate share hospital allocations for designated public hospitals shall be determined for each successor demonstration year as set forth below. With respect to successor demonstration year 10, allocations shall be determined separately for each of the periods of July 1, 2014, through June 30, 2015, and July 1, 2015, through October 31, 2015. (1) The department shall determine the maximum federal disproportionate share hospital allotment that is available under this section for the successor demonstration year. (2) An initial allocation shall be made to Kern Medical Center for the periods and in the amounts specified below: (A) For successor demonstration year 6, the amount of eight million dollars ($8,000,000). (B) For successor demonstration years 7 through 9, the amount of twelve million dollars ($12,000,000). (C) For the period of July 1, 2014, through June 30, 2015, the amount of twelve million dollars ($12,000,000). (D) For the period of July 1, 2015, through October 31, 2015, the amount of four million dollars ($4,000,000). (3) Each designated public hospital shall be allocated an amount per hospital discharge as specified in this paragraph. The number of discharges per category occurring in the relevant period shall be derived from each hospital’s data as reported pursuant to Section 14166.8. The reported discharges shall relate to the same hospital services for which costs are calculated for purposes of this section. (A) One thousand one hundred dollars ($1,100) per hospital discharge with respect to an uninsured individual. (B) Nine hundred dollars ($900) per hospital discharge with respect to an individual enrolled in the Low Income Health Program. (C) Seven hundred fifty dollars ($750) per hospital discharge with respect to a Medi-Cal beneficiary, excluding discharges for which Medicare payments were received. (4) The remaining available federal disproportionate share hospital allotment, after the allocations are made pursuant to paragraphs (2) and (3), shall be allocated to designated public hospitals as follows: (A) The department shall calculate for each designated public hospital an initial DSH claiming ability amount. For the purposes of this article, the “initial DSH claiming ability amount” means the total sum of the hospital’s uncompensated Medi-Cal, Low Income Health Program, and uninsured costs of hospital services that are reported as eligible certified public expenditures for disproportionate share hospital payments pursuant to Section 14166.8. For hospitals described in subdivision (d), the total sum shall be multiplied by 175 percent. (B) The remaining available federal disproportionate share hospital allotment shall be allocated pro rata among the designated public hospitals based upon each hospital’s initial DSH claiming ability amount as determined pursuant to subparagraph (A). (c) Each designated public hospital shall receive its allocation of federal disproportionate share hospital payments in one or both of the following forms: (1) Distributions from the Demonstration Disproportionate Share Hospital Fund established pursuant to subdivision (d) of Section 14166.9, consisting of federal funds claimed and received by the department, pursuant to clauses (ii) and (iii) of subparagraph (A) of paragraph (2) of subdivision (a) of Section 14166.9 based on designated public hospitals’ certified public expenditures up to 100 percent of uncompensated Medi-Cal and uninsured costs. These distributions may be made to a designated public hospital independent of the amount of uncompensated Medi-Cal and uninsured costs certified as public expenditures by that hospital pursuant to Section 14166.8. (2) Intergovernmental transfer-funded payments, as described in subdivision (d). For purposes of determining whether the hospital has received its allocation of federal disproportionate share hospital payments established under this section, only the federal share of intergovernmental transfer-funded payments shall be considered. (d) Designated public hospitals that meet the requirements of Section 1396r-4(b)(1)(A) of Title 42 of the United States Code regarding the Medicaid inpatient utilization rate or Section 1396r-4(b)(1)(B) of Title 42 of the United States Code regarding the low-income utilization rate, may receive intergovernmental transfer-funded disproportionate share hospital payments as follows: (1) The department shall establish the amount of the hospital’s intergovernmental transfer-funded disproportionate share hospital payment. The total amount of that payment, consisting of the federal and nonfederal components, shall in no case exceed an amount equal to 75 percent of the hospital’s uncompensated Medi-Cal, Low Income Health Program, and uninsured costs of hospital services, determined in accordance with the Special Terms and Conditions for the successor demonstration project and the applicable provisions of the Medi-Cal State Plan. (2) A transfer amount shall be determined for each hospital that is subject to this subdivision, equal to the nonfederal share of the payment amount established for the hospital pursuant to paragraph (1). The transfer amount determined shall be paid by the hospital, or the public entity with which the hospital is affiliated, and deposited into the Medi-Cal Inpatient Payment Adjustment Fund established pursuant to subdivision (b) of Section 14163. The sources of funds utilized for the transfer amount shall not include impermissible provider taxes or donations as defined under Section 1396b(w) of Title 42 of the United States Code or other federal funds. For this purpose, federal funds do not include delivery system reform incentive pool payments or patient care revenue received as payment for services rendered under programs such as designated state health programs, the Low Income Health Program, Medicare, or Medicaid. (3) The department shall pay the amounts established pursuant to paragraph (1) to each hospital using the transfer amounts deposited pursuant to paragraph (2) as the nonfederal share of those payments. (e) The total federal disproportionate share hospital funds allocated under this section to designated public hospitals with respect to each successor demonstration year, in combination with the federal share of disproportionate share hospital payment adjustments made to nondesignated public hospitals pursuant to Section 14166.16 and applicable provisions of the Medi-Cal State Plan for the same successor demonstration year, shall not exceed the applicable federal disproportionate share hospital allotment. (f) (1) Each designated public hospital shall receive quarterly interim payments of its disproportionate share hospital allocation during the successor demonstration year, except that, with respect to the period of July 1, 2015, through October 31, 2015, the interim payment shall be made in October 2015. The determinations set forth in subdivisions (a) to (e), inclusive, shall be made on an interim basis prior to the start of each successor demonstration year. The department shall use the same cost and statistical data used in determining the interim payments for Medi-Cal inpatient hospital services under Section 14166.4, and available payments and uncompensated and uninsured cost data, including data from the Medi-Cal paid claims file and the hospital’s books and records, for the corresponding period. (2) Prior to the distribution of payments in accordance with paragraph (1) and subdivisions (g) and (h) to a designated public hospital that is part of a hospital system containing multiple designated public hospitals licensed to the same governmental entity, the department shall consult with the applicable governmental entity. The department shall implement any adjustments to the payment distributions for the hospitals in that hospital system as requested by the governmental entity if the net effect of the requested adjustments for those hospitals is zero. These payment redistributions shall recognize the level of care provided to Medi-Cal and uninsured patients and shall maintain the viability and effectiveness of the hospital system. (3) If the determinations pursuant to subdivision (g) or (h) for a successor demonstration year result in total federal disproportionate share hospital funds claimable for distribution to designated public hospitals under this section that, in combination with the federal share of disproportionate share hospital payment adjustments made to nondesignated public hospitals for the same successor demonstration year as described in subdivision (e), are less than the applicable federal disproportionate share hospital allotment, the department shall follow the steps described in subparagraphs (A) to (C), inclusive. For purposes of this paragraph, the determinations for successor demonstration year 10 shall be made for the period of July 1, 2014, through June 30, 2015. (A) The maximum available federal disproportionate share hospital funds for designated public hospitals for the successor demonstration year shall be determined by subtracting the federal share of disproportionate share hospital payment adjustments payable to nondesignated public hospitals pursuant to Section 14166.16 and applicable provisions of the Medi-Cal State Plan for the same successor demonstration year from the applicable federal disproportionate share hospital allotment. (B) A reduction factor shall be calculated by dividing the total federal disproportionate share hospital funds that are claimable for distributions to designated public hospitals pursuant to subdivision (g) or (h), as applicable, by the maximum available federal disproportionate share hospital funds determined under subparagraph (A). (C) The reduction factor calculated under subparagraph (B) shall be multiplied by the applicable allocation amount specified in paragraph (2) of subdivision (b), by the applicable amount per discharge specified in paragraph (3) of subdivision (b), and by the remaining available allotment otherwise allocable under paragraph (4) of subdivision (b). The total of these allocation amounts shall be incorporated as the payment distributions to be made pursuant to subdivision (g) or (h), as applicable. (4) With respect to the period of July 1, 2014, through June 30, 2015, and notwithstanding subdivision (e) of Section 14184.30, if a final audit, reconciliation, or judicial or administrative determination is made or implemented subsequent to the applicable finalization date set forth in paragraph (1) of subdivision (e) of Section 14184.30 and results in federal disproportionate share hospital funds distributable to designated public hospitals in addition to the aggregate amount distributed pursuant to paragraph (3), the department shall proceed as follows: (A) The department shall perform revised distribution calculations pursuant to subdivision (b) and, if applicable, paragraph (3). (B) The amounts that would be allocated to each designated public hospital under the revised distribution calculations in subparagraph (A) shall be compared to the amounts previously distributed to the hospital for the same successor demonstration year. (C) The additional federal disproportionate share hospital funds shall be distributed to those designated public hospitals to which additional amounts would be due under the revised distribution calculations. (D) The timing of the adjustments under this paragraph shall be determined by the department in consultation with the affected designated public hospitals. (E) Notwithstanding any other law, if the affiliated governmental entity for the designated public hospital is a county subject to Article 12 (commencing with Section 17612.1) of Chapter 6 of Part 5, the department, in consultation with the affected designated public hospital and the Department of Finance, shall determine how to account for whether any additional payment amount distributed to the designated public hospital pursuant to subparagraph (C) would otherwise have affected, if at all, the applicable county’s redirection obligation for the 2014–15 fiscal year pursuant to paragraphs (4) and (5) of subdivision (a) of Section 17612.3 and shall determine which adjustments, if any, are necessary to either the repayment amount or the applicable county’s redirection obligation. For purposes of this subparagraph, subdivision (f) of Section 17612.2 of this code and paragraph (7) of subdivision (e) of Section 101853 of the Health and Safety Code shall apply. (g) No later than April 1 following the end of the relevant reporting period for the successor demonstration year, the department shall undertake an interim reconciliation of payments based on Medicare and other cost, payment, discharge, and statistical data submitted by the hospital for the successor demonstration year, and shall adjust payments to the hospital accordingly. (h) Each designated public hospital shall receive its disproportionate share hospital allocation, as computed pursuant to subdivisions (a) to (e), inclusive, subject to final audits of all applicable Medicare and other cost, payment, discharge, and statistical data for the successor demonstration year. (Amended by Stats. 2017, Ch. 52, Sec. 60. (SB 97) Effective July 10, 2017. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.7.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section sets out how designated public hospitals can receive safety net care pool payments and how the department must calculate, distribute, reconcile, and adjust those payments.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.7. (a) (1) With respect to each project year through October 31, 2010, designated public hospitals, or governmental entities with which they are affiliated, shall be eligible to receive safety net care pool payments from the Health Care Support Fund established pursuant to Section 14166.21. The total amount of these payments, in combination with the federal share of certified public expenditures for Medicaid inpatient hospital services determined for the project year under subdivision (a) of Section 14166.4, any supplemental reimbursement for physician and nonphysician practitioner services rendered to hospital inpatients determined for the project year under subdivision (e) of Section 14166.4, and the federal disproportionate share hospital allocation determined under Section 14166.6, shall not exceed the hospital’s baseline funding amount or adjusted baseline funding amount, as appropriate. (2) The department shall establish the amount of the safety net care pool payment described in paragraph (1) for each designated public hospital in a manner that maximizes federal Medicaid funding to the state during the term of the demonstration project. (3) A safety net care pool payment amount may be paid to a designated public hospital, or governmental entity with which it is affiliated, pursuant to this section independent of the amount of uncompensated Medi-Cal and uninsured costs that is certified as public expenditures pursuant to Section 14166.8, provided that, in accordance with the Special Terms and Conditions for the demonstration project, the recipient hospital does not return any portion of the funds received to any unit of government, excluding amounts recovered by the state or federal government. (4) In establishing the amount to be paid to each designated public hospital under this subdivision, the department shall minimize to the extent possible the redistribution of federal funds that are based on certified public expenditures as described in paragraph (3). (b) (1) Each designated public hospital, or governmental entity with which it is affiliated, shall receive the amount established pursuant to subdivision (a) in quarterly interim payments during the project year. The determination of the interim payments shall be made on an interim basis prior to the start of each project year, except that, with respect to the 2005–06 project year, the determination of the interim payments shall be made prior to January 1, 2006. The department shall use the same cost and statistical data that is used in determining the interim payments for Medi-Cal inpatient hospital services under Section 14166.4 and for the disproportionate share hospital allocations under Section 14166.6, for the corresponding period. (2) Prior to the distribution of payments in accordance with paragraph (1) and with subdivision (c) to a designated public hospital that is part of a hospital system containing multiple designated public hospitals licensed to the same governmental entity, the department shall consult with the applicable governmental entity. The department shall implement any adjustments to the payment distributions for the hospitals in that hospital system as requested by the governmental entity if the net effect of the requested adjustments for those hospitals is zero. These payment redistributions shall recognize the level of care provided to Medi-Cal and uninsured patients and shall maintain the viability and effectiveness of the hospital system. The adjustments made pursuant to this paragraph with respect to an affected hospital shall be disregarded in the application of the limitations described in paragraph (1) of subdivision (a), and in paragraph (3) of subdivision (a) of Section 14166.6. (c) (1) No later than April 1 following the end of the project year, the department shall undertake an interim reconciliation of the payment amount established pursuant to subdivision (a) for each designated public hospital using Medicare and other cost, payment, and statistical data submitted by the hospital for the project year, and shall adjust payments to the hospital accordingly. (2) The final payment to a designated public hospital for purposes of subdivision (b) and paragraph (1) of this subdivision, shall be subject to final audits of all applicable Medicare and other cost, payment, and statistical data for the project year, and the distribution priorities set forth in Section 14166.20. (d) (1) Each designated public hospital, or governmental entity with which it is affiliated, shall be eligible to receive additional safety net care pool payments above the baseline funding amount or adjusted baseline funding amount, as appropriate, from the Health Care Support Fund, established pursuant to Section 14166.21, for the project year through October 31, 2010, in accordance with the stabilization funding determination for the hospital made pursuant to Section 14166.75. (2) Payment of the additional safety net care pool amounts shall be subject to the distribution priorities set forth in Section 14166.21. (3) The provisions of this section shall apply only with respect to the demonstration project term, and shall not apply with respect to the successor demonstration project term. (Amended by Stats. 2011, Ch. 86, Sec. 9. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.71.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section sets how the department calculates, allocates, pays, and later reconciles safety net care pool payments for designated public hospitals.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.71. (a) (1) With respect to each successor demonstration year, designated public hospitals, or governmental entities with which they are affiliated, shall be eligible to receive safety net care pool payments for uncompensated care from the Health Care Support Fund established pursuant to Section 14166.21. Safety net care pool payments for uncompensated care shall be allocated to designated public hospitals as follows: (A) The department shall determine the maximum amount of safety net pool payments for uncompensated care that is available to designated public hospitals for the successor demonstration year. (B) The department shall calculate for each designated public hospital an initial SNCP claiming ability amount. For the purposes of this article, “initial SNCP claiming ability amount” means the total sum of the uncompensated Medi-Cal, Low Income Health Program, and uninsured costs of services incurred by the designated public hospital, the governmental entity, nonhospital clinics, and other provider types with which it is affiliated, that are reported as eligible certified public expenditures for safety net care pool uncompensated care claiming pursuant to Section 14166.8. (C) The available safety net pool payments shall be allocated pro rata among the designated public hospitals based upon each hospital’s initial SNCP claiming ability amount as determined pursuant to subparagraph (B). (2) The department shall establish the amount of the safety net care pool payment described in paragraph (1) for each designated public hospital in a manner that maximizes federal Medicaid funding to the state during the term of the successor demonstration project. (3) A safety net care pool payment amount may be paid to a designated public hospital, or governmental entity with which it is affiliated, pursuant to this section independent of the amount of uncompensated Medi-Cal and uninsured costs that is certified as public expenditures pursuant to Section 14166.8, provided that, in accordance with the Special Terms and Conditions for the successor demonstration project, the recipient hospital does not return any portion of the funds received to any unit of government, excluding amounts recovered by the state or federal government. (4) In establishing the amount to be paid to each designated public hospital under this subdivision, the department shall minimize to the extent possible the redistribution of federal funds that are based on certified public expenditures as described in paragraph (3). (b) (1) Each designated public hospital, or governmental entity with which it is affiliated, shall receive the amount established pursuant to subdivision (a) in quarterly interim payments during the successor demonstration year. The determination of the interim payments shall be made on an interim basis prior to the start of each successor demonstration year. The department shall use the same cost and statistical data that is used in determining the interim payments for Medi-Cal inpatient hospital services under Section 14166.4 and for the disproportionate share hospital allocations under Section 14166.61, for the corresponding period. (2) Prior to the distribution of payments in accordance with paragraph (1) and subdivision (c) to a designated public hospital that is part of a hospital system containing multiple designated public hospitals licensed to the same governmental entity, the department shall consult with the applicable governmental entity. The department shall implement any adjustments to the payment distributions for the hospitals in that hospital system as requested by the governmental entity if the net effect of the requested adjustments for those hospitals is zero. These payment redistributions shall recognize the level of care provided to Medi-Cal and uninsured patients and shall maintain the viability and effectiveness of the hospital system. (c) (1) No later than April 1 following the end of the relevant reporting period for the successor demonstration year, the department shall undertake an interim reconciliation of the payment amount established pursuant to subdivision (a) for each designated public hospital using Medicare and other cost, payment, and statistical data submitted by the hospital for the successor demonstration year, and shall adjust payments to the hospital accordingly. (2) The final payment to a designated public hospital for purposes of subdivision (b) and paragraph (1) of this subdivision, shall be subject to final audits of all applicable Medicare and other cost, payment, discharge, and statistical data for the successor demonstration year. (Added by Stats. 2011, Ch. 86, Sec. 10. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.75.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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This section sets how certain stabilization funding for designated public hospitals must be allocated, including amounts for some hospitals and consultation and final-allocation duties for the department.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.75. (a) For services provided during the 2005–06 and 2006–07 project years, the amount allocated to designated public hospitals pursuant to subparagraph (A) of paragraph (2) and subparagraph (A) of paragraph (5) of subdivision (b) of Section 14166.20 shall be allocated, in accordance with this section, among the designated public hospitals. For services provided during the 2007–08, 2008–09, and 2009–10 project years through October 31, 2010, amounts allocated to designated public hospitals as stabilization funding pursuant to any provision of this article, unless otherwise specified, shall be allocated among the designated public hospitals in accordance with this section. All amounts allocated to designated public hospitals in accordance with this section shall be paid as direct grants, which shall not constitute Medi-Cal payments. (b) The baseline funding amount, as determined under Section 14166.5, for San Mateo Medical Center shall be increased by eight million dollars ($8,000,000) for purposes of this section. (c) The following payments shall be made from the amount identified in subdivision (a), in addition to any other payments due to the University of California hospitals and health system and County of Los Angeles hospitals under this section: (1) The lower of eleven million dollars ($11,000,000) or 3.67 percent of the amount identified in subdivision (a) to the University of California hospitals and health system. (2) For each of the 2005–06 and 2006–07 project years, in the event that the one hundred eighty million dollars ($180,000,000) identified in paragraph 41 of the Special Terms and Conditions for the demonstration project is available in the safety net care pool for the project year, the lower of twenty-three million dollars ($23,000,000) or 7.67 percent of the amount identified in subdivision (a) to the County of Los Angeles, Department of Health Services, hospitals. If an amount less than the one hundred eighty million dollars ($180,000,000) is available during the project year, the amount determined under this paragraph shall be reduced proportionately. (d) For the 2005–06 and 2006–07 project years, the amount identified in subdivision (a), as reduced by the amounts identified in subdivision (c), shall be distributed among the designated public hospitals pursuant to this subdivision. (1) Designated public hospitals that are donor hospitals, and their associated donated certified public expenditures, shall be identified as follows: (A) An initial pro rata allocation of the amount subject to this subdivision shall be made to each designated public hospital, based upon the hospital’s baseline funding amount determined pursuant to Section 14166.5, and as further adjusted in subdivision (b). This initial allocation shall be used for purposes of the calculations under subparagraph (C) and paragraph (3). (B) The federal financial participation amount arising from the certified public expenditures of each designated public hospital, including the expenditures of the governmental entity, nonhospital clinics, and other provider types with which it is affiliated, that were claimed by the department from the federal disproportionate share hospital allotment pursuant to subparagraphs (A) and (C) of paragraph (2) of subdivision (a) of Section 14166.9, and from the safety net care pool funds pursuant to paragraph (3) of subdivision (a) of Section 14166.9, shall be determined. (C) The amount of federal financial participation received by each designated public hospital, and by the governmental entity, nonhospital clinics, and other provider types with which it is affiliated, based on certified public expenditures from the federal disproportionate share hospital allotment pursuant to paragraph (1) of subdivision (b) of Section 14166.6, and from the safety net care pool payments pursuant to subdivision (a) of Section 14166.7 shall be identified. With respect to this identification, if a payment adjustment for a hospital has been made pursuant to paragraph (2) of subdivision (f) of Section 14166.6, or paragraph (2) of subdivision (b) of Section 14166.7, the amount of federal financial participation received by the hospital based on certified public expenditures shall be determined as though no such payment adjustment had been made. The resulting amount shall be increased by amounts distributed to the hospital pursuant to subdivision (c) of this section, paragraph (1) of subdivision (b) of Section 14166.20, and the initial allocation determined for the hospitals in subparagraph (A). (D) If the amount in subparagraph (B) is greater than the amount determined in subparagraph (C), the hospital is a donor hospital, and the difference between the two amounts is deemed to be that donor hospital’s associated donated certified public expenditures amount. (2) Seventy percent of the total amount subject to this subdivision shall be allocated pro rata among the designated public hospitals based upon each hospital’s baseline funding amount determined pursuant to Section 14166.5, and as further adjusted in subdivision (b). (3) The lesser of the remaining 30 percent of the total amount subject to this subdivision or the total amounts of donated certified public expenditures for all donor hospitals, shall be distributed pro rata among the donor hospitals based upon the donated certified public expenditures amount determined for each donor hospital. Any amounts not distributed pursuant to this paragraph shall be distributed in the same manner as set forth in paragraph (2). (e) For the 2007–08 and subsequent project years through October 31, 2010, the amount identified in subdivision (a), as reduced by the amounts identified in subdivision (c), shall be distributed among the designated public hospitals pursuant to this subdivision. (1) Each designated public hospital that renders inpatient hospital services under the health care coverage initiative program authorized pursuant to Part 3.5 (commencing with Section 15900) shall be allocated an amount equal to the amount of the federal safety net pool funds claimed and received with respect to the services rendered by the hospital, including services rendered to enrollees of a managed care organization, to the extent the amount was included in the determination of total stabilization funding for the project year pursuant to Section 14166.20. (2) Each designated public hospital for which, during the project year, the sum of the allowable costs incurred in rendering inpatient hospital services to Medi-Cal beneficiaries and the allowable costs incurred with respect to supplemental reimbursement for physician and nonphysician practitioner services rendered to Medi-Cal hospital inpatients, as specified in Section 14166.4, exceeds the allowable costs incurred for those services rendered in the prior year, shall be allocated an amount equal to 60 percent of the difference in the allowable costs, multiplied by the applicable federal medical assistance percentage. The allocations under this paragraph, however, shall be reduced pro rata as necessary to ensure that the total of those allocations does not exceed 80 percent of the amount subject to this subdivision after the allocations in paragraph (1). For purposes of this paragraph, the most recent cost data that are available at the time of the department’s determinations for the project year pursuant to Section 14166.20 shall be used. (3) The remaining amount subject to this subdivision that is not otherwise allocated pursuant to paragraphs (1) and (2) shall be allocated as set forth below: (A) Designated public hospitals that are donor hospitals, and their associated donated certified public expenditures, shall be identified as follows: (i) An initial pro rata allocation of the amount subject to this paragraph shall be made to each designated public hospital, based upon the total allowable costs incurred by each hospital, or governmental entity with which it is affiliated, in rendering hospital services to the uninsured during the project year as reported pursuant to Section 14166.8. This initial allocation shall be used for purposes of the calculations under clause (iii) and subparagraph (C). (ii) The federal financial participation amount arising from the certified public expenditures of each designated public hospital, including the expenditures of the governmental entity, nonhospital clinics, and other provider types with which it is affiliated, that were claimed by the department from the federal disproportionate share hospital allotment pursuant to subparagraphs (A) and (C) of paragraph (2) of subdivision (a) of Section 14166.9, and from the safety net care pool funds pursuant to paragraph (3) of subdivision (a) of Section 14166.9, shall be determined. (iii) The amount of federal financial participation received by each designated public hospital, and by the governmental entity, nonhospital clinics, and other provider types with which it is affiliated, based on certified public expenditures from the federal disproportionate share hospital allotment pursuant to paragraph (1) of subdivision (b) of Section 14166.6, and from the safety net care pool payments pursuant to subdivision (a) of Section 14166.7 shall be identified. With respect to this identification, if a payment adjustment for a hospital has been made pursuant to paragraph (2) of subdivision (f) of Section 14166.6, or paragraph (2) of subdivision (b) of Section 14166.7, the amount of federal financial participation received by the hospital based on certified public expenditures shall be determined as though no payment adjustment had been made. The resulting amount shall be increased by amounts distributed to the hospital pursuant to subdivision (c), paragraphs (1) and (2) of this subdivision, paragraph (1) of subdivision (b) of Section 14166.20, and the initial allocation determined for the hospitals in clause (i). (iv) If the amount in clause (ii) is greater than the amount determined in clause (iii), the hospital is a donor hospital, and the difference between the two amounts is deemed to be that donor hospital’s associated donated certified public expenditures amount. (B) Fifty percent of the total amount subject to this paragraph shall be allocated pro rata among the designated public hospitals in the same manner described in clause (i) of subparagraph (A). (C) The lesser of the remaining 50 percent of the total amount subject to this paragraph, the total amounts of donated certified public expenditures for all donor hospitals or that amount that is 30 percent of the amount subject to this subdivision after the allocations in paragraph (1), shall be distributed pro rata among the donor hospitals based upon the donated certified public expenditures amount determined for each donor hospital. Any amounts not distributed pursuant to this subparagraph shall be distributed in the same manner as set forth in subparagraph (B). (D) The federal financial participation amount arising from the certified public expenditures that has been paid to designated public hospitals, or the governmental entities with which they are affiliated, pursuant to subdivision (g) of Section 14166.221 shall be disregarded for purposes of this paragraph. (f) The department shall consult with designated public hospital representatives regarding the appropriate distribution of stabilization funding before stabilization funds are allocated and paid to hospitals. No later than 30 days after this consultation, the department shall issue a final allocation of stabilization funding under this section that shall not be modified for any reason other than mathematical errors or mathematical omissions on the part of the department. (g) The provisions of this section shall apply only with respect to the demonstration project term, and shall not apply with respect to the successor demonstration project term. (Amended by Stats. 2011, Ch. 86, Sec. 11. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.77.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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Designated public hospital systems must submit reports and payment requests on schedule, make required fund transfers, and meet milestone-based conditions to receive incentive pool funding; the department must disburse payments and may reallocate funding in some cases.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.77. (a) (1) The amount of delivery system reform incentive pool funding, consisting of both the federal and nonfederal share of payments, that is made available to each designated public hospital system in the aggregate for the term of the successor demonstration project shall be based initially on the delivery system reform proposals that are submitted by the designated public hospitals to the department for review and submission to the federal Centers for Medicare and Medicaid Services for final approval. The initial percentages of delivery system reform incentive pool funding among the designated public hospital systems for each successor demonstration year shall be determined based on the annual components as contained in the approved proposals. (2) The actual receipt of funds shall be conditioned on the designated public hospital system’s progress toward, and achievement of, the specified milestones and other metrics established in its approved delivery system reform incentive pool proposal. A designated public hospital system may carry forward available incentive pool funding associated with milestones and metrics from one year to a subsequent period as authorized by the Special Terms and Conditions and the final delivery system reform incentive pool protocol. (3) The department may reallocate incentive pool funding under conditions specified, and as authorized by, the Special Terms and Conditions and the final delivery system reform incentive pool protocol. (b) Each designated public hospital system shall be individually responsible for progress toward, and achievement of, milestones and other metrics in its proposal, as well as other applicable requirements specified in the Special Terms and Conditions and the final delivery system reform incentive pool protocol, in order to receive its specified allocation of incentive pool funding under this section. (1) The designated public hospital system shall submit semiannual reports and requests for payment to the department by March 31 and the September 30 following the end of the second and fourth quarters of the successor demonstration year, or comply with such other process as approved by the federal Centers for Medicare and Medicaid Services. A standardized report form shall be developed jointly by the department and designated public hospital systems for this purpose. (2) Within 14 days after the semiannual report due date, the designated public hospital system or its affiliated governmental entity shall make an intergovernmental transfer of funds equal to the nonfederal share that is necessary to draw down the federal funding for the pool payment related to the achievement or progress metric that is certified. The intergovernmental transfers shall be deposited into the Public Hospital Investment, Improvement, and Incentive Fund, established pursuant to Section 14182.4. (3) The department shall draw down the federal funding and pay both the nonfederal and federal shares of the incentive payment to the designated public hospital system or other affiliated governmental provider as applicable. If the intergovernmental transfer is made within the appropriate 14-day timeframe, the incentive payment shall be disbursed within seven days with the expedited payment process as approved by the federal Centers for Medicare and Medicaid Services, otherwise the payment shall be disbursed within 20 days of when the transfer is made. (4) Notwithstanding any other provision of this subdivision, payment requests for successor demonstration year 6 shall be submitted, processed, and paid in accordance with the expedited payment process as approved by the federal Centers for Medicare and Medicaid Services. (5) The designated public hospital system or other affiliated governmental provider is responsible for any fee or cost required to implement the expedited payment process in accordance with Section 8422.1 of the State Administrative Manual. (c) In the event of a conflict between any provision of this section and the Special Terms and Conditions for the successor demonstration project and the final delivery system reform incentive pool protocol, the Special Terms and Conditions and the final delivery system reform incentive pool protocol shall control. (Added by Stats. 2011, Ch. 86, Sec. 12. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.8.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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Designated public hospitals must submit specified reports to the department within five months after each project year ends, and related officials must certify report accuracy and funding compliance.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.8. (a) Within five months after the end of each project year or successor demonstration year, each of the designated public hospitals shall submit to the department all of the following reports: (1) The hospital’s Medicare cost report for the project year or successor demonstration year. (2) Other cost reporting and statistical data necessary for the determination of amounts due the hospital under the demonstration project or successor demonstration project, as requested by the department. (b) For each project year or successor demonstration year, the reports shall identify all of the following: (1) The costs incurred in providing inpatient hospital services to Medi-Cal beneficiaries on a fee-for-service basis and physician and nonphysician practitioner services costs, as identified in subdivision (e) of Section 14166.4. (2) The amount of uncompensated costs incurred in providing hospital services to Medi-Cal beneficiaries, including managed care enrollees. (3) The costs incurred in providing hospital services to uninsured individuals. (4) (A) Discharge data, commencing with successor demonstration year 6, and retrospectively for prior periods as necessary to establish interim payment determinations, for the following patient categories: (i) Uninsured patients. (ii) Low Income Health Program patients. (iii) Medi-Cal patients, excluding discharges for which Medicare payments were received. (B) The department shall consult with the designated public hospitals regarding a methodology for adjusting prior period discharge data to reflect the projected number of discharges relating to Low Income Health Program patients for the period at issue. (c) (1) Each designated public hospital, or governmental entity with which it is affiliated, that operates nonhospital clinics or provides physician, nonphysician practitioner, or other health care services that are not identified as hospital services under the Special Terms and Conditions for the demonstration project and successor demonstration project, may report and certify all, or a portion, of the uncompensated Medi-Cal and uninsured costs of the services furnished. (2) Notwithstanding paragraph (1), beginning with the 2012–13 fiscal year, and for each successor demonstration year thereafter, each designated public hospital, or governmental entity with which it is affiliated, that operates nonhospital clinics or provides physician, nonphysician practitioner, or other health care services that are not identified as hospital services under the Special Terms and Conditions for the successor demonstration project, shall report and certify all of the uncompensated uninsured costs of the services furnished that meet the requirements of subdivisions (d) and (e). (3) The amount of these uncompensated costs to be claimed by the department shall be determined by the department in consultation with the governmental entity so as to optimize the level of claimable federal Medicaid funding. (d) Reports submitted under this section shall include all allowable costs. (e) The appropriate public official shall certify to all of the following: (1) The accuracy of the reports required under this section. (2) That the expenditures to meet the reported costs comply with Section 433.51 of Title 42 of the Code of Federal Regulations. (3) That the sources of funds used to make the expenditures certified under this section do not include impermissible provider taxes or donations as defined under Section 1396b(w) of Title 42 of the United States Code or other federal funds. For this purpose, federal funds do not include delivery system reform incentive pool payments, patient care revenue received as payment for services rendered under programs such as designated state health programs, the Low Income Health Program, Medicare, or Medicaid. (f) The certification of public expenditures made pursuant to this section shall be based on a schedule established by the department. The director may require the designated public hospitals to submit quarterly estimates of anticipated expenditures, if these estimates are necessary to obtain interim payments of federal Medicaid funds. All reported expenditures shall be subject to reconciliation to allowable costs, as determined in accordance with applicable implementing documents for the demonstration project and successor demonstration project. (g) Subject to the determination made under paragraph (3) of subdivision (c), the director shall seek Medicaid federal financial participation for all certified public expenditures reported by the designated public hospitals and recognized under the demonstration project and successor demonstration project, to the extent consistent with Section 14166.9. (h) Governmental or public entities other than those that operate a designated public hospital may, at the request of a governmental or public entity, certify uncompensated Medi-Cal and uninsured costs in accordance with this section, subject to the department’s discretion and prior approval of the federal Centers for Medicare and Medicaid Services. (i) The timeframes for data submission and reporting periods may be adjusted as necessary with respect to the 2010–11 project year through October 31, 2010, and successor demonstration years 6 and 10. (Amended by Stats. 2012, Ch. 23, Sec. 89. (AB 1467) Effective June 27, 2012. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14166.9.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. )
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The department must decide how federal funds are sourced and prioritized for payments to designated public hospitals, and must transfer certain received federal funds into specified funds.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.2. Medi-Cal Hospital Care/Uninsured Hospital Care Demonstration Project Act [14166 - 14166.26] ( Article 5.2 added by Stats. 2005, Ch. 560, Sec. 1. ) ## 14166.9. (a) The department, in consultation with the designated public hospitals, shall determine the mix of sources of federal funds for payments to the designated public hospitals in a manner that provides baseline funding to hospitals as applicable during the demonstration project term and maximizes federal Medicaid funding to the state during the terms of the demonstration project and successor demonstration project. (1) During the demonstration project term through October 31, 2010, federal funds shall be claimed according to the following priorities: (A) The certified public expenditures of the designated public hospitals for inpatient hospital services and physician and nonphysician practitioner services, as identified in subdivision (e) of Section 14166.4, rendered to Medi-Cal beneficiaries. (B) Federal disproportionate share hospital allotment, subject to the federal hospital-specific limit, in the following order: (i) Those hospital expenditures that are eligible for federal financial participation only from the federal disproportionate share hospital allotment. (ii) Payments funded with intergovernmental transfers, consistent with the requirements of the demonstration project, up to the hospital’s baseline funding amount or adjusted baseline funding amount, as appropriate, for the project year. (iii) Any other certified public expenditures for hospital services that are eligible for federal financial participation from the federal disproportionate share hospital allotment. (C) Safety net care pool funds, using the optimal combination of hospital-certified public expenditures and certified public expenditures of a hospital, or governmental entity with which the hospital is affiliated, that operates nonhospital clinics or provides physician, nonphysician practitioner, or other health care services that are not identified as hospital services under the Special Terms and Conditions for the demonstration project, except that certified public expenditures reported by the County of Los Angeles or its designated public hospitals shall be the exclusive source of certified public expenditures for claiming those federal funds deposited in the South Los Angeles Medical Services Preservation Fund under Section 14166.25. (D) Health care expenditures of the state that represent alternate state funding mechanisms approved by the federal Centers for Medicare and Medicaid Services under the demonstration project as set forth in Section 14166.22. (2) During each successor demonstration year, federal funds for payments to the designated public hospitals pursuant to Sections 14166.61 and 14166.71 shall be claimed according to the following priorities: (A) With respect to the applicable federal disproportionate share hospital allotment, subject to the federal hospital-specific limit, in the following order: (i) Payments funded with intergovernmental transfers, as determined pursuant to subdivision (d) of Section 14166.61. (ii) Those hospital expenditures that are eligible for federal financial participation only from the federal disproportionate share hospital allotment. (iii) Any other certified public expenditures for hospital services that are eligible for federal financial participation from the federal disproportionate share hospital allotment. (B) With respect to safety net care pool payments for uncompensated care, in the following order: (i) The certified public expenditures of the designated public hospitals, or the governmental entities with which they are affiliated that operate nonhospital clinics or provide physician, nonphysician practitioner, or other health care services, that are not identified as hospital services under the Special Terms and Conditions for the successor demonstration project and eligible for federal financial participation from the safety net care pool for uncompensated care. (ii) The available certified public expenditures of designated public hospitals for hospital services that are eligible for federal financial participation from either the federal disproportionate share hospital allotment or safety net care pool for uncompensated care, that were not otherwise claimed for purposes of subparagraph (A). (b) The department shall implement these priorities, to the extent possible, in a manner that minimizes the redistribution of federal funds that are based on the certified public expenditures of the designated public hospitals. (c) The department may adjust the claiming priorities to the extent that these adjustments result in additional federal medicaid funding during the term of the demonstration project and successor demonstration project, or facilitate the objectives of subdivision (b). (d) There is hereby established in the State Treasury the “Demonstration Disproportionate Share Hospital Fund.” All federal funds received by the department with respect to the certified public expenditures claimed pursuant to subparagraphs (A) and (C) of paragraph (2) of subdivision (a) shall be transferred to the fund. Notwithstanding Section 13340 of the Government Code, the fund shall be continuously appropriated to the department solely for the purposes specified in Sections 14166.6 and 14166.61. (e) (1) Except as provided in Section 14166.25, all federal safety net care pool funds claimed and received by the department based on health care expenditures incurred by the designated public hospitals, or other governmental entities, shall be transferred to the Health Care Support Fund, established pursuant to Section 14166.21. (2) The department shall separately identify and account for federal safety net care pool funds claimed and received by the department under the health care coverage initiative program authorized under Part 3.5 (commencing with Section 15900) and under paragraphs 43 and 44 of the Special Terms and Conditions for the demonstration project. (3) With respect to those funds identified under paragraph (2), the department shall separately identify and account for federal safety net care pool funds claimed and received for inpatient hospital services rendered under the health care coverage initiative, including services rendered to enrollees of a managed care organization, by designated public hospitals, nondesignated public hospitals, and project year private DSH hospitals. (Amended by Stats. 2011, Ch. 86, Sec. 14. (AB 1066) Effective July 15, 2011. Conditionally inoperative as provided in Section 14166.26 or in subd. (b) or (g) of Section 14166.2. Repealed on date prescribed in Section 14166.26 or in subd. (b) or (g) of Section 14166.2.)
14167.35.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.22. Quality Assurance Fee Act [14167.35 - 14167.37] ( Article 5.22 heading added by Stats. 2015, Ch. 303, Sec. 622. )
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This section creates the Hospital Quality Assurance Revenue Fund and directs how hospital fee payments must be collected, transmitted, used, adjusted, and eventually phased out.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.22. Quality Assurance Fee Act [14167.35 - 14167.37] ( Article 5.22 heading added by Stats. 2015, Ch. 303, Sec. 622. ) ## 14167.35. (a) The Hospital Quality Assurance Revenue Fund is hereby created in the State Treasury. (b) (1) All fees required to be paid to the state pursuant to this article shall be paid in the form of remittances payable to the department. (2) The department shall directly transmit the fee payments to the Treasurer to be deposited in the Hospital Quality Assurance Revenue Fund. Notwithstanding Section 16305.7 of the Government Code, any interest and dividends earned on deposits in the fund shall be retained in the fund for purposes specified in subdivision (c). (c) All funds in the Hospital Quality Assurance Revenue Fund, together with any interest and dividends earned on money in the fund, shall, upon appropriation by the Legislature, be used exclusively to enhance federal financial participation for hospital services under the Medi-Cal program, to provide additional reimbursement to, and to support quality improvement efforts of, hospitals, and to minimize uncompensated care provided by hospitals to uninsured patients, in the following order of priority: (1) To pay for the department’s staffing and administrative costs directly attributable to implementing Article 5.21 (commencing with Section 14167.1) and this article, including any administrative fees that the director determines shall be paid to mental health plans pursuant to subdivision (d) of Section 14167.11 and repayment of the loan made to the department from the Private Hospital Supplemental Fund pursuant to the act that added this section. (2) To pay for the health care coverage for children in the amount of eighty million dollars ($80,000,000) for each subject fiscal quarter for which payments are made under Article 5.21 (commencing with Section 14167.1). (3) To make increased capitation payments to managed health care plans pursuant to Article 5.21 (commencing with Section 14167.1). (4) To pay funds from the Hospital Quality Assurance Revenue Fund pursuant to Section 14167.5 that would have been used for grant payments and that are retained by the state, and to make increased payments to hospitals, including grants, pursuant to Article 5.21 (commencing with Section 14167.1), both of which shall be of equal priority. (5) To make increased payments to mental health plans pursuant to Article 5.21 (commencing with Section 14167.1). (d) Any amounts of the quality assurance fee collected in excess of the funds required to implement subdivision (c), including any funds recovered under subdivision (d) of Section 14167.14 or subdivision (e) of Section 14167.36, shall be refunded to general acute care hospitals, pro rata with the amount of quality assurance fee paid by the hospital, subject to the limitations of federal law. If federal rules prohibit the refund described in this subdivision, the excess funds shall be deposited in the Distressed Hospital Fund to be used for the purposes described in Section 14166.23, and shall be supplemental to and not supplant existing funds. (e) Any methodology or other provision specified in Article 5.21 (commencing with Section 14167.1) and this article may be modified by the department, in consultation with the hospital community, to the extent necessary to meet the requirements of federal law or regulations to obtain federal approval or to enhance the probability that federal approval can be obtained, provided the modifications do not violate the spirit and intent of Article 5.21 (commencing with Section 14167.1) or this article and are not inconsistent with the conditions of implementation set forth in Section 14167.36. (f) The department, in consultation with the hospital community, shall make adjustments, as necessary, to the amounts calculated pursuant to Section 14167.32 in order to ensure compliance with the federal requirements set forth in Section 433.68 of Title 42 of the Code of Federal Regulations or elsewhere in federal law. (g) The department shall request approval from the federal Centers for Medicare and Medicaid Services for the implementation of this article. In making this request, the department shall seek specific approval from the federal Centers for Medicare and Medicaid Services to exempt providers identified in this article as exempt from the fees specified, including the submission, as may be necessary, of a request for waiver of the broad based requirement, waiver of the uniform fee requirement, or both, pursuant to paragraphs (e)(1) and (e)(2) of Section 433.68 of Title 42 of the Code of Federal Regulations. (h) (1) For purposes of this section, a modification pursuant to this section shall be implemented only if the modification, change, or adjustment does not do either of the following: (A) Reduces or increases the supplemental payments or grants made under Article 5.21 (commencing with Section 14167.1) in the aggregate for the 2008–09, 2009–10, and 2010–11 federal fiscal years to a hospital by more than 2 percent of the amount that would be determined under this article without any change or adjustment. (B) Reduces or increases the amount of the fee payable by a hospital in total under this article for the 2008–09, 2009–10, and 2010–11 federal fiscal years by more than 2 percent of the amount that would be determined under this article without any change or adjustment. (2) The department shall provide the Joint Legislative Budget Committee and the fiscal and appropriate policy committees of the Legislature a status update of the implementation of Article 5.21 (commencing with Section 14167.1) and this article on January 1, 2010, and quarterly thereafter. Information on any adjustments or modifications to the provisions of this article or Article 5.21 (commencing with Section 14167.1) that may be required for federal approval shall be provided coincident with the consultation required under subdivisions (f) and (g). (i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this article or Article 5.21 (commencing with Section 14167.1) by means of provider bulletins, all plan letters, or other similar instruction, without taking regulatory action. The department shall also provide notification to the Joint Legislative Budget Committee and to the appropriate policy and fiscal committees of the Legislature within five working days when the above-described action is taken in order to inform the Legislature that the action is being implemented. (j) Notwithstanding any law, the Controller may use the funds in the Hospital Quality Assurance Revenue Fund for cashflow loans to the General Fund as provided in Sections 16310 and 16381 of the Government Code. (k) Notwithstanding Sections 14167.17 and 14167.40, subdivisions (b) to (h), inclusive, shall become inoperative on January 1, 2013, subdivisions (a), (i), and (j) shall remain operative until January 1, 2018, and as of January 1, 2018, this section is repealed. (Amended by Stats. 2013, Ch. 657, Sec. 4. (SB 239) Effective October 8, 2013. Subds. (b) through (h) became inoperative on January 1, 2013, as provided in subd. (k). Repealed as of January 1, 2018, by its own provisions. However, pursuant to Section 14169.75 as amended Nov. 8, 2016, by Prop. 52, this section is not repealed (and subds. (a), (i), (j), and (k) remain operative) for as long as Article 5.230 (comm. with Section 14169.50) is operative.)
14167.37.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.22. Quality Assurance Fee Act [14167.35 - 14167.37] ( Article 5.22 heading added by Stats. 2015, Ch. 303, Sec. 622. )
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The department must make public certain program documents and post specified hospital payment and rate information on its website.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.22. Quality Assurance Fee Act [14167.35 - 14167.37] ( Article 5.22 heading added by Stats. 2015, Ch. 303, Sec. 622. ) ## 14167.37. (a) (1) The department shall make available all public documentation it uses to administer and audit the program authorized under Article 5.230 (commencing with Section 14169.50) pursuant to the California Public Records Act (Division 10 (commencing with Section 7920.000) of Title 1 of the Government Code). (2) In addition, upon request from a hospital, the department shall require Medi-Cal managed care plans to furnish hospitals with the amounts the plan intends to pay to the hospital pursuant to Article 5.230 (commencing with Section 14169.50). Nothing in this paragraph shall require the department to reconcile payments made to individual hospitals from Medi-Cal managed care plans. (b) Notwithstanding subdivision (a), the department shall post all of the following on the department’s internet website: (1) Within 10 business days after receipt of approval of the hospital quality assurance fee program under Article 5.230 (commencing with Section 14169.50) from the federal Centers for Medicare and Medicaid Services (CMS), the hospital quality assurance fee final model and upper payment limit calculations. (2) Quarterly updates on payments, fee schedules, and model updates when applicable. (3) Within 10 business days after receipt, information on managed care rate approvals. (c) For purposes of this section, the following definitions shall apply: (1) “Fee schedules” mean the dates on which the hospital quality assurance fee will be due from the hospitals and the dates on which the department will submit fee-for-service payments to the hospitals. “Fee schedules” also include the dates on which the department is expected to submit payments to managed care plans. (2) “Hospital quality assurance fee final model” means the spreadsheet calculating the supplemental amounts based on the upper payment limit calculation from claims and hospital data sources of days and hospital services once CMS approves the program under Article 5.230 (commencing with Section 14169.50). (3) “Upper payment limit calculation” means the determination of the federal upper payment limit on the amount of the Medicaid payment for which federal financial participation is available for a class of service and a class of health care providers, as specified in Part 447 of Title 42 of the Code of Federal Regulations, and that has been approved by CMS. (Amended by Stats. 2021, Ch. 615, Sec. 455. (AB 474) Effective January 1, 2022. Operative January 1, 2023, pursuant to Sec. 463 of Stats. 2021, Ch. 615.)
14168.31.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
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This section defines terms used for the Hospital Quality Assurance Fee Act, including fee rates, hospital categories, and the program period.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.31. For the purposes of this article, the following definitions shall apply: (a) (1) “Aggregate quality assurance fee” means, with respect to a hospital that is not a prepaid health plan hospital, the sum of all of the following: (A) The annual fee-for-service days for an individual hospital multiplied by the fee-for-service per diem quality assurance fee rate, divided by two. (B) The annual managed care days for an individual hospital multiplied by the managed care per diem quality assurance fee rate, divided by two. (C) The annual Medi-Cal days for an individual hospital multiplied by the Medi-Cal per diem quality assurance fee rate, divided by two. (2) “Aggregate quality assurance fee” means, with respect to a hospital that is a prepaid health plan hospital, the sum of all of the following: (A) The annual fee-for-service days for an individual hospital multiplied by the fee-for-service per diem quality assurance fee rate, divided by two. (B) The annual managed care days for an individual hospital multiplied by the prepaid health plan hospital managed care per diem quality assurance fee rate, divided by two. (C) The annual Medi-Cal managed care days for an individual hospital multiplied by the prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate, divided by two. (D) The annual Medi-Cal fee-for-service days for an individual hospital multiplied by the Medi-Cal per diem quality assurance fee rate, divided by two. (3) “Aggregate quality assurance fee after the application of the fee percentage” means the aggregate quality assurance fee multiplied by the fee percentage for the program period. (b) “Annual fee-for-service days” means the number of fee-for-service days of each hospital subject to the quality assurance fee, as reported on the day’s data source. (c) “Annual managed care days” means the number of managed care days of each hospital subject to the quality assurance fee, as reported on the day’s data source. (d) “Annual Medi-Cal days” means the number of Medi-Cal days of each hospital subject to the quality assurance fee, as reported on the day’s data source. (e) “Converted hospital” shall mean a hospital described in subdivision (b) of Section 14168.1. (f) “Days data source” means the following: (1) For a hospital that did not submit an Annual Financial Disclosure Report to the Office of Statewide Health Planning and Development for a fiscal year ending during 2007, but submitted that report for a fiscal period ending in 2008 that includes at least 10 months of 2007, the Annual Financial Disclosure Report submitted by the hospital to the Office of Statewide Health Planning and Development for the fiscal period in 2008 that includes at least 10 months of 2007. (2) For a hospital owned by Kaiser Foundation Hospitals that submitted corrections to reported patient days to the Office of Statewide Health Planning and Development for its fiscal year ending in 2007 before July 31, 2009, the corrected data. (3) For all other hospitals, the hospital’s Annual Financial Disclosure Report in the Office of Statewide Health Planning and Development files as of October 31, 2008, for its fiscal year ending during 2007. (g) “Designated public hospital” shall have the meaning given in subdivision (d) of Section 14166.1 as of January 1, 2011. (h) “Exempt facility” means any of the following: (1) A public hospital, which shall include either of the following: (A) A hospital, as defined in paragraph (25) of subdivision (a) of Section 14105.98. (B) A tax-exempt nonprofit hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code and operating a hospital owned by a local health care district, and is affiliated with the health care district hospital owner by means of the district’s status as the nonprofit corporation’s sole corporate member. (2) With the exception of a hospital that is in the Charitable Research Hospital peer group, as set forth in the 1991 Hospital Peer Grouping Report published by the department, a hospital that is a hospital designated as a specialty hospital in the hospital’s Office of Statewide Health Planning and Development Hospital Annual Disclosure Report for the hospital’s fiscal year ending in the 2007 calendar year. (3) A hospital that satisfies the Medicare criteria to be a long-term care hospital. (4) A small and rural hospital as specified in Section 124840 of the Health and Safety Code designated as that in the hospital’s Office of Statewide Health Planning and Development Hospital Annual Disclosure Report for the hospital’s fiscal year ending in the 2007 calendar year. (i) “Federal approval” means the last approval by the federal government required for the implementation of this article and Article 5.226 (commencing with Section 14168.1). (j) (1) “Fee-for-service per diem quality assurance fee rate” means a fixed daily fee on fee-for-service days. (2) The fee-for-service per diem quality assurance fee rate must be no greater than or equal to two hundred fifty-three dollars and twenty-nine cents ($253.29) per day. (3) Upon federal approval or conditional federal approval described in Section 14168.34, the director shall determine the fee-for-service per diem quality assurance fee rate based on the funds required to make the payments specified in Article 5.226 (commencing with Section 14168.1), in consultation with the hospital community. (k) “Fee-for-service days” means inpatient hospital days where the service type is reported as “acute care,” “psychiatric care,” and “chemical dependency care and rehabilitation care,” and the payer category is reported as “Medicare traditional,” “county indigent programs-traditional,” “other third parties-traditional,” “other indigent,” and “other payers,” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (l) “Fee percentage” means a fraction, expressed as a percentage, the numerator of which is the amount of payments for the program period under Sections 14168.2, 14168.3, and 14168.5, for which federal financial participation is available and the denominator of which is one billion eight hundred ninety nine million eight hundred eleven thousand one hundred eighty three dollars ($1,899,811,183). (m) “General acute care hospital” means any hospital licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code. (n) “Hospital community” means any hospital industry organization or system that represents children’s hospitals, nondesignated public hospitals, designated public hospitals, private safety-net hospitals, and other public or private hospitals. (o) “Managed care days” means inpatient hospital days where the service type is reported as “acute care,” “psychiatric care,” and “chemical dependency care and rehabilitation care,” and the payer category is reported as “Medicare managed care,” “county indigent programs-managed care,” and “other third parties-managed care,” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (p) “Managed care per diem quality assurance fee rate” means a fixed fee on managed care days of twenty-seven dollars and twenty-five cents ($27.25) per day. (q) “Medi-Cal days” means inpatient hospital days where the service type is reported as “acute care,” “psychiatric care,” and “chemical dependency care and rehabilitation care,” and the payer category is reported as “Medi-Cal traditional” and “Medi-Cal managed care,” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (r) “Medi-Cal fee-for-service days” means inpatient hospital days where the service type is reported as “acute care,” “psychiatric care,” and “chemical dependency care and rehabilitation care,” and the payer category is reported as “Medi-Cal traditional” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (s) “Medi-Cal managed care days” means inpatient hospital days as reported on the days data source where the service type is reported as “acute care,” “psychiatric care,” and “chemical dependency care and rehabilitation care,” and the payer category is reported as “Medi-Cal managed care” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (t) “Medi-Cal per diem quality assurance fee rate” means a fixed fee on Medi-Cal days of two hundred seventy-five dollars ($275) per day. (u) “New hospital” means a hospital operation, business, or facility functioning under current or prior ownership as a private hospital that does not have a days data source or a hospital that has a days data source in whole, or in part, from a previous operator where there is an outstanding monetary liability owed to the state in connection with the Medi-Cal program and the new operator did not assume liability for the outstanding monetary obligation. (v) “Nondesignated public hospital” means either of the following: (1) A public hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code, is not designated as a specialty hospital in the hospital’s annual financial disclosure report for the hospital’s latest fiscal year ending in 2007, and satisfies the definition in paragraph (25) of subdivision (a) of Section 14105.98, excluding designated public hospitals. (2) A tax-exempt nonprofit hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code, is not designated as a specialty hospital in the hospital’s annual financial disclosure report for the hospital’s latest fiscal year ending in 2007, is operating a hospital owned by a local health care district, and is affiliated with the health care district hospital owner by means of the district’s status as the nonprofit corporation’s sole corporate member. (w) “Prepaid health plan hospital” means a hospital owned by a nonprofit public benefit corporation that shares a common board of directors with a nonprofit health care service plan. (x) “Prepaid health plan hospital managed care per diem quality assurance fee rate” means a fixed fee on non-Medi-Cal managed care days for prepaid health plan hospitals of fifteen dollars and twenty-six cents ($15.26) per day. (y) “Prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate” means a fixed fee on Medi-Cal managed care days for prepaid health plan hospitals of one hundred fifty-four dollars ($154) per day. (z) “Prior fiscal year data” means any data taken from sources that the department determines are the most accurate and reliable at the time the determination is made, or may be calculated from the most recent audited data using appropriate update factors. The data may be from prior fiscal years, current fiscal years, or projections of future fiscal years. (aa) “Private hospital” means a hospital that meets all of the following conditions: (1) Is licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code. (2) Is in the Charitable Research Hospital peer group, as set forth in the 1991 Hospital Peer Grouping Report published by the department, or is not designated as a specialty hospital in the hospital’s Office of Statewide Health Planning and Development Annual Financial Disclosure Report for the hospital’s latest fiscal year ending in 2007. (3) Does not satisfy the Medicare criteria to be classified as a long-term care hospital. (4) Is a nonpublic hospital, nonpublic converted hospital, or converted hospital as those terms are defined in paragraphs (26) to (28), inclusive, respectively, of subdivision (a) of Section 14105.98. (ab) “Program period” means the period from January 1, 2011, to June 30, 2011, inclusive. (ac) “Subject fiscal quarter” means a state fiscal quarter during the program period. (ad) “Upper payment limit” means a federal upper payment limit on the amount of the Medicaid payment for which federal financial participation is available for a class of service and a class of health care providers, as specified in Part 447 of Title 42 of the Code of Federal Regulations. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in Sections 14168.38 (subd. (d), para. (1)) and 14168.40. Repealed on or after January 1, 2013, as prescribed in Section 14168.41.)
14168.32.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
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Hospitals in the covered class must pay a quality assurance fee, and the department must send notice and may collect interest and penalties for late payment.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.32. (a) There shall be imposed on each general acute care hospital that is not an exempt facility a quality assurance fee, provided that a quality assurance fee under this article shall not be imposed on a converted hospital. (b) The quality assurance fee shall be computed starting on January 1, 2011, and continue through and including June 30, 2011. (c) Subject to Section 14168.34, upon receipt of federal approval, the following shall become operative: (1) Within 10 business days following receipt of the notice of federal approval from the federal government, the department shall send notice to each hospital subject to the quality assurance fee, and publish on its Internet Web site, the following information: (A) The date that the state received notice of federal approval. (B) The fee percentage for the program period. (2) The notice to each hospital subject to the quality assurance fee shall also state the following: (A) The aggregate quality assurance fee after the application of the fee percentage for the program period. (B) The aggregate quality assurance fee. (C) The amount of each payment due from the hospital with respect to the aggregate quality assurance fee. (D) The date on which each payment is due. (3) The hospitals shall pay the aggregate quality assurance fee, as follows: (A) If the notice of federal approval is received before March 15, 2011, the aggregate quality assurance fee shall be paid on or before the later of March 1, 2011, or the fifth day after the receipt of the notice of federal approval. (B) If the notice of federal approval is received on or after March 15, 2011, the aggregate quality assurance fee shall be made in one or more payments. The payments shall be made on the sixth of each month on or after the date federal approval is received and June 6, 2011. (4) Notwithstanding paragraph (3), the amount of each hospital’s aggregate quality assurance fee after the application of the fee percentage that has not been paid by the hospital before June 15, 2011, pursuant to paragraph (3), shall be paid by the hospital no later than June 15, 2011. (d) The quality assurance fee, as paid pursuant to this section, shall be paid by each hospital subject to the fee to the department for deposit in the Hospital Quality Assurance Revenue Fund. Deposits may be accepted at any time and will be credited toward the program period. (e) This section shall become inoperative if the federal Centers for Medicare and Medicaid Services denies approval for, or does not approve before January 1, 2012, the implementation of this article or Article 5.226 (commencing with Section 14168.1), and either or both articles cannot be modified by the department pursuant to subdivision (d) of Section 14168.33 in order to meet the requirements of federal law or to obtain federal approval. (f) In no case shall the aggregate fees collected in a federal fiscal year pursuant to this section and Section 14167.32 exceed the maximum percentage of the annual aggregate net patient revenue for hospitals subject to the fee that is prescribed pursuant to federal law and regulations as necessary to preclude a finding that an indirect guarantee has been created. (g) (1) Interest shall be assessed on quality assurance fees not paid on the date due at the greater of 10 percent per annum or the rate at which the department assesses interest on Medi-Cal program overpayments to hospitals that are not repaid when due. Interest shall begin to accrue the day after the date the payment was due and shall be deposited in the Hospital Quality Assurance Revenue Fund. (2) In the event that any fee payment is more than 60 days overdue, a penalty equal to the interest charge described in paragraph (1) shall be assessed and due for each month for which the payment is not received after 60 days. (h) When a hospital fails to pay all or part of the quality assurance fee on or before the date that payment is due, the department may the following day immediately begin to deduct the unpaid assessment and interest owed from any Medi-Cal payments or other state payments to the hospital in accordance with Section 12419.5 of the Government Code until the full amount is recovered. All amounts, except penalties, deducted by the department under this subdivision shall be deposited in the Hospital Quality Assurance Revenue Fund. The remedy provided to the department by this section is in addition to other remedies available under law. (i) The payment of the quality assurance fee shall not be considered as an allowable cost for Medi-Cal cost reporting and reimbursement purposes. (j) The department shall work in consultation with the hospital community to implement this article and Article 5.226 (commencing with Section 14168.1). (k) This subdivision creates a contractually enforceable promise on behalf of the state to use the proceeds of the quality assurance fee, including any federal matching funds, solely and exclusively for the purposes set forth in this article as they existed on the effective date of this article, to limit the amount of the proceeds of the quality assurance fee to be used to pay for the health care coverage of children to the amounts specified in this article, to limit any payments for the department’s costs of administration to the amounts set forth in this article on the effective date of this article, to maintain and continue prior reimbursement levels as set forth in Section 14168.14 on the effective date of that article, and to otherwise comply with all its obligations set forth in Article 5.226 (commencing with Section 14168.1) and this article provided that amendments that arise from, or have as a basis, a decision, advice, or determination by the federal Centers for Medicare and Medicaid Services relating to federal approval of the quality assurance fee or the payments set forth in this article or Article 5.226 (commencing with Section 14168.1) shall control for the purposes of this subdivision. (l) For the purpose of this article, references to the receipt of notice by the state of federal approval of the implementation of this article shall refer to the last date that the state receives notice of all federal approval or waivers required for implementation of this article and Article 5.226 (commencing with Section 14168.1). (m) (1) Effective July 1, 2011, the rates payable to hospitals and managed health care plans under Medi-Cal shall be the rates then payable without the supplemental and increased capitation payments set forth in Article 5.226 (commencing with Section 14168.1). (2) The supplemental payments and other payments under Article 5.226 (commencing with Section 14168.1) shall be regarded as quality assurance payments, the implementation or suspension of which does not affect a determination of the adequacy of any rates under federal law. (n) (1) Subject to paragraph (2), the director may waive any or all interest and penalties assessed under this article in the event that the director determines, in his or her sole discretion, that the hospital has demonstrated that imposition of the full quality assurance fee on the timelines applicable under this article has a high likelihood of creating a financial hardship for the hospital or a significant danger of reducing the provision of needed health care services. (2) Waiver of some or all of the interest or penalties under this subdivision shall be conditioned on the hospital’s agreement to make fee payments, or to have the payments withheld from payments otherwise due from the Medi-Cal program to the hospital, on a schedule developed by the department that takes into account the financial situation of the hospital and the potential impact on services. (3) A decision by the director under this subdivision shall not be subject to judicial review. (4) If fee payments are remitted to the department after the date determined by the department to be the final date for calculating the final supplemental payments under this article and Article 5.226 (commencing with Section 14168.1), the fee payments shall be retained in the fund for purposes of funding supplemental payments supported by a hospital quality assurance fee program implemented under subsequent legislation, provided however that if supplemental payments are not implemented under subsequent legislation, then those fee payments shall be deposited to the Distressed Hospital Fund. (5) If during the implementation of this article, fee payments that were due under Articles 5.21 and 5.22 are remitted to the department under a payment plan or for any other reason, and the final date for calculating the final supplemental payments under Articles 5.21 and 5.22 has passed, then those fee payments shall be deposited to the fund to support the uses established by this article. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in subd. (e). Conditionally inoperative as provided in Sections 14168.38 (subd. (d), para. (1)) and 14168.40. Repealed on or after January 1, 2013, as prescribed in Section 14168.41.)
14168.33.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
Verify source ↗

Fees under this article must be paid as remittances to the department, which must send them to the Treasurer for deposit in the Hospital Quality Assurance Revenue Fund.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.33. (a) (1) All fees required to be paid to the state pursuant to this article shall be paid in the form of remittances payable to the department. (2) The department shall directly transmit the fee payments to the Treasurer to be deposited in the Hospital Quality Assurance Revenue Fund, created pursuant to Section 14167.35. Notwithstanding Section 16305.7 of the Government Code, any interest and dividends earned on deposits in the fund from the proceeds of the fee assessed pursuant to this article shall be retained in the fund for purposes specified in subdivision (b). (b) Notwithstanding subdivision (c) of Section 14167.35, all funds from the proceeds of the fee assessed pursuant to this article in the Hospital Quality Assurance Revenue Fund, together with any interest and dividends earned on money in the fund, shall, upon appropriation by the Legislature, continue to be used exclusively to enhance federal financial participation for hospital services under the Medi-Cal program, to provide additional reimbursement to, and to support quality improvement efforts of, hospitals, and to minimize uncompensated care provided by hospitals to uninsured patients, in the following order of priority: (1) To pay for the department’s staffing and administrative costs directly attributable to implementing Article 5.226 (commencing with Section 14168.1) and this article, not to exceed five hundred thousand dollars ($500,000). (2) To pay for the health care coverage for children in the amount of one hundred five million dollars ($105,000,000) for each subject fiscal quarter for which payments are made under Article 5.226 (commencing with Section 14168.1). (3) To make increased capitation payments to managed health care plans pursuant to Article 5.226 (commencing with Section 14168.1). (4) To reimburse the General Fund for the increase in the overall compensation to a private hospital that is attributable to its change in status from contract hospital to noncontract hospital, pursuant to subdivision (a) of Section 14168.10. (5) To make increased payments to hospitals pursuant to Article 5.226 (commencing with Section 14168.1). (6) To make increased payments to mental health plans pursuant to Article 5.226 (commencing with Section 14168.1). (c) Any amounts of the quality assurance fee collected in excess of the funds required to implement subdivision (b), including any funds recovered under subdivision (d) of Section 14168.13 or subdivision (e) of Section 14168.38, shall be refunded to general acute care hospitals, pro rata with the amount of quality assurance fee paid by the hospital, subject to the limitations of federal law. If federal rules prohibit the refund described in this subdivision, the excess funds shall be deposited in the Distressed Hospital Fund to be used for the purposes described in Section 14166.23, and shall be supplemental to and not supplant existing funds. (d) Any methodology or other provision specified in Article 5.226 (commencing with Section 14168.1) or this article may be modified by the department, in consultation with the hospital community, to the extent necessary to meet the requirements of federal law or regulations to obtain federal approval or to enhance the probability that federal approval can be obtained, provided the modifications do not violate the spirit and intent of Article 5.226 (commencing with Section 14168.1) or this article and are not inconsistent with the conditions of implementation set forth in Section 14168.40. (e) The department, in consultation with the hospital community, shall make adjustments, as necessary, to the amounts calculated pursuant to Section 14168.32 in order to ensure compliance with the federal requirements set forth in Section 433.68 of Title 42 of the Code of Federal Regulations or elsewhere in federal law. (f) The department shall request approval from the federal Centers for Medicare and Medicaid Services for the implementation of this article. In making this request, the department shall seek specific approval from the federal Centers for Medicare and Medicaid Services to exempt providers identified in this article as exempt from the fees specified, including the submission, as may be necessary, of a request for waiver of the broad-based requirement, waiver of the uniform fee requirement, or both, pursuant to paragraphs (1) and (2) of subdivision (e) of Section 433.68 of Title 42 of the Code of Federal Regulations. (g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this article or Article 5.226 (commencing with Section 14168.1) by means of provider bulletins, all plan letters, or other similar instruction, without taking regulatory action. The department shall also provide notification to the Joint Legislative Budget Committee and to the appropriate policy and fiscal committees of the Legislature within five working days when the above-described action is taken in order to inform the Legislature that the action is being implemented. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in Sections 14168.38 (subd. (d), para. (1)) and 14168.40. Repealed on or after January 1, 2013, as prescribed in Section 14168.41.)
14168.34.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
Verify source ↗

The department may impose and collect the quality assurance fee, and make related payments, only when it has a sufficient letter indicating likely federal approval. The director must find the letter meets the stated requirements and has authority to manage interim fee collection and payment timing.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.34. (a) Notwithstanding any other provision of this article or Article 5.226 (commencing with Section 14168.1) requiring federal approvals, the department may impose and collect the quality assurance fee and may make payments under this article and Article 5.226 (commencing with Section 14168.1), including increased capitation payments, based upon receiving a letter from the federal Centers for Medicare and Medicaid Services or the United States Department of Health and Human Services that indicates likely federal approval, but only if and to the extent that the letter is sufficient as set forth in subdivision (b). (b) In order for the letter to be sufficient under this section, the director shall find that the letter meets both of the following requirements: (1) The letter is in writing and signed by an official of the federal Centers for Medicare and Medicaid Services or an official of the United States Department of Health and Human Services. (2) The director, after consultation with the hospital community, has determined, in the exercise of his or her sole discretion, that the letter provides a sufficient level of assurance to justify advanced implementation of the fee and payment provisions. (c) Nothing in this section shall be construed as modifying the requirement under Section 14168.13 that payments shall be made only to the extent a sufficient amount of funds collected as the quality assurance fee are available to cover the nonfederal share of those payments. (d) Upon notice from the federal government that final federal approval for the fee model under this article or for any payment method under Article 5.226 (commencing with Section 14168.1) has been denied, any fees collected pursuant to this section shall be refunded and any payments made pursuant to this article or Article 5.226 (commencing with Section 14168.1) shall be recouped, including, but not limited to, supplemental payments, increased capitation payments, payments to hospitals by health care plans resulting from the increased capitation payments, increased payments to mental health plans, and payments for the health care coverage of children. To the extent fees were paid by a hospital that also received payments under this section, the payments may first be recouped from fees that would otherwise be refunded to the hospital prior to the use of any other recoupment method allowed under law. (e) Any payment made pursuant to this section shall be a conditional payment until all final federal approvals necessary to fully implement this article and Article 5.226 (commencing with Section 14168.1) have been received. (f) The director shall have broad authority under this section to collect the quality assurance fee for an interim period after receipt of the letter described in subdivision (a) pending receipt of all necessary federal approvals. This authority shall include discretion to determine both of the following: (1) Whether the quality assurance fee should be collected on a full or pro rata basis during the interim period. (2) The dates on which payments of the quality assurance fee are due. (g) The department may draw against the Hospital Quality Assurance Revenue Fund for all administrative costs associated with implementation under this article or Article 5.226 (commencing with Section 14168.1). (h) This section shall be implemented only to the extent federal financial participation is not jeopardized by implementation prior to the receipt of all necessary final federal approvals. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in Sections 14168.38 (subd. (d), para. (1)) and 14168.40. Repealed on or after January 1, 2013, as prescribed in Section 14168.41.)
14168.35.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
Verify source ↗

The director may change timelines in this article if federal approval is not secured by March 15, 2011 and the director finds the change is operationally necessary; the department must notify legislative committees before using a modified timeline and must consult hospital representatives when developing one.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.35. (a) Notwithstanding any other provision of law, the director shall have discretion to modify any timeline or timelines in this article or Article 5.226 (commencing with Section 14168.1) if the letter that indicates likely federal approval, as described in Section 14168.34, is not secured by March 15, 2011, and the director determines that it is impossible from an operational perspective to implement a timeline or timelines without the modification. (b) The department shall notify the fiscal and policy committees of the Legislature prior to implementing a modified timeline or timelines under subdivision (a). (c) The department shall consult with representatives of the hospital community in developing a modified timeline or timelines pursuant to this section. (d) The discretion to modify timelines under this section shall include, but not be limited to, discretion to accelerate payments to plans or hospitals. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in Sections 14168.38 (subd. (d), para. (1)) and 14168.40. Repealed on or after January 1, 2013, as prescribed in Section 14168.41.)
14168.36.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
Verify source ↗

If federal approval and funding conditions are met, the department must make certain hospital payments; if funds are insufficient, the director must consult on a payment plan, and inconsistent payments must be recouped.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.36. (a) Upon receipt of a letter that indicates likely federal approval that the director determines is sufficient for implementation under Section 14168.34, or upon the receipt of all final federal approvals necessary for the implementation of this article and Article 5.226 (commencing with Section 14168.1), the following shall occur: (1) To the maximum extent possible, and consistent with the availability of funds in the Hospital Quality Assurance Revenue Fund, the department shall make all of the payments under Sections 14168.2, 14168.3, and 14168.5, including, but not limited to, supplemental payments and increased capitation payments, prior to July 1, 2011. (2) The department shall make supplemental payments to hospitals under Article 5.226 (commencing with Section 14168.1) consistent with the timeframe described in Section 14168.11 or a modified timeline developed pursuant to Section 14168.35. (b) Notwithstanding any other provision of this article or Article 5.226 (commencing with Section 14168.1), if the director determines, on or after June 15, 2011, that there are insufficient funds available in the Hospital Quality Assurance Revenue Fund to make all scheduled payments under Article 5.226 (commencing with Section 14168.1) before July 1, 2011, he or she shall consult with representatives of the hospital community to develop an acceptable plan for making additional payments to hospitals and managed health care plans in the third and fourth quarters of 2011 to maximize the use of delinquent fee payments or other deposits or interest projected to become available in the fund after June 15, 2011, but before September 15, 2011. (c) Nothing in this section shall require the department to continue to make payments under Article 5.226 (commencing with Section 14168.1) if, after the consultation required under subdivision (b), the director determines in the exercise of his or her sole discretion that a workable plan for the continued payments cannot be developed. (d) Subdivisions (b) and (c) shall be implemented only if and to the extent federal financial participation is available for continued supplemental payments and to providers and continued increased capitation payments to managed health care plans. (e) If any payment or payments made pursuant to this section are found to be inconsistent with federal law, the department shall recoup the payments by means of withholding or any other available remedy. (f) Nothing in this section shall be read as affecting the department’s ongoing authority to continue, after June 30, 2011, to collect quality assurance fees imposed on or before June 30, 2011. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in Sections 14168.38 (subd. (d), para. (1)) and 14168.40. Repealed on or after January 1, 2013, as prescribed in Section 14168.41.)
14168.37.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
Verify source ↗

If federal approval or a likely approval letter is not received by June 1, 2011, this article becomes inoperative and is repealed, unless a later statute enacted before that date deletes or extends the deadline.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.37. Notwithstanding any other provision of law, if actual federal approval or a letter that indicates likely federal approval in accordance with Section 14168.34 has not been received on or before June 1, 2011, then this article shall become inoperative, and as of June 1, 2011, is repealed, unless a later enacted statute, that is enacted before June 1, 2011, deletes or extends that date. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in Sections 14168.38 (subd. (d), para. (1)) and 14168.40. Repealed on or after January 1, 2013, as prescribed in Section 14168.41. Note: Conditions in this section for repeal of Article 5.227 (commencing with Section 14168.31) failed.)
14168.38.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
Verify source ↗

This section says the hospital quality assurance fee program operates only while listed conditions are met, and hospitals must pay the fee unless federal approval conditions are not satisfied.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.38. (a) This article shall be implemented only as long as all of the following conditions are met: (1) Subject to Section 14168.33, the quality assurance fee is established in a manner that is fundamentally consistent with this article. (2) The quality assurance fee, including any interest on the fee after collection by the department, is deposited in a segregated fund apart from the General Fund. (3) The proceeds of the quality assurance fee, including any interest and related federal reimbursement, may only be used for the purposes set forth in this article. (b) No hospital shall be required to pay the quality assurance fee to the department unless and until the state receives and maintains federal approval of the quality assurance fee as set forth in this article and Article 5.226 (commencing with Section 14168.1) from the federal Centers for Medicare and Medicaid Services. (c) Hospitals shall be required to pay the quality assurance fee to the department as set forth in this article only as long as all of the following conditions are met: (1) The federal Centers for Medicare and Medicaid Services allows the use of the quality assurance fee as set forth in this article. (2) Article 5.226 (commencing with Section 14168.1) is enacted and remains in effect and hospitals are reimbursed the increased rates for services during the program period, as defined in Section 14168.1. (3) The full amount of the quality assurance fee assessed and collected pursuant to this article remains available only for the purposes specified in this article. (d) This article shall become inoperative if either of the following occurs: (1) In the event, and on the effective date, of a final judicial determination made by any court of appellate jurisdiction or a final determination by the United States Department of Health and Human Services or the federal Centers for Medicare and Medicaid Services that any element of this article or any provision of Section 14166.115 cannot be implemented. (2) In the event both of the following conditions exist: (A) The federal Centers for Medicare and Medicaid Services denies approval for, or does not approve before January 1, 2012, the implementation of Article 5.226 (commencing with Section 14168.1) or this article. (B) Either or both articles cannot be modified by the department pursuant to subdivision (d) of Section 14168.33 in order to meet the requirements of federal law or to obtain federal approval. (e) If this article becomes inoperative pursuant to paragraph (1) of subdivision (d) and the determination applies to any period or periods of time prior to the effective date of the determination, the department may recoup all payments made pursuant to Article 5.226 (commencing with Section 14168.1) during that period or those periods of time. (f) (1) In the event that all necessary final federal approvals are not received as described and anticipated under this article or Article 5.226 (commencing with Section 14168.1), the director shall have the discretion and authority to develop procedures for recoupment from managed health care plans, and from hospitals under contract with managed health care plans, of any amounts received pursuant to this article or Article 5.226 (commencing with Section 14168.1). (2) Any procedure instituted pursuant to this subdivision shall be developed in consultation with representatives from managed health care plans and representatives of the hospital community. (3) Any procedure instituted pursuant to this subdivision shall be in addition to all other remedies made available under the law, pursuant to contracts between the department and the managed health care plans, or pursuant to contracts between the managed health care plans and the hospitals. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in this section (subd. (d), para. (1)) and Section 14168.40. Repealed on or after January 1, 2013, as prescribed in Section 14168.41. Note: Provisions for inoperation affect Article 5.227, commencing with Section 14168.31.)
14168.39.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
Verify source ↗

Supplemental payments or other payments under Article 5.226 are required and payable only in a quarter when a fee payment obligation exists.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.39. Notwithstanding any other provision of this article or Article 5.226 (commencing with Section 14168.1), supplemental payments or other payments under Article 5.226 (commencing with Section 14168.1) shall only be required and payable in any quarter for which a fee payment obligation exists. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in Sections 14168.38 (subd. (d), para. (1)) and 14168.40. Repealed on or after January 1, 2013, as prescribed in Section 14168.41.)
14168.40.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
Verify source ↗

This section makes Article 5.227 and related Article 5.226 requirements inoperative if specified legal, funding, or financial-disadvantage triggers occur, and it gives the director authority to recoup certain payments and refund hospital fees in some cases.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.40. (a) This article and Article 5.226 (commencing with Section 14168.1) shall become inoperative and the requirements for supplemental payments or other payments under Article 5.226 (commencing with Section 14168.1) shall be retroactively invalidated, on the first day of the first month of the calendar quarter following notification to the Joint Legislative Budget Committee by the Department of Finance, that any of the following have occurred: (1) A final judicial determination by the California Supreme Court or any California Court of Appeal that the revenues collected pursuant to this article that are deposited in the Hospital Quality Assurance Revenue Fund are either of the following: (A) “General Fund proceeds of taxes appropriated pursuant to Article XIII B of the California Constitution,” as used in subdivision (b) of Section 8 of Article XVI of the California Constitution. (B) “Allocated local proceeds of taxes,” as used in subdivision (b) of Section 8 of Article XVI of the California Constitution. (2) The department has sought but has not received federal financial participation for the supplemental payments and other costs required by this article for which federal financial participation has been sought. (3) A lawsuit related to this article, Article 5.226 (commencing with Section 14168.1), or Section 14166.115 is filed against the state and a preliminary injunction or other order has been issued that results in a financial disadvantage to the state. (4) The director, in consultation with the Department of Finance, determines that the implementation of this article or Article 5.226 (commencing with Section 14168.1) has resulted in a financial disadvantage to the state. (b) For purposes of this section, “financial disadvantage to the state” means either: (1) A loss of federal financial participation. (2) A cost to the General Fund, that is equal to or greater than one-quarter of 1 percent of the General Fund expenditures authorized in the most recent annual Budget Act. (c) (1) The director shall have the authority to recoup any payments made under Article 5.226 (commencing with Section 14168.1) if any of the following apply: (A) Recoupment of payments made under Article 5.226 (commencing with Section 14168.1) is ordered by a court. (B) Federal financial participation is not available for payments made under Article 5.226 (commencing with Section 14168.1) for which federal financial participation has been sought. (C) Recoupment of payments made under Article 5.226 (commencing with Section 14168.1) is necessary to prevent a General Fund cost that is estimated to be equal to or greater than one-quarter of 1 percent of the General Fund expenditures authorized in the most recent annual Budget Act and that results from implementation of a court order or the unavailability of federal financial participation. (2) In the event payments are recouped for a particular quarter, fees paid by a hospital for that quarter pursuant to this article shall be refunded to the extent that the hospital meets both of the following conditions: (A) The hospital has actually paid the fee for the subject quarter and for all prior quarters. (B) The hospital has returned the payment received pursuant to Article 5.226 (commencing with Section 14168.1) for that quarter, or has had that payment recouped through a withholding of funds owed by Medi-Cal or other state payments, or recouped through other means. (d) In the event the department determines that recoupment of supplemental payments is necessary to implement any provision of this section, the department may recoup payments made pursuant to Article 5.226 (commencing with Section 14168.1) from fees paid by the hospital pursuant to this article. (e) Concurrent with invoking any provision of this section, the director shall notify the fiscal and appropriate policy committees of the Legislature of the intended action and the specific reason or reasons for the proposed action. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in this section (subd. (a)) and Section 14168.38 (subd. (d), para. (1)). Repealed on or after January 1, 2013, as prescribed in Section 14168.41. Note: Provisions for inoperation affect Article 5.227, commencing with Section 14168.31. (Article 5.226 was repealed.))
14168.40.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
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The department must implement this article by policy letters or similar instructions, and not by taking further regulatory action.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.40.5. Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this article by means of policy letters or similar instructions, without taking further regulatory action. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in Sections 14168.38 (subd. (d), para. (1)) and 14168.40. Repealed on or after January 1, 2013, as prescribed in Section 14168.41.)
14168.41.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. )
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This article stays in effect until the later of the stated dates, then is repealed unless a later statute changes that date.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.227. Hospital Quality Assurance Fee Act of 2011 [14168.31 - 14168.41] ( Article 5.227 added by Stats. 2011, Ch. 19, Sec. 8. ) ## 14168.41. This article shall remain in effect only until January 1, 2013, the date of the last payment of quality assurance fee payments pursuant to this article, or the date of the last payment from the department pursuant to Article 5.226 (commencing with Section 14168.1), whichever is later, and as of that date is repealed, unless a later enacted statute, that is enacted before that date, deletes or extends that date. (Added by Stats. 2011, Ch. 19, Sec. 8. (SB 90) Effective April 13, 2011. Conditionally inoperative as provided in Sections 14168.38 (subd. (d), para. (1)) and 14168.40. Repealed on or after January 1, 2013, as prescribed by its own provisions. Note: Repeal affects Article 5.227, commencing with Section 14168.31.)
14169.1.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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This section defines terms used in the article about Medi-Cal hospital provider rate improvements.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.1. For the purposes of this article, the following definitions shall apply: (a) “Acute psychiatric days” means the total number of Medi-Cal specialty mental health service administrative days, Medi-Cal specialty mental health service acute care days, acute psychiatric administrative days, and acute psychiatric acute days identified in the Tentative Medi-Cal Utilization Statistics for the 2011–12 state fiscal year as calculated by the department as of July 21, 2011. (b) “Converted hospital” means a private hospital that becomes a designated public hospital or a nondesignated public hospital on or after July 1, 2011. (c) “Days data source” means the hospital’s Annual Financial Disclosure Report filed with the Office of Statewide Health Planning and Development as of May 5, 2011, for its fiscal year ending during 2009. (d) “Designated public hospital” shall have the meaning given in subdivision (d) of Section 14166.1 as of July 1, 2011. (e) “General acute care days” means the total number of Medi-Cal general acute care days paid by the department to a hospital for services in the 2009 calendar year, as reflected in the state paid claims file on July 15, 2011. (f) “High acuity days” means Medi-Cal coronary care unit days, pediatric intensive care unit days, intensive care unit days, neonatal intensive care unit days, and burn unit days paid by the department during the 2009 calendar year, as reflected in the state paid claims file prepared by the department on July 15, 2011. (g) “Hospital inpatient services” means all services covered under Medi-Cal and furnished by hospitals to patients who are admitted as hospital inpatients and reimbursed on a fee-for-service basis by the department directly or through its fiscal intermediary. Hospital inpatient services include outpatient services furnished by a hospital to a patient who is admitted to that hospital within 24 hours of the provision of the outpatient services that are related to the condition for which the patient is admitted. Hospital inpatient services do not include services for which a managed health care plan is financially responsible. (h) “Hospital outpatient services” means all services covered under Medi-Cal furnished by hospitals to patients who are registered as hospital outpatients and reimbursed by the department on a fee-for-service basis directly or through its fiscal intermediary. Hospital outpatient services do not include services for which a managed health care plan is financially responsible, or services rendered by a hospital-based federally qualified health center for which reimbursement is received pursuant to Section 14132.100. (i) “Individual hospital acute psychiatric supplemental payment” means the total amount of acute psychiatric hospital supplemental payments to a subject hospital for a quarter for which the supplemental payments are made. The “individual hospital acute psychiatric supplemental payment” shall be calculated for subject hospitals by multiplying the number of acute psychiatric days for the individual hospital for which a mental health plan was financially responsible by the amount calculated in accordance with paragraph (2) of subdivision (b) of Section 14169.3 and dividing the result by four. (j) (1) “Managed health care plan” means a health care delivery system that manages the provision of health care and receives prepaid capitated payments from the state in return for providing services to Medi-Cal beneficiaries. (2) (A) Managed health care plans include county organized health systems and entities contracting with the department to provide services pursuant to two-plan models and geographic managed care. Entities providing these services contract with the department pursuant to any of the following: (i) Article 2.7 (commencing with Section 14087.3). (ii) Article 2.8 (commencing with Section 14087.5). (iii) Article 2.81 (commencing with Section 14087.96). (iv) Article 2.91 (commencing with Section 14089). (B) Managed health care plans do not include any of the following: (i) Mental health plans contracting to provide mental health care for Medi-Cal beneficiaries pursuant to Chapter 8.9 (commencing with Section 14700). (ii) Health plans not covering inpatient services such as primary care case management plans operating pursuant to Section 14088.85. (iii) Program for All-Inclusive Care for the Elderly organizations operating pursuant to Chapter 8.75 (commencing with Section 14591). (k) “Medi-Cal managed care days” means the total number of general acute care days, including well baby days, listed for the county organized health system and prepaid health plans identified in the Tentative Medi-Cal Utilization Statistics for the 2011–12 fiscal year, as calculated by the department as of July 21, 2011. (l) “Medicaid inpatient utilization rate” means Medicaid inpatient utilization rate as defined in Section 1396r-4 of Title 42 of the United States Code and as set forth in the final disproportionate share hospital eligibility list for the 2010–11 fiscal year released by the department as of May 1, 2011. (m) “Mental health plan” means a mental health plan that contracts with the state to furnish or arrange for the provision of mental health services to Medi-Cal beneficiaries pursuant to Chapter 8.9 (commencing with Section 14700). (n) “New hospital” means a hospital operation, business, or facility functioning under current or prior ownership as a private hospital that does not have a days data source or a hospital that has a days data source in whole, or in part, from a previous operator where there is an outstanding monetary liability owed to the state in connection with the Medi-Cal program and the new operator did not assume liability for the outstanding monetary obligation. (o) “New noncontract hospital” means a private hospital that was a contract hospital on March 1, 2011, and elects to become a noncontract hospital at any time between March 1, 2011, and the end of the program period. (p) “Nondesignated public hospital” means either of the following: (1) A public hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code, is not designated as a specialty hospital in the hospital’s Annual Financial Disclosure Report for the hospital’s latest fiscal year ending in 2009, and satisfies the definition in paragraph (25) of subdivision (a) of Section 14105.98, excluding designated public hospitals. (2) A tax-exempt nonprofit hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code, is not designated as a specialty hospital in the hospital’s Annual Financial Disclosure Report for the hospital’s latest fiscal year ending in 2009, is operating a hospital owned by a local health care district, and is affiliated with the health care district hospital owner by means of the district’s status as the nonprofit corporation’s sole corporate member. (q) “Outpatient base amount” means the total amount of payments for hospital outpatient services made to a hospital in the 2009 calendar year, as reflected in the state paid claims files prepared by the department on June 2, 2011. (r) “Private hospital” means a hospital that meets all of the following conditions: (1) Is licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code. (2) Is in the Charitable Research Hospital peer group, as set forth in the 1991 Hospital Peer Grouping Report published by the department, or is not designated as a specialty hospital in the hospital’s Office of Statewide Health Planning and Development Annual Financial Disclosure Report for the hospital’s latest fiscal year ending in 2009. (3) Does not satisfy the Medicare criteria to be classified as a long-term care hospital. (4) Is a nonpublic hospital, nonpublic converted hospital, or converted hospital as those terms are defined in paragraphs (26) to (28), inclusive, respectively, of subdivision (a) of Section 14105.98. (s) “Program period” means the period from July 1, 2011, to December 31, 2013, inclusive. (t) “Subject fiscal quarter” means a state fiscal quarter beginning on or after July 1, 2011, and ending before January 1, 2014. (u) “Subject fiscal year” means a state fiscal year that ends after July 1, 2011, and begins before January 1, 2014. (v) “Subject hospital” means a hospital that meets all of the following conditions: (1) Is licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code. (2) Is in the Charitable Research Hospital peer group, as set forth in the 1991 Hospital Peer Grouping Report published by the department, or is not designated as a specialty hospital in the hospital’s Office of Statewide Health Planning and Development Annual Financial Disclosure Report for the hospital’s latest fiscal year ending in 2009. (3) Does not satisfy the Medicare criteria to be classified as a long-term care hospital. (w) “Subject month” means a calendar month beginning on or after July 1, 2011, and ending before January 1, 2014. (x) “Upper payment limit” means a federal upper payment limit on the amount of the Medicaid payment for which federal financial participation is available for a class of service and a class of health care providers, as specified in Part 447 of Title 42 of the Code of Federal Regulations. The applicable upper payment limit shall be separately calculated for inpatient and outpatient hospital services. (Amended by Stats. 2012, Ch. 34, Sec. 233. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.10.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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The department must implement this section by policy letters or similar instructions, and a supplemental payment for a new noncontract hospital must be reduced in specified circumstances.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.10. (a) For only as long as the selective provider contracting program pursuant to Article 2.6 (commencing with Section 14081) is in effect, the amount of any supplemental payment under this article for a new noncontract hospital shall be reduced by the amount by which that hospital’s overall payment for services for Medi-Cal patients during the program period was increased by reason of its becoming a noncontract hospital. (b) The amount of the nonfederal share of any supplemental payment reduction under subdivision (a) shall be transferred from the Hospital Quality Assurance Revenue Fund to the General Fund at the time the reduced supplemental payment under subdivision (a) is made. (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this section by means of policy letters or similar instructions, without taking further regulatory action. (Added by Stats. 2011, Ch. 286, Sec. 7. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.11.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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The department must distribute money from the Hospital Quality Assurance Revenue Fund according to the section’s payment rules and deadlines.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.11. The department shall make disbursements from the Hospital Quality Assurance Revenue Fund consistent with the following: (a) Fund disbursements shall be made periodically within 15 days of each date on which quality assurance fees are due from hospitals. (b) The funds shall be disbursed in accordance with the order of priority set forth in subdivision (b) of Section 14169.33, except that funds may be set aside for increased capitation payments to managed care health plans pursuant to subdivision (f) of Section 14169.5. (c) The funds shall be disbursed in each payment cycle in accordance with the order of priority set forth in subdivision (b) of Section 14169.33 as modified by subdivision (b), and so that the supplemental payments and grants to hospitals, increased capitation payments to managed health care plans, increased payments to mental health plans, direct payments to hospitals of acute psychiatric supplemental payments, and supplemental payments for out-of-network emergency and poststabilization services for the Low Income Health Program are made to the maximum extent for which funds are available. (d) To the maximum extent possible, consistent with the availability of funds in the quality assurance fund and the timing of federal approvals, the supplemental payments and grants to hospitals, increased capitation payments to managed health care plans, and increased payments to mental health plans under this article shall be made before December 31, 2013, except that supplemental payments for out-of-network emergency and poststabilization services for the Low Income Health Program shall be made before April 1, 2014. (e) The aggregate amount of funds to be disbursed to private hospitals shall be determined under Sections 14169.2 and 14169.3. The aggregate amount of funds to be disbursed to managed health care plans shall be determined under Section 14169.5. The aggregate amount of direct grants to designated and nondesignated public hospitals shall be determined under Section 14169.7. The aggregate amount of supplemental payments to be disbursed to private hospitals for out-of-network and poststabilization services for the Low Income Health Program shall be determined under Section 14169.7.5. (Amended by Stats. 2012, Ch. 452, Sec. 6. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.12.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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This section keeps certain hospital payment rates from being reduced below specified baseline rates for defined periods.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.12. (a) Exclusive of payments made under Article 5.21 (commencing with Section 14167.1) and Article 5.226 (commencing with Section 14168.1), payment rates for hospital outpatient services, furnished by private hospitals, nondesignated public hospitals, and designated public hospitals before December 31, 2013, exclusive of amounts payable under this article, shall not be reduced below the rates in effect on July 1, 2011. (b) Rates payable to hospitals for hospital inpatient services furnished before December 31, 2013, under contracts negotiated pursuant to the selective provider contracting program under Article 2.6 (commencing with Section 14081), shall not be reduced below the contract rates in effect on July 1, 2011. This subdivision shall not prohibit changes to the supplemental payments paid to individual hospitals under Sections 14166.12, 14166.17, and 14166.23, provided that the aggregate amount of the payments for each subject fiscal year is not less than the minimum amount permitted under Section 14167.13. (c) Notwithstanding Section 14105.281, exclusive of payments made under Article 5.21 (commencing with Section 14167.1) and Article 5.226 (commencing with Section 14168.1), payments to private hospitals for hospital inpatient services furnished before January 1, 2014, that are not reimbursed under a contract negotiated pursuant to the selective provider contracting program under Article 2.6 (commencing with Section 14081), exclusive of amounts payable under this article, shall not be less than the amount of payments that would have been made under the payment methodology in effect on the effective date of this article. (d) Upon the implementation of the new Medi-Cal inpatient hospital reimbursement methodology based on diagnosis-related groups pursuant to Section 14105.28, the requirements in subdivisions (b) and (c) shall be met if the rates paid under the new Medi-Cal inpatient hospital reimbursement methodology based on diagnosis-related groups result in an average payment per discharge to all hospitals subject to the new reimbursement methodology, calculated on an aggregate basis per subject fiscal year, exclusive of amounts payable under this article, amounts payable under Sections 14166.11 and 14166.23, and if amounts payable under Sections 14166.12 and 14166.17 are not included in the payments under the diagnosis-related group methodology and continue to be paid separately to hospitals, exclusive of those amounts, that is not less than the average payment per discharge to the hospitals, exclusive of amounts payable under this article, amounts payable under Sections 14166.11 and 14166.23, and if amounts payable under Sections 14166.12 and 14166.17 are not included in the payments under the diagnosis-related group methodology and continue to be paid separately to hospitals, exclusive of those amounts, calculated on an aggregate basis for the fiscal year ending June 30, 2012, adjusted, in consultation with the hospital community, to reflect the movement of populations into managed care under Article 5.4 (commencing with Section 14180). (e) Solely for purposes of this article, a rate reduction or a change in a rate methodology that is enjoined by a court shall be included in the determination of a rate or a rate methodology until all appeals or judicial reviews have been exhausted and the rate reduction or change in rate methodology has been permanently enjoined, denied by the federal government, or otherwise permanently prevented from being implemented. (f) Disproportionate share replacement payments to private hospitals for the 2011–12 fiscal year shall be not less than the amount determined pursuant to Section 14166.11 as reduced pursuant to paragraph (3) of subdivision (b) of Section 14166.115. Disproportionate share replacement payments to private hospitals for the 2012–13 fiscal year shall not be less than the amount determined pursuant to Section 14166.11, as reduced pursuant to paragraph (4) of subdivision (b) of Section 14166.115. Disproportionate share replacement payments to private hospitals for the period of July 1, 2013, through December 31, 2013, shall be not less than the amount determined pursuant to Section 14166.11, as reduced by paragraph (5) of subdivision (b) of Section 14166.115. For purposes of this subdivision, references to Section 14166.11 are to the version of Section 14166.11 in effect on the effective date of the act that added this subdivision. (Added by Stats. 2011, Ch. 286, Sec. 7. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.13.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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The director and department must take steps to implement this article, including seeking approvals, amending contracts, and not making payments until required federal approvals and fee collection conditions are met.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.13. (a) The director shall do all of the following: (1) Promptly submit any state plan amendment or waiver request that may be necessary to implement this article. (2) Promptly seek federal approvals or waivers as may be necessary to implement this article and to obtain federal financial participation to the maximum extent possible for the payments under this article. (3) Amend the contracts between the managed health care plans and the department as necessary to incorporate the provisions of Sections 14169.5 and 14169.6 and promptly seek all necessary federal approvals of those amendments. The department shall pursue amendments to the contracts as soon as possible after the effective date of this article and Article 5.229 (commencing with Section 14169.31), and shall not wait for federal approval of this article or Article 5.229 (commencing with Section 14169.31) prior to pursuing amendments to the contracts. The amendments to the contracts shall, among other provisions, set forth an agreement to increase capitation payments to managed health care plans under Section 14169.5 and increase payments to hospitals under Section 14169.6 in a manner that relates back to July 1, 2011, or as soon thereafter as possible, conditioned on obtaining all federal approvals necessary for federal financial participation for the increased capitation payments to the managed health care plans. (b) In implementing this article, the department may utilize the services of the Medi-Cal fiscal intermediary through a change order to the fiscal intermediary contract to administer this program, consistent with the requirements of Sections 14104.6, 14104.7, 14104.8, and 14104.9. Contracts entered into for purposes of implementing this article or Article 5.229 (commencing with Section 14169.31) shall not be subject to Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code. (c) This article shall become inoperative if either of the following occurs: (1) In the event, and on the effective date, of a final judicial determination made by any court of appellate jurisdiction or a final determination by the federal Department of Health and Human Services or the federal Centers for Medicare and Medicaid Services that Section 14169.2, Section 14169.3, or any provision of Section 14166.115 cannot be implemented. (2) In the event both of the following conditions exist: (A) The federal Centers for Medicare and Medicaid Services denies approval for, or does not approve before January 1, 2013, the implementation of Section 14169.2, Section 14169.3, or the quality assurance fee established pursuant to Article 5.229 (commencing with Section 14169.31). (B) Section 14169.2, Section 14169.3, or Article 5.229 (commencing with Section 14169.31) cannot be modified by the department pursuant to subdivision (e) of Section 14169.33 in order to meet the requirements of federal law or to obtain federal approval. (d) If this article becomes inoperative pursuant to paragraph (1) of subdivision (c) and the determination applies to any period or periods of time prior to the effective date of the determination, the department shall have authority to recoup all payments made pursuant to this article during that period or those periods of time. (e) In the event any hospital, or any party on behalf of a hospital, shall initiate a case or proceeding in any state or federal court in which the hospital seeks any relief of any sort whatsoever, including, but not limited to, monetary relief, injunctive relief, declaratory relief, or a writ, based in whole or in part on a contention that any or all of this article or Article 5.229 (commencing with Section 14169.31) is unlawful and may not be lawfully implemented, both of the following shall apply: (1) Payments shall not be made to the hospital pursuant to this article until the case or proceeding is finally resolved, including the final disposition of all appeals. (2) Any amount computed to be payable to the hospital pursuant to this section for a project year shall be withheld by the department and shall be paid to the hospital only after the case or proceeding is finally resolved, including the final disposition of all appeals. (f) Subject to Section 14169.34, no payment shall be made under this article until all necessary federal approvals for the payment and for the fee provisions in Article 5.229 (commencing with Section 14169.31) have been obtained and the fee has been imposed and collected. Notwithstanding any other provision of law, payments under this article shall be made only to the extent that the fee established in Article 5.229 (commencing with Section 14169.31) is collected and available to cover the nonfederal share of the payments. (g) A hospital’s receipt of payments under this article for services rendered prior to the effective date of this article is conditioned on the hospital’s continued participation in Medi-Cal for at least 30 days after the effective date of this article. (h) All payments made by the department to hospitals, managed health care plans, and mental health plans under this article shall be made only from the following: (1) The quality assurance fee set forth in Article 5.229 (commencing with Section 14169.31) and due and payable on or before December 31, 2013, along with any interest or other investment income thereon. (2) Federal reimbursement and any other related federal funds. (Amended by Stats. 2012, Ch. 23, Sec. 101. (AB 1467) Effective June 27, 2012. Conditionally inoperative as provided in this section (subd. (c), para. (1)) and Section 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16. Note: Provisions for inoperation affect Article 5.228, commencing with Section 14169.1.)
14169.14.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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The director may proportionately reduce certain supplemental or increased capitation payments if paying them would reduce other amounts owed under federal law.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.14. Notwithstanding any other provision of this article or Article 5.229 (commencing with Section 14169.31), the director may proportionately reduce the amount of any supplemental payments or increased capitation payments under this article to the extent that the payment would result in the reduction of other amounts payable to a hospital or managed health care plan or mental health plan due to the application of federal law. (Added by Stats. 2011, Ch. 286, Sec. 7. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.15.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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The director may decide not to implement or stop implementing this article and related Article 5.229, and may retroactively invalidate supplemental or other payment requirements.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.15. The director may, pursuant to Section 14169.40, decide not to implement or to discontinue implementation of this article and Article 5.229 (commencing with Section 14169.31), and to retroactively invalidate the requirements for supplemental payments or other payments under this article. (Added by Stats. 2011, Ch. 286, Sec. 7. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.16.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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This article stays in effect only until the latest of the listed dates, and it then expires and is scheduled for repeal under the stated conditions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.16. (a) This article shall remain operative only until the later of the following: (1) January 1, 2015. (2) The date of the last payment of the quality assurance fee payments pursuant to Article 5.229 (commencing Section 14169.31). (3) The date of the last payment from the department pursuant to this article. (b) If this article becomes inoperative under paragraph (1) of subdivision (a), this article shall be repealed on January 1, 2015, unless a later enacted statute enacted before that date, deletes or extends that date. (c) If this article becomes inoperative under paragraph (2) or (3) of subdivision (a), this article shall be repealed on January 1 of the year following the date this article becomes inoperative, unless a later enacted statute enacted before that date, deletes or extends that date. (Amended by Stats. 2012, Ch. 452, Sec. 7. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in this section. Repealed on or after January 1, 2015, by its own provisions. Note: Termination provisions affect Article 5.228, commencing with Section 14169.1.)
14169.17.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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If federal approval or a likely approval letter is not received by December 1, 2013, this article becomes inoperative and is repealed on that date unless a later statute changes the date.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.17. Notwithstanding any other provision of law, if federal approval or a letter that indicates likely federal approval in accordance with Section 14169.34 has not been received on or before December 1, 2013, then this article shall become inoperative, and as of December 1, 2013, is repealed, unless a later enacted statute, that is enacted before December 1, 2013, deletes or extends that date. (Amended by Stats. 2012, Ch. 452, Sec. 8. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16. Note: Conditions in this section for repeal of Article 5.228 (commencing with Section 14169.1) failed.)
14169.17.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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The department must implement this article using policy letters or similar instructions, and it does not need to take further regulatory action.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.17.5. Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this article by means of policy letters or similar instructions, without taking further regulatory action. (Added by Stats. 2011, Ch. 286, Sec. 7. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.18.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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If the director finds this article has become inoperative, the director must issue and distribute a declaration.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.18. If the director determines that this article has become inoperative pursuant to Section 14169.13, 14169.16, 14169.17, or 14169.40, the director shall execute a declaration stating that this determination has been made and stating the basis for this determination. The director shall retain the declaration and provide a copy, within five working days of the execution of the declaration, to the fiscal and appropriate policy committees of the Legislature. In addition, the director shall post the declaration on the department’s Internet Web site and the director shall send the declaration to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel. (Amended by Stats. 2012, Ch. 452, Sec. 9. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.19.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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This section states the Legislature’s intent to consider legislation for increased hospital payments and corresponding fee increases under specified Medi-Cal-related conditions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.19. (a) It is the intent of the Legislature to consider legislation requiring the director to seek approval to increase payments to hospitals in accordance with subdivision (b) of Section 14169.2, subdivision (a) of Section 14169.3, and subdivision (c) of Section 14169.5, and to adopt a corresponding increase in the fee imposed pursuant to Article 5.229 (commencing with Section 14169.31), consistent with federal law and regulations, if the director determines that the maximum available upper payment limits in subdivision (b) of Section 14169.2 or subdivision (a) of Section 14169.3, or the amount of federal financial participation for increased capitation payments to managed care health plans in subdivision (c) of Section 14169.5, have increased during the program period. (b) It is the intent of the Legislature that the legislation described in subdivision (a) shall do both of the following: (1) Require the director to work in consultation with the hospital community in seeking any necessary approvals from the federal Centers for Medicare and Medicaid Services to increase payments to hospitals and to impose corresponding fee increases. (2) Require that, in the event that the director determines that the maximum available upper payment limits in subdivision (b) of Section 14169.2 or subdivision (a) of Section 14169.3, or the amount of federal financial participation for increased capitation payments to managed care health plans in subdivision (c) of Section 14169.5, have increased during the program period, the increases shall first be made available for the purposes of this section prior to being used for other purposes. (c) Notwithstanding any other provision of this article or Article 5.229 (commencing with Section 14169.31), failure to secure, or denial of, any necessary federal approvals required by the legislation described in subdivision (a) shall not affect implementation of this article or Article 5.229 (commencing with Section 14169.31). (Added by Stats. 2011, Ch. 286, Sec. 7. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.2.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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Private hospitals are to receive supplemental payments for hospital outpatient services, with special payment rules and exclusions for new and converted hospitals.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.2. (a) Private hospitals shall be paid supplemental amounts for the provision of hospital outpatient services as set forth in this section. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services and shall not affect any other payments to hospitals. The supplemental amounts shall result in payments equal to the statewide aggregate upper payment limit for private hospitals as it may be modified by Section 14169.19. (b) Except as set forth in subdivisions (e) and (f), each private hospital shall be paid an amount for each subject fiscal year equal to a percentage of the hospital’s outpatient base amount. The percentage shall be the same for each hospital for a subject fiscal year. The percentage shall result in payments to hospitals that equal the applicable federal upper payment limit as provided in Section 14169.19 for a subject fiscal year, except for the 2011–12 state fiscal year during which the percentage shall result in payments to hospitals that equal the applicable federal upper payment limit for the 2011–12 state fiscal year, less any amounts paid pursuant to Section 14168.2 and accounted toward the federal upper payment limits for the entire 2011–12 state fiscal year. For purposes of this subdivision the applicable federal upper payment limit shall be the federal upper payment limit for hospital outpatient services furnished by private hospitals for each subject fiscal year. (c) In the event federal financial participation for a subject fiscal year is not available for all of the supplemental amounts payable to private hospitals under subdivision (b) due to the application of a federal upper payment limit or for any other reason, both of the following shall apply: (1) The total amount payable to private hospitals under subdivision (b) for the subject fiscal year shall be reduced to the amount for which federal financial participation is available. (2) The amount payable under subdivision (b) to each private hospital for the subject fiscal year shall be equal to the amount computed under subdivision (b) multiplied by the ratio of the total amount for which federal financial participation is available to the total amount computed under subdivision (b). (d) The supplemental amounts set forth in this section are inclusive of federal financial participation. (e) Payments shall not be made under this section to a new hospital. (f) No payments shall be made under this section to a converted hospital. (Added by Stats. 2011, Ch. 286, Sec. 7. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.3.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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Private hospitals are entitled to supplemental Medi-Cal inpatient payments, with specific formulas and limits, and payments are barred to new or converted hospitals.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.3. (a) Except as provided in Section 14169.19, private hospitals shall be paid supplemental amounts for the provision of hospital inpatient services for the program period as set forth in this section. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services and shall not affect any other payments to hospitals. The supplemental amounts shall result in payments equal to the statewide aggregate upper payment limit for private hospitals for each subject fiscal year as it may be modified pursuant to Section 14169.19. (b) Except as set forth in subdivisions (g) and (h), each private hospital shall be paid the following amounts as applicable for the provision of hospital inpatient services for each subject fiscal year: (1) Nine hundred seventy-four dollars and ten cents ($974.10) multiplied by the hospital’s general acute care days for supplemental payments for the 2011–12 subject fiscal year, one thousand eighty-nine dollars and ninety-two cents ($1,089.92) multiplied by the hospital’s general acute care days for supplemental payments for the 2012–13 subject fiscal year, and one thousand two hundred sixty-four dollars and six cents ($1,264.06) multiplied by the hospital’s general acute care days for supplemental payments for the 2013–14 subject fiscal year, divided by two. (2) For the hospital’s acute psychiatric days that were paid directly by the department and were not the financial responsibility of a mental health plan, six hundred ninety-five dollars ($695) multiplied by the hospital’s acute psychiatric days for supplemental payments for the 2011–12 subject fiscal year, seven hundred ninety dollars ($790) multiplied by the hospital’s acute psychiatric days for supplemental payments for the 2012–13 subject fiscal year, and nine hundred fifty-five dollars ($955) multiplied by the hospital’s acute psychiatric days for supplemental payments for the 2013–14 subject fiscal year, divided by two. (3) (A) For the 2011–12 and 2012–13 subject fiscal years, one thousand three hundred fifty dollars ($1,350) multiplied by the number of the hospital’s high acuity days if the hospital’s Medicaid inpatient utilization rate is less than 41.6 percent and greater than 5 percent and at least 5 percent of the hospital’s general acute care days are high acuity days. (B) For the 2013–14 subject fiscal year, one thousand three hundred fifty dollars ($1,350) multiplied by the number of the hospital’s high acuity days, divided by two, if the hospital’s Medicaid inpatient utilization rate is less than 41.6 percent and greater than 5 percent and at least 5 percent of the hospital’s general acute care days are high acuity days. (C) The amount under this paragraph shall be in addition to the amounts specified in paragraphs (1) and (2). (4) (A) For the 2011–12 and 2012–13 subject fiscal years, one thousand three hundred fifty dollars ($1,350) multiplied by the number of the hospital’s high acuity days if the hospital qualifies to receive the amount set forth in paragraph (3) and has been designated as a Level I, Level II, Adult/Ped Level I, or Adult/Ped Level II trauma center by the Emergency Medical Services Authority established pursuant to Section 1797.1 of the Health and Safety Code. (B) For the 2013–14 subject fiscal year, one thousand three hundred fifty dollars ($1,350) multiplied by the number of the hospital’s high acuity days, divided by two, if the hospital qualifies to receive the amount set forth in paragraph (3) and has been designated as a Level I, Level II, Adult/Ped Level I, or Adult/Ped Level II trauma center by the Emergency Medical Services Authority established pursuant to Section 1797.1 of the Health and Safety Code. (C) The amount under this paragraph shall be in addition to the amounts specified in paragraphs (1), (2), and (3). (c) A private hospital that provided Medi-Cal subacute services during the 2009 calendar year and has a Medicaid inpatient utilization rate that is greater than 5 percent and less than 41.6 percent shall be paid a supplemental amount during each subject fiscal year equal to 40 percent of the Medi-Cal subacute payments paid by the department to the hospital during the 2009 calendar year, as reflected in the state paid claims file prepared by the department on July 14, 2011, except for the 2013–14 subject fiscal year during which the supplemental amount shall be equal to 20 percent of the Medi-Cal subacute payments paid by the department to the hospital during the 2009 calendar year, as reflected in the state paid claims file prepared by the department on July 14, 2011. (d) (1) In the event federal financial participation for a subject fiscal year is not available for all of the supplemental amounts payable to private hospitals under subdivision (b) due to the application of a federal upper payment limit or for any other reason, both of the following shall apply: (A) The total amount payable to private hospitals under subdivision (b) for the subject fiscal year shall be reduced to reflect the amount for which federal financial participation is available. (B) The amount payable under subdivision (b) to each private hospital for the subject fiscal year shall be equal to the amount computed under subdivision (b) multiplied by the ratio of the total amount for which federal financial participation is available to the total amount computed under subdivision (b). (2) In the event federal financial participation for a subject fiscal year is not available for all of the supplemental amounts payable to private hospitals under subdivision (c) due to the application of a federal upper payment limit or for any other reason, both of the following shall apply: (A) The total amount payable to private hospitals under subdivision (c) for the subject fiscal year shall be reduced to reflect the amount for which federal financial participation is available. (B) The amount payable under subdivision (c) to each private hospital for the subject fiscal year shall be equal to the amount computed under subdivision (c) multiplied by the ratio of the total amount for which federal financial participation is available to the total amount computed under subdivision (c). (e) If the amount otherwise payable to a hospital under this section for a subject fiscal year exceeds the amount for which federal financial participation is available for that hospital, the amount due to the hospital for that subject fiscal year shall be reduced to the amount for which federal financial participation is available. (f) The amounts set forth in this section are inclusive of federal financial participation. (g) Payments shall not be made under this section to a new hospital. (h) Payments shall not be made under this section to a converted hospital. (i) (1) The department shall increase payments to mental health plans for the program period exclusively for the purpose of making payments to private hospitals. The aggregate amount of the increased payments for a subject fiscal quarter shall be the total of the individual hospital acute psychiatric supplemental payment amounts for all hospitals for which federal financial participation is available. (2) The payments described in paragraph (1) may be made directly by the department to hospitals when federal law does not require that the payments be transmitted to hospitals via mental health plans. (Amended by Stats. 2012, Ch. 452, Sec. 2. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.31.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
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This section defines terms and fee rates for the Private Hospital Quality Assurance Fee Act of 2011, including hospital categories, reporting days, the program period, and several per-diem fee amounts.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.31. For the purposes of this article, the following definitions shall apply: (a) (1) “Aggregate quality assurance fee” means, with respect to a hospital that is not a prepaid health plan hospital, the sum of all of the following: (A) The annual fee-for-service days for an individual hospital multiplied by the fee-for-service per diem quality assurance fee rate. (B) The annual managed care days for an individual hospital multiplied by the managed care per diem quality assurance fee rate. (C) The annual Medi-Cal days for an individual hospital multiplied by the Medi-Cal per diem quality assurance fee rate. (2) “Aggregate quality assurance fee” means, with respect to a hospital that is a prepaid health plan hospital, the sum of all of the following: (A) The annual fee-for-service days for an individual hospital multiplied by the fee-for-service per diem quality assurance fee rate. (B) The annual managed care days for an individual hospital multiplied by the prepaid health plan hospital managed care per diem quality assurance fee rate. (C) The annual Medi-Cal managed care days for an individual hospital multiplied by the prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate. (D) The annual Medi-Cal fee-for-service days for an individual hospital multiplied by the Medi-Cal per diem quality assurance fee rate. (3) “Aggregate quality assurance fee after the application of the fee percentage” means the aggregate quality assurance fee multiplied by the fee percentage for each subject fiscal year. (b) “Annual fee-for-service days” means the number of fee-for-service days of each hospital subject to the quality assurance fee, as reported on the days data source. (c) “Annual managed care days” means the number of managed care days of each hospital subject to the quality assurance fee, as reported on the days data source. (d) “Annual Medi-Cal days” means the number of Medi-Cal days of each hospital subject to the quality assurance fee, as reported on the days data source. (e) “Converted hospital” shall mean a hospital described in subdivision (b) of Section 14169.1. (f) “Days data source” means the hospital’s Annual Financial Disclosure Report filed with the Office of Statewide Health Planning and Development as of May 5, 2011, for its fiscal year ending during 2009. (g) “Designated public hospital” shall have the meaning given in subdivision (d) of Section 14166.1 as of January 1, 2011. (h) “Exempt facility” means any of the following: (1) A public hospital, which shall include either of the following: (A) A hospital, as defined in paragraph (25) of subdivision (a) of Section 14105.98. (B) A tax-exempt nonprofit hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code and operating a hospital owned by a local health care district, and is affiliated with the health care district hospital owner by means of the district’s status as the nonprofit corporation’s sole corporate member. (2) With the exception of a hospital that is in the Charitable Research Hospital peer group, as set forth in the 1991 Hospital Peer Grouping Report published by the department, a hospital that is a hospital designated as a specialty hospital in the hospital’s Office of Statewide Health Planning and Development Hospital Annual Financial Disclosure Report for the hospital’s fiscal year ending in the 2009 calendar year. (3) A hospital that satisfies the Medicare criteria to be a long-term care hospital. (4) A small and rural hospital as specified in Section 124840 of the Health and Safety Code designated as that in the hospital’s Office of Statewide Health Planning and Development Hospital Annual Financial Disclosure Report for the hospital’s fiscal year ending in the 2009 calendar year. (i) “Federal approval” means the approval by the federal government of both the quality assurance fee established pursuant to this article and the supplemental payments to private hospitals described in Sections 14169.2 and 14169.3. (j) (1) “Fee-for-service per diem quality assurance fee rate” means a fixed daily fee on fee-for-service days. (2) The fee-for-service per diem quality assurance fee rate shall be three hundred eight dollars and thirty-six cents ($308.36) per day. (3) Upon federal approval or conditional federal approval described in Section 14169.34, the director shall determine the fee-for-service per diem quality assurance fee rate based on the funds required to make the payments specified in Article 5.228 (commencing with Section 14169.1), in consultation with the hospital community. (k) “Fee-for-service days” means inpatient hospital days where the service type is reported as “acute care,” “psychiatric care,” and “rehabilitation care,” and the payer category is reported as “Medicare traditional,” “county indigent programs-traditional,” “other third parties-traditional,” “other indigent,” and “other payers,” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (l) “Fee percentage” means a fraction, expressed as a percentage, the numerator of which is the amount of payments for each subject fiscal year under Sections 14169.2, 14169.3, 14169.5, and 14169.7.5, for which federal financial participation is available and the denominator of which is four billion eight hundred sixty-six million seven hundred four thousand one hundred fifteen dollars ($4,866,704,115). (m) “General acute care hospital” means any hospital licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code. (n) “Hospital community” means any hospital industry organization or system that represents hospitals. (o) “Managed care days” means inpatient hospital days where the service type is reported as “acute care,” “psychiatric care,” and “rehabilitation care,” and the payer category is reported as “Medicare managed care,” “county indigent programs-managed care,” and “other third parties-managed care,” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (p) “Managed care per diem quality assurance fee rate” means a fixed fee on managed care days of eighty-six dollars and forty cents ($86.40) per day. (q) “Medi-Cal days” means inpatient hospital days where the service type is reported as “acute care,” “psychiatric care,” and “rehabilitation care,” and the payer category is reported as “Medi-Cal traditional” and “Medi-Cal managed care,” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (r) “Medi-Cal fee-for-service days” means inpatient hospital days where the service type is reported as “acute care,” “psychiatric care,” and “rehabilitation care,” and the payer category is reported as “Medi-Cal traditional” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (s) “Medi-Cal managed care days” means inpatient hospital days as reported on the days data source where the service type is reported as “acute care,” “psychiatric care,” and “rehabilitation care,” and the payer category is reported as “Medi-Cal managed care” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (t) “Medi-Cal per diem quality assurance fee rate” means a fixed fee on Medi-Cal days of three hundred eighty-three dollars and twenty cents ($383.20) per day. (u) “New hospital” means a hospital operation, business, or facility functioning under current or prior ownership as a private hospital that does not have a days data source or a hospital that has a days data source in whole, or in part, from a previous operator where there is an outstanding monetary liability owed to the state in connection with the Medi-Cal program and the new operator did not assume liability for the outstanding monetary obligation. (v) “Nondesignated public hospital” means either of the following: (1) A public hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code, is not designated as a specialty hospital in the hospital’s Annual Financial Disclosure Report for the hospital’s latest fiscal year ending in 2009, and satisfies the definition in paragraph (25) of subdivision (a) of Section 14105.98, excluding designated public hospitals. (2) A tax-exempt nonprofit hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code, is not designated as a specialty hospital in the hospital’s Annual Financial Disclosure Report for the hospital’s latest fiscal year ending in 2009, is operating a hospital owned by a local health care district, and is affiliated with the health care district hospital owner by means of the district’s status as the nonprofit corporation’s sole corporate member. (w) “Prepaid health plan hospital” means a hospital owned by a nonprofit public benefit corporation that shares a common board of directors with a nonprofit health care service plan. (x) “Prepaid health plan hospital managed care per diem quality assurance fee rate” means a fixed fee on non-Medi-Cal managed care days for prepaid health plan hospitals of forty-eight dollars and thirty-eight cents ($48.38) per day. (y) “Prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate” means a fixed fee on Medi-Cal managed care days for prepaid health plan hospitals of two hundred fourteen dollars and fifty-nine cents ($214.59) per day. (z) “Prior fiscal year data” means any data taken from sources that the department determines are the most accurate and reliable at the time the determination is made, or may be calculated from the most recent audited data using appropriate update factors. The data may be from prior fiscal years, current fiscal years, or projections of future fiscal years. (aa) “Private hospital” means a hospital that meets all of the following conditions: (1) Is licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code. (2) Is in the Charitable Research Hospital peer group, as set forth in the 1991 Hospital Peer Grouping Report published by the department, or is not designated as a specialty hospital in the hospital’s Office of Statewide Health Planning and Development Annual Financial Disclosure Report for the hospital’s latest fiscal year ending in 2009. (3) Does not satisfy the Medicare criteria to be classified as a long-term care hospital. (4) Is a nonpublic hospital, nonpublic converted hospital, or converted hospital as those terms are defined in paragraphs (26) to (28), inclusive, respectively, of subdivision (a) of Section 14105.98. (ab) “Program period” means the period from July 1, 2011, to December 31, 2013, inclusive. (ac) “Subject fiscal quarter” means a state fiscal quarter during the program period. (ad) “Subject fiscal year” means a state fiscal year that ends after July 1, 2011, and begins before January 1, 2014. (ae) “Upper payment limit” means a federal upper payment limit on the amount of the Medicaid payment for which federal financial participation is available for a class of service and a class of health care providers, as specified in Part 447 of Title 42 of the Code of Federal Regulations. The applicable upper payment limit shall be separately calculated for inpatient and outpatient hospital services. (Amended by Stats. 2012, Ch. 452, Sec. 10. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41.)
14169.32.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
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General acute care hospitals that are not exempt facilities must pay a quality assurance fee, while converted hospitals are excluded.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.32. (a) There shall be imposed on each general acute care hospital that is not an exempt facility a quality assurance fee, provided that a quality assurance fee under this article shall not be imposed on a converted hospital. (b) The quality assurance fee shall be computed starting on July 1, 2011, and continue through and including December 31, 2013. (c) Subject to Section 14169.34, upon receipt of federal approval, the following shall become operative: (1) Within 10 business days following receipt of the notice of federal approval from the federal government, the department shall send notice to each hospital subject to the quality assurance fee, and publish on its Internet Web site, the following information: (A) The date that the state received notice of federal approval. (B) The fee percentage for each subject fiscal year. (2) The notice to each hospital subject to the quality assurance fee shall also state the following: (A) The aggregate quality assurance fee after the application of the fee percentage for each subject fiscal year. (B) The aggregate quality assurance fee. (C) The amount of each payment due from the hospital with respect to the aggregate quality assurance fee. (D) The date on which each payment is due. (3) The hospitals shall pay the aggregate quality assurance fee after application of the fee percentage for all subject fiscal years in 10 installments. The department shall establish the date that each installment is due, provided that the first installment shall be due no earlier than 20 days following the department sending the notice pursuant to paragraph (1), and the installments shall be paid at least one month apart, but if possible, the installments shall be paid on a quarterly basis. (4) Notwithstanding any other provision of this section, the amount of each hospital’s aggregate quality assurance fee after the application of the fee percentage for each subject fiscal year that has not been paid by the hospital before December 15, 2013, pursuant to paragraphs (3) and (8), shall be paid by the hospital no later than December 15, 2013. (5) (A) Notwithstanding subdivision (l) of Section 14169.31, for the purpose of determining the installments under paragraph (3), the department shall use an interim fee percentage as follows: (i) One hundred percent for subject fiscal year 2011–12 until the federal government has approved or disapproved additional capitation payments described in Section 14169.5 for that subject fiscal year. (ii) One hundred percent for subject fiscal year 2012–13 until the federal government has approved or disapproved additional capitation payments described in Section 14169.5 for that subject fiscal year. (iii) Fifty percent for subject fiscal year 2013–14 until the federal government has approved or disapproved additional capitation payments described in Section 14169.5 for that subject fiscal year. (B) The director may use a lower interim fee percentage for each subject fiscal year under this paragraph as the director, in his or her discretion, determines is reasonable in order to generate sufficient but not excessive installment payments to make the payments described in subdivision (b) of Section 14169.33. (6) The director shall determine the final fee percentage for each subject fiscal year within 15 days of the approval or disapproval, in whole or in part, by the federal government of all changes to the capitation rates of managed health care plans requested by the department to implement Section 14169.5 for that subject fiscal year, but in no event later than December 1, 2013. At the time the director determines the final fee percentage for a subject fiscal year, the director shall also determine the amount of future installment payments of the quality assurance fee for each hospital subject to the fee, if any are due. The amount of each future installment payment shall be established by the director with the objective that the total of the installment payments of the quality assurance fee due from a hospital shall equal the director’s estimate for each subject fiscal year for the hospital of the aggregate quality assurance fee after the application of the fee percentage. (7) The director, within 15 days of determining the final fee percentage for a subject fiscal year pursuant to paragraph (6), shall send notice to each hospital subject to the quality assurance fee of the following information: (A) The final fee percentage for each subject fiscal year for which the final fee percentage has been determined. (B) The fee percentage determined under paragraph (5) for each subject fiscal year for which the final fee percentage has not been determined. (C) The aggregate quality assurance fee after application of the fee percentage for each subject fiscal year. (D) The director’s estimate of total quality assurance fee payments due from the hospital under this article whether or not paid. This amount shall be the sum of the aggregate quality assurance fee after application of the fee percentage for each subject fiscal year using the fee percentages contained in the notice. (E) The total quality assurance fee payments that the hospital has made under this article. (F) The amount, if any, by which the total quality assurance fee payments due from the hospital under this article as described in subparagraph (C) exceed the total quality assurance fee payments that the hospital has made under this article. (G) The amount of each remaining installment of the quality assurance fee, if any, due from the hospital and the date each installment is due. This amount shall be the amount described in subparagraph (F) divided by the number of installment payments remaining. (8) Each hospital that is sent a notice under paragraph (7) shall pay the additional installments of the quality assurance fee that are due, if any, in the amounts and at the times set forth in the notice unless superseded by a subsequent notice from the department. (9) The department shall refund to a hospital paying the quality assurance fee the amount, if any, by which the total quality assurance fee payments that the hospital has made under this article for all subject fiscal years exceed the total quality assurance fee payments due from the hospital under this article within 30 days of the date on which the notice is sent to the hospital under paragraph (7). (d) The quality assurance fee, as paid pursuant to this section, shall be paid by each hospital subject to the fee to the department for deposit in the Hospital Quality Assurance Revenue Fund. Deposits may be accepted at any time and will be credited toward the program period. (e) This section shall become inoperative if the federal Centers for Medicare and Medicaid Services denies approval for, or does not approve before July 1, 2014, the implementation of the quality assurance fee pursuant to this article or the supplemental payments to private hospitals described in Sections 14169.2 and 14169.3, and either or both provisions cannot be modified by the department pursuant to subdivision (d) of Section 14169.33 in order to meet the requirements of federal law or to obtain federal approval. (f) In no case shall the aggregate fees collected in a federal fiscal year pursuant to this section and Sections 14167.32 and 14168.32 exceed the maximum percentage of the annual aggregate net patient revenue for hospitals subject to the fee that is prescribed pursuant to federal law and regulations as necessary to preclude a finding that an indirect guarantee has been created. (g) (1) Interest shall be assessed on quality assurance fees not paid on the date due at the greater of 10 percent per annum or the rate at which the department assesses interest on Medi-Cal program overpayments to hospitals that are not repaid when due. Interest shall begin to accrue the day after the date the payment was due and shall be deposited in the Hospital Quality Assurance Revenue Fund. (2) In the event that any fee payment is more than 60 days overdue, a penalty equal to the interest charge described in paragraph (1) shall be assessed and due for each month for which the payment is not received after 60 days. (h) When a hospital fails to pay all or part of the quality assurance fee on or before the date that payment is due, the department may immediately begin to deduct the unpaid assessment and interest from any Medi-Cal payments owed to the hospital, or, in accordance with Section 12419.5 of the Government Code, from any other state payments owed to the hospital until the full amount is recovered. All amounts, except penalties, deducted by the department under this subdivision shall be deposited in the Hospital Quality Assurance Revenue Fund. The remedy provided to the department by this section is in addition to other remedies available under law. (i) The payment of the quality assurance fee shall not be considered as an allowable cost for Medi-Cal cost reporting and reimbursement purposes. (j) The department shall work in consultation with the hospital community to implement this article and Article 5.228 (commencing with Section 14169.1). (k) This subdivision creates a contractually enforceable promise on behalf of the state to use the proceeds of the quality assurance fee, including any federal matching funds, solely and exclusively for the purposes set forth in this article as they existed on September 16, 2011, to limit the amount of the proceeds of the quality assurance fee to be used to pay for the health care coverage of children to the amounts specified in this article, to limit any payments for the department’s costs of administration to the amounts set forth in this article on September 16, 2011, to maintain and continue prior reimbursement levels as set forth in Section 14169.12 on September 16, 2011, and to otherwise comply with all its obligations set forth in Article 5.228 (commencing with Section 14169.1) and this article provided that amendments that arise from, or have as a basis, a decision, advice, or determination by the federal Centers for Medicare and Medicaid Services relating to federal approval of the quality assurance fee or the payments set forth in this article or Article 5.228 (commencing with Section 14169.1) shall control for the purposes of this subdivision. (l) (1) Effective January 1, 2014, the rates payable to hospitals and managed health care plans under Medi-Cal shall be the rates then payable without the supplemental and increased capitation payments set forth in Article 5.228 (commencing with Section 14169.1). (2) The supplemental payments and other payments under Article 5.228 (commencing with Section 14169.1) shall be regarded as quality assurance payments, the implementation or suspension of which does not affect a determination of the adequacy of any rates under federal law. (m) (1) Subject to paragraph (2), the director may waive any or all interest and penalties assessed under this article in the event that the director determines, in his or her sole discretion, that the hospital has demonstrated that imposition of the full quality assurance fee on the timelines applicable under this article has a high likelihood of creating a financial hardship for the hospital or a significant danger of reducing the provision of needed health care services. (2) Waiver of some or all of the interest or penalties under this subdivision shall be conditioned on the hospital’s agreement to make fee payments, or to have the payments withheld from payments otherwise due from the Medi-Cal program to the hospital, on a schedule developed by the department that takes into account the financial situation of the hospital and the potential impact on services. (3) A decision by the director under this subdivision is not subject to judicial review. (4) If fee payments are remitted to the department after the date determined by the department to be the final date for calculating the final supplemental payments under this article and Article 5.228 (commencing with Section 14169.1), the fee payments shall be retained in the fund for purposes of funding supplemental payments supported by a hospital quality assurance fee program implemented under subsequent legislation, provided, however, that if supplemental payments are not implemented under subsequent legislation, then those fee payments shall be deposited in the Distressed Hospital Fund. (5) If during the implementation of this article, fee payments that were due under Article 5.21 (commencing with Section 14167.1) and Article 5.22 (commencing with Section 14167.31), or Article 5.227 (commencing with Section 14168.31), are remitted to the department under a payment plan or for any other reason, and the final date for calculating the final supplemental payments under those articles has passed, those fee payments shall be deposited in the fund to support the uses established by this article. (Amended by Stats. 2013, Ch. 76, Sec. 220. (AB 383) Effective January 1, 2014. Conditionally inoperative as provided in subd. (e). Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41.)
14169.33.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
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The department must transmit fee payments to the Treasurer, request federal approval, make required adjustments, and notify legislative committees within five working days when it uses informal instructions. It may also modify certain provisions and implement the article by bulletins or similar instructions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.33. (a) (1) All fees required to be paid to the state pursuant to this article shall be paid in the form of remittances payable to the department. (2) The department shall directly transmit the fee payments to the Treasurer to be deposited in the Hospital Quality Assurance Revenue Fund, created pursuant to Section 14167.35. Notwithstanding Section 16305.7 of the Government Code, any interest and dividends earned on deposits in the fund from the proceeds of the fee assessed pursuant to this article shall be retained in the fund for purposes specified in subdivision (b). (b) Notwithstanding subdivision (c) of Section 14167.35 and subdivision (b) of Section 14168.33, all funds from the proceeds of the fee assessed pursuant to this article in the Hospital Quality Assurance Revenue Fund, together with any interest and dividends earned on money in the fund, shall, upon appropriation by the Legislature, continue to be used exclusively to enhance federal financial participation for hospital services under the Medi-Cal program, to provide additional reimbursement to, and to support quality improvement efforts of, hospitals, and to minimize uncompensated care provided by hospitals to uninsured patients, as well as to pay for the state’s administrative costs and to provide funding for children’s health coverage, in the following order of priority: (1) To pay for the department’s staffing and administrative costs directly attributable to implementing Article 5.228 (commencing with Section 14169.1) and this article, not to exceed two million five hundred thousand dollars ($2,500,000) for the program period. (2) To pay for the health care coverage for children in the amount of eighty-five million dollars ($85,000,000) for each subject fiscal quarter during the 2011–12 subject fiscal year, in the amount of one hundred thirty-four million two hundred fifty thousand dollars ($134,250,000) for each subject fiscal quarter during the 2012–13 subject fiscal year, and in the amount of one hundred forty-four million two hundred fifty thousand dollars ($144,250,000) for each subject fiscal quarter during the 2013–14 subject fiscal year. (3) To make increased capitation payments to managed health care plans pursuant to Article 5.228 (commencing with Section 14169.1). (4) To reimburse the General Fund for the increase in the overall compensation to a private hospital that is attributable to its change in status from contract hospital to noncontract hospital, pursuant to subdivision (a) of Section 14169.10. (5) To make increased payments or grants to hospitals pursuant to Article 5.228 (commencing with Section 14169.1). (6) To make increased payments to mental health plans pursuant to Article 5.228 (commencing with Section 14169.1). (7) To make supplemental payments for out-of-network emergency and poststabilization services provided by private hospitals to Medicaid Coverage Expansion enrollees in the Low Income Health Program in the amount of thirty-three million two hundred thousand dollars ($33,200,000) for each fiscal quarter pursuant to Section 14169.7.5. (c) Any amounts of the quality assurance fee collected in excess of the funds required to implement subdivision (b), including any funds recovered under subdivision (d) of Section 14169.13 or subdivision (e) of Section 14169.38, shall be refunded to general acute care hospitals, pro rata with the amount of quality assurance fee paid by the hospital, subject to the limitations of federal law. If federal rules prohibit the refund described in this subdivision, the excess funds shall be deposited in the Distressed Hospital Fund to be used for the purposes described in Section 14166.23, and shall be supplemental to and not supplant existing funds. (d) Any methodology or other provision specified in Article 5.228 (commencing with Section 14169.1) or this article may be modified by the department, in consultation with the hospital community, to the extent necessary to meet the requirements of federal law or regulations to obtain federal approval or to enhance the probability that federal approval can be obtained, provided the modifications do not violate the spirit and intent of Article 5.228 (commencing with Section 14169.1) or this article and are not inconsistent with the conditions of implementation set forth in Section 14169.40. (e) The department, in consultation with the hospital community, shall make adjustments, as necessary, to the amounts calculated pursuant to Section 14169.32 in order to ensure compliance with the federal requirements set forth in Section 433.68 of Title 42 of the Code of Federal Regulations or elsewhere in federal law. (f) The department shall request approval from the federal Centers for Medicare and Medicaid Services for the implementation of this article. In making this request, the department shall seek specific approval from the federal Centers for Medicare and Medicaid Services to exempt providers identified in this article as exempt from the fees specified, including the submission, as may be necessary, of a request for waiver of the broad-based requirement, waiver of the uniform fee requirement, or both, pursuant to paragraphs (1) and (2) of subdivision (e) of Section 433.68 of Title 42 of the Code of Federal Regulations. (g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this article or Article 5.228 (commencing with Section 14169.1) by means of provider bulletins, all plan letters, or other similar instruction, without taking regulatory action. The department shall also provide notification to the Joint Legislative Budget Committee and to the appropriate policy and fiscal committees of the Legislature within five working days when the above-described action is taken in order to inform the Legislature that the action is being implemented. (Amended by Stats. 2012, Ch. 452, Sec. 12. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41.)
14169.34.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
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The department may collect the quality assurance fee and make related payments if it receives a qualifying federal approval letter, and the director must decide whether that letter is sufficient.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.34. (a) Notwithstanding any other provision of this article or Article 5.228 (commencing with Section 14169.1) requiring federal approvals, the department may impose and collect the quality assurance fee and may make payments under this article and Article 5.228 (commencing with Section 14169.1), including increased capitation payments, based upon receiving a letter from the federal Centers for Medicare and Medicaid Services or the United States Department of Health and Human Services that indicates likely federal approval, but only if and to the extent that the letter is sufficient as set forth in subdivision (b). (b) In order for the letter to be sufficient under this section, the director shall find that the letter meets both of the following requirements: (1) The letter is in writing and signed by an official of the federal Centers for Medicare and Medicaid Services or an official of the United States Department of Health and Human Services. (2) The director, after consultation with the hospital community, has determined, in the exercise of his or her sole discretion, that the letter provides a sufficient level of assurance to justify advanced implementation of the fee and payment provisions. (c) Nothing in this section shall be construed as modifying the requirement under Section 14169.13 that payments shall be made only to the extent a sufficient amount of funds collected as the quality assurance fee are available to cover the nonfederal share of those payments. (d) Upon notice from the federal government that final federal approval for the fee model under this article or for the supplemental payments to private hospitals under Section 14169.2 or 14169.3 has been denied, any fees collected pursuant to this section shall be refunded and any payments made pursuant to this article or Article 5.228 (commencing with Section 14169.1) shall be recouped, including, but not limited to, supplemental payments, increased capitation payments, payments to hospitals by health care plans resulting from the increased capitation payments, increased payments to mental health plans, and payments for the health care coverage of children. To the extent fees were paid by a hospital that also received payments under this section, the payments may first be recouped from fees that would otherwise be refunded to the hospital prior to the use of any other recoupment method allowed under law. (e) Any payment made pursuant to this section shall be a conditional payment until final federal approval has been received. (f) The director shall have broad authority under this section to collect the quality assurance fee for an interim period after receipt of the letter described in subdivision (a) pending receipt of all necessary federal approvals. This authority shall include discretion to determine both of the following: (1) Whether the quality assurance fee should be collected on a full or pro rata basis during the interim period. (2) The dates on which payments of the quality assurance fee are due. (g) The department may draw against the Hospital Quality Assurance Revenue Fund for all administrative costs associated with implementation under this article or Article 5.228 (commencing with Section 14169.1). (h) This section shall be implemented only to the extent federal financial participation is not jeopardized by implementation prior to the receipt of all necessary final federal approvals. (Amended by Stats. 2012, Ch. 23, Sec. 105. (AB 1467) Effective June 27, 2012. Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41.)
14169.35.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
Verify source ↗

The director may modify timelines in this article or Article 5.228 if federal approval is not secured by December 15, 2013 and operational implementation is impossible without the change.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.35. (a) Notwithstanding any other provision of law, the director shall have discretion to modify any timeline or timelines in this article or Article 5.228 (commencing with Section 14169.1) if the letter that indicates likely federal approval, as described in Section 14169.34, is not secured by December 15, 2013, and the director determines that it is impossible from an operational perspective to implement a timeline or timelines without the modification. (b) The department shall notify the fiscal and policy committees of the Legislature prior to implementing a modified timeline or timelines under subdivision (a). (c) The department shall consult with representatives of the hospital community in developing a modified timeline or timelines pursuant to this section. (d) The discretion to modify timelines under this section shall include, but not be limited to, discretion to accelerate payments to plans or hospitals. (Added by Stats. 2011, Ch. 286, Sec. 8. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41.)
14169.36.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
Verify source ↗

The department must make specified hospital-related payments when federal approval or a qualifying federal-approval letter is received, subject to fund availability and some timing limits.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.36. (a) Upon receipt of a letter that indicates likely federal approval that the director determines is sufficient for implementation under Section 14169.34, or upon the receipt of federal approval, the following shall occur: (1) To the maximum extent possible, and consistent with the availability of funds in the Hospital Quality Assurance Revenue Fund, the department shall make all of the payments under Sections 14169.2, 14169.3, 14169.5, 14169.7, and 14169.7.5, including, but not limited to, supplemental payments and increased capitation payments, prior to January 1, 2014, except that the increased capitation payments under Section 14169.5 shall not be made until federal approval is obtained for these payments. (2) The department shall make supplemental payments to hospitals under Article 5.228 (commencing with Section 14169.1) consistent with the timeframe described in Section 14169.11 or a modified timeline developed pursuant to Section 14169.35. (b) Notwithstanding any other provision of this article or Article 5.228 (commencing with Section 14169.1), if the director determines, on or after December 15, 2013, that there are insufficient funds available in the Hospital Quality Assurance Revenue Fund to make all scheduled payments under Article 5.228 (commencing with Section 14169.1) before January 1, 2014, he or she shall consult with representatives of the hospital community to develop an acceptable plan for making additional payments to hospitals and managed health care plans to maximize the use of delinquent fee payments or other deposits or interest projected to become available in the fund after December 15, 2013, but before June 15, 2014. (c) Nothing in this section shall require the department to continue to make payments under Article 5.228 (commencing with Section 14169.1) if, after the consultation required under subdivision (b), the director determines in the exercise of his or her sole discretion that a workable plan for the continued payments cannot be developed. (d) Subdivisions (b) and (c) shall be implemented only if and to the extent federal financial participation is available for continued supplemental payments and to providers and continued increased capitation payments to managed health care plans. (e) If any payment or payments made pursuant to this section are found to be inconsistent with federal law, the department shall recoup the payments by means of withholding or any other available remedy. (f) Nothing in this section shall be read as affecting the department’s ongoing authority to continue, after December 31, 2013, to collect quality assurance fees imposed on or before December 31, 2013. (Amended by Stats. 2012, Ch. 23, Sec. 106. (AB 1467) Effective June 27, 2012. Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41.)
14169.37.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
Verify source ↗

This section makes the article inoperative and repealed on December 1, 2013 if the required federal approval has not been received by then, unless a later enacted statute changes that date.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.37. Notwithstanding any other provision of law, if actual federal approval or a letter that indicates likely federal approval in accordance with Section 14169.34 has not been received on or before December 1, 2013, then this article shall become inoperative, and as of December 1, 2013, is repealed, unless a later enacted statute, that is enacted before December 1, 2013, deletes or extends that date. (Added by Stats. 2011, Ch. 286, Sec. 8. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41. Note: Conditions in this section for repeal of Article 5.229 (commencing with Section 14169.31) failed.)
14169.38.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
Verify source ↗

The article works only while specified federal-approval and funding conditions are met; otherwise it can become inoperative, and the department may recoup certain payments.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.38. (a) This article shall be implemented only as long as all of the following conditions are met: (1) Subject to Section 14169.33, the quality assurance fee is established in a manner that is fundamentally consistent with this article. (2) The quality assurance fee, including any interest on the fee after collection by the department, is deposited in a segregated fund apart from the General Fund. (3) The proceeds of the quality assurance fee, including any interest and related federal reimbursement, may only be used for the purposes set forth in this article. (b) No hospital shall be required to pay the quality assurance fee to the department unless and until the state receives and maintains federal approval. (c) Hospitals shall be required to pay the quality assurance fee to the department as set forth in this article only as long as all of the following conditions are met: (1) The federal Centers for Medicare and Medicaid Services allows the use of the quality assurance fee as set forth in this article in accordance with federal approval. (2) Article 5.228 (commencing with Section 14169.1) is enacted and remains in effect and hospitals are reimbursed the increased rates for services during the program period, as defined in Section 14169.1. (3) The full amount of the quality assurance fee assessed and collected pursuant to this article remains available only for the purposes specified in this article. (d) This article shall become inoperative if either of the following occurs: (1) In the event, and on the effective date, of a final judicial determination made by any court of appellate jurisdiction or a final determination by the United States Department of Health and Human Services or the federal Centers for Medicare and Medicaid Services that the quality assurance fee established pursuant to this article or any provision of Section 14166.115 cannot be implemented. (2) In the event both of the following conditions exist: (A) The federal Centers for Medicare and Medicaid Services denies approval for, or does not approve before January 1, 2014, the implementation of Sections 14169.2 and 14169.3 or this article. (B) Section 14169.2, Section 14169.3, or this article cannot be modified by the department pursuant to subdivision (d) of Section 14169.33 in order to meet the requirements of federal law or to obtain federal approval. (e) If this article becomes inoperative pursuant to paragraph (1) of subdivision (d) and the determination applies to any period or periods of time prior to the effective date of the determination, the department may recoup all payments made pursuant to Article 5.228 (commencing with Section 14169.1) during that period or those periods of time. (f) (1) In the event that all necessary final federal approvals are not received as described and anticipated under this article or Article 5.228 (commencing with Section 14169.1), the director shall have the discretion and authority to develop procedures for recoupment from managed health care plans, and from hospitals under contract with managed health care plans, of any amounts received pursuant to this article or Article 5.228 (commencing with Section 14169.1). (2) Any procedure instituted pursuant to this subdivision shall be developed in consultation with representatives from managed health care plans and representatives of the hospital community. (3) Any procedure instituted pursuant to this subdivision shall be in addition to all other remedies made available under the law, pursuant to contracts between the department and the managed health care plans, or pursuant to contracts between the managed health care plans and the hospitals. (Amended by Stats. 2012, Ch. 23, Sec. 107. (AB 1467) Effective June 27, 2012. Conditionally inoperative as provided in this section (subd. (d), para. (1)) and Section 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41. Note: Provisions for inoperation affect Article 5.229, commencing with Section 14169.31.)
14169.39.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
Verify source ↗

Supplemental payments or other payments under Article 5.228 are required and payable only for quarters in which a fee payment obligation exists.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.39. Notwithstanding any other provision of this article or Article 5.228 (commencing with Section 14169.1), supplemental payments or other payments under Article 5.228 (commencing with Section 14169.1) shall only be required and payable in any quarter for which a fee payment obligation exists. (Added by Stats. 2011, Ch. 286, Sec. 8. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41.)
14169.40.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
Verify source ↗

This section sets conditions under which the article and related payment requirements become inoperative, lets the director recoup certain payments, and requires the director to notify legislative committees when invoking the section.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.40. (a) This article and Article 5.228 (commencing with Section 14169.1) shall become inoperative and the requirements for supplemental payments or other payments under Article 5.228 (commencing with Section 14169.1) shall be retroactively invalidated, on the first day of the first month of the calendar quarter following notification to the Joint Legislative Budget Committee by the Department of Finance, that any of the following have occurred: (1) A final judicial determination by the California Supreme Court or any California Court of Appeal that the revenues collected pursuant to this article that are deposited in the Hospital Quality Assurance Revenue Fund are either of the following: (A) “General Fund proceeds of taxes appropriated pursuant to Article XIII B of the California Constitution,” as used in subdivision (b) of Section 8 of Article XVI of the California Constitution. (B) “Allocated local proceeds of taxes,” as used in subdivision (b) of Section 8 of Article XVI of the California Constitution. (2) The department has sought but has not received federal financial participation for the supplemental payments and other costs required by this article for which federal financial participation has been sought. (3) A lawsuit related to this article, Article 5.228 (commencing with Section 14169.1), or Section 14166.115 is filed against the state and a preliminary injunction or other order has been issued that results in a financial disadvantage to the state. (4) The director, in consultation with the Department of Finance, determines that the implementation of this article or Article 5.228 (commencing with Section 14169.1) has resulted in a financial disadvantage to the state. (b) For purposes of this section, “financial disadvantage to the state” means either of the following: (1) A loss of federal financial participation. (2) A cost to the General Fund, that is equal to or greater than one-quarter of 1 percent of the General Fund expenditures authorized in the most recent annual Budget Act. (c) (1) The director shall have the authority to recoup any payments made under Article 5.228 (commencing with Section 14169.1) if any of the following apply: (A) Recoupment of payments made under Article 5.228 (commencing with Section 14169.1) is ordered by a court. (B) Federal financial participation is not available for payments made under Article 5.228 (commencing with Section 14169.1) for which federal financial participation has been sought. (C) Recoupment of payments made under Article 5.228 (commencing with Section 14169.1) is necessary to prevent a General Fund cost that is estimated to be equal to or greater than one-quarter of 1 percent of the General Fund expenditures authorized in the most recent annual Budget Act and that results from implementation of a court order or the unavailability of federal financial participation. (2) In the event payments are recouped for a particular quarter, fees paid by a hospital for that quarter pursuant to this article shall be refunded to the extent that the hospital meets both of the following conditions: (A) The hospital has actually paid the fee for the subject quarter and for all prior quarters. (B) The hospital has returned the payment received pursuant to Article 5.228 (commencing with Section 14169.1) for that quarter, or has had that payment recouped through a withholding of funds owed by Medi-Cal or other state payments, or recouped through other means. (d) In the event the department determines that recoupment of supplemental payments is necessary to implement any provision of this section, the department may recoup payments made pursuant to Article 5.228 (commencing with Section 14169.1) from fees paid by the hospital pursuant to this article. (e) Concurrent with invoking any provision of this section, the director shall notify the fiscal and appropriate policy committees of the Legislature of the intended action and the specific reason or reasons for the proposed action. (Added by Stats. 2011, Ch. 286, Sec. 8. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in this section (subd. (a)) and Section 14169.38 (subd. (d), para. (1)), or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41. Note: Provisions for inoperation affect Articles 5.228 (comm. with Section 14169.1) and 5.229 (comm. with Section 14169.31).)
14169.40.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
Verify source ↗

The department must implement this article using policy letters or similar instructions, and it does not need to take further regulatory action.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.40.5. Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department shall implement this article by means of policy letters or similar instructions, without taking further regulatory action. (Added by Stats. 2011, Ch. 286, Sec. 8. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41.)
14169.41.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
Verify source ↗

This article stays in force only until the latest of the listed dates or payment events, and then it is set to be repealed under the stated conditions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.41. (a) This article shall remain operative only until the later of the following: (1) January 1, 2015. (2) The date of the last payment of the quality assurance fee payments pursuant to this article. (3) The date of the last payment from the department pursuant to Article 5.228 (commencing with Section 14169.1). (b) If this article becomes inoperative under paragraph (1) of subdivision (a), this article shall be repealed on January 1, 2015, unless a later enacted statute enacted before that date, deletes or extends that date. (c) If this article becomes inoperative under paragraph (2) or (3) of subdivision (a), this article shall be repealed on January 1 of the year following the date this article becomes inoperative, unless a later enacted statute enacted before that date, deletes or extends that date. (Amended by Stats. 2012, Ch. 452, Sec. 13. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in this section. Repealed on or after January 1, 2015, by its own provisions. Note: Termination provisions affect Article 5.229, commencing with Section 14169.31.)
14169.42.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. )
Verify source ↗

If the director finds this article has become inoperative, the director must issue a declaration, keep it, share it with specified legislative committees within five working days, post it online, and send it to several state officials.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.229. Private Hospital Quality Assurance Fee Act of 2011 [14169.31 - 14169.42] ( Article 5.229 added by Stats. 2011, Ch. 286, Sec. 8. ) ## 14169.42. If the director determines that this article has become inoperative pursuant to Section 14169.37, 14169.38, 14169.40, or 14169.41, the director shall execute a declaration stating that this determination has been made and stating the basis for this determination. The director shall retain the declaration and provide a copy, within five working days of the execution of the declaration, to the fiscal and appropriate policy committees of the Legislature. In addition, the director shall post the declaration on the department’s Internet Web site and the director shall send the declaration to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel. (Amended by Stats. 2012, Ch. 452, Sec. 14. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.38 (subd. (d), para. (1)) and 14169.40, or on date prescribed in Section 14169.41. Repealed on or after January 1, 2015, as provided in Section 14169.41.)
14169.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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The department must increase Medi-Cal managed care capitation payments, and each plan must spend those extra payments on hospital services.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.5. (a) The department shall increase capitation payments to Medi-Cal managed health care plans for each subject fiscal year as set forth in this section. (b) The increased capitation payments shall be made as part of the monthly capitated payments made by the department to managed health care plans. (c) The aggregate amount of increased capitation payments to all Medi-Cal managed health care plans for each subject fiscal year shall be the maximum amount for which federal financial participation is available on an aggregate statewide basis for the applicable subject fiscal year as it may be adjusted pursuant to Section 14169.19. (d) The department shall determine the amount of the increased capitation payments for each managed health care plan. The department shall consider the composition of Medi-Cal enrollees in the plan, the anticipated utilization of hospital services by the plan’s Medi-Cal enrollees, and other factors that the department determines are reasonable and appropriate to ensuring access to high-quality hospital services by the plan’s enrollees. (e) The amount of increased capitation payments to each Medi-Cal managed health care plan shall not exceed an amount that results in capitation payments that are certified by the state’s actuary as meeting federal requirements, taking into account the requirement that all of the increased capitation payments under this section shall be paid by the Medi-Cal managed health care plans to hospitals for hospital services to Medi-Cal enrollees of the plan. (f) (1) The increased capitation payments to managed health care plans under this section shall be made to support the availability of hospital services and ensure access to hospital services for Medi-Cal beneficiaries. The increased capitation payments to managed health care plans shall commence no later than the later of December 31, 2011, or within 90 days of the date on which all necessary federal approvals have been received, and shall include, but not be limited to, the sum of the increased payments for all prior months for which payments are due. (2) (A) To secure the necessary funding for the payment or payments made pursuant to paragraph (1), the department may accumulate funds in the Hospital Quality Assurance Revenue Fund for the purpose of funding managed health care capitation payments under this article regardless of the date on which capitation payments are scheduled to be paid in order to secure the necessary total funding for managed health care payments by December 31, 2013. (B) To the extent feasible, the department shall accumulate funds under subparagraph (A) by retaining 10 percent of the total necessary funding from each of the 10 installments of the quality assurance fee received from hospitals under Article 5.229 (commencing with Section 14169.31), provided that the department may adjust the applicable dates and amounts as necessary to accumulate sufficient funding by December 31, 2013. (g) Payments to managed health care plans that would be paid consistent with actuarial certification and enrollment in the absence of the payments made pursuant to this section, including, but not limited to, payments described in Section 14182.15, shall not be reduced as a consequence of payment under this section. (h) (1) Each managed health care plan shall expend 100 percent of any increased capitation payments it receives under this section on hospital services. (2) The department may issue change orders to amend contracts with managed health care plans as needed to adjust monthly capitation payments in order to implement this section. (3) For entities contracting with the department pursuant to Article 2.91 (commencing with Section 14089), any incremental increase in capitation rates pursuant to this section shall not be subject to negotiation and approval by the California Medical Assistance Commission. (i) (1) In the event federal financial participation is not available for all of the increased capitation payments determined for a month pursuant to this section for any reason, the increased capitation payments mandated by this section for that month shall be reduced proportionately to the amount for which federal financial participation is available. (2) The determination under this subdivision for any month in the program period shall be made after accounting for all federal financial participation necessary for full implementation of Section 14182.15 for that month. (j) It is the intent of the Legislature that payments made available to designated public hospitals under this section shall replace, to the extent feasible, increased revenues that could be available to the hospitals under Section 14168.7 in the absence of this section and assuming other federal funds to the hospitals would not be reduced as a result of the payments. If this intent cannot be effectuated under this act, it is the intent of the Legislature to enact subsequent legislation to accomplish this purpose through other means. (Amended by Stats. 2012, Ch. 452, Sec. 3. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.50.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The section says the Legislature wants a hospital quality assurance fee to support supplemental Medi-Cal payments, and requires the State Department of Health Care Services to try to obtain federal approvals.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.50. The Legislature finds and declares all of the following: (a) The Legislature continues to recognize the essential role that hospitals play in serving the state’s Medi-Cal beneficiaries. To that end, it has been, and remains, the intent of the Legislature to improve funding for hospitals and obtain all available federal funds to make supplemental Medi-Cal payments to hospitals. (b) It is the intent of the Legislature that funding provided to hospitals through a hospital quality assurance fee be continued with the goal of increasing access to care and improving hospital reimbursement through supplemental Medi-Cal payments to hospitals. (c) It is the intent of the Legislature to recognize the fundamental structure of the components used to develop a successful hospital quality assurance fee program. (d) It is the intent of the Legislature to impose a quality assurance fee to be paid by hospitals, which would be used to increase federal financial participation in order to make supplemental Medi-Cal payments to hospitals, and to help pay for health care coverage for low-income children. (e) The State Department of Health Care Services shall make every effort to obtain the necessary federal approvals to implement the quality assurance fee described in subdivision (d) in order to make supplemental Medi-Cal payments to hospitals. (f) It is the intent of the Legislature that the quality assurance fee be implemented only if all of the following conditions are met: (1) The quality assurance fee is established in consultation with the hospital community. (2) The quality assurance fee, including any interest earned after collection by the department, is deposited into segregated funds apart from the General Fund and used exclusively for supplemental Medi-Cal payments to hospitals, direct grants to public hospitals, health care coverage for low-income children, and for the department’s direct costs of administering the program. (3) No hospital shall be required to pay the quality assurance fee to the department unless and until the state receives and maintains federal approval of the quality assurance fee and related supplemental payments to hospitals. (4) The full amount of the quality assurance fee assessed and collected remains available only for the purposes specified by the Legislature in this article. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.51.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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This section defines terms used in the Medi-Cal hospital reimbursement article and gives the department authority to establish and rebase certain data used in the program.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.51. For purposes of this article, the following definitions shall apply: (a) “Acute psychiatric days” means the total number of Medi-Cal specialty mental health service administrative days, Medi-Cal specialty mental health service acute care days, acute psychiatric administrative days, and acute psychiatric acute days identified in the Final Medi-Cal Utilization Statistics for the state fiscal year preceding the rebase calculation year as calculated by the department as of the retrieval date. (b) “Acute psychiatric per diem supplemental rate” means a fixed per diem supplemental payment for acute psychiatric days. (c) “Annual fee-for-service days” means the number of fee-for-service days of each hospital subject to the quality assurance fee, as reported on the days data source. (d) “Annual managed care days” means the number of managed care days of each hospital subject to the quality assurance fee, as reported on the days data source. (e) “Annual Medi-Cal days” means the number of Medi-Cal days of each hospital subject to the quality assurance fee, as reported on the days data source. (f) “Base calendar year” means a calendar year that ends before a subject fiscal year begins, but no more than six years before a subject fiscal year begins. Beginning with the third program period, the department shall establish the base calendar year during the rebase calculation year as the calendar year for which the most recent data is available that the department determines is reliable. (g) “Converted hospital” means a private hospital that becomes a designated public hospital or a nondesignated public hospital on or after the first day of a program period. (h) “Days data source” means either: (1) if a hospital’s Annual Financial Disclosure Report for its fiscal year ending in the base calendar year includes data for a full fiscal year of operation, the hospital’s Annual Financial Disclosure Report retrieved from the Office of Statewide Health Planning and Development as retrieved by the department on the retrieval date pursuant to Section 14169.59, for its fiscal year ending in the base calendar year; or (2) if a hospital’s Annual Financial Disclosure Report for its fiscal year ending in the base calendar year includes data for more than one day, but less than a full year of operation, the department’s best and reasonable estimates of the hospital’s Annual Financial Disclosure Report if the hospital had operated for a full year. (i) “Department” means the State Department of Health Care Services. (j) “Designated public hospital” shall have the meaning given in subdivision (d) of Section 14166.1. (k) “Director” means the Director of Health Care Services. (l) “Exempt facility” means any of the following: (1) A public hospital, which shall include either of the following: (A) A hospital, as defined in paragraph (25) of subdivision (a) of Section 14105.98. (B) A tax-exempt nonprofit hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code and operating a hospital owned by a local health care district, and is affiliated with the health care district hospital owner by means of the district’s status as the nonprofit corporation’s sole corporate member. (2) With the exception of a hospital that is in the Charitable Research Hospital peer group, as set forth in the 1991 Hospital Peer Grouping Report published by the department, a hospital that is designated as a specialty hospital in the hospital’s most recently filed Office of Statewide Health Planning and Development Hospital Annual Financial Disclosure Report, as of the first day of a program period. (3) A hospital that satisfies the Medicare criteria to be a long-term care hospital. (4) A small and rural hospital as specified in Section 124840 of the Health and Safety Code designated as that in the hospital’s most recently filed Office of Statewide Health Planning and Development Hospital Annual Financial Disclosure Report, as of the first day of a program period. (m) “Federal approval” means the approval by the federal government of both the quality assurance fee established pursuant to this article and the supplemental payments to private hospitals described pursuant to this article. (n) “Fee-for-service per diem quality assurance fee rate” means a fixed fee on fee-for-service days. (o) “Fee-for-service days” means inpatient hospital days as reported on the days data source where the service type is reported as “acute care,” “psychiatric care,” or “rehabilitation care,” and the payer category is reported as “Medicare traditional,” “county indigent programs-traditional,” “other third parties-traditional,” “other indigent,” or “other payers,” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (p) “Fund” means the Hospital Quality Assurance Revenue Fund established by Section 14167.35. (q) “General acute care days” means the total number of Medi-Cal general acute care days, including well baby days, less any acute psychiatric inpatient days, paid by the department to a hospital for services in the base calendar year, as reflected in the state paid claims file on the retrieval date. (r) “General acute care hospital” means any hospital licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code. (s) “General acute care per diem supplemental rate” means a fixed per diem supplemental payment for general acute care days. (t) “High acuity days” means Medi-Cal coronary care unit days, pediatric intensive care unit days, intensive care unit days, neonatal intensive care unit days, and burn unit days paid by the department to a hospital for services in the base calendar year, as reflected in the state paid claims file prepared by the department on the retrieval date. (u) “High acuity per diem supplemental rate” means a fixed per diem supplemental payment for high acuity days for specified hospitals in Section 14169.55. (v) “High acuity trauma per diem supplemental rate” means a fixed per diem supplemental payment for high acuity days for specified hospitals in Section 14169.55 that have been designated as specified types of trauma hospitals. (w) “Hospital community” includes, but is not limited to, the statewide hospital industry organization and systems representing general acute care hospitals. (x) “Hospital inpatient services” means all services covered under Medi-Cal and furnished by hospitals to patients who are admitted as hospital inpatients and reimbursed on a fee-for-service basis by the department directly or through its fiscal intermediary. Hospital inpatient services include outpatient services furnished by a hospital to a patient who is admitted to that hospital within 24 hours of the provision of the outpatient services that are related to the condition for which the patient is admitted. Hospital inpatient services do not include services for which a managed health care plan is financially responsible. (y) “Hospital outpatient services” means all services covered under Medi-Cal furnished by hospitals to patients who are registered as hospital outpatients and reimbursed by the department on a fee-for-service basis directly or through its fiscal intermediary. Hospital outpatient services do not include services for which a managed health care plan is financially responsible, or services rendered by a hospital-based federally qualified health center for which reimbursement is received pursuant to Section 14132.100. (z) “Managed care days” means inpatient hospital days as reported on the days data source where the service type is reported as “acute care,” “psychiatric care,” or “rehabilitation care,” and the payer category is reported as “Medicare managed care,” “county indigent programs-managed care,” or “other third parties-managed care,” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (aa) “Managed care per diem quality assurance fee rate” means a fixed fee on managed care days. (ab) (1) “Managed health care plan” means a health care delivery system that manages the provision of health care and receives prepaid capitated payments from the state in return for providing services to Medi-Cal beneficiaries. (2) (A) Managed health care plans include county organized health systems and entities contracting with the department to provide or arrange services for Medi-Cal beneficiaries pursuant to the two-plan model, geographic managed care, or regional managed care for the rural expansion. Entities providing these services contract with the department pursuant to any of the following: (i) Article 2.7 (commencing with Section 14087.3). (ii) Article 2.8 (commencing with Section 14087.5). (iii) Article 2.81 (commencing with Section 14087.96). (iv) Article 2.82 (commencing with Section 14087.98). (v) Article 2.91 (commencing with Section 14089). (B) Managed health care plans do not include any of the following: (i) Mental health plans contracting to provide mental health care for Medi-Cal beneficiaries pursuant to Chapter 8.9 (commencing with Section 14700). (ii) Health plans not covering inpatient services such as primary care case management plans operating pursuant to Section 14088.85. (iii) Program of All-Inclusive Care for the Elderly organizations operating pursuant to Chapter 8.75 (commencing with Section 14591). (ac) “Medi-Cal days” means inpatient hospital days as reported on the days data source where the service type is reported as “acute care,” “psychiatric care,” or “rehabilitation care,” and the payer category is reported as “Medi-Cal traditional” or “Medi-Cal managed care,” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (ad) “Medi-Cal fee-for-service days” means inpatient hospital days as reported on the days data source where the service type is reported as “acute care,” “psychiatric care,” or “rehabilitation care,” and the payer category is reported as “Medi-Cal traditional” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (ae) “Medi-Cal managed care days” means the total number of general acute care days, including well baby days, listed for the county organized health system and prepaid health plans identified in the Final Medi-Cal Utilization Statistics for the state fiscal year preceding the rebase calculation year, as calculated by the department as of the retrieval date. (af) “Medi-Cal managed care fee days” means inpatient hospital days as reported on the days data source where the service type is reported as “acute care,” “psychiatric care,” or “rehabilitation care,” and the payer category is reported as “Medi-Cal managed care” for purposes of the Annual Financial Disclosure Report submitted by hospitals to the Office of Statewide Health Planning and Development. (ag) “Medi-Cal per diem quality assurance fee rate” means a fixed fee on Medi-Cal days. (ah) “Medicaid inpatient utilization rate” means Medicaid inpatient utilization rate as defined in Section 1396r-4 of Title 42 of the United States Code and as set forth in the Final Medi-Cal Utilization Statistics for the state fiscal year preceding the rebase calculation year, as calculated by the department as of the retrieval date. (ai) “New hospital” means a hospital operation, business, or facility functioning under current or prior ownership as a private hospital that does not have a days data source or a hospital that has a days data source in whole, or in part, from a previous operator where there is an outstanding monetary obligation owed to the state in connection with the Medi-Cal program and the hospital is not, or does not agree to become, financially responsible to the department for the outstanding monetary obligation in accordance with subdivision (d) of Section 14169.61. (aj) “Nondesignated public hospital” means either of the following: (1) A public hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code, is not designated as a specialty hospital in the hospital’s most recently filed Annual Financial Disclosure Report, as of the first day of a program period, and satisfies the definition in paragraph (25) of subdivision (a) of Section 14105.98, excluding designated public hospitals. (2) A tax-exempt nonprofit hospital that is licensed under subdivision (a) of Section 1250 of the Health and Safety Code, is not designated as a specialty hospital in the hospital’s most recently filed Annual Financial Disclosure Report, as of the first day of a program period, is operating a hospital owned by a local health care district, and is affiliated with the health care district hospital owner by means of the district’s status as the nonprofit corporation’s sole corporate member. (ak) “Outpatient base amount” means the total amount of payments for hospital outpatient services made to a hospital in the base calendar year, as reflected in the state paid claims files prepared by the department as of the retrieval date. (al) “Outpatient supplemental rate” means a fixed proportional supplemental payment for Medi-Cal outpatient services. (am) “Prepaid health plan hospital” means a hospital owned by a nonprofit public benefit corporation that shares a common board of directors with a nonprofit health care service plan, which exclusively contracts with no more than two medical groups in the state to provide or arrange for professional medical services for the enrollees of the plan, as of the effective date of this article. (an) “Prepaid health plan hospital managed care per diem quality assurance fee rate” means a fixed fee on non-Medi-Cal managed care fee days for prepaid health plan hospitals. (ao) “Prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate” means a fixed fee on Medi-Cal managed care fee days for prepaid health plan hospitals. (ap) “Private hospital” means a hospital that meets all of the following conditions: (1) Is licensed pursuant to subdivision (a) of Section 1250 of the Health and Safety Code. (2) Is in the Charitable Research Hospital peer group, as set forth in the 1991 Hospital Peer Grouping Report published by the department, or is not designated as a specialty hospital in the hospital’s most recently filed Office of Statewide Health Planning and Development Annual Financial Disclosure Report, as of the first day of a program period. (3) Does not satisfy the Medicare criteria to be classified as a long-term care hospital. (4) Is a nonpublic hospital, nonpublic converted hospital, or converted hospital as those terms are defined in paragraphs (26) to (28), inclusive, respectively, of subdivision (a) of Section 14105.98. (5) Is not a nondesignated public hospital or a designated public hospital. (aq) “Program period” means a period not to exceed three years during which a fee model and a supplemental payment model developed under this article shall be effective. The first program period shall be the period beginning January 1, 2014, and ending December 31, 2016, inclusive. The second program period shall be the period beginning on January 1, 2017, and ending June 30, 2019. Each subsequent program period shall begin on the day immediately following the last day of the immediately preceding program period and shall end on the last day of a state fiscal year, as determined by the department. (ar) “Quality assurance fee” means the quality assurance fee assessed pursuant to Section 14169.52 and collected on the basis of the quarterly quality assurance fee. (as) (1) “Quarterly quality assurance fee” means, with respect to a hospital that is not a prepaid health plan hospital, the sum of all of the following: (A) The annual fee-for-service days for an individual hospital multiplied by the fee-for-service per diem quality assurance fee rate, divided by four. (B) The annual managed care days for an individual hospital multiplied by the managed care per diem quality assurance fee rate, divided by four. (C) The annual Medi-Cal days for an individual hospital multiplied by the Medi-Cal per diem quality assurance fee rate, divided by four. (2) “Quarterly quality assurance fee” means, with respect to a hospital that is a prepaid health plan hospital, the sum of all of the following: (A) The annual fee-for-service days for an individual hospital multiplied by the fee-for-service per diem quality assurance fee rate, divided by four. (B) The annual managed care days for an individual hospital multiplied by the prepaid health plan hospital managed care per diem quality assurance fee rate, divided by four. (C) The annual Medi-Cal managed care fee days for an individual hospital multiplied by the prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate, divided by four. (D) The annual Medi-Cal fee-for-service days for an individual hospital multiplied by the Medi-Cal per diem quality assurance fee rate, divided by four. (at) “Rebase calculation year” means a state fiscal year during which the department shall rebase the data, including, but not limited to, the days data source, used for the following: acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days, pursuant to Section 14169.59. Beginning with the third program period, the rebase calculation year for a program period shall be the last subject fiscal year of the immediately preceding program period. (au) “Rebase year” means the first state fiscal year of a program period and shall immediately follow a rebase calculation year. (av) “Retrieval date” means a day for each data element during the last quarter of the rebase calculation year upon which the department retrieves the data, including, but not limited to, the days data source, used for the following: acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days, pursuant to Section 14169.59. The retrieval date for each data element may be a different date within the quarter as determined to be necessary and appropriate by the department. (aw) “Subacute supplemental rate” means a fixed proportional supplemental payment for acute inpatient services based on a hospital’s prior provision of Medi-Cal subacute services. (ax) “Subject fiscal quarter” means a state fiscal quarter beginning on or after the first day of a program period and ending on or before the last day of a program period. (ay) “Subject fiscal year” means a state fiscal year beginning on or after the first day of a program period and ending on or before the last day of a program period. (az) “Subject month” means a calendar month beginning on or after the first day of a program period and ending on or before the last day of a program period. (ba) “Transplant days” means the number of Medi-Cal days for Medicare Severity-Diagnosis Related Groups (MS-DRGs) 1, 2, 5 to 10, inclusive, 14, 15, or 652, according to the Patient Discharge Data File Documentation from the Office of Statewide Health Planning and Development for the base calendar year accessed on the retrieval date. (bb) “Transplant per diem supplemental rate” means a fixed per diem supplemental payment for transplant days. (bc) “Upper payment limit” means a federal upper payment limit on the amount of the Medicaid payment for which federal financial participation is available for a class of service and a class of health care providers, as specified in Part 447 of Title 42 of the Code of Federal Regulations. The applicable upper payment limit shall be separately calculated for inpatient and outpatient hospital services. (Amended by Stats. 2014, Ch. 442, Sec. 26. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
14169.52.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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This section imposes a quality assurance fee on covered general acute care hospitals and sets payment, notice, interest, penalty, deduction, and waiver rules.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.52. (a) There shall be imposed on each general acute care hospital that is not an exempt facility a quality assurance fee, except that a quality assurance fee under this article shall not be imposed on a converted hospital for the periods when the hospital is a public hospital or a new hospital with respect to a program period. (b) The department shall compute the quarterly quality assurance fee for each subject fiscal year during a program period pursuant to Section 14169.59. (c) Subject to Section 14169.63, on the later of the date of the department’s receipt of federal approval or the first day of each program period, the following shall commence: (1) Within 10 business days following receipt of the notice of federal approval, the department shall send notice to each hospital subject to the quality assurance fee, which shall contain the following information: (A) The date that the state received notice of federal approval. (B) The quarterly quality assurance fee for each subject fiscal year. (C) The date on which each payment is due. (2) The hospitals shall pay the quarterly quality assurance fee, based on a schedule developed by the department. The department shall establish the date that each payment is due, provided that the first payment shall be due no earlier than 20 days following the department sending the notice pursuant to paragraph (1), and the payments shall be paid at least one month apart, but if possible, the payments shall be paid on a quarterly basis. (3) Notwithstanding any other provision of this section, the amount of each hospital’s quarterly quality assurance fee for a program period that has not been paid by the hospital before 15 days prior to the end of a program period shall be paid by the hospital no later than 15 days prior to the end of a program period. (4) Each hospital described in subdivision (a) shall pay the quarterly quality assurance fees that are due, if any, in the amounts and at the times set forth in the notice unless superseded by a subsequent notice from the department. (d) The quality assurance fee, as assessed pursuant to this section, shall be paid by each hospital subject to the fee to the department for deposit in the fund. Deposits may be accepted at any time and shall be credited toward the program period for which the fees were assessed. This article shall not affect the ability of a hospital to pay fees assessed for a program period after the end of that program period. (e) This section shall become inoperative if the federal Centers for Medicare and Medicaid Services denies approval for, or does not approve before December 1, 2016, the implementation of the quality assurance fee pursuant to this article or the supplemental payments to private hospitals pursuant to this article for the first program period. (f) In no case shall the aggregate fees collected in a federal fiscal year pursuant to this section, former Section 14167.32, Section 14168.32, and Section 14169.32 exceed the maximum percentage of the annual aggregate net patient revenue for hospitals subject to the fee that is prescribed pursuant to federal law and regulations as necessary to preclude a finding that an indirect guarantee has been created. (g) (1) Interest shall be assessed on quality assurance fees not paid on the date due at the greater of 10 percent per annum or the rate at which the department assesses interest on Medi-Cal program overpayments to hospitals that are not repaid when due. Interest shall begin to accrue the day after the date the payment was due and shall be deposited in the fund. (2) In the event that any fee payment is more than 60 days overdue, a penalty equal to the interest charge described in paragraph (1) shall be assessed and due for each month for which the payment is not received after 60 days. (h) When a hospital fails to pay all or part of the quality assurance fee on or before the date that payment is due, the department may immediately begin to deduct the unpaid assessment and interest from any Medi-Cal payments owed to the hospital, or, in accordance with Section 12419.5 of the Government Code, from any other state payments owed to the hospital until the full amount is recovered. All amounts, except penalties, deducted by the department under this subdivision shall be deposited in the fund. The remedy provided to the department by this section is in addition to other remedies available under law. (i) The payment of the quality assurance fee shall not be considered as an allowable cost for Medi-Cal cost reporting and reimbursement purposes. (j) The department shall work in consultation with the hospital community to implement this article. (k) This subdivision creates a contractually enforceable promise on behalf of the state to use the proceeds of the quality assurance fee, including any federal matching funds, solely and exclusively for the purposes set forth in this article, to limit the amount of the proceeds of the quality assurance fee to be used to pay for the health care coverage of children as provided in Section 14169.53, to limit any payments for the department’s costs of administration to the amounts set forth in this article, to maintain and continue prior reimbursement levels as set forth in Section 14169.68 on the effective date of that section, and to otherwise comply with all its obligations set forth in this article, provided that amendments that arise from, or have as a basis for, a decision, advice, or determination by the federal Centers for Medicare and Medicaid Services relating to federal approval of the quality assurance fee or the payments set forth in this article shall control for the purposes of this subdivision. (l) (1) Subject to paragraph (2), the director may waive any or all interest and penalties assessed under this article in the event that the director determines, in his or her sole discretion, that the hospital has demonstrated that imposition of the full quality assurance fee on the timelines applicable under this article has a high likelihood of creating a financial hardship for the hospital or a significant danger of reducing the provision of needed health care services. (2) Waiver of some or all of the interest or penalties under this subdivision shall be conditioned on the hospital’s agreement to make fee payments, or to have the payments withheld from payments otherwise due from the Medi-Cal program to the hospital, on a schedule developed by the department that takes into account the financial situation of the hospital and the potential impact on services. (3) A decision by the director under this subdivision shall not be subject to judicial review. (4) If fee payments are remitted to the department after the date determined by the department to be the final date for calculating the final supplemental payments for a program period under this article, the fee payments shall be refunded to general acute care hospitals, pro rata with the amount of quality assurance fee paid by the hospital in the program period, subject to the limitations of federal law. If federal rules prohibit the refund described in this paragraph, the excess funds shall be used as quality assurance fees for the next program period for general acute care hospitals, pro rata with the quality assurance fees paid by the hospital for the program period. (5) If during the implementation of this article, fee payments that were due under former Article 5.21 (commencing with Section 14167.1) and former Article 5.22 (commencing with Section 14167.31), or former Article 5.226 (commencing with Section 14168.1) and Article 5.227 (commencing with Section 14168.31), or Article 5.228 (commencing with Section 14169.1) and Article 5.229 (commencing with Section 14169.31) are remitted to the department under a payment plan or for any other reason, and the final date for calculating the final supplemental payments under those articles has passed, then those fee payments shall be deposited in the fund to support the uses established by this article. (Amended by Stats. 2014, Ch. 442, Sec. 27. (SB 1465) Effective September 18, 2014. Section conditionally inoperative as provided in subd. (e). Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
14169.53.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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Fees owed under this article must be paid to the department, which sends them to the Treasurer for deposit in the fund, and the department must use and administer the fund for the article’s specified hospital and Medi-Cal purposes.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.53. (a) (1) All fees required to be paid to the state pursuant to this article shall be paid in the form of remittances payable to the department. (2) The department shall directly transmit the fee payments to the Treasurer to be deposited in the fund. Notwithstanding Section 16305.7 of the Government Code, any interest and dividends earned on deposits in the fund from the proceeds of the fee assessed pursuant to this article shall be retained in the fund for purposes specified in subdivision (b). (b) (1) Notwithstanding subdivision (c) of Section 14167.35, subdivision (b) of Section 14168.33, and subdivision (b) of Section 14169.33, all funds from the proceeds of the fee assessed pursuant to this article in the fund, together with any interest and dividends earned on money in the fund, shall continue to be used exclusively to enhance federal financial participation for hospital services under the Medi-Cal program, to provide additional reimbursement to, and to support quality improvement efforts of, hospitals, and to minimize uncompensated care provided by hospitals to uninsured patients, as well as to pay for the state’s administrative costs and to provide funding for children’s health coverage, in the following order of priority: (A) (i) To pay for the department’s staffing and administrative costs directly attributable to implementing this article, not to exceed two hundred fifty thousand dollars ($250,000), except as provided in clause (ii), for each subject fiscal quarter, exclusive of any federal matching funds. (ii) Notwithstanding any other law, during any fiscal quarter for which the department incurs staffing or administrative costs due to the implementation of the federal Medicaid pass-through payment requirements codified in Section 438.6 of Title 42 of the Code of Federal Regulations as of March 20, 2017, or other federal requirements imposed as of the effective date of the act that added this clause, which significantly impact the implementation of this article, to pay for the department’s staffing and administrative costs that are directly attributable to implementing this article, not to exceed five hundred thousand dollars ($500,000) for each subject fiscal quarter, exclusive of any federal matching funds. (B) To pay for the health care coverage, as described in subdivision (g), except that for the two subject fiscal quarters in the 2013–14 fiscal year, the amount for children’s health care coverage shall be one hundred fifty-five million dollars ($155,000,000) for each subject fiscal quarter, exclusive of any federal matching funds. (C) To make increased capitation payments to managed health care plans pursuant to this article and Section 14169.82, including the nonfederal share of capitation payments to managed health care plans pursuant to this article and Section 14169.82 for services provided to individuals who meet the eligibility requirements in Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)), and who meet the conditions described in Section 1905(y) of the federal Social Security Act (42 U.S.C. Sec. 1396d(y)). (D) To make increased payments and direct grants to hospitals pursuant to this article and Section 14169.83, including the nonfederal share of payments to hospitals under this article and Section 14169.83 for services provided to individuals who meet the eligibility requirements in Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)), and who meet the conditions described in Section 1905(y) of the federal Social Security Act (42 U.S.C. Sec. 1396d(y)). (2) Notwithstanding subdivision (c) of Section 14167.35, subdivision (b) of Section 14168.33, and subdivision (b) of Section 14169.33, and notwithstanding Section 13340 of the Government Code, the moneys in the fund shall be continuously appropriated during the first program period only, without regard to fiscal year, for the purposes of this article, Article 5.229 (commencing with Section 14169.31), Article 5.228 (commencing with Section 14169.1), Article 5.227 (commencing with Section 14168.31), former Article 5.226 (commencing with Section 14168.1), former Article 5.22 (commencing with Section 14167.31), and former Article 5.21 (commencing with Section 14167.1). (3) Notwithstanding any other law, for the second program period and subsequent program periods, the moneys in the fund shall be continuously appropriated, without regard to fiscal year, for the purposes of this article and Sections 14169.82 and 14169.83. (c) Any amounts of the quality assurance fee collected in excess of the funds required to implement subdivision (b), including any funds recovered under subdivision (d) of Section 14169.61, shall be refunded to general acute care hospitals, pro rata with the amount of quality assurance fee paid by the hospital, subject to the limitations of federal law. If federal rules prohibit the refund described in this subdivision, the excess funds shall be used as quality assurance fees for the next program period for general acute care hospitals, pro rata with the amount of quality assurance fees paid by the hospital for the program period. (d) Any methodology or other provision specified in this article may be modified by the department, in consultation with the hospital community, to the extent necessary to meet the requirements of federal law or regulations to obtain federal approval or to enhance the probability that federal approval can be obtained, provided the modifications do not violate the spirit, purposes, and intent of this article and are not inconsistent with the conditions of implementation set forth in Section 14169.72. The department shall notify the Joint Legislative Budget Committee and the fiscal and appropriate policy committees of the Legislature 30 days prior to implementation of a modification pursuant to this subdivision. (e) The department, in consultation with the hospital community, shall make adjustments, as necessary, to the amounts calculated pursuant to Section 14169.52 in order to ensure compliance with the federal requirements set forth in Section 433.68 of Title 42 of the Code of Federal Regulations or elsewhere in federal law. (f) The department shall request approval from the federal Centers for Medicare and Medicaid Services for the implementation of this article. In making this request, the department shall seek specific approval from the federal Centers for Medicare and Medicaid Services to exempt providers identified in this article as exempt from the fees specified, including the submission, as may be necessary, of a request for waiver of the broad-based requirement, waiver of the uniform fee requirement, or both, pursuant to paragraphs (1) and (2) of subdivision (e) of Section 433.68 of Title 42 of the Code of Federal Regulations. (g) (1) For purposes of this subdivision, the following definitions shall apply: (A) “Actual net benefit” means the net benefit determined by the department for a net benefit period after the conclusion of the net benefit period using payments and grants actually made, and fees actually collected, for the net benefit period. (B) “Aggregate fees” means the aggregate fees collected from hospitals under this article. (C) “Aggregate payments” means the aggregate payments and grants made directly or indirectly to hospitals under this article, including payments and grants described in Sections 14169.54, 14169.55, 14169.57, and 14169.58, and subdivision (b) of Section 14169.82. (D) “Net benefit” means the aggregate payments for a net benefit period minus the aggregate fees for the net benefit period. (E) “Net benefit period” means a subject fiscal year or portion thereof that is in a program period and begins on or after July 1, 2014. (F) “Preliminary net benefit” means the net benefit determined by the department for a net benefit period prior to the beginning of that net benefit period using estimated or projected data. (2) The amount of funding provided for children’s health care coverage under subdivision (b) for a net benefit period shall be equal to 24 percent of the net benefit for that net benefit period. (3) The department shall determine the preliminary net benefit for all net benefit periods in the first program period before July 1, 2014. The department shall determine the preliminary net benefit for all net benefit periods in a subsequent program period before the beginning of the program period. (4) The department shall determine the actual net benefit and make the reconciliation described in paragraph (5) for each net benefit period within six months after the date determined by the department pursuant to subdivision (h). (5) For each net benefit period, the department shall reconcile the amount of moneys in the fund used for children’s health coverage based on the preliminary net benefit with the amount of the fund that may be used for children’s health coverage under this subdivision based on the actual net benefit. For each net benefit period, any amounts that were in the fund and used for children’s health coverage in excess of the 24 percent of the actual net benefit shall be returned to the fund, and the amount, if any, by which 24 percent of the actual net benefit exceeds 24 percent of the preliminary net benefit shall be available from the fund to the department for children’s health coverage. The department shall notify the Joint Legislative Budget Committee and the fiscal and appropriate policy committees of the Legislature of the results of the reconciliation for each net benefit period pursuant to this paragraph within five working days of performing the reconciliation. (6) The department shall make all calculations and reconciliations required by this subdivision in consultation with the hospital community using data that the department determines is the best data reasonably available. (h) After consultation with the hospital community, the department shall determine a date upon which substantially all fees have been paid and substantially all supplemental payments, grants, and rate range increases have been made for a program period, which date shall be no later than two years after the end of a program period. After the date determined by the department pursuant to this subdivision, no further supplemental payments shall be made under the program period, and any fees collected with respect to the program period shall be used for a subsequent program period consistent with this section. This subdivision does not affect the department’s authority to collect quality assurance fees for a program period after the end of the program period or after the date determined by the department pursuant to this subdivision. The department shall notify the Joint Legislative Budget Committee and fiscal and appropriate policy committees of that date within five working days of the determination. (i) Use of the fee proceeds to enhance federal financial participation pursuant to subdivision (b) shall include use of the proceeds to supply the nonfederal share, if any, of payments to hospitals under this article for services provided to individuals who meet the eligibility requirements in Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)), and who meet the conditions described in Section 1905(y) of the federal Social Security Act (42 U.S.C. Sec. 1396d(y)) such that expenditures for services provided to the individual are eligible for the enhanced federal medical assistance percentage described in that section. (Amended by Stats. 2018, Ch. 47, Sec. 2. (SB 849) Effective June 27, 2018. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
14169.54.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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Private hospitals are entitled to supplemental outpatient payments under this section, generally paid quarterly and adjusted for program-period timing and federal funding limits.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.54. (a) Private hospitals shall be paid supplemental amounts for each subject fiscal quarter in a program period for the provision of hospital outpatient services as set forth in this section. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services and shall not affect any other payments to hospitals. The supplemental amounts shall result in payments equal to the statewide aggregate upper payment limit for private hospitals for each subject fiscal year. (b) Except as set forth in subdivisions (d) and (e), each private hospital shall be paid an amount for each subject fiscal year equal to the outpatient supplemental rate multiplied by the hospital’s outpatient base amount, which payments shall be made on a quarterly basis. The outpatient supplemental rate shall result in payments to hospitals that equal the applicable federal upper payment limit for the subject fiscal year, except that with respect to a subject fiscal year that begins before the start of a program period or that ends after the end of the program period for which the payments are made, the outpatient supplemental rate shall result in payments to hospitals that equal a percentage of the applicable upper payment limit where the percentage equals the percentage of the subject fiscal year that occurs during the program period. For purposes of this subdivision, the applicable federal upper payment limit shall be the federal upper payment limit for hospital outpatient services furnished by private hospitals for each subject fiscal year. (c) In the event federal financial participation for a subject fiscal year is not available for all of the supplemental amounts payable to private hospitals under subdivision (b) due to the application of an upper payment limit or for any other reason, both of the following shall apply: (1) The total amount payable to private hospitals under subdivision (b) for the subject fiscal year shall be reduced to the amount for which federal financial participation is available. (2) The amount payable under subdivision (b) to each private hospital for the subject fiscal year shall be equal to the amount computed under subdivision (b) multiplied by the ratio of the total amount for which federal financial participation is available to the total amount computed under subdivision (b). (d) Payments shall not be made under this section for the periods when a hospital is a new hospital during a program period. (e) Payments shall be made to a converted hospital that converts during a subject fiscal quarter by multiplying the hospital’s outpatient supplemental payment as calculated in subdivision (b) by the number of days that the hospital was a private hospital in the subject fiscal quarter, divided by the number of days in the subject fiscal quarter. Payments shall not be made to a converted hospital in any subsequent subject fiscal quarter. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.55.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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Private hospitals are to receive supplemental payments for inpatient hospital services, with special rules for new and converted hospitals and reductions when federal funding is limited.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.55. (a) Private hospitals shall be paid supplemental amounts for the provision of hospital inpatient services for each subject fiscal quarter in a program period as set forth in this section. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services and shall not affect any other payments to hospitals. The inpatient supplemental amounts shall result in payments to hospitals that equal the applicable federal upper payment limit for the subject fiscal year, except that with respect to a subject fiscal year that begins before the start of a program period or that ends after the end of the program period for which the payments are made, the inpatient supplemental amounts shall result in payments to hospitals that equal a percentage of the applicable upper payment limit where the percentage equals the percentage of the subject fiscal year that occurs during the program period. (b) Except as set forth in subdivisions (e) and (f), each private hospital shall be paid the sum of the following amounts as applicable for the provision of hospital inpatient services for each subject fiscal quarter: (1) A general acute care per diem supplemental rate multiplied by the hospital’s general acute care days. (2) An acute psychiatric per diem supplemental rate multiplied by the hospital’s acute psychiatric days. (3) A high acuity per diem supplemental rate multiplied by the number of the hospital’s high acuity days if the hospital’s Medicaid inpatient utilization rate is less than the percent required to be eligible to receive disproportionate share replacement funds for the state fiscal year ending in the base calendar year and greater than 5 percent and at least 5 percent of the hospital’s general acute care days are high acuity days. (4) A high acuity trauma per diem supplemental rate multiplied by the number of the hospital’s high acuity days if the hospital qualifies to receive the amount set forth in paragraph (3) and has been designated as a Level I, Level II, Adult/Ped Level I, or Adult/Ped Level II trauma center by the Emergency Medical Services Authority established pursuant to Section 1797.1 of the Health and Safety Code. (5) A transplant per diem supplemental rate multiplied by the number of the hospital’s transplant days if the hospital’s Medicaid inpatient utilization rate is less than the percent required to be eligible to receive disproportionate share replacement funds for the state fiscal year ending in the base calendar year and greater than 5 percent. (6) A payment for hospital inpatient services equal to the subacute supplemental rate multiplied by the Medi-Cal subacute payments as reflected in the state paid claims file prepared by the department as of the retrieval date for the base calendar year if the private hospital provided Medi-Cal subacute services during the base calendar year. (c) In the event federal financial participation for a subject fiscal year is not available for all of the supplemental amounts payable to private hospitals under subdivision (b) due to the application of an upper payment limit or for any other reason, both of the following shall apply: (1) The total amount payable to private hospitals under subdivision (b) for the subject fiscal year shall be reduced to reflect the amount for which federal financial participation is available. (2) The amount payable under subdivision (b) to each private hospital for the subject fiscal year shall be equal to the amount computed under subdivision (b) multiplied by the ratio of the total amount for which federal financial participation is available to the total amount computed under subdivision (b). (d) If the amount otherwise payable to a hospital under this section for a subject fiscal year exceeds the amount for which federal financial participation is available for that hospital, the amount due to the hospital for that subject fiscal year shall be reduced to the amount for which federal financial participation is available. (e) Payments shall not be made under this section for the periods when a hospital is a new hospital during a program period. (f) Payments shall be made to a converted hospital that converts during a subject fiscal quarter by multiplying the hospital’s supplemental payment as calculated in subdivision (b) by the number of days that the hospital was a private hospital in the subject fiscal quarter, divided by the number of days in the subject fiscal quarter. Payments shall not be made to a converted hospital in any subsequent subject fiscal quarter. (Amended by Stats. 2014, Ch. 442, Sec. 29. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
14169.56.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The department must increase Medi-Cal managed care capitation payments, and plans must spend the extra money on hospital services.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.56. (a) The department shall increase capitation payments to Medi-Cal managed health care plans for each subject fiscal year as set forth in this section. (b) (1) Subject to the limitation in paragraph (2), the increased capitation payments shall be made as part of the monthly capitated payments made by the department to managed health care plans. The aggregate amount of increased capitation payments to all Medi-Cal managed health care plans for each subject fiscal year, or portion thereof, shall be the maximum amount for which federal financial participation is available on an aggregate statewide basis for the applicable subject fiscal year within a program period, or portion thereof. (2) (A) The limitation in subparagraph (B) shall be applied with respect to a subject fiscal year or portion thereof for which the federal matching assistance percentage is less than 90 percent for expenditures for services furnished to individuals who meet the eligibility requirements in Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)), and who meet the conditions described in Section 1905(y) of the federal Social Security Act (42 U.S.C. Sec. 1396d(y)). (B) During a subject fiscal year or portion thereof described in subparagraph (A), the aggregate amount of the increased capitation payments under this section shall not exceed the aggregate amount of the increased capitation payments that would be made if the nonfederal share of the increased capitation payments were the amount that the nonfederal share would have been if the federal matching assistance percentage were 90 percent for expenditures for services furnished to individuals who meet the eligibility requirements in Section 1902(a)(10)(A)(i)(VIII) of Title XIX of the federal Social Security Act (42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII)), and who meet the conditions described in Section 1905(y) of the federal Social Security Act (42 U.S.C. Sec. 1396d(y)). (c) The department shall determine the amount of the increased capitation payments for each managed health care plan for each subject fiscal year or portion thereof during a program period. The department shall consider the composition of Medi-Cal enrollees in the plan, the anticipated utilization of hospital services by the plan’s Medi-Cal enrollees, and other factors that the department determines are reasonable and appropriate to ensure access to high-quality hospital services by the plan’s enrollees. (d) The amount of increased capitation payments to each Medi-Cal managed health care plan shall not exceed an amount that results in capitation payments that are certified by the state’s actuary as meeting federal requirements, taking into account the requirement that all of the increased capitation payments under this section shall be paid by the Medi-Cal managed health care plans to hospitals for hospital services to Medi-Cal enrollees of the plan. (e) (1) The increased capitation payments to managed health care plans under this section shall be made to support the availability of hospital services and ensure access to hospital services for Medi-Cal beneficiaries. The increased capitation payments to managed health care plans shall commence within 90 days after the date on which all necessary federal approvals have been received, and shall include, but not be limited to, the sum of the increased payments for all prior months for which payments are due. (2) To secure the necessary funding for the payment or payments made pursuant to paragraph (1), the department may accumulate funds in the fund, for the purpose of funding managed health care capitation payments under this article regardless of the date on which capitation payments are scheduled to be paid in order to secure the necessary total funding for managed health care payments by the end of a program period. (f) Payments to managed health care plans that would be paid consistent with actuarial certification and enrollment in the absence of the payments made pursuant to this section, including, but not limited to, payments described in Section 14182.15, shall not be reduced as a consequence of payments under this section. (g) (1) Each managed health care plan shall expend 100 percent of any increased capitation payments it receives under this section on hospital services as provided in Section 14169.57. (2) The department may issue change orders to amend contracts with managed health care plans as needed to adjust monthly capitation payments in order to implement this section. (3) For entities contracting with the department pursuant to Article 2.91 (commencing with Section 14089), any incremental increase in capitation rates pursuant to this section shall not be subject to negotiation and approval by the department. (h) (1) In the event federal financial participation is not available for all of the increased capitation payments determined for a month pursuant to this section for any reason, the increased capitation payments mandated by this section for that month shall be reduced proportionately to the amount for which federal financial participation is available. (2) The determination under this subdivision for any month in a program period shall be made after accounting for all federal financial participation necessary for full implementation of Section 14182.15 for that month. (Amended by Stats. 2014, Ch. 442, Sec. 30. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
14169.57.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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Managed health care plans receiving increased capitation payments must use the increases for hospital services and provide required documentation.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.57. (a) Each managed health care plan receiving increased capitation payments under Section 14169.56 shall expend the capitation rate increases in a manner consistent with actuarial certification, enrollment, and utilization on hospital services. Each managed health care plan shall expend increased capitation payments on hospital services within 30 days of receiving the increased capitation payments to the extent they are made for a subject month that is prior to the date on which the payments are received by the managed health care plan. (b) The sum of all expenditures made by a managed health care plan for hospital services pursuant to this section shall equal, or approximately equal, all increased capitation payments received by the managed health care plan, consistent with actuarial certification, enrollment, and utilization, from the department pursuant to Section 14169.56. (c) Any delegation or attempted delegation by a managed health care plan of its obligation to expend the capitation rate increases under this section shall not relieve the plan from its obligation to expend those capitation rate increases. Managed health care plans shall submit the documentation that the department may require to demonstrate compliance with this subdivision. The documentation shall demonstrate actual expenditure of the capitation rate increases for hospital services, and not assignment to subcontractors of the managed health care plan’s obligation of the duty to expend the capitation rate increases. (d) The supplemental hospital payments made by managed health care plans pursuant to this section shall reflect the overall purpose of this article. (e) This article is not intended to create a private right of action by a hospital against a managed care plan provided that the managed health care plan expends all increased capitation payments for hospital services. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.58.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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This section sets grant amounts for designated and nondesignated public hospitals and tells the director how to allocate, distribute, and withhold parts of those grants.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.58. (a) (1) For the first program period, designated public hospitals shall be paid direct grants in support of health care expenditures, which shall not constitute Medi-Cal payments, and which shall be funded by the quality assurance fee set forth in this article. For the first program period, the aggregate amount of the grants to designated public hospitals funded by the quality assurance fee set forth in this article shall be forty-five million dollars ($45,000,000) in the aggregate for the two subject fiscal quarters in the 2013–14 subject fiscal year, ninety-three million dollars ($93,000,000) for the 2014–15 subject fiscal year, one hundred ten million five hundred thousand dollars ($110,500,000) for the 2015–16 subject fiscal year, and sixty-two million five hundred thousand dollars ($62,500,000) in the aggregate for the two subject fiscal quarters in the 2016–17 subject fiscal year. (2) (A) Of the direct grant amounts set forth in paragraph (1), the director shall allocate twenty-four million five hundred thousand dollars ($24,500,000) in the aggregate for the two subject fiscal quarters in the 2013–14 subject fiscal year, fifty million five hundred thousand dollars ($50,500,000) for the 2014–15 subject fiscal year, sixty million five hundred thousand dollars ($60,500,000) for the 2015–16 subject fiscal year, and thirty-four million five hundred thousand dollars ($34,500,000) in the aggregate for the two subject fiscal quarters in the 2016–17 subject fiscal year among the designated public hospitals pursuant to a methodology developed in consultation with the designated public hospitals. (B) Of the direct grant amounts set forth in subparagraph (A), the director shall distribute six million one hundred twenty-five thousand dollars ($6,125,000) for each subject fiscal quarter in the 2013–14 subject fiscal year, six million three hundred twelve thousand five hundred dollars ($6,312,500) for each subject fiscal quarter in the 2014–15 subject fiscal year, seven million five hundred sixty-two thousand five hundred dollars ($7,562,500) for each subject fiscal quarter in the 2015–16 subject fiscal year, and eight million six hundred twenty-five thousand dollars ($8,625,000) for each subject fiscal quarter in the 2016–17 subject fiscal year in accordance with the timeframes specified in subdivision (a) of Section 14169.66. (C) Of the direct grant amounts set forth in subparagraph (A), the director shall distribute six million one hundred twenty-five thousand dollars ($6,125,000) for each subject fiscal quarter in the 2013–14 subject fiscal year, six million three hundred twelve thousand five hundred dollars ($6,312,500) for each subject fiscal quarter in the 2014–15 subject fiscal year, seven million five hundred sixty-two thousand five hundred dollars ($7,562,500) for each subject fiscal quarter in the 2015–16 subject fiscal year, and eight million six hundred twenty-five thousand dollars ($8,625,000) for each subject fiscal quarter in the 2016–17 subject fiscal year only upon 100 percent of the rate range increases being distributed to managed health care plans pursuant to subparagraph (D) for the respective subject fiscal quarter. If the rate range increases pursuant to subparagraph (D) are distributed to managed health care plans, the direct grant amounts described in this subparagraph shall be distributed to designated public hospitals no later than 30 days after the rate range increases have been distributed to managed health care plans pursuant to subparagraph (D). (D) Of the direct grant amounts set forth in paragraph (1), twenty million five hundred thousand dollars ($20,500,000) in the aggregate for the two subject fiscal quarters in the 2013–14 subject fiscal year, forty-two million five hundred thousand dollars ($42,500,000) for the 2014–15 subject fiscal year, fifty million dollars ($50,000,000) for the 2015–16 subject fiscal year, and twenty-eight million dollars ($28,000,000) in the aggregate for the two subject fiscal quarters in the 2016–17 subject fiscal year shall be withheld from payment to the designated public hospitals by the director, and shall be used as the nonfederal share for rate range increases, as defined in paragraph (4) of subdivision (b) of Section 14301.4, to risk-based payments to managed care health plans that contract with the department to serve counties where a designated public hospital is located. The rate range increases shall apply to managed care rates for beneficiaries other than newly eligible beneficiaries, as defined in subdivision (s) of Section 17612.2, and shall enable plans to compensate hospitals for Medi-Cal health services and to support the Medi-Cal program. Each managed health care plan shall expend 100 percent of the rate range increases on hospital services within 30 days of receiving the increased payments. Rate range increases funded under this subparagraph shall be allocated among plans pursuant to a methodology developed in consultation with the hospital community. (3) Notwithstanding any other provision of law, any amounts withheld from payment to the designated public hospitals by the director as the nonfederal share for rate range increases, including those described in subparagraph (D) of paragraph (2), shall not be considered hospital fee direct grants as defined under subdivision (k) of Section 17612.2 and shall not be included in the determination under paragraph (1) of subdivision (a) of Section 17612.3. (b) (1) For the first program period, nondesignated public hospitals shall be paid direct grants in support of health care expenditures, which shall not constitute Medi-Cal payments, and which shall be funded by the quality assurance fee set forth in this article. For the first program period, the aggregate amount of the grants funded by the quality assurance fee set forth in this article to nondesignated public hospitals shall be twelve million five hundred thousand dollars ($12,500,000) in the aggregate for two subject fiscal quarters in the 2013–14 subject fiscal year, twenty-five million dollars ($25,000,000) for the 2014–15 subject fiscal year, thirty million dollars ($30,000,000) for the 2015–16 subject fiscal year, and seventeen million five hundred thousand dollars ($17,500,000) in the aggregate for the two subject fiscal quarters in the 2016–17 subject fiscal year. (2) (A) Of the direct grant amounts set forth in paragraph (1), the director shall allocate two million five hundred thousand dollars ($2,500,000) in the aggregate for the two subject fiscal quarters in the 2013–14 subject fiscal year, five million dollars ($5,000,000) for the 2014–15 subject fiscal year, six million dollars ($6,000,000) for the 2015–16 subject fiscal year, and three million five hundred thousand dollars ($3,500,000) in the aggregate for the two subject fiscal quarters in the 2016–17 subject fiscal year among the nondesignated public hospitals pursuant to a methodology developed in consultation with the nondesignated public hospitals. (B) Of the direct grant amounts set forth in paragraph (1), ten million dollars ($10,000,000) in the aggregate for the two subject fiscal quarters in the 2013–14 subject fiscal year, twenty million dollars ($20,000,000) for the 2014–15 subject fiscal year, twenty-four million dollars ($24,000,000) for the 2015–16 subject fiscal year, and fourteen million dollars ($14,000,000) in the aggregate for the two subject fiscal quarters in the 2016–17 subject fiscal year shall be withheld from payment to the nondesignated public hospitals by the director, and shall be used as the nonfederal share for rate range increases, as defined in paragraph (4) of subdivision (b) of Section 14301.4, to risk-based payments to managed care health plans that contract with the department. The rate range increases shall enable plans to compensate hospitals for Medi-Cal health services and to support the Medi-Cal program. Each managed health care plan shall expend 100 percent of the rate range increases on hospital services within 30 days of receiving the increased payments. Rate range increases funded under this subparagraph shall be allocated among plans pursuant to a methodology developed in consultation with the hospital community. (c) If the amounts set forth in this section for rate range increases are not actually used for rate range increases as described in this section, the direct grant amounts set forth in this section that are withheld pursuant to subparagraph (D) of paragraph (2) of subdivision (a) and subparagraph (B) of paragraph (2) of subdivision (b) shall be returned to the fund subject to paragraph (4) of subdivision (l) of Section 14169.52. (d) For subsequent program periods, designated public hospitals and nondesignated public hospitals may be paid direct grants pursuant to subdivision (e) of Section 14169.59 upon appropriation in the annual Budget Act. (Amended by Stats. 2014, Ch. 442, Sec. 31. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
14169.59.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The department must calculate hospital reimbursement-related data and rates each rebase year, and the director may later revise certain fee rates if federal approval is obtained.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.59. (a) The department shall determine during each rebase calculation year the number of subject fiscal years in the next program period. (b) During each rebase calculation year, the department shall retrieve the data, including, but not limited to, the days data source, used to determine the following for the subsequent program period: acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days. The department shall pull data from the most recent base calendar year for which the department determines reliable data is available for all hospitals. (c) (1) During each rebase calculation year, the department shall determine all of the following supplemental payment rates for the subsequent program period, which supplemental payment rates shall be specified in provisional language in the annual Budget Act: (A) The acute psychiatric per diem supplemental rate for each subject fiscal year during the program period. (B) The general acute care per diem supplemental rate for each subject fiscal year during the program period. (C) The high acuity per diem supplemental rate for each subject fiscal year during the program period. (D) The high acuity trauma per diem supplemental rate for each subject fiscal year during the program period. (E) The outpatient supplemental rate for each subject fiscal year during the program period. (F) The subacute supplemental rate for each subject fiscal year during the program period. (G) The transplant per diem supplemental rate for each subject fiscal year during the program period. (2) During each rebase calculation year, the department shall determine all of the following fee rates for the subsequent program period, which fee rates shall be specified in provisional language in the annual Budget Act: (A) The fee-for-service per diem quality assurance fee rate for each subject fiscal year during the program period. (B) The managed care per diem quality assurance fee rate for each subject fiscal year during the program period. (C) The Medi-Cal per diem quality assurance fee rate for each subject fiscal year during the program period. (D) The prepaid health plan hospital managed care per diem quality assurance fee rate for each subject fiscal year during the program period. (E) The prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate for each subject fiscal year during the program period. (d) The department shall determine the rates set forth in subdivision (c) based on the data retrieved pursuant to subdivision (b). Each rate determined by the department shall be the same for all hospitals to which the rate applies. These rates shall be specified in provisional language in the annual Budget Act. The department shall determine the rates in accordance with all of the following: (1) The rates shall meet the requirements of federal law and be established in a manner to obtain federal approval. (2) The department shall consult with the hospital community in determining the rates. (3) The supplemental payments and other Medi-Cal payments for hospital outpatient services furnished by private hospitals for each fiscal year shall equal as close as possible the applicable federal upper payment limit. (4) The supplemental payments and other Medi-Cal payments for hospital inpatient services furnished by private hospitals for each fiscal year shall equal as close as possible the applicable federal upper payment limit. (5) The increased capitation payments to managed health care plans shall result in the maximum payments to the plans permitted by federal law. (6) The quality assurance fee proceeds shall be adequate to make the expenditures described in this article, but shall not be more than necessary to make the expenditures. (7) The relative values of per diem supplemental payment rates to one another for the various categories of patient days shall be generally consistent with the relative values during the first program period under this article. (8) The relative values of per diem fee rates to one another for the various categories of patient days shall be generally consistent with the relative values during the first program period under this article. (9) The rates shall result in supplemental payments and quality assurance fees that are consistent with the purposes of this article. (e) During each rebase calculation year, the director shall determine the amounts and allocation methodology, if any, of direct grants to designated public hospitals and nondesignated public hospitals for each subject fiscal year in a program period, in consultation with the hospital community. The amounts and allocation methodology may include a withholding of direct grants to be used as the nonfederal share for rate range increases. These amounts shall be specified in provisional language in the annual Budget Act. (f) (1) Notwithstanding any other provision in this article, the following shall apply to the first program period under this article: (A) The first program period under this article shall be the period from January 1, 2014, to December 31, 2016, inclusive. (B) The acute psychiatric days shall be those identified in the Final Medi-Cal Utilization Statistics for the 2012–13 state fiscal year as calculated by the department as of December 17, 2012. (C) The days data source shall be the hospital’s Annual Financial Disclosure Report filed with the Office of Statewide Health Planning and Development as of June 6, 2013, for its fiscal year ending during the 2010 calendar year. (D) The general acute care days shall be those identified in the 2010 calendar year, as reflected in the state paid claims file on April 26, 2013. (E) The high acuity days shall be those paid during the 2010 calendar year, as reflected in the state paid claims file prepared by the department on April 26, 2013. (F) The Medi-Cal managed care days shall be those identified in the Final Medi-Cal Utilization Statistics for the 2012–13 fiscal year, as calculated by the department as of December 17, 2012. (G) The outpatient base amount shall be those payments for outpatient services made to a hospital in the 2010 calendar year, as reflected in the state paid claims files prepared by the department on April 26, 2013. (H) The transplant days shall be those identified in the 2010 Patient Discharge Data File Documentation from the Office of Statewide Health Planning and Development accessed on June 28, 2011. (I) With respect to a hospital described in subdivision (f) of Section 14165.50, both of the following shall apply: (i) The hospital shall not be considered a new hospital as defined in Section 14169.51 for the purposes of this article. (ii) To the extent permitted by federal law and other federal requirements, the department shall use the best available and reasonable current estimates or projections made with respect to the hospital for an annual period as the data, including, but not limited to, the days data source and data described as being derived from a state paid claims file, used for all purposes, including, but not limited to, the calculation of supplemental payments and the quality assurance fee. The estimates and projections shall be deemed to reflect paid claims and shall be used for each data element regardless of the time period otherwise applicable to the data element. The data elements include, but are not limited to, acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days. (2) Notwithstanding any other provision in this article, the following shall apply to determine the supplemental payment rates for the first program period: (A) The acute psychiatric per diem supplemental rate shall be nine hundred sixty-five dollars ($965) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, nine hundred seventy dollars ($970) for the subject fiscal quarters in the 2014–15 subject fiscal year, nine hundred seventy-five dollars ($975) for the subject fiscal quarters in the 2015–16 subject fiscal year and nine hundred seventy-five dollars ($975) for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (B) The general acute care per diem supplemental rate shall be eight hundred twenty-four dollars and forty cents ($824.40) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, one thousand one hundred ten dollars and sixty-seven cents ($1,110.67) for the subject fiscal quarters in the 2014–15 subject fiscal year, one thousand three hundred thirty-five dollars and forty-two cents ($1,335.42) for the subject fiscal quarters in the 2015–16 subject fiscal year, and one thousand four hundred forty-one dollars and twenty cents ($1,441.20) for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (C) The high acuity per diem supplemental rate shall be two thousand five hundred dollars ($2,500) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2014–15 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2015–16 subject fiscal year, and two thousand five hundred dollars ($2,500) for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (D) The high acuity trauma per diem supplemental rate shall be two thousand five hundred dollars ($2,500) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2014–15 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2015–16 subject fiscal year, and two thousand five hundred dollars ($2,500) for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (E) The outpatient supplemental rate shall be 119 percent of the outpatient base amount for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, 268 percent of the outpatient base amount for the subject fiscal quarters in the 2014–15 subject fiscal year, 292 percent of the outpatient base amount for the subject fiscal quarters in the 2015–16 subject fiscal year, and 151 percent of the outpatient base amount for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (F) The subacute supplemental rate shall be 50 percent for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, 55 percent for the subject fiscal quarters in the 2014–15 subject fiscal year, 60 percent for the subject fiscal quarters in the 2015–16 subject fiscal year, and 60 percent for the first two subject fiscal quarters in the 2016–17 subject fiscal year of the Medi-Cal subacute payments paid by the department to the hospital during the 2010 calendar year, as reflected in the state paid claims file prepared by the department on April 26, 2013. (G) The transplant per diem supplemental rate shall be two thousand five hundred dollars ($2,500) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2014–15 subject fiscal year, two thousand five hundred dollars ($2,500) for the subject fiscal quarters in the 2015–16 subject fiscal year, and two thousand five hundred dollars ($2,500) for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (3) Notwithstanding any other provision in this article, the following shall apply to determine the fee rates for the first program period: (A) The fee-for-service per diem quality assurance fee rate shall be three hundred seventy-four dollars and ninety-one cents ($374.91) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, four hundred twenty-five dollars and twenty-two cents ($425.22) for the subject fiscal quarters in the 2014–15 subject fiscal year, four hundred eighty dollars and eleven cents ($480.11) for the subject fiscal quarters in the 2015–16 subject fiscal year, and five hundred forty-two dollars and ten cents ($542.10) for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (B) The managed care per diem quality assurance fee rate shall be one hundred forty-five dollars ($145) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, one hundred forty-five dollars ($145) for the subject fiscal quarters in the 2014–15 subject fiscal year, one hundred seventy dollars ($170) for the subject fiscal quarters in the 2015–16 subject fiscal year, and one hundred seventy dollars ($170) for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (C) The Medi-Cal per diem quality assurance fee rate shall be four hundred fifty-seven dollars and ten cents ($457.10) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, four hundred ninety-seven dollars and eight cents ($497.08) for the subject fiscal quarters in the 2014–15 subject fiscal year, five hundred sixty-eight dollars and fifteen cents ($568.15) for the subject fiscal quarters in the 2015–16 subject fiscal year, and six hundred eighteen dollars and fourteen cents ($618.14) for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (D) The prepaid health plan hospital managed care per diem quality assurance fee rate shall be eighty-one dollars and twenty cents ($81.20) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, eighty-one dollars and twenty cents ($81.20) for the subject fiscal quarters in the 2014–15 subject fiscal year, ninety-five dollars and twenty cents ($95.20) for the subject fiscal quarters in the 2015–16 subject fiscal year, and ninety-five dollars and twenty cents ($95.20) for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (E) The prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate shall be two hundred fifty-five dollars and ninety-seven cents ($255.97) for the two remaining subject fiscal quarters in the 2013–14 subject fiscal year, two hundred seventy-eight dollars and thirty-seven cents ($278.37) for the subject fiscal quarters in the 2014–15 subject fiscal year, three hundred eighteen dollars and sixteen cents ($318.16) for the subject fiscal quarters in the 2015–16 subject fiscal year, and three hundred forty-six dollars and sixteen cents ($346.16) for the first two subject fiscal quarters in the 2016–17 subject fiscal year. (F) Upon federal approval or conditional federal approval described in Section 14169.63, the director shall have the discretion to revise the fee-for-service per diem quality assurance fee rate, the managed care per diem quality assurance fee rate, the Medi-Cal per diem quality assurance fee rate, the prepaid health plan hospital managed care per diem quality assurance fee rate, or the prepaid health plan hospital Medi-Cal managed care per diem quality assurance fee rate, based on the funds required to make the payments specified in this article, in consultation with the hospital community. (g) Notwithstanding any other provision in this article, the following shall apply to the second program period under this article: (1) The second program period under this article shall begin on January 1, 2017, and shall end on June 30, 2019. (2) The retrieval date shall occur between October 1, 2016, and December 31, 2016. (3) The base calendar year shall be the 2013 calendar year, or a more recent calendar year for which the department determines reliable data is available. (4) The rebase calculation year shall be the 2015–16 state fiscal year. (5) With respect to a hospital described in subdivision (f) of Section 14165.50, both of the following shall apply: (A) The hospital shall not be considered a new hospital as defined in subdivision (ai) of Section 14169.51 for the purposes of this article. (B) To the extent permitted by federal law or other federal requirements, the department shall use the best available and reasonable current estimates or projections made with respect to the hospital for an annual period as to the data, including, but not limited to, the days data source and data described as being derived from a state paid claims file, used for all purposes, including, but not limited to, the calculation of supplemental payments and the quality assurance fee. The estimates and projections shall be deemed to reflect paid claims and shall be used for each data element regardless of the time period otherwise applicable to the data element. The data elements include, but are not limited to, acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days. (h) Commencing January 2016, the department shall provide a clear narrative description along with fiscal detail in the Medi-Cal estimate package, submitted to the Legislature in January and May of each year, of all of the calculations made by the department pursuant to this section for the second program period and every program period thereafter. (Amended by Stats. 2014, Ch. 442, Sec. 32. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
14169.6.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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Managed health care plans that receive increased capitation payments must spend those funds on hospital services and provide compliance documentation if the department asks.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.6. (a) Each managed health care plan receiving increased capitation payments under Section 14169.5 shall expend the capitation rate increases in a manner consistent with actuarial certification, enrollment, and utilization on hospital services. Each managed health care plan shall expend increased capitation payments on hospital services within 30 days of receiving the increased capitation payments to the extent they are made for a subject month that is prior to the date on which the payments are received by the managed health care plan. (b) The sum of all expenditures made by a managed health care plan for hospital services pursuant to this section shall equal, or approximately equal, all increased capitation payments received by the managed health care plan, consistent with actuarial certification, enrollment, and utilization, from the department pursuant to Section 14169.5. (c) Any delegation or attempted delegation by a managed health care plan of its obligation to expend the capitation rate increases under this section shall not relieve the plan from its obligation to expend those capitation rate increases. Managed health care plans shall submit the documentation the department may require to demonstrate compliance with this subdivision. The documentation shall demonstrate actual expenditure of the capitation rate increases for hospital services, and not assignment to subcontractors of the managed health care plan’s obligation of the duty to expend the capitation rate increases. (d) The supplemental hospital payments made by managed health care plans pursuant to this section shall reflect the overall purpose of the act. (e) This article is not intended to create a private right of action by a hospital against a managed care plan provided that the managed health care plan expends all increased capitation payments for hospital services. (Added by Stats. 2011, Ch. 286, Sec. 7. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.60.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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Payments under this section for private hospitals are excluded from certain payment-limit calculations, and the section’s supplemental payments are treated as quality assurance payments.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.60. (a) The amount of any payments made under this article to private hospitals, including the amount of payments made under Sections 14169.54 and 14169.55 and additional payments to private hospitals by managed health care plans pursuant to Section 14169.57, shall not be included in the calculation of the low-income percent or the OBRA 1993 payment limitation, as defined in paragraph (24) of subdivision (a) of Section 14105.98, for purposes of determining payments to private hospitals. (b) The supplemental payments and other payments under this article shall be regarded as quality assurance payments, the implementation or suspension of which does not affect a determination of the adequacy of any rates under federal law. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.61.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The section says certain hospital payments must go to the hospital’s licensee, and the licensee must pay quality assurance fees when due. It also gives the director and department powers and duties tied to hospital ownership changes and repayment responsibilities.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.61. (a) (1) Except as provided in this section, all data and other information relating to a hospital that are used for the purposes of this article, including, without limitation, the days data source, shall continue to be used to determine the payments to that hospital, regardless of whether the hospital has undergone one or more changes of ownership. (2) All supplemental payments to a hospital under this article shall be made to the licensee of a hospital on the date the supplemental payment is made. All quality assurance fee payments under this article shall be paid by the licensee of a hospital on the date the quarterly quality assurance fee payment is due. (b) The data of separate facilities prior to a consolidation shall be aggregated for the purposes of this article if: (1) a private hospital consolidates with another private hospital, (2) the facilities operate under a consolidated hospital license, (3) data for a period prior to the consolidation is used for purposes of this article, and (4) neither hospital has had a change of ownership on or after the effective date of this article unless paragraph (2) of subdivision (d) has been satisfied by the new owner. Data of a facility that was a separately licensed hospital prior to the consolidation shall not be included in the data, including the days data source, for the purpose of determining payments to the facility or the quality assurance fees due from the facility under the article for any time period during which the facility is closed. A facility shall be deemed to be closed for purposes of this subdivision on the first day of any period during which the facility has no general acute, psychiatric, or rehabilitation inpatients for at least 30 consecutive days. A facility that has been deemed to be closed under this subdivision shall no longer be deemed to be closed on the first subsequent day on which it has general acute, psychiatric, or rehabilitation inpatients. (c) The payments to a hospital under this article shall not be made, and the quality assurance fees shall not be due, for any period during which the hospital is closed. A hospital shall be deemed to be closed on the first day of any period during which the hospital has no general acute, psychiatric, or rehabilitation inpatients for at least 30 consecutive days. A hospital that has been deemed to be closed under this subdivision shall no longer be deemed to be closed on the first subsequent day on which it has general acute, psychiatric, or rehabilitation inpatients. Payments under this article to a hospital and installment payments of the aggregate quality assurance fee due from a hospital that is closed during any portion of a subject fiscal quarter shall be reduced by applying a fraction, expressed as a percentage, the numerator of which shall be the number of days during the applicable subject fiscal quarter that the hospital is closed during the subject fiscal year and the denominator of which shall be the number of days in the subject fiscal quarter. (d) The following provisions shall apply only for purposes of this article, and shall have no application outside of this article nor shall they affect the assumption of any outstanding monetary obligation to the Medi-Cal program: (1) The director shall develop and describe in provider bulletins and on the department’s Internet Web site a process by which the new operator of a hospital that has a days data source in whole or in part from a previous operator may enter into an agreement with the department to confirm that it is financially responsible or to become financially responsible to the department for the outstanding monetary obligation to the Medi-Cal program of the previous operator in order to avoid being classified as a new hospital for purposes of this article. This process shall be available for changes of ownership that occur before, on, or after January 1, 2014, but only in regard to payments under this article and otherwise shall have no retroactive effect. (2) The outstanding monetary obligation referred to in subdivision (ai) of Section 14169.51 shall include responsibility for all of the following: (A) Payment of the quality assurance fee established pursuant to this article. (B) Known overpayments that have been asserted by the department or its fiscal intermediary by sending a written communication that is received by the hospital prior to the date that the new operator becomes the licensee of the hospital. (C) Overpayments that are asserted after such date and arise from customary reconciliations of payments, such as cost report settlements, and, with the exception of overpayments described in subparagraph (B), shall exclude liabilities arising from the fraudulent or intentionally criminal act of a prior operator if the new operator did not knowingly participate in or continue the fraudulent or criminal act after becoming the licensee. (3) The department shall have the discretion to determine whether the new owner properly and fully agreed to be financially responsible for the outstanding monetary obligation in connection with the Medi-Cal program and seek additional assurances as the department deems necessary, except that a new owner that executes an agreement with the department to be financially responsible for the monetary obligations as described in paragraph (1) shall be conclusively deemed to have agreed to be financially responsible for the outstanding monetary obligation in connection with the Medi-Cal program. The department shall have the discretion to establish the terms for satisfying the outstanding monetary obligation in connection with the Medi-Cal program, including, but not limited to, recoupment from amounts payable to the hospital under this section. (Amended by Stats. 2014, Ch. 442, Sec. 33. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
14169.62.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The director may correct identified material and egregious data errors in this article, and those determinations are generally not subject to judicial review.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.62. Notwithstanding any provision in this article, the director may correct any identified material and egregious errors in the data, including, but not limited to, the days data source, used for the following: acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days. An error is material and egregious if the error is clear to the director based on information the director finds to be reliable and results in an increase or decrease to a hospital’s supplemental payment amounts under this article, or in a hospital’s quality assurance fee payments, of at least one million dollars ($1,000,000) for any subject fiscal year. The director’s determination whether to exercise his or her discretion under this section and any determination made by the director under this section shall not be subject to judicial review, except that a hospital may bring a writ of mandate under Section 1085 of the Code of Civil Procedure to rectify an abuse of discretion by the department in correcting that hospital’s data when that correction results in greater fees for that hospital pursuant to Sections 14169.52 and 14169.53 or lower supplemental payments for that hospital pursuant to Section 14169.54 and 14169.55. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.63.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The department may collect the quality assurance fee and make related payments if it receives a qualifying federal letter, and the director must find the letter is sufficient.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.63. (a) Notwithstanding any other provision of this article requiring federal approvals, the department may impose and collect the quality assurance fee and may make payments under this article, including increased capitation payments, based upon receiving a letter from the federal Centers for Medicare and Medicaid Services or the United States Department of Health and Human Services that indicates likely federal approval, but only if and to the extent that the letter is sufficient as set forth in subdivision (b). (b) In order for the letter to be sufficient under this section, the director shall find that the letter meets both of the following requirements: (1) The letter is in writing and signed by an official of the federal Centers for Medicare and Medicaid Services or an official of the United States Department of Health and Human Services. (2) The director, after consultation with the hospital community, has determined, in the exercise of his or her sole discretion, that the letter provides a sufficient level of assurance to justify advanced implementation of the fee and payment provisions. (c) Nothing in this section shall be construed as modifying the requirement under Section 14169.69 that payments shall be made only to the extent a sufficient amount of funds collected as the quality assurance fee are available to cover the nonfederal share of those payments. (d) Upon notice from the federal government that final federal approval for the fee model under this article or for the supplemental payments to private hospitals under Section 14169.54 or 14169.55 has been denied, any fees collected pursuant to this section shall be refunded and any payments made pursuant to this article shall be recouped, including, but not limited to, supplemental payments and grants, increased capitation payments, payments to hospitals by health care plans resulting from the increased capitation payments, and payments for the health care coverage of children. To the extent fees were paid by a hospital that also received payments under this section, the payments may first be recouped from fees that would otherwise be refunded to the hospital prior to the use of any other recoupment method allowed under law. (e) Any payment made pursuant to this section shall be a conditional payment until final federal approval has been received. (f) The director shall have broad authority under this section to collect the quality assurance fee for an interim period after receipt of the letter described in subdivision (a) pending receipt of all necessary federal approvals. This authority shall include discretion to determine both of the following: (1) Whether the quality assurance fee should be collected on a full or pro rata basis during the interim period. (2) The dates on which payments of the quality assurance fee are due. (g) The department may draw against the fund for all administrative costs associated with implementation under this article, consistent with subdivision (b) of Section 14169.53. (h) This section shall be implemented only to the extent federal financial participation is not jeopardized by implementation prior to the receipt of all necessary final federal approvals. (Amended by Stats. 2014, Ch. 442, Sec. 34. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by stats. 2013, Ch. 657 (SB 239).)
14169.64.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The director may change certain payment-related timelines if operationally necessary, and the department must give advance notice and consult the hospital community.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.64. (a) Notwithstanding any other provision in this article, the director may modify any timeline or timelines related to the assessment of the quality assurance fee or Medi-Cal payments under this article, including capitation payments, if the director, upon consultation with the hospital community, determines that it is impossible from an operational perspective to implement a timeline or timelines without the modification. (b) The department shall notify the Joint Budget Legislative Committee and the fiscal and appropriate policy committees of the Legislature five working days prior to implementing a modified timeline or timelines under subdivision (a). (c) The department shall consult with representatives of the hospital community in developing a modified timeline or timelines pursuant to this section. (d) The discretion to modify timelines under this section shall include, but not be limited to, discretion to accelerate payments to plans or hospitals. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.65.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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After federal approval or a qualifying letter of likely approval, the department must make specified payments by the end of the program period, and it must recoup any payment that is inconsistent with federal law.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.65. (a) Upon receipt of a letter that indicates likely federal approval that the director determines is sufficient for implementation under Section 14169.63, or upon the receipt of federal approval, the following shall occur: (1) To the maximum extent possible, and consistent with the availability of funds in the fund, the department shall make all of the payments under Sections 14169.54, 14169.55, and 14169.56, including, but not limited to, supplemental payments and increased capitation payments, prior to the end of a program period, except that the increased capitation payments under Section 14169.56 shall not be made until federal approval is obtained for these payments. (2) The department shall make supplemental payments to hospitals under this article consistent with the timeframe described in Section 14169.66 or a modified timeline developed pursuant to Section 14169.64. (b) If any payment or payments made pursuant to this section are found to be inconsistent with federal law, the department shall recoup the payments by means of withholding or any other available remedy. (c) This section shall not affect the department’s ongoing authority to continue, after the end of a program period, to collect quality assurance fees imposed on or before the end of the program period. (Amended by Stats. 2014, Ch. 442, Sec. 35. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
14169.66.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The department must distribute money from the fund under specified priority rules and timing requirements.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.66. The department shall make disbursements from the fund consistent with the following: (a) Fund disbursements shall be made periodically within 15 days of each date on which quality assurance fees are due from hospitals. (b) The funds shall be disbursed in accordance with the order of priority set forth in subdivision (b) of Section 14169.53, except that funds may be set aside for increased capitation payments to managed care health plans pursuant to subdivision (e) of Section 14169.56. (c) The funds shall be disbursed in each payment cycle in accordance with the order of priority set forth in subdivision (b) of Section 14169.53 as modified by subdivision (b), and so that the supplemental payments and direct grants to hospitals and the increased capitation payments to managed health care plans are made to the maximum extent for which funds are available. (d) To the maximum extent possible, consistent with the availability of funds in the fund and the timing of federal approvals, the supplemental payments and direct grants to hospitals and increased capitation payments to managed health care plans under this article shall be made before the last day of a program period. (e) The aggregate amount of funds to be disbursed to private hospitals shall be determined under Sections 14169.54 and 14169.55. The aggregate amount of funds to be disbursed to managed health care plans shall be determined under Section 14169.56. The aggregate amount of direct grants to designated and nondesignated public hospitals shall be determined under Section 14169.58. (Amended by Stats. 2014, Ch. 442, Sec. 36. (SB 1465) Effective September 18, 2014. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52. This section was added by Stats. 2013, Ch. 657 (SB 239).)
14169.67.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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Supplemental payments or other payments under this article are required only for quarters in which a fee payment obligation exists.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.67. Notwithstanding any other provision of this article, supplemental payments or other payments under this article shall only be required and payable in any quarter for which a fee payment obligation exists. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.68.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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Medi-Cal hospital fee-for-service payments must stay at least as high as the December 31, 2013 benchmark, applied separately by hospital service category, with limits for federal-law compliance and federal funding.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.68. (a) In order to ensure that the proceeds of the quality assurance fee, the matching amount provided by the federal government, and any interest earned on those proceeds are used to supplement existing funding for hospital services provided to Medi-Cal patients and not supplant such funding, the aggregate fee-for-service payments under the Medi-Cal program to hospitals for hospital services furnished on and after January 1, 2014, for each fiscal year or portion thereof that is in a program period shall not be less than the aggregate amounts that would have been paid for those services under the rates and payment methodologies in effect on December 31, 2013. This provision shall be applied separately for each category of hospital services. (b) For purposes of this section, all of the following definitions shall apply: (1) “Aggregate amounts” means payments that would have been made on a fee-for-service basis to a hospital under Medi-Cal where the nonfederal share of the payments would have been appropriated from state general funds with the exception of disproportionate share replacement payments made under Section 14166.11. Aggregate amounts do not include payments made pursuant to Article 5.228 (commencing with Section 14169.1). (2) “Aggregate fee-for-service payments” means all payments made on a fee-for-service basis to a hospital under Medi-Cal where the nonfederal share of the payments were appropriated from state general funds with the exception of disproportionate share replacement payments made under Section 14166.11. Aggregate fee-for-service payments do not include payments made under this article. (3) “Hospital services” means all services covered under Medi-Cal furnished by a hospital, including, but not limited to, hospital inpatient services, hospital outpatient services, skilled nursing facility services furnished by a hospital, and subacute services furnished by a hospital. (c) Disproportionate share replacement payments to private hospitals shall be not less than the amount determined pursuant to Section 14166.11. For purposes of this subdivision, references to Section 14166.11 are to the version of Section 14166.11 in effect on the effective date of this article. (d) This section shall be implemented only to the extent it does not violate federal law and only to the extent available federal financial participation is not jeopardized. (e) This section shall not require a rate or level of funding to be maintained where federal financial participation for the rate or level of funding has been reduced or eliminated by federal law. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.69.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The director and department must take steps to implement this article, but payments are restricted until required federal approvals and fee collection are in place.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.69. (a) The director shall do all of the following: (1) Promptly submit any state plan amendment or waiver request that may be necessary to implement this article. (2) Promptly seek federal approvals or waivers as may be necessary to implement this article and to obtain federal financial participation to the maximum extent possible for the payments under this article. (3) Amend the contracts between the managed health care plans and the department as necessary to incorporate the provisions of Sections 14169.56 and 14169.57 and promptly seek all necessary federal approvals of those amendments. The department shall pursue amendments to the contracts as soon as possible after the effective date of this article, and shall not wait for federal approval of this article prior to pursuing amendments to the contracts. The amendments to the contracts shall, among other provisions, set forth an agreement to increase capitation payments to managed health care plans under Section 14169.56 and increase payments to hospitals under Section 14169.57 in a manner that relates back to the beginning of a program period, or as soon thereafter as possible, conditioned on obtaining all federal approvals necessary for federal financial participation for the increased capitation payments to the managed health care plans. (b) In implementing this article, the department may utilize the services of the Medi-Cal fiscal intermediary through a change order to the fiscal intermediary contract to administer this program, consistent with the requirements of Sections 14104.6, 14104.7, 14104.8, and 14104.9. Contracts entered into for purposes of implementing this article shall not be subject to Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code. (c) In the event any hospital, or any party on behalf of a hospital, initiates a case or proceeding in any state or federal court in which the hospital seeks any relief of any sort whatsoever, including, but not limited to, monetary relief, injunctive relief, declaratory relief, or a writ, based in whole or in part on a contention that any or all of this article is unlawful and may not be lawfully implemented, both of the following shall apply: (1) Payments shall not be made to the hospital pursuant to this article until the case or proceeding is finally resolved, including the final disposition of all appeals. (2) Any amount computed to be payable to the hospital pursuant to this article for a subject fiscal year shall be withheld by the department and shall be paid to the hospital only after the case or proceeding is finally resolved, including the final disposition of all appeals. (d) Subject to Section 14169.63, no payment shall be made under this article until all necessary federal approvals for the payment and for the fee provisions in this article have been obtained and the fee has been imposed and collected. Notwithstanding any other law, payments under this article shall be made only to the extent that the fee established in this article is collected and available to cover the nonfederal share of the payments. (e) All payments made by the department to hospitals and managed health care plans under this article shall be made only from the following: (1) The quality assurance fee set forth in this article, along with any interest or other investment income thereon. (2) Federal reimbursement and any other related federal funds. (f) In order to ensure access to care to hospital services, the director shall seek federal approval for supplemental payments for hospital services provided to all Medi-Cal populations, including the optional and expansion populations. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.7.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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This section sets grant amounts for designated and nondesignated public hospitals and requires the director to allocate the funds.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.7. (a) (1) Designated public hospitals shall be paid direct grants in support of health care expenditures, which shall not constitute Medi-Cal payments, and which shall be funded by the quality assurance fee set forth in Article 5.229 (commencing with Section 14169.31). The aggregate amount of the grants to designated public hospitals shall be fifty million dollars ($50,000,000) for the 2011–12 fiscal year, forty-three million dollars ($43,000,000) for the 2012–13 fiscal year, and twenty-one million five hundred thousand dollars ($21,500,000) for the 2013–14 fiscal year. The director shall allocate the amounts specified in this paragraph pursuant to paragraph (2). (2) For the 2011–12 fiscal year, the director shall allocate the fifty million dollars ($50,000,000) identified in paragraph (1) among the designated public hospitals pursuant to a methodology developed in consultation with the designated public hospitals. For the 2012–13 fiscal year, the director shall allocate the forty-three million dollars ($43,000,000) identified in paragraph (1) among the designated public hospitals pursuant to a methodology developed in consultation with the designated public hospitals. For the 2013–14 fiscal year, the state shall retain the twenty-one million five hundred thousand dollars ($21,500,000) identified in paragraph (1) to pay for health care coverage for children in addition to the amounts identified in Section 14169.33. (b) Nondesignated public hospitals shall be paid direct grants in support of health care expenditures, and shall be funded by the quality assurance fee set forth in Article 5.229 (commencing with Section 14169.31). The aggregate amount of the grants to nondesignated public hospitals for each subject fiscal year shall be eighteen million six hundred thousand dollars ($18,600,000), except that for the 2013–14 subject fiscal year, the aggregate amount of the grants shall be nine million three hundred thousand dollars ($9,300,000). The director shall allocate the amounts specified in this subdivision among the nondesignated public hospitals pursuant to a methodology developed in consultation with the nondesignated public hospitals. (Amended by Stats. 2012, Ch. 452, Sec. 4. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.7.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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This section creates a state treasury fund and sets rules for how money in it must be deposited, returned, allocated, and used for out-of-network emergency care payments.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.7.5. (a) The Low Income Health Program MCE Out-of-Network Emergency Care Services Fund is hereby established in the State Treasury. The moneys in the fund shall, upon appropriation by the Legislature to the department, be used solely for the purposes specified in this section. Notwithstanding Section 16305.7 of the Government Code, any and all interest and dividends earned on money in the fund shall be used exclusively for the purposes of this section. (b) The fund shall consist of the following: (1) Funds transferred from governmental entities, at the option of the governmental entity, to the state for deposit into the fund in an aggregate amount of twenty million dollars ($20,000,000) per subject fiscal year, except that for the 2013–14 subject fiscal year, the aggregate amount of the transfer shall be ten million dollars ($10,000,000). (2) Proceeds of the quality assurance fee set forth in Article 5.229 (commencing with Section 14169.31) that, subject to paragraph (1) of subdivision (a) of Section 14169.36, are transferred from the Hospital Quality Assurance Revenue Fund and deposited into the fund in an aggregate amount of sixty-six million four hundred thousand dollars ($66,400,000) per subject fiscal year, except that for the 2013–14 subject fiscal year, the aggregate amount of the proceeds of the quality assurance fee deposited into the fund shall be thirty-three million two hundred thousand dollars ($33,200,000). (c) Any amounts of the quality assurance fee deposited to the fund in excess of the funds required to implement this section shall be returned to the Hospital Quality Assurance Revenue Fund. (d) Any amounts deposited to the fund as described in paragraph (1) of subdivision (b) that are in excess of the funds required to implement this section shall be returned to the transferring entity. (e) Consistent with the Special Terms and Conditions for the California’s Bridge to Reform Section 1115(a) Medicaid Demonstration (11-W-00193/9), moneys in the fund shall be used with respect to Low Income Health Programs (LIHPs) operating pursuant to Part 3.6 (commencing with Section 15909) as the source for the nonfederal share of expenditures for coverage for the Medicaid Coverage Expansion (MCE) population of medically necessary hospital emergency services for emergency medical conditions and required poststabilization care furnished by private hospitals that are outside the LIHP coverage network, subject to the following: (1) Moneys in the fund shall only be used to fund the nonfederal share of supplemental payments made to private hospital out-of-network emergency care services providers by the LIHP for the MCE population in accordance with this section. (2) Supplemental payments under this section shall supplement but shall not supplant amounts that would have been paid absent the provisions of this section. (f) Moneys in the fund shall be allocated with respect to each subject fiscal year as follows: (1) Within 60 days after the last day of each subject fiscal year, each LIHP shall report utilization data to the department on approved hospital emergency services for emergency medical conditions and required poststabilization care, in accordance with Paragraph 63.f.ii of the Special Terms and Conditions of California’s Bridge to Reform Section 1115(a) Medicaid Demonstration (11-W-00193/9), provided to MCE enrollees by out-of-network private hospitals during that year. The reported data shall be as specified by the department, and shall include the number of emergency room encounters and the number of inpatient hospital days. (2) The department shall, in consultation with the hospital community, determine the amount of funding for the nonfederal share of supplemental payments available for each reported emergency room encounter or inpatient day by dividing the total funds available by the total number of inpatient days or emergency visits in accordance with subparagraphs (A) and (B). (A) Seventy percent of the moneys in the fund shall be allocated for the nonfederal share of supplemental payments to private hospitals for approved out-of-network inpatient hospital emergency and poststabilization care, in accordance with Paragraph 63.f.ii of the Special Terms and Conditions of California’s Bridge to Reform Section 1115(a) Medicaid Demonstration (11-W-00193/9). (B) Thirty percent of the available funds shall be allocated for the nonfederal share of supplemental payments to private hospitals for approved out-of-network hospital emergency room services (excluding emergency room visits, in accordance with Paragraph 63.f.ii of the Special Terms and Conditions of California’s Bridge to Reform Section 1115(a) Medicaid Demonstration (11-W-00193/9), that resulted in an approved out-of-network inpatient hospital stay), provided that for any emergency room visit that results in a hospital stay for which a supplemental payment is available under subparagraph (A), no supplemental payment shall be available under this subparagraph. (C) The allocations and total available fund amount shall be adjusted as necessary so as to be consistent with the requirement in paragraph (1) of subdivision (g). (g) (1) The department shall obtain federal financial participation for moneys in the fund to the full extent permitted by federal law. Moneys shall be allocated from the fund by the department to be matched by federal funds in accordance with the Special Terms and Conditions for the Medicaid Demonstration, or pursuant to other federal approvals or waivers as necessary. (2) The department shall disburse moneys from the fund to the LIHPs in accordance with the calculations in subdivision (f) within 60 days after completing the calculations. The moneys shall be distributed to the LIHPs solely for purposes of funding the nonfederal portion of the supplemental out-of-network amounts determined for each service in subdivision (f) to out-of-network hospital emergency care services providers. (3) The LIHPs shall make the supplemental payments described in paragraph (2) within 30 days of receiving the nonfederal share from the department. (h) It is the intent of the Legislature that for each subject fiscal year, the first twenty million dollars ($20,000,000), or, for subject fiscal year 2013–14, the first ten million dollars ($10,000,000), of the nonfederal share for the emergency hospital services payments are funded with intergovernmental transfers described in paragraph (1) of subdivision (b). (i) This section shall be implemented only if, and to the extent that, both of the following conditions exist: (1) All necessary federal approvals have been obtained for the implementation of this section and federal financial participation is available. (2) The ability of the department to maximize federal funding is not jeopardized. (j) In designing and implementing the program for supplemental payments created under this section, the director shall have discretion, after consultation with the hospital community and the LIHPs, to modify timelines and to make modifications to the operational requirements of this section, but only to the extent necessary to secure federal approval or to ensure successful operation of the program and to effectuate the intent of this section. (k) Notwithstanding any other provision of this article or Article 5.229 (commencing with Section 14169.31), federal disapproval of the program developed pursuant to the requirements of this section shall not affect the implementation of the remainder of this article or Article 5.229 (commencing with Section 14169.31). (l) As an alternative to, and in lieu of, disbursing moneys from the fund to the LIHPs under this section, the department may make supplemental payments from the fund directly to hospitals as determined in accordance with subdivision (f) when federal financial participation is available for those payments. (Amended by Stats. 2012, Ch. 452, Sec. 5. (SB 920) Effective September 22, 2012. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.70.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The department may implement this article using provider bulletins, all plan letters, or similar instructions without regulatory action, and must notify specified legislative bodies within five working days after taking that action.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.70. Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this article by means of provider bulletins, all plan letters, or other similar instruction, without taking regulatory action. The department shall also provide notification to the Joint Legislative Budget Committee and to the fiscal and appropriate policy committees of the Legislature within five working days when the above-described action is taken in order to inform the Legislature that the action is being implemented. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.71.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The director may proportionately reduce certain supplemental or increased capitation payments if paying them would reduce other amounts owed because of federal law.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.71. Notwithstanding any other provision of this article, the director may proportionately reduce the amount of any supplemental payments or increased capitation payments under this article to the extent that the payment would result in the reduction of other amounts payable to a hospital or managed health care plan due to the application of federal law. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.72.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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This article becomes inoperative if certain federal, legislative, funding, litigation, or fund-use conditions occur.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.72. This article shall become inoperative if any of the following occurs: (a) The effective date of a final judicial determination made by any court of appellate jurisdiction or a final determination by the United States Department of Health and Human Services or the federal Centers for Medicare and Medicaid Services that the quality assurance fee established pursuant to this article, or Section 14169.54 or 14169.55, cannot be implemented. This subdivision shall not apply to any final judicial determination made by any court of appellate jurisdiction in a case brought by hospitals located outside the state. (b) The federal Centers for Medicare and Medicaid Services denies approval for, or does not approve on or before the last day of a program period, the implementation of Sections 14169.52, 14169.53, 14169.54, and 14169.55, and the department fails to modify Section 14169.52, 14169.53, 14169.54, or 14169.55 pursuant to subdivision (d) of Section 14169.53 in order to meet the requirements of federal law or to obtain federal approval. (c) The Legislature fails to appropriate moneys in the fund in the annual Budget Act, or fails to appropriate such moneys in a separate bill enacted within thirty (30) days following enactment of the annual Budget Act. (d) The department has sought but has not received federal financial participation for the supplemental payments and other costs required by this article for which federal financial participation has been sought. (e) A lawsuit related to this article is filed against the state and a preliminary injunction or other order has been issued that results in a financial disadvantage to the state. For purposes of this subdivision, “financial disadvantage to the state” means either of the following: (1) A loss of federal financial participation. (2) A net General Fund cost incurred due to the act. (f) The proceeds of the fee and any interest and dividends earned on deposits are not deposited into the fund or are not used as provided in Section 14169.53. (g) The proceeds of the fee, the matching amount provided by the federal government, and interest and dividends earned on deposits in the fund are not used as provided in Section 14169.68. (Amended November 8, 2016, by initiative Proposition 52, Sec. 4.1. Article 5.230, commencing with Section 14169.50, is conditionally inoperative as prescribed in this section. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.73.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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If the article becomes inoperative, hospitals generally do not have to pay the fee, and the director must issue, keep, publish, and distribute a declaration plus start a wind-down plan.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.73. In the event this article becomes inoperative pursuant to Section 14169.72, all of the following shall apply: (a) No hospital shall be required to pay the fee except for any fee owed prior to the article becoming inoperative. (b) The director shall execute a declaration stating that he or she has determined that the article is inoperative and shall state the basis for this determination. The director shall retain the declaration and provide a copy, within five working days of the execution of the declaration, to the fiscal and appropriate policy committees of the Legislature. In addition, the director shall post the declaration on the department’s Internet Web site and the director shall send the declaration to the Secretary of State, the Secretary of the Senate, the Chief Clerk of the Assembly, and the Legislative Counsel. (c) Upon execution of the declaration described in subdivision (b), the director shall implement a plan, in consultation with the hospital community and the Legislature, to wind down the program consistent with the purposes of the article, including the recoupment of payments made under this article if ordered by a court. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed by Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.74.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The Department of Finance must report a yearly budget estimate difference in General Fund benefit starting with the 2014–15 proposed budget.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.74. Beginning with the proposed budget for the 2014–15 fiscal year, and each fiscal year thereafter, the Department of Finance shall report in the Governor’s proposed budget and the May Revision the difference in General Fund benefit for the upcoming fiscal year resulting from this article and what was anticipated at the time the Budget Act of 2013 was enacted. It is the intent of the Legislature that additional General Fund benefit be appropriated to supplement, and not supplant, funding for health and human service programs, which may include the cost of medical interpreters. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Inoperative on date prescribed by Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.75.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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The listed subdivisions of Section 14167.35 are not repealed and stay operative while this article remains operative.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.75. Notwithstanding subdivision (k) of Section 14167.35, subdivisions (a), (i), and (j) of Section 14167.35, creating the fund, are not repealed and shall remain operative as long as this article remains operative. (Amended November 8, 2016, by initiative Proposition 52, Sec. 4.2. Inoperative on date prescribed in Section 14169.72. Repealed on January 1 after inoperative date, pursuant to Section 14169.76. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.76.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. )
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This article is repealed on January 1 of the year after it becomes inoperative.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.230. Medi-Cal Hospital Reimbursement Improvement Act of 2013 [14169.50 - 14169.76] ( Article 5.230 added by Stats. 2013, Ch. 657, Sec. 6. ) ## 14169.76. This article is repealed on January 1 of the year following the date on which the article becomes inoperative. (Added by Stats. 2013, Ch. 657, Sec. 6. (SB 239) Effective October 8, 2013. Repealed, by its own provisions, on January 1 after inoperative date prescribed in Section 14169.72. Note: Repeal affects Article 5.230, commencing with Section 14169.50. Note: See Section 3.5 of Article XVI of the Constitution, which was added on Nov. 8, 2016, by initiative Proposition 52.)
14169.8.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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Amounts paid under this article to private hospitals, and certain related payments, must not be counted when calculating specified payment limits or stabilization funding.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.8. (a) The amount of any payments made under this article to private hospitals, including the amount of payments made under Sections 14169.2, 14169.3, and 14169.7.5 and additional payments to private hospitals by managed health care plans pursuant to Section 14169.5, shall not be included in the calculation of the low-income percent or the OBRA 1993 payment limitation, as defined in paragraph (24) of subdivision (a) of Section 14105.98, for purposes of determining payments to private hospitals. (b) The amount of any payments made to a hospital under this article shall not be included in the calculation of stabilization funding under Article 5.2 (commencing with Section 14166) or any successor legislation, including legislation implementing California’s Bridge to Reform Section 1115(a) Medicaid Demonstration (11-W-00193/9). (Added by Stats. 2011, Ch. 286, Sec. 7. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14169.81.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.231. Medi-Cal Hospital Reimbursement Improvement and Restoration Act of 2013 [14169.81 - 14169.83] ( Article 5.231 added by Stats. 2013, Ch. 657, Sec. 7. )
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The department must set a calendar-year rate year for certain skilled nursing facilities starting January 1, 2024, seek needed federal approvals, and may implement the section through informal guidance instead of regulation.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.231. Medi-Cal Hospital Reimbursement Improvement and Restoration Act of 2013 [14169.81 - 14169.83] ( Article 5.231 added by Stats. 2013, Ch. 657, Sec. 7. ) ## 14169.81. (a) Notwithstanding Sections 14105.191 and 14105.192, reimbursement for services provided by skilled nursing facilities that are distinct parts of general acute care hospitals shall be determined, for dates of service on or after October 1, 2013, without application of the reductions and limitations set forth in Sections 14105.191 and 14105.192. (b) For dates of service on or after January 1, 2024, the department shall adopt a rate year based on the calendar year for skilled nursing facilities that are distinct parts of general acute care hospitals, including subacute care units. (c) In implementing this section, the department shall seek any federal approvals it deems necessary. This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. (d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement this section by means of provider bulletins or notices, policy letters, or other similar instructions, without taking regulatory action. (Amended by Stats. 2023, Ch. 42, Sec. 155. (AB 118) Effective July 10, 2023.)
14169.82.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.231. Medi-Cal Hospital Reimbursement Improvement and Restoration Act of 2013 [14169.81 - 14169.83] ( Article 5.231 added by Stats. 2013, Ch. 657, Sec. 7. )
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The department must consult, develop proposed fee-program modifications, give advance notice before implementing them, and pay managed care plan rate range increases subject to stated conditions. Medi-Cal managed care plans must pass those increases through as additional payments to specified hospitals.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.231. Medi-Cal Hospital Reimbursement Improvement and Restoration Act of 2013 [14169.81 - 14169.83] ( Article 5.231 added by Stats. 2013, Ch. 657, Sec. 7. ) ## 14169.82. (a) In consultation with the hospital community, as defined in Section 14169.51, the department shall develop proposed modifications to the quality assurance fee program under Article 5.230 (commencing with Section 14169.50) to collect additional fees solely designated for use under this section. In addition, the department shall consult with the hospital community to enable intergovernmental transfers from nondesignated public hospitals solely designated for use under this section. The department shall notify the Joint Legislative Budget Committee and fiscal and appropriate policy committees 30 working days prior to implementing a modification pursuant to this section. (b) To the extent federal financial participation is not jeopardized and consistent with federal law, and subject to the conditions set forth in subdivision (c), the department shall pay Medi-Cal managed care plans rate range increases, as defined by paragraph (4) of subdivision (b) of Section 14301.4, for the purpose of increasing payments to private hospitals and nondesignated public hospitals in counties that do not have designated public hospitals. Nondesignated public hospitals shall be given priority relative to accessing rate range funds in counties where a nondesignated public hospital is the only public hospital. (c) Payments to Medi-Cal managed care plans pursuant to subdivision (b) are conditioned on both of the following: (A) The Medi-Cal managed care plan shall pay all of the rate range increases provided under this section as additional payments to private hospitals and nondesignated public hospitals for providing and making available services to Medi-Cal enrollees of the plan. (B) The amount of the increases to Medi-Cal managed care plans shall be limited to the total amount of payments possible, including federal financial participation, based on the amount of fees actually collected and intergovernmental transfers actually provided pursuant to subdivision (a) as the nonfederal share for these payments. (Added by Stats. 2013, Ch. 657, Sec. 7. (SB 239) Effective October 8, 2013.)
14169.83.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.231. Medi-Cal Hospital Reimbursement Improvement and Restoration Act of 2013 [14169.81 - 14169.83] ( Article 5.231 added by Stats. 2013, Ch. 657, Sec. 7. )
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The director must describe a process for certain out-of-state acute care hospitals serving Medi-Cal beneficiaries to opt in to pay the quality assurance fee and receive supplemental payments. The department must use reliable data for estimates and projections, and the director may change the procedure as needed to comply with law.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.231. Medi-Cal Hospital Reimbursement Improvement and Restoration Act of 2013 [14169.81 - 14169.83] ( Article 5.231 added by Stats. 2013, Ch. 657, Sec. 7. ) ## 14169.83. To the extent permitted by federal law and other federal requirements, the director shall develop and describe in provider bulletins and on the department’s Internet Web site a process by which a private general acute care hospital located outside the state that serves Medi-Cal beneficiaries may opt in to pay the quality assurance fee on all applicable categories of patient days and receive supplemental payments for the Medi-Cal program patient days pursuant to Article 5.230 (commencing with Section 14169.50), in the same manner that the hospital could participate if it were located in the state. Notwithstanding Section 14169.51, the department shall rely on reliable data to make reasonable estimates or projections made with respect to the hospital as to the data, including, but not limited to, the days data source, used for the following: acute psychiatric days, annual fee-for-service days, annual managed care days, annual Medi-Cal days, fee-for-service days, general acute care days, high acuity days, managed care days, Medi-Cal days, Medi-Cal fee-for-service days, Medi-Cal managed care days, Medi-Cal managed care fee days, outpatient base amount, and transplant days, used to calculate the fees due and the supplemental payments. The director may modify the procedure set forth in this section to the minimum extent necessary to comply with applicable law, in consultation with the hospital community as defined in Section 14169.51. (Added by Stats. 2013, Ch. 657, Sec. 7. (SB 239) Effective October 8, 2013.)
14169.9.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. )
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Hospital payments under this article are not made for any part of a fiscal year when the hospital is closed.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.228. Medi-Cal Hospital Provider Rate Improvement Act of 2011 [14169.1 - 14169.19] ( Article 5.228 added by Stats. 2011, Ch. 286, Sec. 7. ) ## 14169.9. The payments to a hospital under this article shall not be made for any portion of a subject fiscal year during which the hospital is closed. A hospital shall be deemed to be closed on the first day of any period during which the hospital has no acute inpatients for at least 30 consecutive days. Payments under this article to a hospital that is closed during any portion of a subject fiscal year shall be reduced by applying a fraction, expressed as a percentage, the numerator of which shall be the number of days during the applicable subject fiscal year that the hospital is closed and the denominator of which shall be 365. (Added by Stats. 2011, Ch. 286, Sec. 7. (SB 335) Effective September 16, 2011. Conditionally inoperative as provided in Sections 14169.13 (subd. (c), para. (1)) and 14169.40, or on date prescribed in Section 14169.16. Repealed on or after January 1, 2015, as provided in Section 14169.16.)
14170.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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The department must audit certain Medi-Cal payments and reported costs, and some providers must keep records for audit review.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14170. (a) (1) Amounts paid for services provided to Medi-Cal beneficiaries shall be audited by the department in the manner and form prescribed by the department. The department shall maintain adequate controls to ensure responsibility and accountability for the expenditure of federal and state funds. Cost reports and other data submitted by providers to a state agency for the purpose of determining reasonable costs for services or establishing rates of payment shall be considered true and correct unless audited or reviewed by the department within 18 months after July 1, 1969, the close of the period covered by the report, or after the date of submission of the original or amended report by the provider, whichever is later. Moreover the cost reports and other data for cost reporting periods beginning on January 1, 1972, and thereafter shall be considered true and correct unless audited or reviewed within three years after the close of the period covered by the report, or after the date of submission of the original or amended report by the provider, whichever is later. (2) (A) Nothing in this section shall be construed to limit the correction of cost reports or rates of payment when inaccuracies are determined to be the result of intent to defraud, or when a delay in the completion of an audit is the result of willful acts by the provider or inability to reach agreement on the terms of final settlement. (B) Nothing in this section shall be construed to preclude the department from further review of cost reports and other data for cost reporting periods beginning on January 1, 1998, after the three-year period contained in paragraph (1) of subdivision (a), where after the three-year period the department discovers information not customarily contained in these cost reports and other data for the fiscal periods in question that indicates the provider may have engaged in practices that have resulted in overreimbursement. (3) Notwithstanding any other provision of law, nursing facilities and all categories of intermediate care facilities for the developmentally disabled which have received and are receiving funds for salary increases pursuant to Sections 14110.6 and 14110.7 shall maintain payroll and personnel records for examination by auditors from the department and the Labor Commissioner beginning March 1985 until the records have been audited, or until December 31, 1992, whichever occurs first. (b) Notwithstanding any other provision of law, costs reported for reimbursement purposes relative to Medi-Cal beneficiaries in nursing facilities that are distinct parts of acute care hospitals shall be audited by the department at least annually. The audits may be performed on a sample basis and, when the sample is statistically reliable, as determined by the department, may be used for ratesetting purposes. (Amended by Stats. 2000, Ch. 322, Sec. 32. Effective January 1, 2001.)
14170.1.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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Before a payment demand is issued, underpayments must be credited against overpayments, and providers must give documentation if they claim an underpayment.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14170.1. (a) Prior to the issuance to a provider of pharmaceutical services of any demand for payment pursuant to an audit or examination conducted under Sections 10722 and 14170, the amount of any underpayment to the provider for validly submitted claims or for valid claims which have inadvertently not been submitted and which arose during the audit period shall be determined and credited toward the amount of any overpayment due to the department. This section shall apply to all audits and examinations conducted under Sections 10722 and 14170 relative to amounts paid during the audit period for services provided to Medi-Cal beneficiaries. No audit may be reopened to provide for underpayments in which a final decision has been reached pursuant to Section 14171 or in which a certificate has been filed pursuant to Section 14172. (b) When a provider of pharmaceutical services asserts that a claim has been underpaid for purposes of receiving a credit against overpayments, as authorized by this section, the provider shall submit to the department information and documentation sufficient to resolve any dispute as to whether such claim was in fact underpaid. (c) For purposes of this section, the term “underpayments” shall include errors made by the pharmacist and errors made by the fiscal intermediary in determining payments for claims submitted within the billing time limits specified in Section 14115. (Amended by Stats. 1986, Ch. 562, Sec. 1.)
14170.10.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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Providers generally may not submit certain Medi-Cal claims unless they have the required order or prescription records; the department and director also have notice-and-implementation powers and duties.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14170.10. (a) No provider shall submit a claim to the department or its fiscal intermediaries for the dispensing or furnishing of a controlled drug, a dangerous drug, or a dangerous device, or a drug or device requiring a written order or prescription for the drug or device to be covered under the Medi-Cal program or for the performance of a clinical laboratory test or examination, unless the provider’s records contain an order authorized by Section 4019 of the Business and Professions Code, or a prescription, including an electronic transmission prescription, signed by the person lawfully authorized by his or her practice act to prescribe or order the dispensing or furnishing of that drug or device to, or for the performance of a clinical laboratory test or examination that meets the federal CLIA standard for test requisition as set forth in Section 493.1241 of Title 42 of the Code of Federal Regulations upon, a Medi-Cal beneficiary, except the following: (1) Providers who are physicians, clinics, hospitals, or other nonpharmacists and who are legally authorized to dispense or furnish drugs or devices directly to their patients, may in lieu of the requirements of this subdivision include a notation in their patients’ medical charts reflecting they have dispensed or furnished the drug or device directly to the patient as authorized by the Business and Professions Code. (2) Anatomical pathology examinations may be ordered by physicians by notation within the patients medical record during inpatient or outpatient surgery provided that these examinations comply with federal CLIA requirements. Any claims made contrary to this section shall be subject to recovery as overpayments. (3) If obtaining a biological specimen is required in order that a test or examination occurs on a periodic basis within an established provider-patient relationship or the furnishing or dispensing of drugs or devices occurs on a periodic basis within an established provider-patient relationship, the provider shall only be required to retain the order or requisition upon obtaining the biological specimen necessary for the initial test or examination or initial furnishing or dispensing of the drug or device, so long as an appropriate record of each test or examination, or furnishing or dispensing, is entered in the patient’s chart. (b) For purposes of this section: (1) “Signed” shall include a signature that meets the conditions of the Electronic Signature in Global and National Commerce Act (15 U.S.C. Sec. 7001). (2) “Controlled substance” shall mean any substance listed in Chapter 2 (commencing with Section 11053) of Division 10 of the Health and Safety Code. (3) “Dangerous drug” or “dangerous device” has the same meaning as in Section 4022 of the Business and Professions Code. (4) “Drug or device” means: (A) “Drug,” as defined in Section 4025 of the Business and Professions Code. (B) “Device,” as defined in Section 4023 of the Business and Professions Code. (C) Pharmaceuticals, medical equipment, medical supplies, orthotics and prosthetics appliances, and other product-like supplies or equipment. (5) “Prescription” has the same meaning as in Section 4040 of the Business and Professions Code. (6) “Electronic transmission prescription” includes both image and data prescriptions. (7) “Electronic image transmission prescription” means any prescription order for which a facsimile of the order is received by a pharmacy or other appropriate provider from a licensed prescriber and that is reduced to writing and processed by the pharmacy or other appropriate provider in accordance with applicable provisions of the Business and Professions Code, including Section 4070. (8) “Electronic data transmission prescription” means any prescription order, other than an electronic image transmission prescription, that is electronically transmitted from a licensed prescriber to a pharmacy or other appropriate provider and which is reduced to writing and processed by the pharmacy or other appropriate provider in accordance with applicable provisions of the Business and Professions Code, including Section 4070. The use of commonly used abbreviations shall not invalidate an otherwise valid prescription. (9) “Clinical laboratory test or examination” means the detection, identification, measurement, evaluation, correlation, monitoring, and reporting of any particular analyte, entity, or substance within a biological specimen for the purpose of obtaining scientific data that may be used as an aid to ascertain the presence, progress, and source of a disease or physiological condition in a human being, or used as an aid in the prevention, prognosis, monitoring, or treatment of a physiological or pathological condition in a human being, or for the performance of nondiagnostic tests for assessing the health of an individual. (c) Notwithstanding any other provision of law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific this section by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of this section, including all of the following: (1) Notifying provider representatives of the proposed action or change. The notice shall occur at least 10 business days prior to the meeting provided for in paragraph (2). (2) Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the action or change. (3) Allowing for written input regarding the action or change. (4) Providing at least 30 days’ advance notice on the effective date of the action or change. (Added by Stats. 2003, Ch. 601, Sec. 16. Effective January 1, 2004.)
14170.11.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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Claims for Medi-Cal reimbursement for nerve conduction tests or electromyography may not be submitted unless the submitter’s records include a required residency certificate or diploma copy for each person performing the test.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14170.11. (a) No person or entity shall submit a claim to the department or its fiscal intermediaries for reimbursement under the Medi-Cal program for a nerve conduction test or for electromyography unless the person or entity’s records contains a copy, for each person performing each test or electromyography, for which a claim is submitted, a certificate or diploma of satisfactory completion of a neurology or physical medicine and rehabilitation residency program accredited by the Accreditation Council of Graduate Medical Education (ACGME). (b) The department may identify by publication, in provider bulletins or similar instructions, requirements that reimbursement from the Medi-Cal program shall only be made for the provision of certain procedures, tests, examinations, or other medical services provided by persons who possess a particular level of education, experience, and training as evidenced by satisfactory completion of medical residency programs or board certification in a particular field and that those submitting claims shall maintain a copy of this certificate or diploma. (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific, this section by means of all county letters, provider bulletins, or similar instructions. Thereafter, the department may adopt regulations in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. (Added by Stats. 2004, Ch. 228, Sec. 25. Effective August 16, 2004.)
14170.12.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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The State Department of Health Care Services may contract with eligible Medicaid Recovery Audit Contractors, despite Government Code Section 19130.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14170.12. Effective January 1, 2012, and notwithstanding Section 19130 of the Government Code, the State Department of Health Care Services may enter into contracts with one or more eligible Medicaid Recovery Audit Contractors (RACs) pursuant to Section 1396a(a)(42)(B) of Title 42 of the United States Code. (Added by Stats. 2012, Ch. 797, Sec. 26. (SB 1529) Effective January 1, 2013.)
14170.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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Provider reimbursement claims cannot be kept under special claims review for more than nine months unless the department shows cause, and the department must give the provider reasons for any extended review.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14170.5. (a) No provider’s claims for reimbursement under this chapter shall be subject to any special claims review procedure for a period in excess of nine months unless the department shows cause why the provider’s claims for reimbursement should continue to be subject to special claims review procedures. (b) The department shall provide notice to a provider of its reasons for determining that the provider shall be subject to extended special claims review. (Added by Stats. 1987, Ch. 608, Sec. 1.)
14170.8.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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Primary suppliers of pharmaceuticals, medical equipment, or supplies must keep accounting records showing their acquisition and sale of those items, and keep those records for 10 years. The records may be audited by the department or its agents, and certain clinics and registered prescription-drug manufacturers are exempt.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14170.8. (a) Notwithstanding any other provision of law, every primary supplier of pharmaceuticals, medical equipment, or supplies shall maintain accounting records to demonstrate the manufacture, assembly, purchase, or acquisition and subsequent sale, of any pharmaceuticals, or medical equipment, or supplies to providers, as defined in Section 14043.1. Accounting records shall include, but not be limited to, inventory records, general ledgers, financial statements, purchase and sales journals and invoices, prescription records, bills of lading, and delivery records. For purposes of this section the term “primary suppliers” shall mean any manufacturer, principal labeler, assembler, wholesaler, or retailer. (b) Accounting records maintained pursuant to subdivision (a) shall be subject to audit or examination by the department or its agents. This audit or examination may include, but is not limited to, verification of what was claimed by the provider. These accounting records shall be maintained for 10 years from the date of sale or the date of service. (c) This section shall not apply to any clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code or to any manufacturer of prescription drugs registered with the federal Food and Drug Administration in accordance with Section 510 of the Food, Drug, and Cosmetic Act (21 U.S.C. Sec. 360). (Amended by Stats. 2022, Ch. 47, Sec. 125. (SB 184) Effective June 30, 2022.)
14171.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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The director must set up administrative appeal processes for certain audit and examination disputes, and the department must meet several hearing, decision, mailing, and interest deadlines.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14171. (a) The director shall establish administrative appeal processes to review grievances or complaints arising from the findings of an audit or examination made pursuant to Sections 10722 and 14170 and for final settlements, including, in the case of hospitals, the application of Sections 51536, 51537, and 51539 of Title 22 of the California Code of Regulations. All these processes shall be established by regulation, pursuant to, and consistent with, Section 100171 of the Health and Safety Code. (b) Different administrative appeal processes may be established by the director for grievances or complaints arising from the determinations of a tentative or final settlement based on audit or examination findings made by or on behalf of the department pursuant to Sections 10722 and 14170. However, consistent with existing practice, no administrative appeal shall be available for tentative settlement of cost reports. (c) The administrative appeal process established by the director for tentative settlements, including, in the case of hospitals, the application of Sections 51536, 51537, and 51539 of Title 22 of the California Code of Regulations shall be an informal process which, however, guarantees a provider the right to present any grievance or complaint to the department in writing. Any subsequent hearings shall be conducted in an informal manner and shall be held at the discretion of the department. (d) The time limitations in subdivisions (e) and (f) for the impartial hearing and the final decisions are mandatory. If the department fails to conduct the hearing or to adopt a final decision thereon within the time limitations provided in subdivisions (e) and (f), the amount of any overpayment which is ultimately determined by the department to be due shall be reduced by 10 percent for each 30-day period, or portion thereof, that the hearing or the decision, or both, are delayed beyond the time limitations provided in subdivisions (e) and (f). However, the time period shall be extended by either of the following: (1) Delay caused by a provider. (2) Extensions of time granted a provider at its sole request or at the joint request of the provider and the department. (e) (1) The administrative appeal process established by the director shall commence with an informal conference with the provider, a representative of the department, and the administrative law judge. The informal conference shall be conducted no later than 90 days after the filing of a timely and specific statement of disputed issues by the provider. The administrative law judge, when appropriate, may assign the administrative appeal to an informal level of review where efforts could be made to resolve facts and issues in dispute in a fair and equitable manner, subject to the requirements of state and federal law. The review conducted at this informal level shall be completed no later than 180 days after the filing of a timely and specific statement of disputed issues by the provider. (2) Nothing in this subdivision shall prohibit the provider from presenting any unresolved grievances or complaints at an impartial hearing pursuant to subdivision (a). The impartial hearing shall be conducted no later than 300 days after the filing of a timely and specific statement of disputed issues by the provider. (3) (A) Subject to subdivision (f), a final decision in a noninstitutional provider appeal shall be adopted within 180 days after the closure of the record of the impartial hearing, and a final decision in an institutional provider appeal shall be adopted within 300 days after the closure of the record of the impartial hearing. (B) The department shall mail a copy of the adopted decision to all parties within 30 days of the date of adoption of the decision. (f) In the event the director intends to modify a proposed decision, on or before the 180th day following the closure of the record of the hearing for noninstitutional providers or the 300th day following the closure of the record of the hearing for institutional providers, the director shall provide written notice of his or her intention to the parties and shall afford the parties an opportunity to present written argument. Following this notice, on or before the 240th day following the closure of the record of the hearing for noninstitutional providers or the 420th day following closure of the record of the hearing for institutional providers, or within that additional time period as is granted pursuant to the sole request of a provider or at the joint request of the provider and the department, the director shall issue a final decision. (g) In the event recovery of a disallowed payment has been made by the department, a provider who prevails in an appeal of a disallowed payment shall be entitled to interest at the rate equal to the monthly average received on investments in the Surplus Money Investment Fund, or simple interest at the rate of 7 percent per annum, whichever is higher, commencing on the date the appeal is formally accepted by the department or the date payment is received by the department, whichever is later. (h) Except as provided in subdivision (i), commencing 60 days after issuance of the first statement of account status or demand for repayment resulting from an audit or examination made pursuant to Sections 10722 and 14170, interest at the rate equal to the monthly average received on investments in the Surplus Money Investment Fund during the month the first statement of account status or demand for repayment was issued, or simple interest at the rate of 7 percent per annum, whichever is higher, shall be assessed against any unrecovered overpayment due to the department. (i) (1) Commencing on the day following the last day of the period covered by an audit or examination made pursuant to Sections 10722 and 14170, interest at the rate established under Section 19269 of the Revenue and Taxation Code which is in effect on the date of the commencement of that interest shall be assessed against any unrecovered overpayment due to the department by providers of durable medical equipment or incontinence supplies. (2) Interest which accrues under this subdivision for recoupment of an overpayment based on the lack of medical necessity for a previously approved claim shall commence to accrue on the date of written demand by the department. (j) The final decision of the director shall be reviewable in accordance with Section 1094.5 of the Code of Civil Procedure within six months of the issuance of the director’s final decision. (Amended by Stats. 2012, Ch. 23, Sec. 108. (AB 1467) Effective June 27, 2012.)
14171.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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Some health care providers must repay improper reimbursements and may owe interest, audit costs, and penalties if claims are found unsupported or fraudulent.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14171.5. Any institutional provider of health care services that obtained reimbursement under this chapter to which it is not entitled shall be subject to the following interest charges or penalties: (a) When it is established upon audit that the provider has claimed payments under this chapter to which it is not entitled, the provider shall pay, in addition to the amount improperly received, interest at the rate specified by subdivision (h) of Section 14171. (b) When it is established upon audit that the provider claimed payments related to services or costs that the department had previously notified the provider in an audit report that the costs or services were not reimbursable, the provider shall pay in addition to the amount improperly claimed, a penalty of 10 percent of the amount improperly claimed after this notice, plus the cost of the audit. In addition, interest shall be assessed at the rate specified in subdivision (h) of Section 14171. Providers who wish to preserve appeal rights or to challenge the department’s positions regarding appeal issues, may claim the cost or services and not be reimbursed therefor if they are identified and presented separately on the cost report. (c) When it is established that the provider fraudulently claimed and received payments under this chapter, the provider shall pay a penalty of 25 percent of the amount improperly claimed, plus the cost of the audit, in addition to the amount thereof. In addition, interest will be assessed at the rate specified by subdivision (h) of Section 14171. A fraudulent claim is a claim upon which the provider has been convicted of fraud upon the program. Nothing in this section shall prevent the imposition of any other civil or criminal penalties to which the provider may be liable. (d) Appeals to action taken in subdivisions (a), (b), and (c) of Section 14171.5 above are subject to the administrative appeals process provided by Section 14171. (e) Penalties paid by providers under subdivisions (a), (b), and (c) of Section 14171.5 are not reimbursable by the program. (f) As used in this section, “the cost of the audit” includes actual hourly wages, travel, and incidental expenses at rates allowable by Department of General Services rules, and applicable overhead costs. (Amended by Stats. 2016, Ch. 31, Sec. 283. (SB 836) Effective June 27, 2016.)
14171.6.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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Providers that improperly claim or receive Medi-Cal reimbursements can owe interest, audit costs, and penalties; the department must pay interest when a provider was underpaid, and some providers are excluded from this section.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14171.6. (a) (1) Any provider, as defined in paragraph (3), that obtains reimbursement under this chapter to which it is not entitled shall be subject to interest charges or penalties as specified in this section. (2) When it is established upon audit that the provider has not received reimbursement to which the provider is entitled, the department shall pay the provider interest assessed at the rate, and in the manner, specified in subdivision (g) of Section 14171. (3) For purposes of this section, “provider” means any provider, as defined in Section 14043.1. (b) When it is established upon audit that the provider has claimed payments under this chapter to which it is not entitled, the provider shall pay, in addition to the amount improperly received, interest at the rate specified by subdivision (h) of Section 14171. (c) (1) When it is established upon audit that the provider claimed payments related to services or costs that the department had previously notified the provider in an audit report that the costs or services were not reimbursable, the provider shall pay, in addition to the amount improperly claimed, a penalty of 10 percent of the amount improperly claimed after receipt of the notice, plus the cost of the audit. (2) In addition to the penalty and costs specified by paragraph (1), interest shall be assessed at the rate specified in subdivision (h) of Section 14171. (3) Providers that wish to preserve appeal rights or to challenge the department’s positions regarding appeal issues may claim the costs or services and not be reimbursed therefor if they are identified and presented separately on the cost report. (d) (1) When it is established that the provider fraudulently claimed and received payments under this chapter, the provider shall pay, in addition to that portion of the claim that was improperly claimed, a penalty of 300 percent of the amount improperly claimed, plus the cost of the audit. (2) In addition to the penalty and costs specified by paragraph (1), interest shall be assessed at the rate specified by subdivision (h) of Section 14171. (3) For purposes of this subdivision, a fraudulent claim is a claim upon which the provider has been convicted of fraud upon the Medi-Cal program. (e) Nothing in this section shall prevent the imposition of any other civil or criminal penalties to which the provider may be liable. (f) Any appeal to any action taken pursuant to subdivision (b), (c), or (d) is subject to the administrative appeals process provided by Section 14171. (g) As used in this section, “cost of the audit” includes actual hourly wages, travel, and incidental expenses at rates allowable by rules adopted by the Department of General Services and applicable overhead costs that are incurred by employees of the state in administering this chapter with respect to the performance of audits. (h) This section shall not apply to any clinic licensed pursuant to subdivision (a) of Section 1204 of the Health and Safety Code, clinics exempt from licensure under Section 1206 of the Health and Safety Code, health facilities licensed under Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code, or to any provider that is operated by a city, county, or school district. (Amended by Stats. 2016, Ch. 31, Sec. 284. (SB 836) Effective June 27, 2016.)
14172.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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The director may file a certificate to recover an overpayment, and the clerk must enter judgment when it is filed. Certain judicial review timing can stop filing or require lien release.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14172. (a) Except as provided in subdivision (b), if any amount is due and payable and unpaid as the result of an overpayment to a provider of health care services, durable medical equipment, or incontinence supplies identified through an audit or examination conducted by or on behalf of the director, and the findings of the audit or examination are completed and no appeal is taken or the director has issued a final decision on the appeal pursuant to Section 14171, and 90 days have elapsed from the completion of that audit or examination or issuance of that final decision on appeal, the director may, not later than three years after the payment became due and owing, file in the office of the Clerk of the Superior Court of Sacramento County, and with the clerk of the superior court of the county in which the provider has its principal place of business, a certificate containing the following: (1) Interest, as prescribed by Section 14171. (2) A statement that the director has complied with this article prior to the filing of the certificate. (3) A request that judgment be entered against the provider in the amount set forth in the certificate. The clerk immediately upon the filing of the certificate shall enter a judgment for the State of California against the provider in the amount set forth in the certificate. The judgment may be filed by the clerk in a looseleaf book entitled “Health Care Overpayment Recovery Judgments.” (b) If the provider seeks judicial review of the final decision of the director pursuant to subdivision (k) of Section 14171 and notice of that action is properly served on the director within 90 days of the issuance of the final decision of the director, the director shall not file any certificate as provided in subdivision (a). If the provider does not seek judicial review of the final decision of the director pursuant to subdivision (k) of Section 14171 and does not properly serve notice within 90 days from the date of the final decision of the director, the director may file the certificate provided in subdivision (a). If the provider seeks judicial review of the final decision of the director more than 90 days from the date of the decision in accordance with subdivision (k) of Section 14171, the director shall within 10 days after receiving notice of that action release any lien imposed pursuant to this article and any judgment entered is for all purposes null and void. (Amended by Stats. 2003, Ch. 62, Sec. 333. Effective January 1, 2004.)
14172.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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The department must issue an account status or repayment demand within 60 days after an audit or examination, and it must wait 60 more days before liquidating an overpayment or penalty.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14172.5. (a) No later than 60 days after the completion of an audit or examination pursuant to Sections 10722 and 14170, the department shall issue the first statement of account status or demand for repayment. (b) (1) Notwithstanding the provisions of Section 14172 or any other law, when it is established that an overpayment has been made to a provider or a civil money penalty assessed pursuant to Section 14123.2, 14123.25, 14171.5, or 14171.6 is due from a provider, the department shall not begin liquidation of the overpayment until 60 days after issuance of the first statement of accountability or demand for repayment after issuance of the audit or examination report establishing the overpayment or the document establishing the penalty. The department shall pursue liquidation of the overpayment or penalty upon expiration of the 60-day period. If the department finds, upon appeal, that no overpayment was made to, or no penalty is due from, the provider, the department shall repay the amount collected, together with the payment of interest thereon, from the date occurring 60 days after issuance of the first statement of accountability or demand for repayment after issuance of the audit or examination report alleging the overpayment or the document establishing the penalty. (2) This subdivision shall not be construed so as to affect the department’s authority under other provisions of law for liquidation of overpayments to providers. (c) Liquidation of the overpayment or penalty may be by any of the following: (1) Lump-sum payment by the provider. (2) Offset against current payments due to the provider. (3) A repayment agreement executed between the provider and the department. (4) Any other method of recovery available to and deemed appropriate by the director. (d) An offset against current payments shall continue until one of the following occurs: (1) The overpayment or penalty is recovered. (2) The department enters into an agreement with the provider for repayment of the overpayment or penalty. (3) The department determines, upon appeal, that there is no overpayment or that the penalty should not have been assessed. (e) The provider shall pay interest on any unrecovered overpayments or penalty assessments as provided by subdivision (h) of Section 14171. If recovery of a disallowed payment has been made by the department, a provider who prevails in an appeal of a disallowed payment or penalty assessment shall be paid interest as provided by subdivision (g) of Section 14171. (f) Nothing in this section shall prohibit a provider from repaying all or a part of the disputed overpayment or penalty assessment without prejudice to the provider’s right to a hearing pursuant to subdivision (b) of Section 14171 or pursuant to Section 100171 of the Health and Safety Code. (g) If a provider appeals the assessment of a civil money penalty, liquidation of the penalty shall be deferred until the appeal is rejected or a final administrative decision is issued. (h) If on the basis of reliable evidence, the department has a valid basis for believing that, with respect to a provider, proceedings have been or will shortly be instituted in a state or federal court for purposes of determining whether the provider is insolvent or bankrupt under appropriate state or federal law, or that a provider is or will shortly be taking action which reasonably might seriously hinder or defeat the department’s ability to collect overpayments in the future, the department may immediately adjust any payments to the provider to a level necessary to insure that no overpayment to the provider is made. (Amended by Stats. 2003, Ch. 601, Sec. 17. Effective January 1, 2004.)
14173.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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A judgment abstract may be recorded to create a lien on the provider’s property, and the lien lasts 10 years unless released or discharged.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14173. An abstract of a judgment obtained pursuant to subdivision (a) of Section 14172 or a copy thereof may be recorded with the county recorder of any county. From the time of recording, the judgment shall constitute a lien upon all real or personal property of the provider in that county owned by the provider at the time, or which the provider may afterwards but before the lien expires, acquire. The lien shall have the force, effect and priority of a judgment lien and shall continue for 10 years from the time of recording of the abstract of judgment obtained pursuant to subdivision (a) of Section 14172 unless sooner released or otherwise discharged. The lien may, within 10 years from the date of recording of the abstract of judgment or within 10 years from the date of the last extension of the lien in the manner herein provided, be extended by recording a new abstract in the office of the county recorder of any county. From the date of such recording the lien shall be extended for 10 years unless sooner released or otherwise discharged. Execution shall issue upon such a judgment upon request of the director in the same manner as execution may issue upon other judgments. Sale shall be held under such execution as prescribed in the Code of Civil Procedure. In all proceedings under this section, the director or his authorized agents may act on behalf of the state. (Amended by Stats. 1982, Ch. 328, Sec. 43. Effective June 30, 1982.)
14174.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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The director may use the summary judgment procedure in this article, and that option is additional to any other collection procedure available.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14174. The right of the director to use the summary judgment procedure contained in this article shall be in addition to any other collection procedure available to him. No action taken by the director shall be construed to be an election to pursue the summary judgment procedure to the exclusion of any other collection procedure. (Amended by Stats. 1978, Ch. 429.)
14175.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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The director may release a lien if the related liability, including accrued interest, has been paid or is legally unenforceable.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14175. The director may release any lien imposed pursuant to subdivision (a) of Section 14172 if he finds that the liability represented by the lien, including any interest accrued thereon, has been paid or is legally unenforceable. (Amended by Stats. 1978, Ch. 429.)
14176.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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The director may recover a due and payable overpayment from a provider, including by a repayment agreement or other legal means.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14176. The director may recover a due and payable overpayment made to a provider which is or has been participating under the provisions of this chapter by means of a repayment agreement executed between such provider and the director, and by any other means available at law. (Amended by Stats. 1978, Ch. 429.)
14176.5.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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If a department audit finds a Medi-Cal overpayment to a qualifying hospital, the department may forgive all or part of the debt and interest.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14176.5. Whenever it has been determined, pursuant to an audit conducted by the department, that an overpayment for Medi-Cal services has been made to a hospital for services rendered from January 1, 1992, to December 31, 1997, the department may forgive all or part of the debt arising from the overpayment, and interest, if the hospital is all of the following: (a) A disproportionate share hospital, as defined in Section 14105.98. (b) Located in Kern County or Monterey County. (c) A nonprofit hospital, as defined in Section 127050 of the Health and Safety Code, or not affiliated with a hospital system. (Added by Stats. 2001, Ch. 649, Sec. 2. Effective January 1, 2002.)
14177.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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If a participating health care provider has been determined to owe an overpayment that is due and payable, the director may recover it by offsetting amounts currently due to the provider.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14177. When it has been determined that a provider of health care services participating under the provisions of this chapter has received an overpayment which is due and payable, the director may recover such overpayment by offset against any amount currently due to a provider under the provisions of this chapter or Chapter 8 (commencing with Section 14200) of this part. (Added by Stats. 1977, Ch. 1046.)
14178.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. )
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Counties are protected from recoupment of certain state funds for pre-July 1, 1982 acts, but they still remain liable for the federal share unless that liability is waived.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.3. Audit, Appeal, and Recovery of Overpayments [14170 - 14178] ( Article 5.3 added by Stats. 1977, Ch. 1046. ) ## 14178. (a) Counties shall be held harmless in accordance with the provisions of this section for state funds to be recouped pursuant to audit exceptions issued for acts performed prior to July 1, 1982. (b) Audit exception for the purpose of this section shall be defined as follows: Demands for recovery resulting from those audit reports issued by the Department of Health Services in which no final settlement or administrative decision adopted by the director has been arrived at prior to the effective date of this section. (c) Such forgiveness of audit exceptions shall apply only to the state’s share of payments made in support of the Medi-Cal program. Counties shall retain liability for payment of the federal portion of payments made for Medi-Cal services unless and until the federal government agrees to waive their rights for repayment of federal share. (d) Audit exceptions regarding county claims related to nonprogram benefits shall remain unaffected by the provisions of the section. County claims for nonprogram benefits shall include claims for return on equity, claims for bad debts, claims for uncompensated care, and any other claims not compensable pursuant to Title XIX of the federal Social Security Act. (e) The amount of the recoupment of the federal portion of valid audit exceptions pursuant to subdivision (c) shall be determined pursuant to the existing administrative appeals process. (f) No provision of this section shall apply to any audit report issued by the Department of Health Services after the effective date of this section relating to acts performed subsequent to July 1, 1982. (Amended by Stats. 1982, Ch. 1594, Sec. 66. Effective September 30, 1982.)
14180.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. )
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The department must seek federal approval for a waiver or demonstration project and follow several conditions before implementing it.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. ) ## 14180. (a) The department shall submit an application to the federal Centers for Medicare and Medicaid Services for a waiver or a demonstration project to implement all of the following: (1) Strengthen California’s health care safety net, which includes disproportionate share hospitals, for low-income and vulnerable Californians. (2) Maximize opportunities to reduce the number of uninsured individuals. (3) Optimize opportunities to increase federal financial participation and maximize financial resources to address uncompensated care. (4) Promote long-term, efficient, and effective use of state and local funds. (5) Improve health care quality and outcomes. (6) Promote home-and community-based care. (b) The waiver or demonstration project shall include proposals to restructure the organization and delivery of services to be more responsive to the health care needs of Medi-Cal enrollees for the purpose of providing the most vulnerable Medi-Cal beneficiaries with access to better coordinated and integrated care that will improve their health outcomes, slow the long-term growth of the Medi-Cal program, and continue support for the safety net care system and the persons who rely on that system for needed care. These restructuring proposals may include, but are not limited to, the following: (1) Better care coordination for seniors and persons with disabilities, dual eligibles, children with special health care needs, and persons with behavioral health conditions, which shall include the establishment of organized delivery systems that incorporate a medical home system and care and disease management, as well as incentives that reward providers and beneficiaries for achieving the desired clinical, utilization, and cost-specific outcomes. (2) Improved coordination between Medicare and Medi-Cal coverage. (3) Improved coordination of care for children with significant medical needs through improved integration of delivery systems and use of medical homes and specialty centers, and providing incentives for specialty and nonspecialty care. (4) Improved integration of physical and behavioral health care. (c) In developing the waiver or demonstration project application, the department shall consult on a regular basis with interested stakeholders and the Legislature. (d) The department shall determine the form of waiver most appropriate to achieve the purposes listed in subdivision (a). (e) The department shall submit the waiver or demonstration project application to the federal Centers for Medicare and Medicaid Services by a date that allows sufficient time for the waiver or demonstration project to be approved by no later than September 1, 2010, or the conclusion of any extension period granted in California’s Medi-Cal Hospital/Uninsured Care Section 1115(a) Medicaid Demonstration (No. 11-W-00193/9), whichever happens last. (f) In order to restructure the Medi-Cal program to improve the delivery of care for specified populations and secure the maximum amount of federal financial participation allowable, any waiver or demonstration project application submitted pursuant to subdivision (a) may specify and seek authority to enroll beneficiaries into specified organized delivery systems. Subject to federal approval, the specified organized delivery systems may include the utilization of an enhanced primary care case management model, a medical home model, or managed care model. The department is authorized to enroll beneficiaries in an organized system of care subject to the conditions in Section 14181. Subject to federal approval, any waiver or demonstration project application submitted pursuant to subdivision (a) shall include processes, and accompanying criteria, by which the department will evaluate and grant exemption, on an individual basis, from this section’s requirements pertaining to the mandatory enrollment of beneficiaries in specified organized delivery systems. (g) (1) The department shall only implement the waiver or demonstration project upon submittal of an implementation plan, pursuant to Section 14181, to the appropriate policy and fiscal committees of the Legislature at least 60 days prior to any appropriation. (2) Pursuant to paragraph (1), mandatory enrollment in any organized delivery system authorized pursuant to a waiver or demonstration project authorized pursuant to this article shall only occur when funds necessary to support that effort have been appropriated. (3) It is the intent of the Legislature to neither impede nor limit the department’s existing statutory authority regarding the operation of the Medi-Cal program and its health care delivery systems by the enactment of this article. (h) The director shall have the discretion to utilize state plan amendments, in whole or in part, to accomplish any or all purposes of this article. In the event the director proceeds with state plan amendments as specified, the department shall provide notification in writing to the chairperson of the Joint Legislative Budget Committee within 15 working days of that action and a brief description and purpose of the amendment. This amendment shall be made available to the Joint Legislative Budget Committee upon the request of the chairperson. (Added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. Effective July 28, 2009.)
14181.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. )
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The agency must submit an implementation plan for the waiver or demonstration project and work with a stakeholder committee.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. ) ## 14181. (a) The California Health and Human Services Agency or successor entity or designated department shall submit an implementation plan to the appropriate policy and fiscal committees of the Legislature for implementation of the federally approved waiver or demonstration project. The implementation plan shall be developed in consultation with a stakeholder advisory committee established pursuant to subdivision (b). The implementation plan shall specifically address the multiple and complex needs of seniors and persons with disabilities, dual eligibles, children with special health care needs, and persons with behavioral health conditions, and the specific strategies the agency or successor entity or designated department will use to ensure the provision of quality, accessible health care services under the waiver or demonstration project, including, at a minimum, the following elements: (1) Criteria, performance standards, and indicators shall be adopted to ensure that plan services meet the multiple and complex needs of beneficiaries and comply with the requirements of this article. The performance standards shall incorporate, at a minimum, existing statutory and regulatory requirements and protections applicable to two-plan model and geographic managed care plans, as well as those protections available under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), but in addition shall include specific requirements and standards based on the multiple and complex care needs of seniors and persons with disabilities, dual eligibles, children with special health care needs, and persons with behavioral health conditions, including, but not limited to, standards where applicable to the organized delivery system model in all of the following areas: (A) Plan readiness. (B) Availability and accessibility of services, including physical access and communication access. (C) Benefit management and scope of services. (D) Care coordination and care management. (E) Beneficiary complaints, grievances, and appeals. (F) Beneficiary participation. (G) Continuity of care. (H) Cultural and linguistic appropriateness. (I) Financial management. (J) Measurement and improvement of health outcomes. (K) Marketing, assignment, enrollment, and disenrollment. (L) Network capacity, including travel time and distance and specialty care access. (M) Performance measurement and improvement. (N) Provider grievances and appeals. (O) Quality care. (P) Recordkeeping and reporting. (2) Strategies to be used to monitor performance of all contractors and to ensure compliance with all components of the waiver or demonstration project. (3) Provision of a comprehensive timeline of key milestones for implementation of the waiver or demonstration project components. (4) Provision of a framework for evaluation of the waiver or demonstration project, including the process, timelines, and criteria for evaluating implementation, as well as the method for providing periodic updates of outcomes and key implementation concerns. (b) Prior to preparing the implementation plan required by this section, the agency or successor entity or designated department, shall convene a stakeholder committee to advise on preparation of the implementation plan. The stakeholder committee shall include, but not be limited to, persons with disabilities, seniors, and representatives of legal services agencies that serve clients in the affected populations, health plans, specialty care providers, physicians, hospitals, county government, labor, and others as deemed appropriate by the agency or successor entity or designated department. The stakeholder committee shall advise on the implementation of the waiver or demonstration project until the expiration of the waiver or demonstration project. (Added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. Effective July 28, 2009.)
14182.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. )
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This section lets the department require certain seniors and people with disabilities without other coverage to enroll in managed care, while requiring plans and the department to provide notices, care coordination, accessibility, and continuity of care protections.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. ) ## 14182. (a) (1) In furtherance of the waiver or demonstration project developed pursuant to Section 14180, the department may require seniors and persons with disabilities who do not have other health coverage to be assigned as mandatory enrollees into new or existing managed care health plans. To the extent that enrollment is required by the department, an enrollee’s access to fee-for-service Medi-Cal shall not be terminated until the enrollee has been assigned to a managed care health plan. (2) For purposes of this section: (A) “Other health coverage” means health coverage providing the same full or partial benefits as the Medi-Cal program, health coverage under another state or federal medical care program, or health coverage under contractual or legal entitlement, including, but not limited to, a private group or indemnification insurance program. (B) “Managed care health plan” means an individual, organization, or entity that enters into a contract with the department pursuant to Article 2.7 (commencing with Section 14087.3), Article 2.81 (commencing with Section 14087.96), Article 2.91 (commencing with Section 14089), or Chapter 8 (commencing with Section 14200). (b) In exercising its authority pursuant to subdivision (a), the department shall do all of the following: (1) Assess and ensure the readiness of the managed care health plans to address the unique needs of seniors or persons with disabilities pursuant to the applicable readiness evaluation criteria and requirements set forth in paragraphs (1) to (8), inclusive, of subdivision (b) of Section 14087.48. (2) Ensure the managed care health plans provide access to providers that comply with applicable state and federal laws, including, but not limited to, physical accessibility and the provision of health plan information in alternative formats. (3) Develop and implement an outreach and education program for seniors and persons with disabilities, not currently enrolled in Medi-Cal managed care, to inform them of their enrollment options and rights under the demonstration project. Contingent upon available private or public dollars other than moneys from the General Fund, the department or its designated agent for enrollment and outreach may partner or contract with community-based, nonprofit consumer or health insurance assistance organizations with expertise and experience in assisting seniors and persons with disabilities in understanding their health care coverage options. Contracts entered into or amended pursuant to this paragraph shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code and any implementing regulations or policy directives. (4) At least three months prior to enrollment, inform beneficiaries who are seniors or persons with disabilities, through a notice written at no more than a sixth grade reading level, about the forthcoming changes to their delivery of care, including, at a minimum, how their system of care will change, when the changes will occur, and who they can contact for assistance with choosing a delivery system or with problems they encounter. In developing this notice, the department shall consult with consumer representatives and other stakeholders. (5) Implement an appropriate cultural awareness and sensitivity training program regarding serving seniors and persons with disabilities for managed care health plans and plan providers and staff in the Medi-Cal Managed Care Division of the department. (6) Establish a process for assigning enrollees into an organized delivery system for beneficiaries who do not make an affirmative selection of a managed care health plan. The department shall develop this process in consultation with stakeholders and in a manner consistent with the waiver or demonstration project developed pursuant to Section 14180. The department shall base plan assignment on an enrollee’s existing or recent utilization of providers, to the extent possible. If the department is unable to make an assignment based on the enrollee’s affirmative selection or utilization history, the department shall base plan assignment on factors, including, but not limited to, plan quality and the inclusion of local health care safety net system providers in the plan’s provider network. (7) Review and approve the mechanism or algorithm that has been developed by the managed care health plan, in consultation with their stakeholders and consumers, to identify, within the earliest possible timeframe, persons with higher risk and more complex health care needs pursuant to paragraph (11) of subdivision (c). (8) Provide managed care health plans with historical utilization data for beneficiaries upon enrollment in a managed care health plan so that the plans participating in the demonstration project are better able to assist beneficiaries and prioritize assessment and care planning. (9) Develop and provide managed care health plans participating in the demonstration project with a facility site review tool for use in assessing the physical accessibility of providers, including specialists and ancillary service providers that provide care to a high volume of seniors and persons with disabilities, at a clinic or provider site, to ensure that there are sufficient physically accessible providers. Every managed care health plan participating in the demonstration project shall make the results of the facility site review tool publicly available on their Internet Web site and shall regularly update the results to the department’s satisfaction. (10) Develop a process to enforce legal sanctions, including, but not limited to, financial penalties, withholding of Medi-Cal payments, enrollment termination, and contract termination, in order to sanction any managed care health plan in the demonstration project that consistently or repeatedly fails to meet performance standards provided in statute or contract. (11) Ensure that managed care health plans provide a mechanism for enrollees to request a specialist or clinic as a primary care provider. A specialist or clinic may serve as a primary care provider if the specialist or clinic agrees to serve in a primary care provider role and is qualified to treat the required range of conditions of the enrollee. (12) Ensure that managed care health plans participating in the demonstration project are able to provide communication access to seniors and persons with disabilities in alternative formats or through other methods that ensure communication, including assistive listening systems, sign language interpreters, captioning, written communication, plain language, or written translations and oral interpreters, including for those who are limited English-proficient, or non-English speaking, and that all managed care health plans are in compliance with applicable cultural and linguistic requirements. (13) Ensure that managed care health plans participating in the demonstration project provide access to out-of-network providers for new individual members enrolled under this section who have an ongoing relationship with a provider if the provider will accept the health plan’s rate for the service offered, or the applicable Medi-Cal fee-for-service rate, whichever is higher, and the health plan determines that the provider meets applicable professional standards and has no disqualifying quality of care issues. (14) Ensure that managed care health plans participating in the demonstration project comply with continuity of care requirements in Section 1373.96 of the Health and Safety Code. (15) Ensure that the medical exemption criteria applied in counties operating under Chapter 4.1 (commencing with Section 53800) or Chapter 4.5 (commencing with Section 53900) of Subdivision 1 of Division 3 of Title 22 of the California Code of Regulations are applied to seniors and persons with disabilities served under this section. (16) Ensure that managed care health plans participating in the demonstration project take into account the behavioral health needs of enrollees and include behavioral health services as part of the enrollee’s care management plan when appropriate. (17) Develop performance measures that are required as part of the contract to provide quality indicators for the Medi-Cal population enrolled in a managed care health plan and for the subset of enrollees who are seniors and persons with disabilities. These performance measures may include measures from the Healthcare Effectiveness Data and Information Set (HEDIS) or measures indicative of performance in serving special needs populations, such as the National Committee for Quality Assurance (NCQA) Structure and Process measures, or both. (18) Conduct medical audit reviews of participating managed care health plans that include elements specifically related to the care of seniors and persons with disabilities. These medical audits shall include, but not be limited to, evaluation of the delivery model’s policies and procedures, performance in utilization management, continuity of care, availability and accessibility, member rights, and quality management. (19) Conduct financial audit reviews to ensure that a financial statement audit is performed on managed care health plans annually pursuant to the Generally Accepted Auditing Standards, and conduct other risk-based audits for the purpose of detecting fraud and irregular transactions. (20) Ensure that managed care health plans maintain a dedicated liaison to coordinate with the department, affected providers, and new individual members for all of the following purposes: (A) To ensure a mechanism for new members to obtain continuity of care as described in paragraph (13). (B) To receive notice, including that a new member has been denied a medical exemption as described in paragraph (15), which is required to include the name or names of the requesting provider, and ensure that the provider’s ability to treat the member is continued as described in paragraphs (11) and (13), if applicable, or, if not applicable, ensure the member is immediately referred to a qualified provider or specialty care center. (C) To assist new members in maintaining an ongoing relationship with a specialist or specialty care center when the specialist is contracting with the plan and the assigned primary care provider has approved a standing referral pursuant to Section 1374.16 of the Health and Safety Code. (21) Ensure that written notice is provided to the beneficiary and the requesting provider if a request for exemption from plan enrollment is denied. The notice shall set out with specificity the reasons for the denial or failure to unconditionally approve the request for exemption from plan enrollment. The notice shall inform the beneficiary and the provider of the right to appeal the decision, how to appeal the decision, and if the decision is not appealed, that the beneficiary shall enroll in a Medi-Cal plan and how that enrollment shall occur. The notice shall also include information of the possibility of continued access to an out-of-network provider pursuant to paragraph (13). A beneficiary who has not been enrolled in a plan shall remain in fee-for-service Medi-Cal if a request for an exemption from plan enrollment or appeal is submitted, until the final resolution. The department shall also require the plans to ensure that these beneficiaries receive continuity of care. (22) Develop a process to track a beneficiary who has been denied a request for exemption from plan enrollment and to notify the plan, if applicable, of the denial, including information identifying the provider. Notwithstanding paragraph (12) of subdivision (c), the plan shall immediately refer the beneficiary for a risk assessment survey and an individual care plan shall be developed within 10 days, including authorization for 30 days of continuity of prescription drugs. (c) Prior to exercising its authority under this section and Section 14180, the department shall ensure that each managed care health plan participating in the demonstration project is able to do all of the following: (1) Comply with the applicable readiness evaluation criteria and requirements set forth in paragraphs (1) to (8), inclusive, of subdivision (b) of Section 14087.48. (2) Ensure and monitor an appropriate provider network, including primary care physicians, specialists, professional, allied, and medical supportive personnel, and an adequate number of accessible facilities within each service area. Managed care health plans shall maintain an updated, accurate, and accessible listing of a provider’s ability to accept new patients and shall make it available to enrollees, at a minimum, by phone, written material, and Internet Web site. (3) Assess the health care needs of beneficiaries who are seniors or persons with disabilities and coordinate their care across all settings, including coordination of necessary services within and, where necessary, outside of the plan’s provider network. (4) Ensure that the provider network and informational materials meet the linguistic and other special needs of seniors and persons with disabilities, including providing information in an understandable manner in plain language, maintaining toll-free telephone lines, and offering member or ombudsperson services. (5) Provide clear, timely, and fair processes for accepting and acting upon complaints, grievances, and disenrollment requests, including procedures for appealing decisions regarding coverage or benefits. Each managed care health plan participating in the demonstration project shall have a grievance process that complies with Section 14450, and Sections 1368 and 1368.01 of the Health and Safety Code. (6) Solicit stakeholder and member participation in advisory groups for the planning and development activities related to the provision of services for seniors and persons with disabilities. (7) Contract with safety net and traditional providers as defined in subdivisions (hh) and (jj) of Section 53810, of Title 22 of the California Code of Regulations, to ensure access to care and services. The managed care health plan shall establish participation standards to ensure participation and broad representation of traditional and safety net providers within a service area. (8) Inform seniors and persons with disabilities of procedures for obtaining transportation services to service sites that are offered by the plan or are available through the Medi-Cal program. (9) Monitor the quality and appropriateness of care for children with special health care needs, including children eligible for, or enrolled in, the California Children’s Services Program, and seniors and persons with disabilities. (10) Maintain a dedicated liaison to coordinate with each regional center operating within the plan’s service area to assist members with developmental disabilities in understanding and accessing services and act as a central point of contact for questions, access and care concerns, and problem resolution. (11) At the time of enrollment apply the risk stratification mechanism or algorithm described in paragraph (7) of subdivision (b) approved by the department to determine the health risk level of beneficiaries. (12) (A) Managed care health plans shall assess an enrollee’s current health risk by administering a risk assessment survey tool approved by the department. This risk assessment survey shall be performed within the following timeframes: (i) Within 45 days of plan enrollment for individuals determined to be at higher risk pursuant to paragraph (11). (ii) Within 105 days of plan enrollment for individuals determined to be at lower risk pursuant to paragraph (11). (B) Based on the results of the current health risk assessment, managed care health plans shall develop individual care plans for higher risk beneficiaries that shall include the following minimum components: (i) Identification of medical care needs, including primary care, specialty care, durable medical equipment, medications, and other needs with a plan for care coordination as needed. (ii) Identification of needs and referral to appropriate community resources and other agencies as needed for services outside the scope of responsibility of the managed care health plan. (iii) Appropriate involvement of caregivers. (iv) Determination of timeframes for reassessment and, if necessary, circumstances or conditions that require redetermination of risk level. (13) (A) Establish medical homes to which enrollees are assigned that include, at a minimum, all of the following elements, which shall be considered in the provider contracting process: (i) A primary care physician who is the primary clinician for the beneficiary and who provides core clinical management functions. (ii) Care management and care coordination for the beneficiary across the health care system including transitions among levels of care. (iii) Provision of referrals to qualified professionals, community resources, or other agencies for services or items outside the scope of responsibility of the managed care health plan. (iv) Use of clinical data to identify beneficiaries at the care site with chronic illness or other significant health issues. (v) Timely preventive, acute, and chronic illness treatment in the appropriate setting. (vi) Use of clinical guidelines or other evidence-based medicine when applicable for treatment of beneficiaries’ health care issues or timing of clinical preventive services. (B) In implementing this section, and the Special Terms and Conditions of the demonstration project, the department may alter the medical home elements described in this paragraph as necessary to secure the increased federal financial participation associated with the provision of medical assistance in conjunction with a health home, as made available under the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and codified in Section 1945 of Title XIX of the federal Social Security Act. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to alter medical home elements under this section at least five days in advance of taking this action. (14) Perform, at a minimum, the following care management and care coordination functions and activities for enrollees who are seniors or persons with disabilities: (A) Assessment of each new enrollee’s risk level and health needs shall be conducted through a standardized risk assessment survey by means such as telephonic, Web-based, or in-person communication or by other means as determined by the department. (B) Facilitation of timely access to primary care, specialty care, durable medical equipment, medications, and other health services needed by the enrollee, including referrals to address any physical or cognitive barriers to access. (C) Active referral to community resources or other agencies for needed services or items outside the managed care health plans responsibilities. (D) Facilitating communication among the beneficiaries’ health care providers, including mental health and substance abuse providers when appropriate. (E) Other activities or services needed to assist beneficiaries in optimizing their health status, including assisting with self-management skills or techniques, health education, and other modalities to improve health status. (d) Except in a county where Medi-Cal services are provided by a county-organized health system, and notwithstanding any other provision of law, in any county in which fewer than two existing managed care health plans contract with the department to provide Medi-Cal services under this chapter, the department may contract with additional managed care health plans to provide Medi-Cal services for seniors and persons with disabilities and other Medi-Cal beneficiaries. (e) Beneficiaries enrolled in managed care health plans pursuant to this section shall have the choice to continue an established patient-provider relationship in a managed care health plan participating in the demonstration project if his or her treating provider is a primary care provider or clinic contracting with the managed care health plan and agrees to continue to treat that beneficiary. (f) The department may contract with existing managed care health plans to operate under the demonstration project to provide or arrange for services under this section. Notwithstanding any other provision of law, the department may enter into the contract without the need for a competitive bid process or other contract proposal process, provided the managed care health plan provides written documentation that it meets all qualifications and requirements of this section. (g) This section shall be implemented only to the extent that federal financial participation is available. (h) (1) The development of capitation rates for managed care health plan contracts shall include the analysis of data specific to the seniors and persons with disabilities population. For the purposes of developing capitation rates for payments to managed care health plans, the director may require managed care health plans, including existing managed care health plans, to submit financial and utilization data in a form, time, and substance as deemed necessary by the department. (2) (A) Notwithstanding Section 14301, the department may incorporate, on a one-time basis for a three-year period, a risk-sharing mechanism in a contract with the local initiative health plan in the county with the highest normalized fee-for-service risk score over the normalized managed care risk score listed in Table 1.0 of the Medi-Cal Acuity Study Seniors and Persons with Disabilities (SPD) report written by Mercer Government Human Services Consulting and dated September 28, 2010, if the local initiative health plan meets the requirements of subparagraph (B). The Legislature finds and declares that this risk-sharing mechanism will limit the risk of beneficial or adverse effects associated with a contract to furnish services pursuant to this section on an at-risk basis. (B) The local initiative health plan shall pay the nonfederal share of all costs associated with the development, implementation, and monitoring of the risk-sharing mechanism established pursuant to subparagraph (A) by means of intergovernmental transfers. The nonfederal share includes the state costs of staffing, state contractors, or administrative costs directly attributable to implementing subparagraph (A). (C) This subdivision shall be implemented only to the extent federal financial participation is not jeopardized. (i) Persons meeting participation requirements for the Program of All-Inclusive Care for the Elderly (PACE) pursuant to Chapter 8.75 (commencing with Section 14591), may select a PACE plan if one is available in that county. (j) Persons meeting the participation requirements in effect on January 1, 2010, for a Medi-Cal primary care case management (PCCM) plan in operation on that date, may select that PCCM plan or a successor health care plan that is licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) to provide services within the same geographic area that the PCCM plan served on January 1, 2010. (k) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. Prior to issuing any letter or similar instrument authorized pursuant to this section, the department shall notify and consult with stakeholders, including advocates, providers, and beneficiaries. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance. (l) Consistent with state law that exempts Medi-Cal managed care contracts from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code, and in order to achieve maximum cost savings, the Legislature hereby determines that an expedited contract process is necessary for contracts entered into or amended pursuant to this section. The contracts and amendments entered into or amended pursuant to this section shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code and the requirements of State Administrative Management Manual Memo 03-10. The department shall make the terms of a contract available to the public within 30 days of the contract’s effective date. (m) In the event of a conflict between the Special Terms and Conditions of the approved demonstration project, including any attachment thereto, and any provision of this part, the Special Terms and Conditions shall control. If the department identifies a specific provision of this article that conflicts with a term or condition of the approved waiver or demonstration project, or an attachment thereto, the term or condition shall control, and the department shall so notify the appropriate fiscal and policy committees of the Legislature within 15 business days. (n) In the event of a conflict between the provisions of this article and any other provision of this part, the provisions of this article shall control. (o) Any otherwise applicable provisions of this chapter, Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) not in conflict with this article or with the terms and conditions of the demonstration project shall apply to this section. (p) To the extent that the director utilizes state plan amendments or waivers to accomplish the purposes of this article in addition to waivers granted under the demonstration project, the terms of the state plan amendments or waivers shall control in the event of a conflict with any provision of this part. (q) (1) Enrollment of seniors and persons with disabilities into a managed care health plan under this section shall be accomplished using a phased-in process to be determined by the department and shall not commence until necessary federal approvals have been acquired or until June 1, 2011, whichever is later. (2) Notwithstanding paragraph (1), and at the director’s discretion, enrollment in Los Angeles County of seniors and persons with disabilities may be phased-in over a 12-month period using a geographic region method that is proposed by Los Angeles County subject to approval by the department. (r) A managed care health plan established pursuant to this section, or under the Special Terms and Conditions of the demonstration project pursuant to Section 14180, shall be subject to, and comply with, the requirement for submission of encounter data specified in Section 14182.1. (s) (1) Commencing January 1, 2011, and until January 1, 2014, the department shall provide the fiscal and policy committees of the Legislature with semiannual updates regarding core activities for the enrollment of seniors and persons with disabilities into managed care health plans pursuant to the pilot program. The semiannual updates shall include key milestones, progress toward the objectives of the pilot program, relevant or necessary changes to the program, submittal of state plan amendments to the federal Centers for Medicare and Medicaid Services, submittal of any federal waiver documents, and other key activities related to the mandatory enrollment of seniors and persons with disabilities into managed care health plans. The department shall also include updates on the transition of individuals into managed care health plans, the health outcomes of enrollees, the care management and coordination process, and other information concerning the success or overall status of the pilot program. (2) (A) The requirement for submitting a report imposed under paragraph (1) is inoperative on January 1, 2015, pursuant to Section 10231.5 of the Government Code. (B) A report to be submitted pursuant to paragraph (1) shall be submitted in compliance with Section 9795 of the Government Code. (t) The department, in collaboration with the State Department of Social Services and county welfare departments, shall monitor the utilization and caseload of the In-Home Supportive Services (IHSS) program before and during the implementation of the pilot program. This information shall be monitored in order to identify the impact of the pilot program on the IHSS program for the affected population. (u) Services under Section 14132.95 or 14132.952, or Article 7 (commencing with Section 12300) of Chapter 3 that are provided to individuals assigned to managed care health plans under this section shall be provided through direct hiring of personnel, contract, or establishment of a public authority or nonprofit consortium, in accordance with and subject to the requirements of Section 12302 or 12301.6, as applicable. (v) The department shall, at a minimum, monitor on a quarterly basis the adequacy of provider networks of the managed care health plans. (w) The department shall suspend new enrollment of seniors and persons with disabilities into a managed care health plan if it determines that the managed care health plan does not have sufficient primary or specialty providers to meet the needs of their enrollees. (Amended by Stats. 2013, Ch. 76, Sec. 221. (AB 383) Effective January 1, 2014. Implementation is contingent upon federal funding, pursuant to subd. (g).)
14182.1.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. )
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The department must convene a stakeholder workgroup, develop data quality submission standards, and notify and consult stakeholders and legislative committees. Managed care health plans must follow the standards when submitting data, and the director may impose a monthly penalty for noncompliance, capped at 2% of the plan’s total monthly capitation rate.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. ) ## 14182.1. (a) Beginning March 2011, the department shall convene a stakeholder workgroup to review the existing encounter, claims, and financial data submission process required by the department under managed care health plan contracts. The workgroup members shall be selected by the department and shall include interested representatives from Medi-Cal managed care health plans, managed care health plan associations, hospitals, individual health care providers, physician groups, and consumer representatives. In reviewing the process, the department shall consider input from the stakeholder workgroup and develop data quality submission standards by October 2011. (b) Beginning January 1, 2012, managed care health plans shall comply with the quality submission standards developed pursuant to subdivision (a) when submitting data to the department. The director may impose a penalty for each month that a managed care health plan fails to submit data in compliance with these standards. The penalty shall be in proportion to that plan’s failure to comply with the data submission standards, as the director in his or her sole discretion determines, and in no event shall the penalty exceed 2 percent of the total monthly capitation rate for that plan. (c) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. Prior to issuing any letter or similar instrument authorized pursuant to this section, the department shall notify and consult with stakeholders, including advocates, providers, and beneficiaries. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance. If the department elects to adopt regulations, the adoption of regulations shall be deemed an emergency and necessary for the immediate preservation of the public peace, health and safety, or general welfare. (Amended by Stats. 2011, Ch. 296, Sec. 335. (AB 1023) Effective January 1, 2012.)
14182.15.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. )
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Public entities may choose to transfer public funds to the state for certain Medi-Cal managed care payments, while the department must coordinate, secure federal approvals, and set up required contracts.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. ) ## 14182.15. (a) It is the intent of the Legislature that, to the extent that it does not jeopardize other federal funding and is permitted by federal law, the intergovernmental transfers described in this section provide support for the nonfederal share of risk-based payments to managed care health plans to enable those plans to compensate designated public hospitals in a sufficient amount to preserve and strengthen the availability and quality of services provided by those hospitals and their affiliated public providers. It is further the intent of the Legislature that transferring public entities elect to provide intergovernmental transfers in an amount that is at least equivalent to the amount of the nonfederal share that they would provide under fee-for-service, as adjusted for utilization. (b) (1) In conjunction with the implementation of Section 14182, a public entity may elect to transfer public funds to the state to be used solely as the nonfederal share of Medi-Cal payments to managed care health plans for the provision of services to Medi-Cal beneficiaries. (2) For purposes of this section, “public entity” means a designated public hospital as defined in subdivision (d) of Section 14166.1, the University of California, or a county or city and county or local hospital authority that is licensed to operate one or more of the designated public hospitals. (c) If a public entity elects to make intergovernmental transfers pursuant to this section, all of the following shall apply: (1) To ensure that the implementation of Section 14182 does not jeopardize the ability of designated public hospitals and their affiliated public providers to continue serving Medi-Cal beneficiaries, to the extent permitted under federal law, the department shall require managed care health plans to pay the designated public hospital and other governmental providers affiliated with the transferring public entity for services rendered to Medi-Cal beneficiaries, amounts that are no less than the amount to which the providers would have otherwise been entitled, including the federal and nonfederal share, on a fee-for-service basis, for the full scope of Medi-Cal services, including supplemental payments and any additional federally permissible amount. The payment amounts required by this paragraph shall be based upon the volume of Medi-Cal services provided by the designated public hospitals and other governmental providers affiliated with the transferring public entity. (2) Except as provided in Section 14105.24, to the extent that the payments described in paragraph (1) result in increased payments by the managed care health plans to the designated public hospitals and other governmental providers affiliated with the transferring public entity that are the basis of increased rates paid by the department to the managed care health plans above the amount that would have been paid in the absence of paragraph (1), the nonfederal share of the increased rates shall be borne by the transferring entity as described in subdivision (d) and there shall be no additional impact on state General Fund expenditures. Additionally, the payment rates shall only be paid to the extent they can be certified as actuarially sound and as permitted under federal law. (d) The department shall meet and confer with the public entities regarding their election to contribute to the nonfederal share of federal Medicaid expenditures under this section and to determine each public entity’s intergovernmental transfer amount, which shall be comprised of the following: (1) An amount that is equivalent to the nonfederal share of the rates of compensation the public entity’s designated public hospital would receive from managed care health plans, without regard to the requirement of paragraph (1) of subdivision (c), for Medi-Cal inpatient days of service that otherwise would have been rendered on a fee-for-service basis in the absence of the implementation of Section 14182 to Medi-Cal enrollees who are seniors and persons with disabilities. (2) An amount that is equivalent to the nonfederal share of the amount which the designated public hospital and other governmental providers affiliated with the transferring entity would have otherwise incurred on a fee-for-service basis for providing Medi-Cal services to the Medi-Cal managed care health plan enrollees they serve, including supplemental payments, excluding the nonfederal share of those amounts the plan will pay for the services without regard to the requirement of paragraph (1) of subdivision (c), and consistent with Section 14105.24, to the extent otherwise applicable. (3) Amounts equivalent to the nonfederal share of additional federally permissible payments. (e) Prior to accepting the transfer amounts from a public entity determined under subdivision (d), the department shall ensure that its contracts with the applicable managed care health plans and the contracts between the managed care health plans and the public entities require, to the extent permitted under federal law, that the managed care health plans pay the designated public hospitals, and other governmental providers affiliated with the transferring entities, amounts that are in furtherance of the intent of this section as described in subdivision (a) and consistent with what the designated public hospital and other governmental providers affiliated with the transferring public entity would have received through fee-for-service, and that the payment amounts meet the requirement of paragraph (1) of subdivision (c). (f) The department shall obtain federal approvals or waivers as necessary to implement this section and to obtain federal matching funds to the maximum extent permitted by federal law. (g) Participation in intergovernmental transfers under this section is voluntary on the part of the transferring entity for purposes of all applicable federal laws. As part of its voluntary participation in the nonfederal share of payments under this section by means of intergovernmental transfers, the transferring entity agrees to reimburse the state for the nonfederal share of state staffing or administrative costs directly attributable to implementation of this section. This section shall be implemented only to the extent federal financial participation is not jeopardized. (Added by Stats. 2010, Ch. 714, Sec. 22. (SB 208) Effective October 19, 2010.)
14182.2.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. )
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The director must establish certain health care delivery models for eligible CCS children, and the department must oversee, evaluate, consult on, and notify others about the program.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. ) ## 14182.2. (a) Notwithstanding Section 14094.3, in furtherance of the waiver or demonstration project developed pursuant to Section 14180, the director shall establish, by January 1, 2012, organized health care delivery models for children eligible for California Children Services (CCS) under Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code. These models shall be chosen from the following: (1) An enhanced primary care case management program. (2) A provider-based accountable care organization. (3) A specialty health care plan. (4) A Medi-Cal managed care plan that includes payment and coverage for CCS-eligible conditions. (b) Each model shall do all of the following: (1) Establish clear standards and criteria for participation, exemption, enrollment, and disenrollment. (2) Provide care coordination that links children and youth with special health care needs with appropriate services and resources in a coordinated manner to achieve optimum health. (3) Establish networks that include CCS-approved providers and maintain the current system of regionalized pediatric specialty and subspecialty services to ensure that children and youth have timely access to appropriate and qualified providers. (4) Coordinate out-of-network access if appropriate and qualified providers are not part of the network or in the region. (5) Ensure that children enrolled in the model receive care for their CCS-eligible medical conditions from CCS-approved providers consistent with the CCS standards of care. (6) Participate in a statewide quality improvement collaborative that includes stakeholders. (7) (A) Establish and support medical homes, incorporating all of the following principles: (i) Each child has a personal physician. (ii) The medical home is a physician-directed medical practice. (iii) The medical home utilizes a whole child orientation. (iv) Care is coordinated or integrated across all of the elements of the health care system and the family and child’s community. (v) Information, education, and support to consumers and families in the program is provided in a culturally competent manner. (vi) Quality and safety practices and measures. (vii) Provides enhanced access to care, including access to after-hours care. (viii) Payment is structured appropriately to recognize the added value provided to children and their families. (B) In implementing this section, and the terms and conditions of the demonstration project, the department may alter the medical home principles described in this paragraph as necessary to secure the increased federal financial participation associated with the provision of medical assistance in conjunction with a health home, as made available under the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and codified in Section 1945 of Title XIX of the federal Social Security Act. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to alter medical home principles under this section at least five days in advance of taking this action. (8) Provide the department with data for quality monitoring and improvement measures, as determined necessary by the department. The department shall institute quality monitoring and improvement measures that are appropriate for children and youth with special health care needs. (c) The services provided under these models shall not be limited to medically necessary services required to treat the CCS-eligible medical condition. (d) Notwithstanding any other provision of law, and to the extent permitted by federal law, the department may require eligible individuals to enroll in these models. (e) At the election of the Managed Risk Medical Insurance Board, and with the consent of the director, children enrolled in the Healthy Families Program pursuant to Part 6.2 (commencing with Section 12693) of Division 2 of the Insurance Code, who are eligible for CCS under Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code, may enroll in the organized health care delivery models established under this section. (f) For the purposes of implementing this section, the department shall seek proposals to establish and test these models of organized health care delivery systems, may enter into exclusive or nonexclusive contracts on a bid or negotiated basis, and may amend existing managed care contracts to provide or arrange for services under this section. Contracts may be statewide or on a more limited geographic basis. Contracts entered into or amended under this section shall be exempt from the provisions of Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code and Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of the Government Code. (g) (1) Entities contracting with the department under this section shall report expenditures for the services provided under the contract. (2) If a contractor is paid according to a capitated or risk-based payment methodology, the rates shall be actuarially sound and take into account care coordination activities. (h) (1) The department shall conduct an evaluation to assess the effectiveness of each model in improving the delivery of health care services for children who are eligible for CCS. The department shall consult with stakeholders in developing an evaluation for the models being tested. (2) The evaluation process shall begin simultaneously with the development and implementation of the model delivery systems to compare the care provided to, and outcomes of, children enrolled in the models with those not enrolled in the models. The evaluation shall include, at a minimum, an assessment of all of the following: (A) The types of services and expenditures for services. (B) Improvement in the coordination of care for children. (C) Improvement in the quality of care. (D) Improvement in the value of care provided. (E) The rate of growth of expenditures. (F) Parent satisfaction. (i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section and any applicable federal waivers and state plan amendments by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action. Prior to issuing any letter or similar instrument authorized pursuant to this section, the department shall notify and consult with stakeholders, including advocates, providers, and beneficiaries. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance. (Added by Stats. 2010, Ch. 714, Sec. 23. (SB 208) Effective October 19, 2010.)
14182.3.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. )
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This section says the new demonstration project generally follows Article 5.2 unless it conflicts with this article or the required federal conditions, and the state, director, department, and transferring entities each have specific funding and implementation rules.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. ) ## 14182.3. (a) To the extent the provisions of Article 5.2 (commencing with Section 14166) do not conflict with the provisions of this article or the Special Terms and Conditions of the new demonstration project created under this article, the provisions of Article 5.2 (commencing with Section 14166) shall continue to apply to the new demonstration project. (b) In the event of a conflict between any provision of this article and the Special Terms and Conditions required by the federal Centers for Medicare and Medicaid Services for the approval of the demonstration project described in Section 14180, the Special Terms and Conditions shall control. (c) (1) Under the demonstration project described in Section 14180, the state shall have priority to claim against and retain the first five hundred million dollars ($500,000,000) in federal funds using expenditures incurred under state-only programs or other programs for which the state is authorized to claim under the Special Terms and Conditions of the demonstration project or federal Medicaid law, including state-only programs that serve special populations, such as those for which state savings were recognized in the Budget Act for the 2010–11 fiscal year. (2) Notwithstanding paragraph (1), if the director determines that the amount of base funding available under the demonstration project described in Section 14180 is less than the six hundred eighty-one million six hundred forty thousand dollars ($681,640,000) available to public hospitals under the original demonstration project, the state may reallocate an amount from the five hundred million dollars ($500,000,000) described in paragraph (1) to increase the amount of base funding under the new demonstration project to six hundred eighty one million six hundred forty thousand dollars ($681,640,000). (3) For purposes of this section, the term “base funding” includes funding for the safety net care pool or a similar pool or fund for health coverage expansion, and for an investment, incentive, or similar pool, but shall not include funds made available to hospitals or counties for inpatient or outpatient Medi-Cal reimbursements, expansion of managed care for seniors and persons with disabilities, or other expansions of systems of care for individuals who are eligible under the Medi-Cal state plan. (4) If the state is unable to claim the full amount of the five hundred million dollars ($500,000,000) described in paragraph (1), any portion of the amount that remains unclaimed may be reallocated to be claimed based on the certified public expenditures of the designated public hospitals. (d) The director shall have authority to maximize available federal financial participation under the demonstration project described in Section 14180, including, but not limited to, authorizing the use of intergovernmental transfers by district hospitals that are not reimbursed under a contract negotiated pursuant to the Selective Provider Contracting Program, to fund the nonfederal share of expenditures to the extent permitted by the Special Terms and Conditions of the demonstration project. (e) Participation in intergovernmental transfers under this section is voluntary on the part of the transferring entity for purposes of all applicable federal laws. As part of its voluntary participation in the nonfederal share of payments under this subdivision by means of intergovernmental transfers, the transferring entity agrees to reimburse the state for the nonfederal share of state staffing or administrative costs directly attributable to the state’s implementation of these voluntary intergovernmental transfers. This subdivision shall be implemented only to the extent federal financial participation is not jeopardized. (f) Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may clarify, interpret, or implement the provisions of this section by means of provider bulletins or similar instructions. The department shall notify the fiscal and appropriate policy committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance. (Amended by Stats. 2011, Ch. 86, Sec. 20. (AB 1066) Effective July 15, 2011.)
14182.4.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. )
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The department must set up and run a hospital investment and incentive program, manage the fund, seek federal participation, and notify legislative committees before issuing instructions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. ) ## 14182.4. (a) To the extent authorized under a federal waiver or demonstration project described in Section 14180 that is approved by the federal Centers for Medicare and Medicaid Services, the department shall establish a program of investment, improvement, and incentive payments for designated public hospitals and, to the extent federal approval is obtained pursuant to subdivision (c) of Section 14166.155, for nondesignated public hospitals to encourage and incentivize delivery system transformation and innovation in preparation for the implementation of federal health care reform. (b) The Public Hospital Investment, Improvement, and Incentive Fund is hereby established in the State Treasury. Notwithstanding Section 13340 of the Government Code, moneys in the fund shall be continuously appropriated, without regard to fiscal years, to the department for the purposes specified in this section. (c) The fund shall consist of any moneys that a county, other political subdivision of the state, or other governmental entity in the state that may elect to transfer to the department for deposit into the fund, as permitted under Section 433.51 of Title 42 of the Code of Federal Regulations or any other applicable federal Medicaid laws. (d) Moneys in the fund shall be used as the source for the nonfederal share of investment, improvement, and incentive payments as authorized under a federal waiver or demonstration project to participating designated public hospitals and, to the extent federal approval is obtained pursuant to subdivision (c) of Section 14166.155, to nondesignated public hospitals, defined in subdivisions (d) and (f) of Section 14166.1 respectively, and the governmental entities with which they are affiliated, that provide the intergovernmental transfers for deposit into the fund. (e) The department shall obtain federal financial participation for moneys in the fund to the full extent permitted by law. Moneys shall be allocated from the fund by the department and used as the nonfederal share for claiming federal funds in accordance with the Special Terms and Conditions of the waiver or demonstration project and Sections 14166.77 and 14166.155, to the extent federal approval is obtained pursuant to subdivision (c) of Section 14166.151, as applicable. The moneys disbursed from the fund, and all associated federal financial participation, shall be distributed only to the designated public hospitals and the governmental entities with which they are affiliated, and to the extent federal approval is obtained pursuant to subdivision (c) of Section 14166.155, to nondesignated public hospitals as described in subdivision (a) and the governmental entities with which they are affiliated. (f) Participation under this section is voluntary on the part of the county or other political subdivision for purposes of all applicable federal laws. As part of its voluntary participation in the nonfederal share of payments under this section, the county or other political subdivision agrees to reimburse the state for the nonfederal share of state staffing or administrative costs directly attributable to implementation of this section. This section shall be implemented only to the extent federal financial participation is not jeopardized. (g) Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may clarify, interpret, or implement the provisions of this section by means of provider bulletins or similar instructions. The department shall notify the fiscal and appropriate policy committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance. (Amended by Stats. 2012, Ch. 23, Sec. 109. (AB 1467) Effective June 27, 2012.)
14182.45.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. )
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The state may provide milestone incentive payments to certain hospitals, with conditions tied to consultation and federal payment requirements.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. ) ## 14182.45. (a) In consultation with the designated public hospitals, as defined in subdivision (d) of Section 14166.1, and to the extent it does not impede the ability of the designated public hospitals to meet the requirements and conditions for delivery system reform incentive payments authorized under Sections 14166.77 and 14182.4, the state may provide for milestone incentive payments to private disproportionate share hospitals and nondesignated public disproportionate share hospitals to create incentives for improvement activities towards, and achievement of, delivery system transformation. The milestone incentive payments to private disproportionate share hospitals and nondesignated public disproportionate share hospitals shall be structured in accordance with the requirements and conditions for delivery system reform incentive payments set forth in the Special Terms and Conditions and as approved by the federal Centers for Medicare and Medicaid Services. Incentive payments may be funded by voluntary intergovernmental transfers made by the designated public hospitals and nondesignated public hospitals. All incentive pool funding, including any potential private and nondesignated public hospital subpools, shall be limited to the total amount of incentive pool funding allowed for delivery system reform incentive payments as set forth in the Special Terms and Conditions. (b) Upon federal approval of the reimbursement methodology in subdivision (b) of Section 14166.151, this section shall become inoperative. (Amended by Stats. 2012, Ch. 23, Sec. 110. (AB 1467) Effective June 27, 2012. Conditionally inoperative as provided in subd. (b).)
14182.9.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. )
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The department may use letters or similar instructions to implement this article without formal rulemaking, but it must first consult stakeholders and give legislative committees at least five days’ notice before issuing instructions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.4. Health Care Coordination, Improvement, and Long-Term Cost Containment Waiver or Demonstration Project [14180 - 14182.9] ( Article 5.4 added by Stats. 2009, 4th Ex. Sess., Ch. 6, Sec. 2. ) ## 14182.9. Notwithstanding 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 department may implement the provisions of this article through all-county welfare director letters or similar instruction, without taking regulatory action. Prior to issuing any letter or similar instrument authorized pursuant to this section, the department shall notify and consult with stakeholders, including advocates, providers, and beneficiaries, in implementing, interpreting, or making specific this article. The department shall notify the appropriate policy and fiscal committees of the Legislature of its intent to issue instructions under this section at least five days in advance of the issuance. (Added by renumbering Section 14182 by Stats. 2010, Ch. 714, Sec. 19. (SB 208) Effective October 19, 2010.)
14184.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )
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This section names the article the Medi-Cal 2020 Demonstration Project Act and explains the policy goals behind the program.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184. (a) This article shall be known, and may be cited, as the Medi-Cal 2020 Demonstration Project Act. (b) The Legislature finds and declares all of the following: (1) The implementation of the federal Patient Protection and Affordable Care Act (Public Law 111-148) and California’s “Bridge to Reform” Medicaid demonstration project have led to the expansion of Medi-Cal coverage to more than 13 million beneficiaries, driving health care delivery system reforms that support expanded access to care, as well as higher quality, efficiency, and beneficiary satisfaction. (2) California’s “Medi-Cal 2020” Medicaid demonstration project, No. 11-W-00193/9, expands on these achievements by continuing to focus on expanded health care system capacity, better coordinated care, and aligned incentives within the Medi-Cal program in order to improve health outcomes for Medi-Cal beneficiaries, while simultaneously containing health care costs. (3) Public safety net providers, including designated public hospitals, and nondesignated public hospitals, which are also known as district and municipal public hospitals, play an essential role in the Medi-Cal program, providing high-quality care to a disproportionate number of low-income Medi-Cal and uninsured populations in the state. Because Medi-Cal covers approximately one-third of the state’s population, the strength of these essential health care systems and hospitals is of critical importance to the health and welfare of the people of California. (4) As a component of the “Medi-Cal 2020” demonstration project, the Global Payment Program provides an opportunity to test an alternative payment model for the remaining uninsured that rewards value and supports providing care at the appropriate place and time, aligning incentives to enhance primary and preventive services for California’s remaining uninsured seeking care in participating public health care systems. (5) As a component of the “Medi-Cal 2020” demonstration project, the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program seeks to improve health outcomes for patients served by participating entities by building on the delivery system transformation work from the “Bridge to Reform” demonstration project. Using evidence-based quality improvement methods, the PRIME program is intended to be ambitious in scope in order to accelerate transformation in care delivery and maximize value for patients, providers, and payers. The PRIME program also seeks to strengthen the ability of designated public hospitals to successfully perform under risk-based alternative payment models (APMs) in the long term. (6) As a component of the “Medi-Cal 2020” demonstration project, the Whole Person Care pilot program creates an opportunity for counties, Medi-Cal managed care plans, and community providers to establish a new model for integrated care delivery that incorporates health care needs, behavioral health, and social support for the state’s most vulnerable, high-user populations. The Whole Person Care pilot program encourages coordination among local partners to address the root causes of poor health outcomes, including immediate health needs and other factors, such as housing and recidivism, that impact a beneficiary’s health status. (7) As a component of the “Medi-Cal 2020” demonstration project, the Dental Transformation Initiative creates innovative opportunities for the Medi-Cal Dental Program to improve access to dental care, continuity of care, and increase the utilization of preventive services aimed at reducing preventable dental conditions for Medi-Cal beneficiaries identified within the project. (c) The implementation of the “Medi-Cal 2020” demonstration project, as set forth in this article, will support all of the following goals: (1) Improving access to health care and health care quality for California’s Medi-Cal and uninsured populations. (2) Promoting value and improving health outcomes for low-income populations. (3) Supporting whole person care by better integrating physical health, behavioral health, and social support services for high-risk, high-utilizing Medi-Cal beneficiaries. (4) Improving the capacity of public safety net providers that provide high-quality care to a disproportionate number of low-income patients with complex health needs in the state. (5) Transitioning from a cost-based reimbursement system toward a reimbursement structure that incentivizes quality and value by financially rewarding alternative models of care that support providers’ ability to deliver care in the most appropriate and cost-effective manner to patients. (Added by Stats. 2016, Ch. 111, Sec. 1. (SB 815) Effective July 25, 2016.)
14184.10.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )
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This section mainly defines terms used in the Medi-Cal 2020 Demonstration Project article, including the demonstration project, demonstration years, designated public hospitals, uninsured, and related payment programs.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.10. For purposes of this article, the following definitions shall apply: (a) “Demonstration project” means the California Medi-Cal 2020 Demonstration Project, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services, effective for the period from December 30, 2015, to December 31, 2020, inclusive, and any applicable extension period. (b) “Demonstration term” means the entire period during which the demonstration project is in effect, as approved by the federal Centers for Medicare and Medicaid Services, including any applicable extension period. (c) “Demonstration year” means the demonstration year as identified in the Special Terms and Conditions that corresponds to a specific period of time as set forth in paragraphs (1) to (6), inclusive. Individual programs under the demonstration project may be operated on program years that differ from the demonstration years identified in paragraphs (1) to (6), inclusive. (1) Demonstration year 11 corresponds to the period of January 1, 2016, to June 30, 2016, inclusive. (2) Demonstration year 12 corresponds to the period of July 1, 2016, to June 30, 2017, inclusive. (3) Demonstration year 13 corresponds to the period of July 1, 2017, to June 30, 2018, inclusive. (4) Demonstration year 14 corresponds to the period of July 1, 2018, to June 30, 2019, inclusive. (5) Demonstration year 15 corresponds to the period of July 1, 2019, to June 30, 2020, inclusive. (6) Demonstration year 16 corresponds to the period of July 1, 2020, to December 31, 2020, inclusive. (d) “Dental Transformation Initiative” or “DTI” means the waiver program intended to improve oral health services for children, as authorized under the Special Terms and Conditions and described in Section 14184.70. (e) “Designated state health program” has the same meaning as set forth in the Special Terms and Conditions. (f) (1) “Designated public hospital” means any one of the following hospitals, and any successor, including any restructured, reorganized, or differently named hospital, which is operated by a county, a city and county, the University of California, or a special hospital authority described in Chapter 5 (commencing with Section 101850) or Chapter 5.5 (commencing with Section 101852) of Part 4 of Division 101 of the Health and Safety Code, or any additional public hospital to the extent identified as a “designated public hospital” in the Special Terms and Conditions or, effective July 1, 2021, the CalAIM Terms and Conditions as defined in Section 14184.101. Unless otherwise provided for in law, in the California Medicaid State Plan, or in the Special Terms and Conditions, all references in law to a designated public hospital as defined in subdivision (d) of Section 14166.1 shall be deemed to refer to a hospital described in this section effective as of January 1, 2016, except as provided in paragraph (2) or, for a hospital not otherwise listed in subparagraphs (A) through (T), inclusive, as of the date specified in the applicable Terms and Conditions or State Plan amendment: (A) UC Davis Medical Center. (B) UC Irvine Medical Center. (C) UC San Diego Medical Center, including, effective no sooner than January 1, 2024, the East Campus Medical Center formerly known as Alvarado Hospital Medical Center. (D) UC San Francisco Medical Center. (E) UCLA Medical Center. (F) Santa Monica/UCLA Medical Center, also known as the Santa Monica-UCLA Medical Center and Orthopaedic Hospital. (G) LA County Health System Hospitals: (i) LA County Harbor/UCLA Medical Center. (ii) LA County Olive View UCLA Medical Center. (iii) LA County Rancho Los Amigos National Rehabilitation Center. (iv) LA General Medical Center. (H) Alameda Health System Hospitals, including the following: (i) Highland Hospital, including the Fairmont and John George Psychiatric facilities. (ii) Alameda Hospital. (iii) San Leandro Hospital. (I) Arrowhead Regional Medical Center. (J) Contra Costa Regional Medical Center. (K) Kern Medical Center. (L) Natividad Medical Center. (M) Riverside University Health System-Medical Center. (N) San Francisco General Hospital. (O) San Joaquin General Hospital. (P) San Mateo Medical Center. (Q) Santa Clara Valley Medical Center. (R) Ventura County Medical Center. (S) The following hospitals, effective no sooner than April 1, 2024: (i) UCLA West Valley Medical Center (formerly West Hills Hospital and Medical Center). (ii) UCI Health – Fountain Valley. (iii) UCI Health – Lakewood. (iv) UCI Health – Placentia Linda. (v) UCI Health – Los Alamitos. (T) The following hospitals, effective no sooner than the later of July 1, 2024, or the first day of the quarter following the closing of the applicable affiliation transaction with the University of California, San Francisco: (i) UCSF Health – St. Mary’s (formerly St. Mary’s Medical Center). (ii) UCSF Health – Saint Francis (formerly Saint Francis Memorial Hospital). (2) For purposes of the following reimbursement methodologies, the hospitals identified in clauses (ii) and (iii) of subparagraph (H) of paragraph (1) shall be deemed to be a designated public hospital as of the following effective dates: (A) For purposes of the fee-for-service payment methodologies established and implemented under Section 14166.4, the effective date shall be the date described in paragraph (3) of subdivision (a) of Section 14184.30. (B) For purposes of Article 5.230 (commencing with Section 14169.50), the effective date shall be January 1, 2017. (g) “Disproportionate share hospital provisions of the Medi-Cal State Plan” means those applicable provisions contained in Attachment 4.19-A of the California Medicaid state plan, approved by the federal Centers for Medicare and Medicaid Services, that implement the payment adjustment program for disproportionate share hospitals. (h) “Federal disproportionate share hospital allotment” means the amount specified for California under Section 1396r-4(f) of Title 42 of the United States Code for a federal fiscal year. (i) “Federal medical assistance percentage” means the federal medical assistance percentage applicable for federal financial participation purposes for medical services under the Medi-Cal State Plan pursuant to Section 1396b(a)(1) of Title 42 of the United States Code. (j) “Global Payment Program” or “GPP” means the payment program authorized under the demonstration project and described in Section 14184.40 that assists participating public health care systems that provide health care for the uninsured and that promotes the delivery of more cost-effective, higher-value health care services and activities. (k) “Nondesignated public hospital” means a public hospital as that term is defined in paragraph (25) of subdivision (a) of Section 14105.98, excluding designated public hospitals. (l) “Nonfederal share percentage” means the difference between 100 percent and the federal medical assistance percentage. (m) “PRIME” means the Public Hospital Redesign and Incentives in Medi-Cal program authorized under the demonstration project and described in Section 14184.50. (n) “Total computable disproportionate share hospital allotment” means the federal disproportionate share hospital allotment for a federal fiscal year, divided by the applicable federal medical assistance percentage with respect to that same federal fiscal year. (o) “Special Terms and Conditions” means those terms and conditions issued by the federal Centers for Medicare and Medicaid Services, including all attachments to those terms and conditions and any subsequent amendments approved by the federal Centers for Medicare and Medicaid Services, that apply to the demonstration project. (p) “Uninsured” means an individual for whom there is no source of third-party coverage for the health care services the individual receives, as determined pursuant to the Special Terms and Conditions. (q) “Whole Person Care pilot program” means a local collaboration among local governmental agencies, Medi-Cal managed care plans, health care and behavioral health providers, or other community organizations, as applicable, that are approved by the department to implement strategies to serve one or more identified target populations, pursuant to Section 14184.60 and the Special Terms and Conditions. (Amended by Stats. 2024, Ch. 40, Sec. 67. (SB 159) Effective June 29, 2024.)
14184.100.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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This section names Article 5.51 the California Advancing and Innovating Medi-Cal (CalAIM) Act and says its implementation should support specified Medi-Cal goals.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.100. (a) This article shall be known, and may be cited, as the California Advancing and Innovating Medi-Cal (CalAIM) Act. (b) The implementation of CalAIM, as set forth in this article and the CalAIM Terms and Conditions, shall support all of the following goals: (1) Identify and manage the risk and needs of Medi-Cal beneficiaries through whole-person-care approaches and addressing social determinants of health. (2) Transition and transform the Medi-Cal program to a more consistent and seamless system by reducing complexity and increasing flexibility. (3) Improve quality outcomes, reduce health disparities, and drive delivery system transformation and innovation through value-based initiatives, modernization of systems, and payment reform. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
14184.101.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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This section defines terms used in the CalAIM article, including CalAIM, CalAIM terms and conditions, and the CalAIM year schedule.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.101. For purposes of this article, and elsewhere in law where specified, the following definitions shall apply: (a) “CalAIM” or “CalAIM initiative” means the respective components of the California Advancing and Innovating Medi-Cal initiative authorized by this article and approved by the federal Centers for Medicare and Medicaid Services in the CalAIM Terms and Conditions. (b) “CalAIM term” means the entire period during which an applicable component of the CalAIM initiative is in effect, as approved by the federal Centers for Medicare and Medicaid Services, including any applicable extension period. (c) “CalAIM Terms and Conditions” means those terms and conditions issued and approved by the federal Centers for Medicare and Medicaid Services, including any attachments, appendices, or similar documents, and subsequent amendments thereto, that govern implementation of the respective components of the CalAIM initiative pursuant to this article. CalAIM Terms and Conditions shall include, at a minimum, any terms and conditions specified in the following: (1) California Advancing and Innovating Medi-Cal Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services pursuant to Section 1315 of Title 42 of the United States Code, effective for the period from January 1, 2022, to December 31, 2031, inclusive, and any applicable extension period, or for any period otherwise approved therein. (2) Any associated Medicaid Waivers as approved by the federal Centers for Medicare and Medicaid Services pursuant to Section 1396n of Title 42 of the United States Code that are necessary to implement a CalAIM component, effective for the period from January 1, 2022, to December 31, 2031, inclusive, and any applicable extension period, or for any period otherwise specified in the CalAIM Terms and Conditions. (3) Any associated Medi-Cal State Plan amendments approved by the federal Centers for Medicare and Medicaid Services that are necessary to implement a CalAIM component. (4) Any provision of a comprehensive risk contract, nonrisk contract, or other similar managed care arrangement, including an intergovernmental agreement, approved by the federal Centers for Medicare and Medicaid Services to implement the authorities described in paragraph (1), (2), or (3). (d) “CalAIM year” or “Initiative Year” means the applicable effective period identified in the CalAIM Terms and Conditions that corresponds to a specific period of time as set forth in paragraphs (1) to (10), inclusive. Individual programs or components under the CalAIM Initiative may be operated on program years that differ from the CalAIM years identified in paragraphs (1) to (10), inclusive, or may be operated without regard to program years, as applicable. (1) Initiative year 1 corresponds to the period of January 1, 2022, to December 31, 2022, inclusive. (2) Initiative year 2 corresponds to the period of January 1, 2023, to December 31, 2023, inclusive. (3) Initiative year 3 corresponds to the period of January 1, 2024, to December 31, 2024, inclusive. (4) Initiative year 4 corresponds to the period of January 1, 2025, to December 31, 2025, inclusive. (5) Initiative year 5 corresponds to the period of January 1, 2026, to December 31, 2026, inclusive. (6) Initiative year 6 corresponds to the period of January 1, 2027, to December 31, 2027, inclusive. (7) Initiative year 7 corresponds to the period of January 1, 2028, to December 31, 2028, inclusive. (8) Initiative year 8 corresponds to the period of January 1, 2029, to December 31, 2029, inclusive. (9) Initiative year 9 corresponds to the period of January 1, 2030, to December 31, 2030, inclusive. (10) Initiative year 10 corresponds to the period of January 1, 2031, to December 31, 2031, inclusive. (e) “Comprehensive risk contract” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations. (f) “Designated public hospital” means any one of the hospitals identified in subdivision (f) of Section 14184.10, and any successor, including any restructured, reorganized, or differently named hospital, that is operated by a county, a city and county, the University of California, or a special hospital authority described in Chapter 5 (commencing with Section 101850) or Chapter 5.5 (commencing with Section 101852) of Part 4 of Division 101 of the Health and Safety Code, or any additional public hospital to the extent identified as a “designated public hospital” in the CalAIM Terms and Conditions. (g) “Federal disproportionate share hospital allotment” means the amount specified for California under Section 1396r-4(f) of Title 42 of the United States Code for a federal fiscal year. (h) “Federal medical assistance percentage” means the federal medical assistance percentage applicable for federal financial participation purposes for medical assistance under the Medi-Cal State Plan pursuant to Section 1396b(a)(1) of Title 42 of the United States Code. (i) “Medi-Cal behavioral health delivery system” means an entity or local agency that contracts with the department to provide covered behavioral health Medi-Cal benefits pursuant to Article 3.2 (commencing with Section 14124.20), or Section 14184.400 and Chapter 8.9 (commencing with Section 14700), or a county Drug Medi-Cal Organized Delivery System pilot authorized under the CalAIM Terms and Conditions and described in Section 14184.401 or authorized under the Medi-Cal 2020 Demonstration Project Act pursuant to Article 5.5 (commencing with Section 14184). (j) “Medi-Cal managed care plan” means any individual, organization, or entity that enters into a comprehensive risk contract with the department to provide covered full-scope health care services to enrolled Medi-Cal beneficiaries pursuant to any provision of this chapter or Chapter 8 (commencing with Section 14200). (k) “Nonrisk contract” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations. (l) “Nonfederal share percentage” means the difference between 100 percent and the applicable federal medical assistance percentage. (m) “Total computable disproportionate share hospital allotment” means the federal disproportionate share hospital allotment for a federal fiscal year, divided by the applicable federal medical assistance percentage with respect to that same federal fiscal year. (Amended by Stats. 2026, Ch. 27, Sec. 88. (SB 164) Effective June 29, 2026.)
14184.102.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department must seek federal approval for and implement CalAIM, consult stakeholders in some cases, issue guidance, and maintain or increase certain Medi-Cal reimbursement rates when required.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.102. (a) Consistent with federal law, the department shall seek federal approval for, and implement, the CalAIM initiative, including, but not limited to, all of the following components: (1) Continuation of the Medi-Cal Managed Care program, described in part in Sections 14184.200 to 14184.208, inclusive, and, elsewhere in this chapter and Chapter 8 (commencing with Section 14200), and which includes any comprehensive risk contract between the department and an individual, organization, or entity to provide covered full-scope health care services to enrolled Medi-Cal beneficiaries pursuant to any provision of this chapter or Chapter 8 (commencing with Section 14200). (2) Continuation of the Global Payment Program, described in Section 14184.40, as amended by the act that added this section, and Section 14184.300. (3) Continuation of the Medi-Cal Specialty Mental Health Services Program, as described in part in Section 14184.400. (4) Continuation of the Drug Medi-Cal organized delivery system program, as described in part in Section 14184.401. (5) Behavioral Health Medical Necessity Changes, Payment Reform, Administrative Simplification, and Behavioral Health Quality Improvement Program, as described in Sections 14184.402, 14184.403, 14184.404, and 14184.405. (6) The State Plan Dental Improvement Program, as described in Section 14184.500. (7) Enhancing County Oversight and Monitoring, as described in Section 14184.600. (8) Providing Access and Transforming Health (PATH) Supports, as described in Section 14184.700. (9) Targeted Pre-Release Medi-Cal Benefits for Qualified Inmates, as described in Section 14184.800. (10) Employment Supports and BridgeCare, as described in Section 14184.900. (b) The department shall report to the Legislature any conflicts between this article and the CalAIM Terms and Conditions, including identification of the specific conflicts and recommendations for conforming language. (c) The department, as appropriate and to the extent practicable, shall consult with interested stakeholders with regard to implementation of applicable components of CalAIM under subdivision (a) in which they will participate, including, but not limited to, the issuance of departmental guidance pursuant to subdivision (d). Interested stakeholders may include, but need not be limited to, designated public hospitals, district and municipal public hospitals, other local governmental agencies, consumer representatives, and Medi-Cal managed care plans. (d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this article or the CalAIM Terms and Conditions, in whole or in part, by means of all-county letters, plan letters, provider bulletins, information notices, or other similar instructions, without taking any further regulatory action. The department shall make use of appropriate processes to ensure that affected stakeholders are timely informed of, and have access to, applicable guidance issued pursuant to this authority, and that this guidance remains publicly available until all payments related to the applicable CalAIM component are finalized. (e) For purposes of implementing this article or the CalAIM Terms and Conditions, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis, and may implement changes to existing information technology systems. Notwithstanding any other law, contracts entered into or amended, or changes to existing information technology systems, pursuant to this subdivision shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code, Section 19130 of the Government Code, and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services. (f) The department shall seek any federal approvals it deems necessary to implement CalAIM under this article and other provisions of law amended by the act that added this subdivision. This shall include, but need not be limited to, approval of any amendment, addition, or technical correction to the CalAIM Terms and Conditions, as the department deems necessary. This article shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. (g) Consistent with subdivision (b), the director shall report to the Legislature on any recommended amendments to any provision, process, or methodology specified in this article, Article 5.4 (commencing with Section 14180), Article 5.5 (commencing with Section 14184), or other sections of law amended by the act that added this subdivision, to the extent necessary to comply with federal law or the CalAIM Terms and Conditions, to obtain or maintain federal approval, or to ensure federal financial participation is available and not otherwise jeopardized, if the amendment is consistent with the goals set forth in this article and its individual components, and does not significantly alter the relative level of support for participating entities. If the director, after consulting with those entities participating in the applicable CalAIM component and that would be affected by that amendment, determines that the potential amendment would be consistent with the goals set forth in this article and would not significantly alter the relative level of support for affected participating entities, the amendment shall be submitted to the Legislature for its consideration. (h) During the course of the CalAIM term, the department may develop and implement successor payment methodologies or programs to continue to support entities participating in one or more components of CalAIM following the expiration of the CalAIM term and that further the goals set forth in this article. The department shall consult with the entities participating in the payment methodologies or program components under CalAIM, affected stakeholders, and the Legislature in the development of any successor payment methodologies or program components pursuant to this subdivision. (i) The department may seek to extend the payment methodologies or programs described in this article, or in the CalAIM Terms and Conditions, including modification thereto, through the CalAIM term or to subsequent time periods by way of amendment or extension of the relevant CalAIM Terms and Conditions, amendment to the Medi-Cal State Plan, or any combination thereof, consistent with the applicable federal requirements. This subdivision shall only be implemented after consultation with the entities participating in, or affected by, those methodologies or programs, and only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. (j) Notwithstanding any other state or local law, including, but not limited to, Section 5328 of this code, and Sections 11812 and 11845.5 of the Health and Safety Code, the sharing of health, social services, housing, and criminal justice information, records, and other data with and among the department, other state departments, including the State Department of Public Health and the State Department of Social Services, Medi-Cal managed care plans, Medi-Cal behavioral health delivery systems, counties, health care providers, social services organizations, care coordination and case management teams, and other authorized provider or plan entities, and contractors of all of those entities, shall be permitted to the extent necessary to implement applicable CalAIM components described in this article and the CalAIM Terms and Conditions, and to the extent consistent with federal law. The department shall issue guidance identifying permissible data-sharing arrangements to implement CalAIM. (k) (1) Notwithstanding any other law, and to the extent authorized by the CalAIM Terms and Conditions, the department may claim federal financial participation for expenditures associated with the designated state health programs identified in the CalAIM Terms and Conditions for use solely by the department as specified in this subdivision. (2) Any federal financial participation claimed pursuant to paragraph (1) shall be used to offset applicable General Fund expenditures. These amounts are hereby appropriated to the department and shall be available for transfer to the General Fund for this purpose. (3) An amount of General Fund moneys equal to the federal financial participation that may be claimed pursuant to paragraph (1) is hereby appropriated to the Health Care Deposit Fund for use by the department for purposes of implementing this article. (4) (A) Notwithstanding any other law, the department shall maintain reimbursement rates in the Medi-Cal program for primary care, obstetric care, and behavioral health services, and shall increase reimbursement rates for those service codes, as necessary to meet federally imposed minimum requirements specified in the CalAIM Terms and Conditions for dates of service on or after January 1, 2024, to the extent required by the federal Centers for Medicare and Medicaid Services as a condition of claiming federal financial participation for designated state health programs as described in this subdivision. (B) To the extent required by the CalAIM Terms and Conditions, subparagraph (A) shall apply to claims for the identified codes paid by the department in fee-for-service and to claims paid by a Medi-Cal managed care plan. (Amended by Stats. 2026, Ch. 27, Sec. 89. (SB 164) Effective June 29, 2026.)
14184.20.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )
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The department must implement the Medi-Cal 2020 demonstration project and related components, consult specified public hospitals and local agencies, give notice to legislative committees within 10 business days after certain actions, and keep guidance publicly available until payments are finalized.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.20. (a) Consistent with federal law, the Special Terms and Conditions, and this article, the department shall implement the Medi-Cal 2020 demonstration project, including, but not limited to, all of the following components: (1) The Global Payment Program, as described in Section 14184.40. (2) The Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program, as described in Section 14184.50. (3) The Whole Person Care pilot program, as described in Section 14184.60. (4) The Dental Transformation Initiative, as described in Section 14184.70. (b) In the event of a conflict between any provision of this article and the Special Terms and Conditions, the Special Terms and Conditions shall control. (c) The department, as appropriate, shall consult with the designated public hospitals, district and municipal public hospitals, and other local governmental agencies with regard to the implementation of the components of the demonstration project under subdivision (a) in which they will participate, including, but not limited to, the issuance of guidance pursuant to subdivision (d). (d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this article or the Special Terms and Conditions, in whole or in part, by means of all-county letters, plan letters, provider bulletins, or other similar instructions, without taking regulatory action. The department shall provide notification to the Joint Legislative Budget Committee and to the Senate Committees on Appropriations, Budget and Fiscal Review, and Health, and the Assembly Committees on Appropriations, Budget, and Health within 10 business days after the above-described action is taken. The department shall make use of appropriate processes to ensure that affected stakeholders are timely informed of, and have access to, applicable guidance issued pursuant to this authority, and that this guidance remains publicly available until all payments related to the applicable demonstration project component are finalized. (e) For purposes of implementing this article or the Special Terms and Conditions, the department may enter into exclusive or nonexclusive contracts, or amend existing contracts, on a bid or negotiated basis. Contracts entered into or amended pursuant to this subdivision shall be exempt from Chapter 6 (commencing with Section 14825) of Part 5.5 of Division 3 of Title 2 of the Government Code and Part 2 (commencing with Section 10100) of Division 2 of the Public Contract Code, and shall be exempt from the review or approval of any division of the Department of General Services. (f) During the course of the demonstration term, the department shall seek any federal approvals it deems necessary to implement the demonstration project and this article. This shall include, but is not limited to, approval of any amendment, addition, or technical correction to the Special Terms and Conditions, and any associated state plan amendment, as deemed necessary. This article shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. (g) The director may modify any process or methodology specified in this article to the extent necessary to comply with federal law or the Special Terms and Conditions of the demonstration project, but only if the modification is consistent with the goals set forth in this article for the demonstration project, and its individual components, and does not significantly alter the relative level of support for participating entities. If the director, after consulting with those entities participating in the applicable demonstration project component and that would be affected by that modification, determines that the potential modification would not be consistent with the goals set forth in this article or would significantly alter the relative level of support for affected participating entities, the modification shall not be made and the director shall execute a declaration stating that this determination has been made. The director shall retain the declaration and provide a copy, within five working days of the execution of the declaration, to the fiscal and appropriate policy committees of the Legislature, and shall work with the affected participating entities and the Legislature to make the necessary statutory changes. The director shall post the declaration on the department’s Internet Web site and the director shall send the declaration to the Secretary of State and the Legislative Counsel. (h) In the event of a determination that the amount of federal financial participation available under the demonstration project is reduced due to the application of penalties set forth in the Special Terms and Conditions, the enforcement of the demonstration project’s budget neutrality limit, or other similar occurrence, the department shall develop the methodology by which payments under the demonstration project shall be reduced, in consultation with the potentially affected participating entities and consistent with the standards and process specified in subdivision (g). To the extent feasible, those reductions shall protect the ability to claim the full amount of the total computable disproportionate share allotment through the Global Payment Program. (i) During the course of the demonstration term, the department may work to develop potential successor payment methodologies that could continue to support entities participating in the demonstration project following the expiration of the demonstration term and that further the goals set forth in this article and in the Special Terms and Conditions. The department shall consult with the entities participating in the payment methodologies under the demonstration project, affected stakeholders, and the Legislature in the development of any potential successor payment methodologies pursuant to this subdivision. (j) The department may seek to extend the payment methodologies described in this article through demonstration year 16 or to subsequent time periods by way of amendment or extension of the demonstration project, amendment to the Medi-Cal State Plan, or any combination thereof, consistent with the applicable federal requirements. This subdivision shall only be implemented after consultation with the entities participating in, or affected by, those methodologies, and only to the extent that any necessary federal approvals are obtained and federal financial participation is available and is not otherwise jeopardized. (k) (1) Notwithstanding any other law, and to the extent authorized by the Special Terms and Conditions, the department may claim federal financial participation for expenditures associated with the designated state health programs identified in the Special Terms and Conditions for use solely by the department as specified in this subdivision. (2) Any federal financial participation claimed pursuant to paragraph (1) shall be used to offset applicable General Fund expenditures. These amounts are hereby appropriated to the department and shall be available for transfer to the General Fund for this purpose. (3) An amount of General Fund moneys equal to the federal financial participation that may be claimed pursuant to paragraph (1) is hereby appropriated to the Health Care Deposit Fund for use by the department. (Amended by Stats. 2016, Ch. 733, Sec. 9. (SB 1477) Effective January 1, 2017.)
14184.200.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department may standardize Medi-Cal managed care enrollment statewide, but it must meet readiness and continuity-of-care conditions, and some beneficiaries are exempt or may request exemption.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.200. (a) Notwithstanding any other law, the department may standardize those populations that are subject to mandatory enrollment in a Medi-Cal managed care plan across all aid code groups and Medi-Cal managed care models statewide, subject to a Medi-Cal managed care plan readiness, continuity of care transition plan, and disenrollment process developed in consultation with stakeholders, in accordance with the CalAIM Terms and Conditions and as described in this section. (1) (A) The department shall ensure the Medi-Cal managed care plan’s readiness for network adequacy includes a geographic access review of rural ZIP Codes to ensure time or distance standards are met, or alternative access standard requests are approved, as applicable, and the plan’s ability to meet existing federal and state mandatory provider type requirements, where available. (B) The department shall not require a population to enroll in managed care if Medi-Cal managed care plans fail to meet the Medi-Cal managed care plan readiness requirements detailed in this paragraph for that population. (2) The Medi-Cal managed care plan shall comply with the continuity of care requirements in Section 1373.96 of the Health and Safety Code and shall be consistent with and no more restrictive than existing or future policy and guidance issued by the department, including All Plan Letter 22-032, any superseding all plan letter, and related guidance. (3) The disenrollment process for an enrollee in any county shall be consistent with and no more restrictive than existing federal and state statutes and regulations, including Section 53889 and subdivision (c) of Section 53891 of Title 22 of the California Code of Regulations. The beneficiary may request a medical exemption from mandatory enrollment in a Medi-Cal managed care plan in accordance with Section 53887 of Title 22 of the California Code of Regulations and may disenroll or be exempted from mandatory enrollment under the limited circumstances set forth in subdivision (c) of Section 53891 of Title 22 of the California Code of Regulations. That disenrollment or exemption from mandatory enrollment in a Medi-Cal managed care plan shall be consistent with subsection (c) of Section 438.56 of Title 42 of the Code of Federal Regulations and applicable state law. (b) (1) Notwithstanding any other law, if the department standardizes those populations subject to mandatory enrollment in a Medi-Cal managed care plan pursuant to subdivision (a), commencing January 1, 2022, and subject to subdivision (f) of Section 14184.102, a non-dual-eligible beneficiary, except a beneficiary identified in paragraph (2), shall be required to enroll, or shall continue to be required to enroll, in a Medi-Cal managed care plan for purposes of their receipt of covered Medi-Cal benefits. (2) Notwithstanding any other law, if the department standardizes those populations subject to mandatory enrollment in a Medi-Cal managed care plan pursuant to subdivision (a), commencing January 1, 2022, or as otherwise specified in this paragraph, subject to subdivision (f) of Section 14184.102, the following dual and non-dual beneficiary groups, as identified by the department, shall be exempt from mandatory enrollment in a Medi-Cal managed care plan: (A) A beneficiary eligible for only restricted-scope Medi-Cal benefits, as described in subdivision (e) of Section 14007.5 and Sections 14005.65 and 14007.7. (B) A beneficiary made eligible on the basis of a share of cost, including, but not limited to, a non-dual-eligible beneficiary residing in a county that is authorized to operate a county organized health system (COHS), as described in Article 2.8 (commencing with Section 14087.5), except for a non-dual-eligible beneficiary that is eligible on the basis of their need for long-term care services with a share of cost, as identified by the department. (C) A beneficiary made eligible on the basis of a federally approved Medi-Cal Presumptive Eligibility program, as determined by the department, but only during the relevant period of presumptive eligibility. (D) An eligible beneficiary who is an inmate of a public institution, or who is released pursuant to Section 26605.6 or 26605.7 of the Government Code. (E) A beneficiary with satisfactory immigration status, including a noncitizen that is lawfully present, who is eligible for only pregnancy-related Medi-Cal coverage and who received services through the Medi-Cal fee-for-service delivery system prior to January 1, 2022, as identified by the department, but only through the end of the postpartum period. (F) A beneficiary without satisfactory immigration status or who is unable to establish satisfactory immigration status as required by Section 14011.2, who is eligible for only pregnancy-related Medi-Cal coverage, excluding a beneficiary enrolled in the Medi-Cal Access Program described in Chapter 2 (commencing Section 15810) of Part 3.3. (G) A non-dual-eligible beneficiary who is an Indian, as defined in subdivision (a) of Section 438.14 of Title 42 of the Code of Federal Regulations, and who elects to forego voluntary enrollment in a Medi-Cal managed care plan. (H) A non-dual-eligible beneficiary eligible on the basis of their receipt of services through a state foster care program, or eligible pursuant to Section 14005.28, who elects to forego voluntary enrollment in a Medi-Cal managed care plan, except for a non-dual beneficiary described in this subparagraph who resides in a county that is authorized to operate COHS, as described in Article 2.8 (commencing with Section 14087.5), or, effective January 1, 2025, in a county operating a Single Plan model of managed care established under Article 2.7 (commencing with Section 14087.3) and Article 2.8 (commencing with Section 14087.5). For the purpose of this subdivision, the following requirements shall apply to non-dual-eligible beneficiaries eligible on the basis of their receipt of services through a state foster care program, or eligible pursuant to Section 14005.28, who are transitioning to mandatory enrollment in a Medi-Cal managed care plan in a county operating a Single Plan model of managed care: (i) Medi-Cal managed care plans shall comply with the access requirements in Section 14197 and in accordance with All Plan Letter 23-001, any superseding all plan letter, and any related guidance. (ii) The department shall use the Intercounty Transfer process as outlined in All County Welfare Directors Letter 18-02E to provide for immediate access to care and treatment services in the month of enrollment when a beneficiary moves from one county to another. (iii) The department shall issue guidance with input from stakeholders, including county child welfare departments. (I) A non-dual-eligible beneficiary enrolled with an entity with a contract with the department pursuant to the Program of All-Inclusive Care for the Elderly (PACE), as described in Chapter 8.75 (commencing with Section 14591). (J) Any other non-dual-eligible beneficiary, as identified by the department, for whom federal law prohibits mandatory enrollment in a Medi-Cal managed care plan. (K) A beneficiary residing in one of the Veterans’ Homes of California, as described in Chapter 1 (commencing with Section 1010) of Division 5 of the Military and Veterans Code. (L) Commencing no sooner than January 1, 2027, and subject to subdivision (f) of Section 14184.102, a beneficiary without satisfactory immigration status or who is unable to establish satisfactory immigration status as required by Section 14011.2, who is eligible pursuant to Section 14007.8 for the full-scope of Medi-Cal benefits, and who is subject to the service limitations described in subdivisions (b), (c), and (k) of Section 14007.8. (c) (1) Notwithstanding any other law, if the department standardizes those populations subject to mandatory enrollment in a Medi-Cal managed care plan pursuant to subdivision (a), commencing January 1, 2023, and subject to subdivision (f) of Section 14184.102, a dual eligible beneficiary, except as provided in paragraph (2) of subdivision (b) or paragraph (2) of this subdivision, shall be required to enroll, or shall continue to be required to enroll, in a Medi-Cal managed care plan for purposes of their receipt of covered Medi-Cal benefits. (2) The following dual eligible beneficiary groups, as identified by the department, shall be exempt from mandatory enrollment in Medi-Cal managed care as described in paragraph (1): (A) A dual eligible beneficiary made eligible on the basis of a share of cost, including, but not limited to, a dual eligible beneficiary residing in a county that is authorized to operate COHS, as described in Article 2.8 (commencing with Section 14087.5), except for a dual eligible beneficiary who is eligible on the basis of their need for long-term care services with a share of cost, as determined by the department. (B) A dual eligible beneficiary enrolled with an entity with a contract with the department pursuant to PACE as described in Chapter 8.75 (commencing with Section 14591). (C) A dual eligible beneficiary enrolled with an entity with a Senior Care Action Network (SCAN) contract with the department. (D) A dual eligible beneficiary who is an Indian, as defined in subsection (a) of Section 438.14 of Title 42 of the Code of Federal Regulations, and who elects to forego voluntary enrollment in a Medi-Cal managed care plan. (E) A dual eligible beneficiary with HIV/AIDS who elects to forego voluntary enrollment in a Medi-Cal managed care plan. (F) A dual eligible beneficiary eligible on the basis of their receipt of services through a state foster care program, or eligible pursuant to Section 14005.28, who elects to forego voluntary enrollment in a Medi-Cal managed care plan, except for a dual beneficiary described in this subparagraph who resides in a county that is authorized to operate COHS, as described in Article 2.8 (commencing with Section 14087.5), or, effective January 1, 2025, in a county operating a Single Plan model of managed care established under Article 2.7 (commencing with Section 14087.3) and Article 2.8 (commencing with Section 14087.5). For the purpose of this subdivision, the following requirements shall apply to non-dual-eligible beneficiaries eligible on the basis of their receipt of services through a state foster care program, or eligible pursuant to Section 14005.28, who are transitioning to mandatory enrollment in a Medi-Cal managed care plan in a county operating a Single Plan model of managed care: (i) Medi-Cal managed care plans shall comply with the access requirements in Section 14197 and in accordance with All Plan Letter 23-001, any superseding all plan letter, and any related guidance. (ii) The department shall use the Intercounty Transfer process as outlined in All County Welfare Directors Letter 18-02E to provide for immediate access to care and treatment services in the month of enrollment when a beneficiary moves from one county to another. (iii) The department shall issue guidance with input from stakeholders, including county child welfare departments. (G) A dual eligible beneficiary residing in one of the Veterans’ Homes of California, as described in Chapter 1 (commencing with Section 1010) of Division 5 of the Military and Veterans Code. (H) Any other dual eligible beneficiary, as identified by the department, for whom federal law prohibits mandatory enrollment in a Medi-Cal managed care plan. (d) (1) This section shall not prohibit a Medi-Cal beneficiary from receiving covered benefits on a temporary basis through the Medi-Cal fee-for-service delivery system pending enrollment into an individual Medi-Cal managed care plan in accordance with this section and the CalAIM Terms and Conditions. (2) This section shall not prohibit certain Medi-Cal beneficiaries eligible for full-scope benefits under the Medi-Cal State plan, as identified by the department, from voluntarily enrolling in a Medi-Cal managed care plan, in accordance with the CalAIM Terms and Conditions. (e) (1) No later than January 1, 2023, in all non-County Organized Health System counties, in areas where a PACE plan is available, the PACE plan shall be presented as an enrollment option, included in enrollment materials, and made available to an applicable beneficiary whenever enrollment choices and options are presented. Outreach and enrollment materials shall enable a Medi-Cal beneficiary to understand what PACE provides, that, if eligible, they may be assessed for PACE eligibility and enroll in PACE, and how they can receive additional information and request to be assessed for PACE eligibility. A person meeting the age qualifications for PACE and who chooses PACE shall not be assigned to a Medi-Cal managed care plan for the lesser of 60 days or until they are assessed for eligibility for PACE and determined not to be eligible for PACE. A person enrolled in a PACE plan shall receive all Medicare and Medi-Cal services from the PACE plan pursuant to the three-way agreement between the PACE plan, the department, and the federal Centers for Medicare and Medicaid Services. (2) In areas of the state where a presentation on Medi-Cal managed care plan enrollment options is unavailable, the department, or its contracted vendor, shall provide informational, outreach, and enrollment materials about the PACE program. (f) For purposes of this section, the following definitions apply: (1) “Dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) or Medicare Part B (42 U.S.C. Sec. 1395j et seq.), or both, and is eligible for medical assistance under the Medi-Cal State Plan. For purposes of this article, “dual eligible beneficiary” shall include both a “full-benefit dual eligible beneficiary” and a “partial-benefit dual eligible beneficiary,” as those terms are defined in this subdivision. (2) “Full-benefit dual eligible beneficiary” means an individual 21 years or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.), Medicare Part B (42 U.S.C. Sec. 1395j et seq.), and Medicare Part D (42 U.S.C. Sec. 1395w-101), and is eligible for medical assistance under the Medi-Cal State Plan. (3) “Non-dual-eligible beneficiary” means an individual eligible for medical assistance under the Medi-Cal State plan, as determined by the department, that is not eligible for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) or Medicare Part B (42 U.S.C. Sec. 1395j et seq.). (4) “Partial-benefit dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.), but not Medicare Part B (42 U.S.C. Sec. 1395j et seq.), or who is enrolled for Medicare Part B (42 U.S.C. Sec. 1395j et seq.), but not Medicare Part A (42 U.S.C. Sec. 1395c et seq.), and is eligible for medical assistance under the Medi-Cal State Plan. (Amended by Stats. 2026, Ch. 27, Sec. 90. (SB 164) Effective June 29, 2026.)
14184.201.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department must standardize certain Medi-Cal benefits statewide and, for listed services, require managed care plans and providers to use the payment and enrollment rules stated here.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.201. (a) Notwithstanding any other law, the department shall standardize those applicable covered Medi-Cal benefits provided by Medi-Cal managed care plans under comprehensive risk contracts with the department on a statewide basis and across all models of Medi-Cal managed care in accordance with this section and the CalAIM Terms and Conditions. (b) (1) Notwithstanding any other law, commencing January 1, 2023, subject to subdivision (f) of Section 14184.102, the department shall include, or continue to include, skilled nursing facility services as capitated benefits in the comprehensive risk contract with each Medi-Cal managed care plan. (2) For contract periods from January 1, 2023, to December 31, 2025, inclusive, during which paragraph (1) is implemented, each Medi-Cal managed care plan shall reimburse a network provider furnishing skilled nursing facility services to a Medi-Cal beneficiary enrolled in that plan, and each network provider of skilled nursing facility services shall accept the payment amount the network provider of skilled nursing facility services would be paid for those services in the Medi-Cal fee-for-service delivery system, as defined by the department in the Medi-Cal State Plan and guidance issued pursuant to subdivision (d) of Section 14184.102. For contract periods commencing on or after January 1, 2026, during which paragraph (1) is implemented, the department may elect to continue the payment requirement described in this paragraph, subject to subdivision (f) of Section 14184.102. (3) For contract periods during which paragraph (1) is implemented, capitation rates paid by the department to a Medi-Cal managed care plan shall be actuarially sound and shall account for the payment levels described in paragraph (2) as applicable. The department may require Medi-Cal managed care plans and network providers of skilled nursing facility services to submit information the department deems necessary to implement this subdivision, at the times and in the form and manner specified by the department. (c) (1) Notwithstanding any other law, commencing January 1, 2024, subject to subdivision (f) of Section 14184.102, the department shall include, or continue to include, institutional long-term care services not described in subdivision (b) as capitated benefits in the comprehensive risk contract with each Medi-Cal managed care plan. (2) For contract periods from January 1, 2024, to December 31, 2025, inclusive, during which paragraph (1) is implemented, each Medi-Cal managed care plan shall reimburse a network provider furnishing institutional long-term care services not described in subdivision (b) to a Medi-Cal beneficiary enrolled in that plan, and each network provider of institutional long-term care services not described in subdivision (b) shall accept the payment amount the network provider of institutional long-term care services would be paid for those services in the Medi-Cal fee-for-service delivery system, as defined by the department in the Medi-Cal State Plan and guidance issued pursuant to subdivision (d) of Section 14184.102. For contract periods commencing on or after January 1, 2026, during which paragraph (1) is implemented, the department may elect to continue the payment requirement described in this paragraph, subject to subdivision (f) of Section 14184.102. (3) For contract periods during which paragraph (1) is implemented, capitation rates paid by the department to a Medi-Cal managed care plan shall be actuarially sound and shall account for the payment levels described in paragraph (2), as applicable. The department may require Medi-Cal managed care plans and network providers of institutional long-term care services to submit information the department deems necessary to implement this subdivision, at the times and in the form and manner specified by the department. (4) The department shall convene, in collaboration with the State Department of Developmental Services (DDS), a workgroup to address transition of intermediate care facility/developmentally disabled (ICF/DD) facilities, and Intermediate Care Facility for the Developmentally Disabled-Nursing (ICF/DD-N) and Intermediate Care Facility for the Developmentally Disabled-Habilitative (ICF/DD-H) Homes from the Medi-Cal fee-for-service delivery system to the Medi-Cal managed care delivery system to ensure a smooth transition to CalAIM. (d) (1) Notwithstanding any other law, commencing January 1, 2022, the department shall include donor and recipient organ transplant surgeries, as described in Section 14132.69 and in the CalAIM Terms and Conditions, and donor and recipient bone marrow transplants, as described in Section 14133.8 and in the CalAIM Terms and Conditions, as capitated benefits in the comprehensive risk contract with each Medi-Cal managed care plan. (2) For contract periods from January 1, 2022, to December 31, 2024, inclusive, during which paragraph (1) is implemented, each applicable Medi-Cal managed care plan shall reimburse a provider furnishing organ or bone marrow transplant surgeries to a Medi-Cal beneficiary enrolled in that plan, and each provider of organ or bone marrow transplant surgeries shall accept the payment amount the provider of organ or bone marrow transplant surgeries would be paid for those services in the Medi-Cal fee-for-service delivery system, as defined by the department in the Medi-Cal State Plan and guidance issued pursuant to subdivision (d) of Section 14184.102. For contract periods commencing on or after January 1, 2025, during which paragraph (1) is implemented, the department may elect to continue the payment requirement described in this paragraph, subject to subdivision (f) of Section 14184.102. (3) For contract periods during which paragraph (1) is implemented, capitation rates paid by the department to a Medi-Cal managed care plan shall be actuarially sound and shall account for the payment levels described in paragraph (2) as applicable. The department may require Medi-Cal managed care plans and providers of organ or bone marrow transplant surgeries to submit information the department deems necessary to implement this subdivision, at the times and in the form and manner specified by the department. (e) (1) Notwithstanding any other law, commencing January 1, 2022, Community-Based Adult Services (CBAS) shall continue to be available as a capitated benefit for a qualified Medi-Cal beneficiary under a comprehensive risk contract with an applicable Medi-Cal managed care plan, in accordance with the CalAIM Terms and Conditions. (2) CBAS shall only be available as a covered Medi-Cal benefit for a qualified Medi-Cal beneficiary under a comprehensive risk contract with an applicable Medi-Cal managed care plan. Medi-Cal beneficiaries who are eligible for CBAS shall enroll in an applicable Medi-Cal managed care plan in order to receive those services, except for beneficiaries exempt from mandatory enrollment in a Medi-Cal managed care plan pursuant to the CalAIM Terms and Conditions and Section 14184.200. (3) CBAS shall be delivered in accordance with applicable state and federal law, including, but not limited to, the federal home and community-based settings regulations set forth in Sections 441.301(c)(4), 441.530(a)(1), and 441.710(a)(1) of Title 42 of the Code of Federal Regulations, and related subregulatory guidance and any amendment issued thereto. (4) For contract periods during which paragraph (1) is implemented, each applicable Medi-Cal managed care plan shall reimburse a network provider furnishing CBAS to a Medi-Cal beneficiary enrolled in that plan, and each network provider of CBAS shall accept the payment amount the network provider of CBAS would be paid for the service in the Medi-Cal fee-for-service delivery system, as defined by the department in guidance issued pursuant to subdivision (d) of Section 14184.102, unless the Medi-Cal managed plan and network provider mutually agree to reimbursement in a different amount. (5) For contract periods during which paragraph (1) is implemented, capitation rates paid by the department to an applicable Medi-Cal managed care plan shall be actuarially sound and shall account for the payment levels described in paragraph (4) as applicable. The department may require applicable Medi-Cal managed care plans and network providers of CBAS to submit information the department deems necessary to implement this subdivision, at the times and in the form and manner specified by the department. (f) Notwithstanding any other law, including, but not limited to, subdivision (a), the department may not transfer responsibility for specialty mental health services in the Counties of Sacramento and Solano from the Medi-Cal managed care plan responsible for those services on July 1, 2022, in those counties until no sooner than all of the following requirements have been met: (1) The requirements of Section 14184.403 have been implemented. (2) Each county and Medi-Cal managed care plan has submitted to the department a transition plan that contains provisions for continuity of care or the transfer of care. (3) Notice has been provided to affected beneficiaries, including the ability of beneficiaries to request continuity of care pursuant to mental health and substance use disorder information notices issued by the department. (g) For purposes of this section, the following definitions apply: (1) “Comprehensive risk contract” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations. (2) “Institutional long-term care services” has the same meaning as set forth in the CalAIM Terms and Conditions and, subject to subdivision (f) of Section 14184.102, includes at a minimum all of the following: (A) Skilled nursing facility services. (B) Subacute facility services. (C) Pediatric subacute facility services. (D) Intermediate care facility services. (3) “Network provider” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations. (Amended by Stats. 2025, Ch. 243, Sec. 23. (SB 862) Effective January 1, 2026.)
14184.203.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department may require Medi-Cal managed care plans and certain subcontractors to get accredited starting with contract periods on or after January 1, 2026, and may allow alternate accreditation in some cases. It may not use accreditation findings to certify compliance, except for credentialing.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.203. (a) For contract periods commencing on or after January 1, 2026, the department may require each Medi-Cal managed care plan and each health plan subcontractor of a Medi-Cal managed care plan to be accredited by the National Committee for Quality Assurance, or an alternative entity pursuant to subdivision (c), in accordance with this section and the CalAIM Terms and Conditions. (b) The department shall not use findings from the accreditation pursuant to subdivision (a) to certify or deem a Medi-Cal managed care plan’s compliance with applicable state and federal Medicaid requirements, except in the area of credentialing. (c) If the department determines that a Medi-Cal managed care plan or an applicable health plan subcontractor thereof is unable to receive accreditation from the National Committee for Quality Assurance due to population size, the department may authorize alternate accreditation if the requirements applied are substantially similar to those applied pursuant to subdivision (a), as determined by the department. (d) For purposes of this section, “subcontractor” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
14184.204.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department must implement and oversee a Medi-Cal population health management program, and each Medi-Cal managed care plan must maintain a beneficiary-centered program with required care, risk, and prevention activities.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.204. (a) Commencing January 1, 2023, subject to subdivision (f) of Section 14184.102, the department shall implement the Population Health Management Program under the Medi-Cal managed care delivery system to improve health outcomes, care coordination, and efficiency through application of standardized health management requirements, in accordance with the CalAIM Terms and Conditions. (b) The department shall require each Medi-Cal managed care plan, after consultation with counties and other affected stakeholders, to develop and maintain a beneficiary-centered population health management program, which is a model of care and plan of action designed to address member health needs at all points along the continuum of care, as described in the CalAIM Terms and Conditions. (c) Each Medi-Cal managed care plan in the population health management program shall, at a minimum, do all of the following: (1) Prioritize preventive and wellness services. (2) Identify and assess beneficiary member risks and needs on an ongoing basis. (3) Manage beneficiary member safety and outcomes during care transitions, across all applicable delivery systems and settings, through effective care coordination. (4) Identify and mitigate social determinants of health and reduce health disparities or inequities. (d) To support implementation of this section, the department shall develop and implement a Medi-Cal Population Health Management service that expands access to available medical, behavioral, and social service data and provides authorized entities access to necessary administrative and clinical data and information with respect to Medi-Cal beneficiaries across Medi-Cal delivery systems and other applicable public programs, as identified by the department. Data will be available at the individual member level and include the ability for bulk downloads for the purposes of population health analytics and clinical management by Medi-Cal managed care plans in support of the population health management activities described in subdivision (f). (e) Population health management program components shall be developed in consultation with appropriate stakeholders, including, but not limited to, the State Department of Public Health, Medi-Cal managed care plans, Medi-Cal behavioral health delivery systems, county public health and social services, providers, community-based organizations, and consumer advocates. (f) The Population Health Management Program shall include, but is not limited to, all of the following: (1) Appropriate use of preventive services for children and adults, and other interventions, including chronic disease management, referrals for behavioral and oral health care services, housing, nutrition, and other health-related social needs. (2) Risk assessment is comparable and consistent between Medi-Cal managed care plans. (3) Any algorithm used to conduct member risk assessment is comparable, standardized, and mitigated for racial and other biases through consideration of disease burden relative to utilization and other patient risk factors beyond cost and historical utilization. The department shall report the underlying measures it uses in its algorithm. (4) Any screening tool used to assess beneficiaries is age appropriate and comparable across Medi-Cal managed care plans. (5) Each Medi-Cal managed care plan incorporates the findings of its Population Needs Assessment in its population health management program. (6) Each Medi-Cal managed care plan describes how it will incorporate preventive and wellness services in partnership with Medi-Cal behavioral health delivery systems, county public health and social services, providers, community-based organizations, and consumer advocates. (g) Beginning no later than January 1, 2024, the department shall annually post an analysis of the Population Health Management Program on its internet website. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
14184.205.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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This section requires the department to implement Medi-Cal enhanced care management and makes managed care plans cover it for specified populations and dates.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.205. (a) Subject to subdivision (f) of Section 14184.102, the department shall implement an enhanced care management (ECM) benefit designed to address the clinical and nonclinical needs on a whole-person-care basis for certain target populations of Medi-Cal beneficiaries enrolled in Medi-Cal managed care plans, in accordance with this section and the CalAIM Terms and Conditions. (b) (1) Subject to the effective dates listed in subdivision (c), the ECM benefit shall be available on a statewide basis to an eligible Medi-Cal beneficiary who is enrolled in an applicable Medi-Cal managed care plan and who meets the criteria in the CalAIM Terms and Conditions for one or more target populations, as determined by the department. A Medi-Cal beneficiary is excluded from ECM while enrolled in a 1915(c) waiver or the Family Mosaic Project, or while receiving California Community Transitions (CCT) Money Follows the Person (MFTP) services. ECM shall be available to a qualifying dual eligible beneficiary, as described under Section 14184.200, except for a dual eligible beneficiary enrolled in a fully integrated program for members who are dually eligible for Medicare and Medicaid, including Cal MediConnect during the duration of the demonstration authorized in Section 14132.275, Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs), and the Programs of All-Inclusive Care for the Elderly (PACE). (2) ECM only shall be available as a covered Medi-Cal benefit under a comprehensive risk contract with a Medi-Cal managed care plan. A Medi-Cal beneficiary who is eligible for ECM shall enroll in a Medi-Cal managed care plan in order to receive those services. (c) (1) A Medi-Cal managed care plan operating in counties in which either the Whole Person Care pilot program, pursuant to Section 14184.60, or the Health Home Program, pursuant to Article 3.9 (commencing with Section 14127), or both, were implemented, as determined by the department, shall be required to cover ECM under its comprehensive risk contract as follows: (A) Commencing January 1, 2022, a Medi-Cal managed care plan described in this paragraph shall be required to cover ECM for existing target populations under either the Whole Person Care pilot program or the Health Home Program, or both, as identified by the department. (B) (i) Commencing January 1, 2023, a Medi-Cal managed care plan described in this paragraph shall be required to cover ECM for other select target populations described in subdivision (d), as identified by the department and in accordance with the CalAIM Terms and Conditions. (ii) Commencing July 1, 2023, a Medi-Cal managed care plan described in this paragraph shall be required to cover ECM for all target populations described in subdivision (d) and in accordance with the CalAIM Terms and Conditions. (2) A Medi-Cal managed care plan operating in counties in which neither the Whole Person Care pilot program, pursuant to Section 14184.60, or the Health Home Program, pursuant to Article 3.9 (commencing with Section 14127), was implemented, as determined by the department, shall be required to cover select ECM target populations, as identified by the department, under its comprehensive risk contract, commencing July 1, 2022. All other target populations, including the target population described in paragraph (7) of subdivision (d), shall be covered commencing January 1, 2023, or July 1, 2023, in accordance with the CalAIM Terms and Conditions. (d) Target populations shall include the following, consistent with the department’s eligibility criteria, and to the extent approved in the CalAIM Terms and Conditions: (1) Children or youth with complex physical, behavioral, developmental, or oral health needs, including, but not limited to, those eligible for California Children’s Services, those involved or with a history of involvement in child welfare or the juvenile justice system, or youth with clinical high-risk syndrome or a first episode of psychosis. (2) Individuals experiencing homelessness. (3) High utilizers with frequent hospital admissions, short-term skilled nursing facility stays, or emergency room visits. (4) Individuals at risk for institutionalization and eligible for long-term care services. (5) Nursing facility residents who want to transition to the community. (6) Individuals with serious mental illness (SMI), and children with serious emotional disturbance (SED) or substance use disorder (SUD). (7) Individuals transitioning from incarceration requiring immediate transition of services to the community. (e) Notwithstanding any other law, for any time period in which a Medi-Cal beneficiary is eligible to receive ECM services through enrollment in their Medi-Cal managed care plan, the beneficiary shall not receive duplicative targeted case management services as described in Section 14132.44 or otherwise authorized in the Medi-Cal State Plan, as determined by the department. (f) Medi-Cal managed plans shall consult and collaborate with Medi-Cal behavioral health delivery systems for the delivery of ECM for beneficiaries with an SMI, SED, or SUD. (g) If a Medi-Cal managed care plan proposes to keep some level of ECM in house instead of contracting with direct providers, the Medi-Cal managed care plan shall demonstrate to the state that its ECM benefit is appropriately community based and shall provide a rationale for not contracting with existing providers. (h) The department shall develop, in consultation with Medi-Cal managed care plans and other appropriate stakeholders, a monitoring plan and reporting template for the implementation of ECM pursuant to this section. The department shall annually publish a public report on reported ECM utilization data, populations served, and demographic data, stratified by age, sex, race, ethnicity, and languages spoken, to the extent statistically reliant data is available. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
14184.206.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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This section lets a Medi-Cal managed care plan choose to cover approved community supports, and sets notice, reporting, and evaluation duties for the department and the plan.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.206. (a) Commencing January 1, 2022, and subject to subdivision (f) of Section 14184.102, a Medi-Cal managed care plan may elect to cover those community supports approved by the department as cost effective and medically appropriate in the comprehensive risk contract that are in lieu of applicable Medi-Cal state plan services, in accordance with the CalAIM Terms and Conditions. (b) (1) Approved community supports pursuant to this section shall be available only to beneficiaries enrolled in a Medi-Cal managed care plan under a comprehensive risk contract, subject to paragraph (2). (2) Approved community supports shall not supplant other covered Medi-Cal benefits that are not the responsibility of the Medi-Cal managed care plan under the comprehensive risk contract, including, but not limited to, in-home supportive services provided pursuant to Article 7 (commencing with Section 12300) of Chapter 3, and Sections 14132.95, 14132.952, and 14132.956. (3) An enrolled Medi-Cal beneficiary shall not be required by their Medi-Cal managed care plan to use the community support. (c) Subject to subdivision (f) of Section 14184.102, community supports that the department may approve include, but need not be limited to, all of the following when authorized by the department in the comprehensive risk contract with each Medi-Cal managed care plan and to the extent the department determines that the community support is a cost-effective and medically appropriate substitute for the applicable covered Medi-Cal benefit under the comprehensive risk contract: (1) Housing transition navigation services. (2) Housing deposits. (3) Housing tenancy and sustaining services. (4) Short-term post-hospitalization housing. (5) Recuperative care or medical respite. (6) Respite. (7) Day habilitation programs. (8) Nursing facility transition or diversion to assisted living facilities, including, but not limited to, residential care facilities for the elderly or adult residential facilities. (9) Nursing facility transition to a home. (10) Personal care and homemaker services. (11) Environmental accessibility adaptations or home modifications. (12) Medically supportive food and nutrition services, including medically tailored meals. (13) Sobering centers. (14) Asthma remediation. (d) The department shall publicly post on its internet website a list of which community supports are offered to enrollees by each Medi-Cal managed care plan. (e) A Medi-Cal managed care plan shall provide information on the available community supports in its member handbook and plan website, including any limitations on community supports on the plan website. (f) The department shall develop, in consultation with Medi-Cal managed care plans and other appropriate stakeholders, a monitoring plan and reporting template for the implementation of community supports pursuant to this section. The department shall annually publish a public report on reported community supports utilization data, populations served, and demographic data, stratified by age, sex, race, ethnicity, and languages spoken, to the extent statistically reliant data are available. (g) The department shall conduct an independent evaluation of the effectiveness of community supports in accordance with the parameters and timeframes specified in the CalAIM Terms and Conditions. (h) The department shall take into account the utilization and actual cost of community supports in developing capitation rates. (i) For purposes of this section, the following definitions apply: (1) “Community supports” means those alternative services and settings approved in the CalAIM Terms and Conditions and administered according to paragraph (2) of subsection (e) of Section 438.3 of Title 42 of the Code of Federal Regulations. (2) “Comprehensive risk contract” has the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations. (Amended by Stats. 2022, Ch. 47, Sec. 127. (SB 184) Effective June 30, 2022.)
14184.207.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department must set up and administer incentive payments for qualifying Medi-Cal managed care plans, and it may offer extra payments if funds are available.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.207. (a) Commencing January 1, 2022, subject to appropriation by the Legislature in an applicable fiscal year and subdivision (f) of section 14184.102, the department shall make incentive payments available to qualifying Medi-Cal managed care plans that meet predefined milestones and metrics associated with implementation of applicable components of CalAIM, including, but not limited to, Sections 14184.205 and 14184.206, as determined by the department and in accordance with the CalAIM Terms and Conditions. (b) The department, in consultation with Medi-Cal managed care plans, consumer advocates, the Medi-Cal behavioral health delivery system, and other stakeholder representatives, shall establish the methodology, parameters, and eligibility criteria for incentive payments pursuant to this section. This shall include, but is not limited to, the milestones and metrics that Medi-Cal managed care plans must meet in order to receive an incentive payment pursuant to this section and the CalAIM Terms and Conditions. (c) The department, in accordance with the CalAIM Terms and Conditions, shall determine if a Medi-Cal managed care plan has earned an incentive payment, and the amount of that payment, for any relevant time period in which this section is implemented. (d) Incentive payments pursuant to this section shall be made in accordance with the requirements for incentive arrangements described in Section 438.6(b)(2) of Title 42 of the Code of Federal Regulations and any associated federal guidance. (e) (1) Notwithstanding subdivision (a), the department may make additional or augmented incentive payments available to Medi-Cal managed care plans, subject to subdivision (f) of Section 14184.102 and to the extent sufficient nonfederal share funds are available for this purpose in each applicable CalAIM year. (2) The nonfederal share of additional or augmented incentive payments pursuant to this subdivision may consist of voluntary intergovernmental transfers of funds provided by eligible governmental agencies or other public entities, pursuant to Section 14164. Upon providing any intergovernmental transfer of funds, a transferring entity shall certify that the transferred funds qualify for federal financial participation pursuant to Section 433.51 of Title 42 of the Code of Federal Regulations and any other applicable Medicaid laws, and in the form and manner specified by the department. An intergovernmental transfer of funds made pursuant to this subdivision shall be considered voluntary for purposes of all state and federal laws. Notwithstanding any other law, the department shall not assess the fee described in subdivision (d) of Section 14301.4 or any other similar fee on the intergovernmental transfers made pursuant to this subdivision. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
14184.208.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department must manage aligned enrollment rules for dual eligible beneficiaries and certain D-SNP contracting requirements, while beneficiaries generally cannot be forced to enroll in a D-SNP to get Medi-Cal benefits.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.208. (a) To promote more integrated care for dual eligible beneficiaries, the department shall seek to align the enrollment of dual eligible beneficiaries in affiliated Medi-Cal managed care plans and Medicare plans, including Medicare Advantage Dual Special Needs Plans (D-SNP), as described in this section and in accordance with the CalAIM Terms and Conditions. A dual eligible beneficiary shall not be required to enroll in a D-SNP for purposes of receiving their Medi-Cal benefits. (b) (1) Commencing January 1, 2023, subject to subdivision (f) of Section 14184.102, the department shall require each Medi-Cal managed care plan operating in Coordinated Care Initiative counties to operate, or continue to operate, a D-SNP in accordance with the CalAIM Terms and Conditions, and in accordance with federal requirements for each D-SNP, to have an executed contract with the department, referred to as a State Medicaid Agency Contract (SMAC). The requirements described in this paragraph shall not be applicable to a subcontracted delegate health plan. (2) In Coordinated Care Initiative counties, beginning in contract year 2023, the department may only contract with a proposed D-SNP that is affiliated with a Medi-Cal managed care plan or a subcontracted delegate health plan, or was contracted with the department for a D-SNP in contract year 2022 in the proposed D-SNP service area. (3) In Coordinated Care Initiative counties, beginning with contract year 2023, dual eligible beneficiaries that are not already enrolled in a D-SNP for contract year 2022 may only enroll in a D-SNP that is affiliated with a Medi-Cal managed care plan or a subcontracted delegate health plan in the beneficiary’s service area. (4) In Coordinated Care Initiative counties, beginning with contract year 2023, a dual eligible beneficiary shall be assigned to a Medi-Cal managed care plan, or subcontracted delegate health plan, that is affiliated with the Medicare Advantage plan, including a D-SNP, in which the dual eligible beneficiary is enrolled. The department may approve exceptions to this policy, to support beneficiary enrollment choice. (c) (1) Commencing January 1, 2026, subject to subdivision (f) of Section 14184.102 and paragraph (5) of this subdivision, the department may require each Medi-Cal managed care plan to operate, or continue to operate, a D-SNP in accordance with the CalAIM Terms and Conditions, and in accordance with federal requirements for each D-SNP to have an executed contract with the department, referred to as an SMAC. The requirements described in this paragraph shall not be applicable to a subcontracted delegate health plan. (2) In non-Coordinated Care Initiative counties, beginning no later than contract year 2025, the department shall only contract with a proposed D-SNP that is affiliated with a Medi-Cal managed care plan or subcontracted delegate health plan, or was contracted with the department for a D-SNP in the proposed D-SNP service area in the contract year that immediately precedes the contract year in which this paragraph is implemented with respect to an individual county. (3) In non-Coordinated Care Initiative counties, beginning no later than contract year 2026, a dual eligible beneficiary shall be assigned to a Medi-Cal managed care plan or a subcontracted delegate health plan that is affiliated with the Medicare Advantage plan, including a D-SNP, in which the dual eligible beneficiary is enrolled. The department may approve exceptions to the requirement described in this subparagraph when it determines necessary to support beneficiary enrollment choice. (4) In non-Coordinated Care Initiative counties, beginning no later than contract year 2025, dual eligible beneficiaries not already enrolled in a D-SNP, in the contract year that immediately precedes the contract year in which this paragraph is implemented with respect to an individual county, may only enroll in a D-SNP that is affiliated with a Medi-Cal managed care plan, or a subcontracted delegate health plan, in the beneficiary’s service area. Beginning no later than contract year 2025, D-SNPs that are not affiliated with a Medi-Cal managed care plan or a subcontracted delegate health plan shall not accept new enrollment of dual eligible beneficiaries. (5) The department shall conduct a feasibility study of D-SNPs, in specific non-Coordinated Care Initiative counties as determined by the department, to be completed no later than July 1, 2022. As a result of the study findings, or evidence provided by a Medi-Cal managed care plan of the potential for significant financial losses that may be incurred by a Medi-Cal managed care plan as a result of operating a D-SNP, and evidence provided by a Medi-Cal managed care plan that the plan has made a good faith effort but is not able to develop a partnership with a D-SNP for coordinated care across Medicare and Medi-Cal, the department may provide, in its sole discretion, an exemption from the requirements in paragraph (1) of this subdivision on an individual plan basis for a period of three years. The department may renew this exemption for successive three-year periods based on study findings or evidence of potential losses, and evidence of a good faith effort, as specified in this paragraph. (d) To ensure dual eligible beneficiaries are fully informed regarding aligned enrollment, the department or the Med-Cal managed care plan, as applicable, shall provide informing notices to affected beneficiaries regarding Medi-Cal plan enrollment changes related to aligned enrollment. The notices shall be developed in consultation with consumer advocates. (e) Beginning in contract year 2023, the department shall include requirements for network adequacy, aligned networks, and continuity of care in the SMAC. The requirements shall be developed in consultation with affected stakeholders. (f) The department shall contract with public or private entities in assisting dual eligible beneficiaries in understanding their health care coverage options, overcoming access to care barriers, and addressing eligibility and enrollment barriers. (g) The department shall convene a workgroup including plans, providers, and consumer stakeholders to discuss transition to a statewide Managed Long-Term Services and Supports and D-SNP structure. (h) For purposes of this section, the following definitions apply: (1) “Coordinated Care Initiative counties” means the Counties of Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. (2) “Dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) or Medicare Part B (42 U.S.C. Sec. 1395j et seq.), or both, and is eligible for medical assistance under the Medi-Cal State Plan. For purposes of this section, “dual eligible beneficiary” shall include both “full-benefit dual eligible beneficiaries” and “partial-benefit dual eligible beneficiaries,” as those terms are defined in this subdivision. (3) “Full-benefit dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.), Medicare Part B (42 U.S.C. Sec. 1395j et seq.), and Medicare Part D (42 U.S.C. Sec. 1395w-101), and is eligible for medical assistance under the Medi-Cal State Plan. (4) “Medicare Advantage Dual Special Needs Plan” or “D-SNP” shall have the same meaning as set forth in Section 1395w-28(b)(6) of Title 42 of the United States Code. (5) “Partial-benefit dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.), but not Medicare Part B (42 U.S.C. Sec. 1395j et seq.), or who is enrolled for Medicare Part B (42 U.S.C. Sec. 1395j et seq.), but not Medicare Part A (42 U.S.C. Sec. 1395c et seq.), and is eligible medical assistance under the Medi-Cal State Plan. (6) “Subcontracted delegate health plan” means a health care service plan that is a subcontractor of a Medi-Cal managed care plan that the department determines to have assumed the entire financial risk for all Medi-Cal services provided to a dual eligible beneficiary that are covered under the applicable comprehensive risk contract of the Medi-Cal managed care plan. (7) “Subcontractor” shall have the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations. (i) For purposes of this section, “Medi-Cal managed care plan” shall not include a managed care plan contract with the AIDS Healthcare Foundation. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
14184.21.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )
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The department must conduct or arrange studies, reports, assessments, evaluations, or similar demonstration project activities required by the Special Terms and Conditions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.21. The department shall conduct, or arrange to have conducted, any study, report, assessment, including the access assessment described in Section 14184.80, evaluation, or other similar demonstration project activity required under the Special Terms and Conditions. (Added by Stats. 2016, Ch. 42, Sec. 1. (AB 1568) Effective July 1, 2016. Operative July 25, 2016, pursuant to Stats. 2016, Ch. 42, Sec. 8, and enactment of SB 815 as Ch. 111.)
14184.30.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )
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This section sets payment rules for Medi-Cal hospital funding, including when certain fee-for-service and disproportionate share hospital payments apply, who may receive them, and how some amounts must be calculated or limited.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.30. The following payment methodologies and requirements implemented pursuant to Article 5.2 (commencing with Section 14166) shall be applicable as set forth in this section. (a) (1) (A) For purposes of Section 14166.4, the references to “project year” and “successor demonstration year” shall include references to the demonstration term, as defined under this article, and to any extensions of the prior federal Medicaid demonstration project entitled “California Bridge to Reform Demonstration (Waiver No. 11-W-00193/9).” (B) For purposes of Section 14166.4, the references to “project year” and “successor demonstration year” shall include references to the CalAIM term, as defined in subdivision (b) of Section 14184.101, and to any extensions of the demonstration project pursuant to this article. (2) The fee-for-service payment methodologies established and implemented under Section 14166.4 shall continue to apply with respect to designated public hospitals approved under the Medi-Cal State Plan. (3) For the hospitals identified in clauses (ii) and (iii) of subparagraph (H) of paragraph (1) of subdivision (f) of Section 14184.10, the department shall seek any necessary federal approvals to apply the fee-for-service payment methodologies established and implemented under Section 14166.4 to these identified hospitals effective no earlier than the 2016–17 state fiscal year. This paragraph shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized. Before the effective date of any necessary federal approval obtained pursuant to this paragraph, these identified hospitals shall continue to be considered nondesignated public hospitals for purposes of the fee-for-service methodology authorized pursuant to Section 14105.28 and the applicable provisions of the Medi-Cal State Plan. (4) The department shall continue to make reimbursement available to qualifying hospitals that meet the eligibility requirements for participation in the supplemental reimbursement program for hospital facility construction, renovation, or replacement pursuant to Section 14085.5 and the applicable provisions of the Medi-Cal State Plan. The department shall continue to make inpatient hospital payments for services that were historically excluded from a hospital’s contract under the Selective Provider Contracting Program established under Article 2.6 (commencing with Section 14081) in accordance with the applicable provisions of the Medi-Cal State Plan. These payments shall not duplicate or supplant any other payments made under this article. (b) During the 2015–16 state fiscal year, and subsequent state fiscal years that commence during the demonstration term or the CalAIM term, payment adjustments to disproportionate share hospitals shall not be made pursuant to Section 14105.98, except as otherwise provided in this article or Article 5.51 (commencing with Section 14184.100). Payment adjustments to disproportionate share hospitals shall be made solely in accordance with this article or Article 5.51 (commencing with Section 14184.100). (1) Except as otherwise provided in this article or Article 5.51(commencing with Section 14184.100), the department shall continue to make all eligibility determinations and perform all payment adjustment amount computations under the disproportionate share hospital payment adjustment program pursuant to Section 14105.98 and pursuant to the disproportionate share hospital provisions of the Medi-Cal State Plan. For purposes of these determinations and computations, which include those made pursuant to Sections 14166.11 and 14166.16, all of the following shall apply: (A) The federal Medicaid DSH reductions pursuant to Section 1396r-4(f)(7) of Title 42 of the United States Code shall be reflected as appropriate, including, but not limited to, the calculations set forth in subparagraph (B) of paragraph (2) of subdivision (am) of Section 14105.98. (B) Services that were rendered under the Low Income Health Program authorized pursuant to Part 3.6 (commencing with Section 15909) shall be included. (2) (A) Notwithstanding Section 14105.98, the federal disproportionate share hospital allotment specified for California under Section 1396r-4(f) of Title 42 of the United States Code for each of federal fiscal years 2016 to 2021, inclusive, shall be aligned with the state fiscal year in which the applicable federal fiscal year commences, and shall be distributed solely for the following purposes: (i) As disproportionate share hospital payments under the methodology set forth in applicable disproportionate share hospital provisions of the Medi-Cal State Plan, which, to the extent permitted under federal law and the Special Terms and Conditions, or the CalAIM Terms and Conditions, shall be limited to the following hospitals: (I) Eligible hospitals, as determined pursuant to Section 14105.98 for each state fiscal year in which the particular federal fiscal year commences, that meet the definition of a public hospital, as specified in paragraph (25) of subdivision (a) of Section 14105.98, and that are not participating as GPP systems under the Global Payment Program. (II) Hospitals that are licensed to the University of California, which meet the requirements set forth in Section 1396r-4(d) of Title 42 of the United States Code. (ii) As a funding component for payments under the Global Payment Program, as described in subparagraph (A) of paragraph (1) of subdivision (c) of Section 14184.40, or paragraph (1) of subdivision (c) of Section 14184.300, and the Special Terms and Conditions or the CalAIM Terms and Conditions. (B) The distribution of the federal disproportionate share hospital allotment to hospitals described in this paragraph shall satisfy the state’s payment obligations, if any, with respect to those hospitals under Section 1396r-4 of Title 42 of the United States Code. (3) (A) During the 2015–16 state fiscal year and subsequent state fiscal years that commence during the demonstration term or the CalAIM term, a public entity shall not be obligated to make any intergovernmental transfer pursuant to Section 14163, and all transfer amount determinations for those state fiscal years shall be suspended. However, intergovernmental transfers shall be made with respect to the disproportionate share hospital payment adjustments made in accordance with clause (ii) of subparagraph (B) of paragraph (6), as applicable. (B) During the 2015–16 state fiscal year and subsequent state fiscal years that commence during the demonstration term or the CalAIM term, transfer amounts from the Medi-Cal Inpatient Payment Adjustment Fund to the Health Care Deposit Fund, as described in paragraph (2) of subdivision (d) of Section 14163, are hereby reduced to zero. Unless otherwise specified in this article or the applicable provisions of Article 5.2 (commencing with Section 14166), this subparagraph shall be disregarded for purposes of the calculations made under Section 14105.98 during the 2015–16 state fiscal year and subsequent state fiscal years that commence during the demonstration term or the CalAIM term. (4) (A) During the state fiscal years for which the Global Payment Program under Section 14184.40, or Section 14184.300, is in effect, designated public hospitals that are participating GPP systems shall not be eligible to receive disproportionate share hospital payments pursuant to otherwise applicable disproportionate share hospital provisions of the Medi-Cal State Plan. (B) Eligible hospitals described in clause (i) of subparagraph (A) of paragraph (2) that are nondesignated public hospitals shall continue to receive disproportionate share hospital payment adjustments as set forth in Section 14166.16. (C) Hospitals described in clause (i) of subparagraph (A) of paragraph (2) that are licensed to the University of California, except as provided in paragraph (4) of subdivision (b) of Section 14184.300, shall receive disproportionate share hospital payments as follows: (i) Subject to clause (iii), each hospital licensed to the University of California may draw and receive federal Medicaid funding from the applicable federal disproportionate share hospital allotment on the amount of certified public expenditures for the hospital’s expenditures that are eligible for federal financial participation as reported in accordance with Section 14166.8 and the applicable disproportionate share hospital provisions of the Medi-Cal State Plan. (ii) Subject to clause (iii) and to the extent the hospital meets the requirement in Section 1396r-4(b)(1)(A) of Title 42 of the United States Code regarding the Medicaid inpatient utilization rate or Section 1396r-4(b)(1)(B) of Title 42 of the United States Code regarding the low-income utilization rate, each hospital shall receive intergovernmental transfer-funded direct disproportionate share hospital payments as provided for under the applicable disproportionate share hospital provisions of the Medi-Cal State Plan. The total amount of these payments to the hospital, consisting of the federal and nonfederal components, shall in no case exceed that amount equal to 75 percent of the hospital’s uncompensated Medi-Cal and uninsured costs of hospital services as reported in accordance with Section 14166.8. (iii) Unless the provisions of subparagraph (D) apply, the aggregate amount of the federal disproportionate share hospital allotment with respect to payments for an applicable state fiscal year to hospitals licensed to the University of California shall be limited to an amount calculated as follows: (I) The maximum amount of federal disproportionate share hospital allotment for the state fiscal year, less the amounts of federal disproportionate share hospital allotment associated with payments to nondesignated public hospitals under subparagraph (B) and other payments, if any, required to be made from the federal disproportionate share hospital allotment, shall be determined. (II) For the 2015–16 state fiscal year, the amount determined in subclause (I) shall be multiplied by 26.296 percent, resulting in the maximum amount of the federal disproportionate share hospital allotment available as disproportionate share hospital payments for the state fiscal year to hospitals that are licensed to the University of California. (III) For the 2016–17 state fiscal year, the amount determined in subclause (I) shall be multiplied by 24.053 percent, resulting in the maximum amount of the federal disproportionate share hospital allotment available as disproportionate share hospital payments for the state fiscal year to hospitals that are licensed to the University of California. (IV) For the 2017–18 state fiscal year, the amount determined in subclause (I) shall be multiplied by 23.150 percent, resulting in the maximum amount of the federal disproportionate share hospital allotment available as disproportionate share hospital payments for the state fiscal year to hospitals that are licensed to the University of California. (V) For each of the 2018–19 and 2019–20 state fiscal years, the amount determined in subclause (I) shall be multiplied by 21.896 percent, resulting in the maximum amount of the federal disproportionate share hospital allotment available as disproportionate share hospital payments for the state fiscal year to hospitals that are licensed to the University of California. (VI) For the 2020–21 state fiscal year, and subsequent state fiscal years or portions thereof during the CalAIM Term, the amount determined in subclause (I) shall be multiplied by a percentage as determined by the department, in consultation with designated public hospitals and consistent with the applicable federal terms and conditions, that will be used to determine the maximum amount of the federal disproportionate share hospital allotment available as disproportionate share hospital payments for the state fiscal year to hospitals that are licensed to the University of California. The percentage shall be communicated in writing to all of the designated public hospitals. (VII) To the extent the limitations set forth in this clause result in payment reductions for the applicable year, those reductions shall be applied pro rata, subject to clause (vii). (iv) Each hospital licensed to the University of California shall receive quarterly interim payments of its disproportionate share hospital allocation during the applicable state fiscal year. The determinations set forth in clauses (i) to (iii), inclusive, shall be made on an interim basis before the start of each state fiscal year, except that the determinations for the 2015–16 state fiscal year shall be made as soon as practicable. The department shall use the same cost and statistical data used in determining the interim payments for Medi-Cal inpatient hospital services under Section 14166.4, and available payments and uncompensated and uninsured cost data, including data from the Medi-Cal paid claims file and the hospital’s books and records, for the corresponding period, to the extent permitted under the Medi-Cal State Plan. (v) No later than April 1 following the end of the relevant reporting period for the applicable state fiscal year, the department shall undertake an interim reconciliation of payments based on Medi-Cal, Medicare, and other cost, payment, discharge, and statistical data submitted by the hospital for the applicable state fiscal year, and shall adjust payments to the hospital accordingly. (vi) Except as otherwise provided in this article or Article 5.51 (commencing with Section 14184.100), each hospital licensed to the University of California shall receive disproportionate share hospital payments subject to final audits of all applicable Medi-Cal, Medicare, and other cost, payment, discharge, and statistical data submitted by the hospital for the applicable state fiscal year. (vii) Before the interim and final distributions of payments pursuant to clauses (iv) to (vi), inclusive, the department shall consult with the University of California, and implement any adjustments to the payment distributions for the hospitals as requested by the University of California, so long as the aggregate net effect of the requested adjustments for the affected hospitals is zero. (D) With respect to any state fiscal year commencing during the demonstration term or the CalAIM term for which the Global Payment Program pursuant to Section 14184.40 or 14184.300 is not in effect, designated public hospitals that are eligible hospitals as determined pursuant to Section 14105.98, and hospitals described in clause (i) of subparagraph (A) of paragraph (2) that are licensed to the University of California, shall claim disproportionate share hospital payments in accordance with the applicable disproportionate share hospital provisions of the Medi-Cal State Plan. The allocation of federal Medicaid funding from the applicable federal disproportionate share hospital allotment shall be made in accordance with the methodology set forth in Section 14166.61. (5) For each applicable state fiscal year during the demonstration term or the CalAIM term, eligible hospitals, as determined pursuant to Section 14105.98, which are nonpublic hospitals, nonpublic-converted hospitals, and converted hospitals, as those terms are defined in paragraphs (26), (27), and (28), respectively, of subdivision (a) of Section 14105.98, shall continue to receive Medi-Cal disproportionate share hospital replacement payment adjustments pursuant to Section 14166.11 and other provisions of this article or Article 5.51 (commencing with Section 14184.100) and applicable provisions of the Medi-Cal State Plan. The payment adjustments so provided shall satisfy the state’s payment obligations, if any, with respect to those hospitals under Section 1396r-4 of Title 42 of the United States Code. The provisions of subdivision (j) of Section 14166.11 shall continue to apply with respect to the 2015–16 state fiscal year and subsequent state fiscal years commencing during the demonstration term or the CalAIM term. Except as may otherwise be required by federal law, the federal share of these payments shall not be claimed from the federal disproportionate share hospital allotment. (6) The nonfederal share of disproportionate share hospital payments and disproportionate share hospital replacement payment adjustments described in paragraphs (4) and (5) shall be derived from the following sources: (A) With respect to the payments described in subparagraph (B) of paragraph (4) that are made to nondesignated public hospitals, the nonfederal share shall consist solely of state General Fund appropriations. (B) With respect to the payments described in subparagraph (C) or (D), as applicable, of paragraph (4) that are made to designated public hospitals, the nonfederal share shall consist of both of the following: (i) Certified public expenditures incurred by the hospitals for hospital expenditures eligible for federal financial participation as reported in accordance with Section 14166.8. (ii) Intergovernmental transfer amounts for direct disproportionate share hospital payments provided for under subparagraph (C) or (D) of paragraph (4) and the applicable disproportionate share hospital provisions of the Medi-Cal State Plan. A transfer amount shall be determined for each hospital that is eligible for these payments, equal to the nonfederal share of the payment amount established for the hospital. The transfer amount determined shall be paid by the hospital, or the public entity with which the hospital is affiliated, and deposited into the Medi-Cal Inpatient Payment Adjustment Fund established pursuant to subdivision (b) of Section 14163, as permitted under Section 433.51 of Title 42 of the Code of Federal Regulations or any other applicable federal Medicaid laws. (C) With respect to the payments described in paragraph (5), the nonfederal share shall consist of state General Fund appropriations. (7) The Demonstration Disproportionate Share Hospital Fund established in the State Treasury pursuant to subdivision (d) of Section 14166.9 shall be retained during the demonstration term and the CalAIM term. All federal funds received by the department with respect to the certified public expenditures claimed pursuant to subparagraph (C), and, as applicable in subparagraph (D), of paragraph (4) shall be transferred to the fund and disbursed to the eligible designated public hospitals pursuant to those applicable provisions. Notwithstanding Section 13340 of the Government Code, moneys deposited in the fund shall be continuously appropriated, without regard to fiscal year, to the department solely for the purposes specified in this article and Article 5.51 (commencing with Section 14184.100). (c) (1) Disproportionate share hospital payment allocations under Sections 14166.3 and 14166.61, and safety net care pool payment allocations under Section 14166.71, that were paid to designated public hospitals with respect to the period July 1, 2015, through October 31, 2015, or for subsequent periods pursuant to Section 14166.253, shall be reconciled to amounts payable to the hospitals under this article as set forth in this subdivision. (2) The disproportionate share hospital payments and safety net care pool payments described in paragraph (1) that were paid to a designated public hospital participating in a GPP system under Section 14184.40 shall be deemed to be interim payments under the Global Payment Program for GPP program year 2015–16, and will be reconciled to and offset against the interim payment amount due to the GPP system under subparagraph (B) of paragraph (4) of subdivision (d) of Section 14184.40, consistent with the Special Terms and Conditions. (3) The disproportionate share hospital payments described in paragraph (1) that were paid to designated public hospitals licensed to the University of California shall be reconciled to and offset against the disproportionate share hospital payments payable to the hospitals under subparagraph (C) of paragraph (4) of subdivision (b) for the 2015–16 state fiscal year. (4) The safety net care pool payments described in paragraph (1) that were paid to designated public hospitals licensed to the University of California shall be recouped and included as available funding under the Global Payment Program for the 2015–16 GPP program year described in subparagraph (B) of paragraph (1) of subdivision (c) of Section 14184.40. (d) During the 2015–16 state fiscal year, and subsequent state fiscal years that commence during the demonstration term or the CalAIM term, costs shall continue to be determined and reported for designated public hospitals in accordance with Sections 14166.8 and 14166.24, except as follows: (1) (A) The provisions of subdivision (c) of Section 14166.8 shall not apply. (B) Notwithstanding subparagraph (A), the department may require the reporting of any data the department deems necessary to satisfy reporting requirements pursuant to the Special Terms and Conditions or the CalAIM Terms and Conditions. (2) The provisions of Sections 14166.221 and 15916 shall not apply with respect to any costs reported for the demonstration term or the CalAIM term pursuant to Section 14166.8. (e) (1) Notwithstanding subdivision (h) of Section 14166.61 and subdivision (c) of Section 14166.71, the disproportionate share hospital allocation and safety net care pool payment determinations and payments for the 2013–14 and 2014–15 state fiscal years shall be deemed final as of the April 30 that is 22 months following the close of the respective state fiscal year, to the extent permitted under federal law and subject to recoupment pursuant to subdivision (f) if it is later determined that federal financial participation is unavailable for any portion of the applicable payments. (2) The determinations and payments shall be finalized using the best available data, including unaudited data, and reasonable current estimates and projections submitted by the designated public hospitals. The department shall accept all appropriate revisions to the data, estimates, and projections previously submitted, including revised cost reports, for purposes of this subdivision, to the extent these revisions are submitted in a timely manner as determined by the department. (f) Upon receipt of a notice of disallowance or deferral from the federal government related to the certified public expenditures or intergovernmental transfers of a designated public hospital or governmental entity with which it is affiliated for disproportionate share hospital payments or safety net care pool payments claimed and distributed pursuant to Section 14166.61, 14166.71, or 15916 for the 2013–14 or 2014–15 state fiscal year, the department shall promptly notify the designated public hospitals and proceed as follows: (1) To the extent there are additional certified public expenditures for the applicable state fiscal year for which federal funds have not been received, but for which federal funds could have been received had additional federal funds been available, including any subsequently allowable expenditures for designated state health programs, the department shall first respond to the deferral or disallowance by substituting the additional certified public expenditures or allowable expenditures for those deferred or disallowed, consistent with the claiming optimization priorities set forth in Section 14166.9, in consultation with the designated public hospitals, but only to the extent that any necessary federal approvals are obtained or these actions are otherwise permitted by federal law. (2) The department shall consult with the designated public hospitals and proceed in accordance with paragraphs (2) and (3) of subdivision (d) of Section 14166.24. (3) If the department elects to appeal pursuant to paragraph (3) of subdivision (d) of Section 14166.24, the department shall not implement any recoupment of payments from the affected designated public hospitals, until a final disposition has been made regarding the deferral or disallowance, including the conclusion of applicable administrative and judicial review, if any. (4) (A) Upon final disposition of the federal deferral or disallowance, the department shall determine the resulting aggregate repayment amount of federal funds for each affected state fiscal year. (B) The department shall determine the ratio of the aggregate repayment amount to the total amount of the federal share of payments finalized and distributed pursuant to Sections 14166.61 and 14166.71 and subdivision (e) for each affected state fiscal year, expressed as a percentage. (5) Notwithstanding paragraph (1) of subdivision (d) of Section 14166.24, the responsibility for repayment of the federal portion of any deferral of disallowance for each affected year shall be determined as follows: (A) The provisions of subdivision (g) of Section 15916 shall be applied to determine the department’s repayment responsibility amount with respect to any deferral or disallowance related to safety net care pool payments, which shall be in addition to amounts determined under subparagraph (E). (B) Using the most recent data for the applicable fiscal year, and reflecting modifications to the applicable initial DSH claiming ability and initial SNCP claiming ability for individual hospitals resulting from the deferral or disallowance, the department shall perform the calculations and determinations for each designated public hospital as set forth in Sections 14166.61 and 14166.71. For this purpose, the calculations and determinations shall assume no reduction in the available federal disproportionate share hospital allotment or in the amount of available safety net care pool payments as a result of the deferral or disallowance. (C) For each designated public hospital, the revised determinations of disproportionate share hospital and safety net care pool payment amounts under subparagraph (B) shall be combined and compared to the combined disproportionate share hospital and safety net care pool payment amounts determined and received by the hospital pursuant to subdivision (e). For this purpose and purposes of subparagraph (D), the applicable data for designated public hospitals described in subparagraph (G) of paragraph (1) of subdivision (f) of Section 14184.10 shall be combined, and the applicable data for designated public hospitals described in subparagraphs (E) and (F) of paragraph (1) of subdivision (f) of Section 14184.10 shall be combined. (D) (i) Subject to subparagraph (E), the repayment of the federal portion of the deferral of disallowance, less the department’s responsibility amount for safety net care pool payments, if any, determined in subparagraph (A), shall be first allocated among each of those designated public hospitals for which the combined revised disproportionate share hospital and safety net care pool payments as determined in subparagraph (B) are less than the combined disproportionate share hospital and safety net care pool payment amounts determined and received pursuant to subdivision (e). Repayment shall be allocated under this initial stage among these hospitals pro rata on the basis of each hospital’s relative reduction as reflected in the revised calculations performed under subparagraph (B), but in no case shall the allocation to a hospital exceed the limit in clause (iii). Repayment amounts that are not allocated due to this limitation shall be allocated pursuant to clause (ii). (ii) Subject to subparagraph (E), any repayment amounts that were unallocated to hospitals due to the limitation in clause (iii) shall be allocated in a second stage among each of the remaining designated public hospitals that has not reached its applicable repayment limit, including the hospitals that were not subject to the allocations under clause (i), based pro rata on the amounts determined and received by the hospital pursuant to subdivision (e), except that no repayment amount for a hospital shall exceed the limitation under clause (iii). The pro rata allocation process will be repeated in subsequent stages with respect to any repayment amounts that cannot be allocated in a prior stage to hospitals due to the limitation under clause (iii), until the entire federal repayment amount has been allocated among the hospitals. (iii) The repayment amount allocated to a designated public hospital pursuant to this subparagraph shall not exceed an amount equal to the percentage of the combined payments determined and received by the hospital pursuant to subdivision (e) that is twice the percentage computed in subparagraph (B) of paragraph (4). (E) Notwithstanding any other law, if the affiliated governmental entity for the designated public hospital is a county subject to the provisions of Article 12 (commencing with Section 17612.1) of Chapter 6 of Part 5, the department, in consultation with the affected designated public hospital, and the Department of Finance, shall determine how to account for whether any repayment amount determined for the designated public hospital pursuant to subparagraph (D) for the 2013–14 and 2014–15 state fiscal years would otherwise have affected, if at all, the applicable county’s redirection obligation for the applicable state fiscal year pursuant to paragraphs (4) and (5) of subdivision (a) of Section 17612.3 and shall determine what adjustments, if any, are necessary to either the repayment amount or the applicable county’s redirection obligation. For purposes of this subparagraph, the provisions of subdivision (f) of Section 17612.2 and paragraph (7) of subdivision (e) of Section 101853 of the Health and Safety Code shall apply. (g) The provisions of Article 5.2 (commencing with Section 14166) shall remain in effect until all payments authorized pursuant to that article have been paid, finalized, and settled, and to the extent its provisions are retained for purposes of this article or Article 5.51 (commencing with Section 14184.100). (h) For purposes of this article, commencing January 1, 2021, and thereafter, any references to “Designated Public Hospital,” “CalAIM term,” or “CalAIM Terms and Conditions” have the same meanings as set forth in Section 14184.101. (Amended by Stats. 2021, Ch. 143, Sec. 400. (AB 133) Effective July 27, 2021.)
14184.300.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department must keep running and administering the Global Payment Program, issue revised scheduling and transfer information, consult GPP systems before certain changes, and may seek federal approval for extra funding components. University of California hospitals may elect to participate if they give timely written notice.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.300. (a) (1) To the extent federal financial participation is available, the department shall continue to implement the Global Payment Program (GPP) as described in Section 14184.40 during the CalAIM term. The department shall continue to administer the GPP in accordance with Section 14184.40, except to the extent changes are approved in the CalAIM Terms and Conditions and except as provided in subdivision (b). (b) (1) Commencing January 1, 2021, the GPP program year shall be aligned with the calendar year. The department shall provide to the GPP systems a revised schedule for the reporting, notification, intergovernmental transfer, and payment set forth in paragraphs (3) and (4) of subdivision (d) of Section 14184.40, which shall maintain the same conditions and timeline, adjusted by six months to align with the calendar year, and consistent with the CalAIM Terms and Conditions. (2) Commencing January 1, 2021, the GPP system-specific IGT factors identified in paragraph (3) of subdivision (g) of Section 14184.40 shall be inapplicable and the initial transfer amount calculated for each GPP system shall be identified by the department and communicated in writing to each GPP system for each applicable GPP program year. (3) Commencing January 1, 2021, for purposes of determining the applicable GPP’s aggregate annual limit, applicable portions of the federal disproportionate share allotment for the federal fiscal year that ends in the GPP program year, and for the federal fiscal year that commences in the applicable GPP program year, shall be appropriately aligned with the GPP program year. (4) Subject to subdivision (f) of Section 14184.102, a hospital that is operated by the University of California, and its affiliated and contracted providers, may elect to participate as a GPP system during the CalAIM terms by providing written notice to the department no later than June 1 of the calendar year immediately preceding the subject GPP program year. (A) A University of California hospital that is approved to participate as a GPP system shall continue to participate as a GPP system for all remaining GPP program years during the CalAIM term, and shall be subject to all other provisions, requirements, and restrictions applicable to GPP systems in accordance with the CalAIM Terms and Conditions. (B) A University of California hospital that is approved to participate as a GPP system shall be ineligible to receive disproportionate share hospital payments through the termination of GPP. (C) If a University of California hospital is approved to participate as a GPP system, the department shall make all appropriate funding and program adjustments necessary to account for the additional participating GPP system in the subject GPP program years, including, but not limited to, the determinations of the federal disproportionate share hospital allotment funding available to nonparticipating University of California hospitals and the resulting GPP aggregate annual limits. (5) Subject to the availability of sufficient nonfederal share funds for this purpose, the department may seek federal approval for, and implement, additional funding and program components for GPP systems that support and further the objectives of CalAIM and GPP. (c) Before implementing any of the modifications described in subdivision (b), the department shall consult with the GPP systems. (d) Except as otherwise provided in the CalAIM Terms and Conditions or in this section, and without limiting the authority in subdivision (g) of Section 14184.102, the rights, obligations, and limitations set forth in Section 14184.40 shall apply to the GPP as continued pursuant to this section. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
14184.301.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The payment methodologies and requirements in Section 14184.30 continue to apply during the CalAIM term and any extension periods while the Global Payment Program is authorized.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.301. The payment methodologies and requirements described in Section 14184.30, as amended by the act that added this section, shall continue to apply during the entirety of the CalAIM term and any extension periods in which the Global Payment Program pursuant to Section 14184.300 is authorized. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
14184.40.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )
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The department must run the Global Payment Program for participating public health care systems serving uninsured patients, and GPP systems must meet service thresholds and transfer funds as a condition of participation.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.40. (a) (1) The department shall implement the Global Payment Program authorized under the demonstration project to support participating public health care systems that provide health care services for the uninsured. Under the Global Payment Program, GPP systems receive global payments based on the health care they provide to the uninsured, in lieu of traditional disproportionate share hospital payments and safety net care pool payments previously made available pursuant to Article 5.2 (commencing with Section 14166). (2) The Global Payment Program is intended to streamline funding sources for care for California’s remaining uninsured population, creating a value-based mechanism to increase incentives to provide primary and preventive care services and other high-value services. The Global Payment Program supports GPP systems for their key role providing and promoting effective, higher value services to California’s remaining uninsured. Promoting more cost-effective and higher value care means that the payment structure rewards the provision of care in more appropriate venues for patients, and will support structural changes to the care delivery system that will improve the options for treating both Medi-Cal and uninsured patients. (3) Under the Global Payment Program, GPP systems will receive Global Payment Program payments calculated using an innovative value-based point methodology that incorporates measures of value for the patient in conjunction with the recognition of costs. To receive the full amount of Global Payment Program payments, a GPP system shall provide a threshold level of services, as measured in the point methodology described in paragraph (2) of subdivision (c), and based on the GPP system’s historical volume, cost, and mix of services. This payment methodology is intended to support GPP systems that continue to provide services to the uninsured, while incentivizing the GPP systems to shift the overall delivery of services for the uninsured to provide more cost-effective, higher value care. (4) The department shall implement and oversee the operation of the Global Payment Program in accordance with the Special Terms and Conditions and the requirements of this section, to maximize the amount of federal financial participation available to participating GPP systems. (b) For purposes of this article, the following definitions apply: (1) “GPP system” means a public health care system that consists of a designated public hospital, as defined in subdivision (f) of Section 14184.10 but excluding the hospitals operated by the University of California, except as provided in paragraph (4) of subdivision (b) of Section 14184.300, and its affiliated and contracted providers. Multiple designated public hospitals operated by a single legal entity may belong to the same GPP system, to the extent set forth in the Special Terms and Conditions. (2) “GPP program year” means a state fiscal year beginning on July 1 and ending on June 30 during which the Global Payment Program is authorized under the demonstration project, beginning with state fiscal year 2015–16, and, as applicable, each state fiscal year thereafter through 2019–20, and any years or partial years during which the Global Payment Program is authorized under an extension or successor to the demonstration project. (c) (1) For each GPP program year, the department shall determine the Global Payment Program’s aggregate annual limit, which is the maximum amount of funding available under the demonstration project for the Global Payment Program and which is the sum of the components described in subparagraphs (A) and (B). To the extent feasible, the aggregate annual limit shall be determined and made available by the department before the implementation of a GPP program year, and shall be updated and adjusted as necessary to reflect changes or adjustments to the amount of funding available for the Global Payment Program. (A) A portion of the federal disproportionate share allotment specified for California under Section 1396r-4(f) of Title 42 of the United States Code shall be included as a component of the aggregate annual limit for each GPP program year. The amount of this portion shall equal the state’s total computable disproportionate share allotment reduced by the maximum amount of funding projected for payments pursuant to subparagraphs (B) and (C) of paragraph (4) of subdivision (b) of Section 14184.30 to disproportionate share hospitals that are not participating in the Global Payment Program. For purposes of this determination, the federal disproportionate share allotment shall be aligned with the GPP program year in which the applicable federal fiscal year commences. (B) The aggregate annual limit shall also include the amount authorized under the demonstration project for the uncompensated care component of the Global Payment Program for the applicable GPP program year, as determined pursuant to the Special Terms and Conditions. (2) The department shall develop a methodology for valuing health care services and activities provided to the uninsured that achieves the goals of the Global Payment Program, including those values set forth in subdivision (a) and as expressed in the Special Terms and Conditions. The points assigned to a particular service or activity shall be the same across all GPP systems. Points for specific services or activities may be increased or decreased over time as the Global Payment Program progresses, to incentivize appropriate changes in the mix of services provided to the uninsured. To the extent necessary, the department shall obtain federal approval for the methodology and any applicable changes to the methodology. (3) For each GPP system, the department shall perform a baseline analysis of the GPP system’s historical volume, cost, and mix of services to the uninsured to establish an annual threshold for purposes of the Global Payment Program. The annual threshold shall be measured in points established through the methodology developed pursuant to paragraph (2) and as set forth in the Special Terms and Conditions. (4) The department shall determine a pro rata allocation percentage for each GPP system by dividing the GPP system’s annual threshold determined in paragraph (3) by the sum of all GPP systems’ thresholds. (5) For each GPP system, the department shall determine an annual budget the GPP system will receive if it achieves its threshold. A GPP system’s annual budget shall equal the allocation percentage determined in paragraph (4) for the GPP system, multiplied by the Global Payment Program’s aggregate annual limit determined in paragraph (1). (6) If there is a change in the aggregate annual limit, the department shall adjust and recalculate each GPP system’s annual threshold or the annual budget in proportion to changes in the aggregate annual limit calculated in paragraph (1) in accordance with the Special Terms and Conditions. (d) The amount of Global Payment Program funding payable to a GPP system for a GPP program year shall be calculated as follows, subject to the Special Terms and Conditions: (1) The full amount of a GPP system’s annual budget shall be payable to the GPP system if the services it provided to the uninsured during the GPP program year, as measured and scored using the point methodology described under paragraph (2) of subdivision (c), meets or exceeds its threshold for a given year. For GPP systems that do not achieve their threshold, the amount payable to the GPP system shall equal its annual budget reduced by the proportion by which it fell short of its threshold. (2) The department shall develop a methodology to redistribute unearned Global Payment Program funds for a given GPP program year to those GPP systems that exceeded their respective threshold for that same year. To the extent sufficient funds are available for all qualifying GPP systems, the GPP system’s redistributed amount shall equal the GPP system’s annual budget multiplied by the percentage by which the GPP system exceeded its threshold, and any remaining amounts of unearned funds will remain undistributed. If sufficient funds are unavailable to make all these payments to qualifying GPP systems, the amounts of these additional payments will be reduced for all qualifying GPP systems by the same proportion, so that the full amount of unearned Global Payment Program funds are redistributed. Redistributed payment amounts calculated pursuant to this paragraph shall be added to the amounts payable to a GPP system calculated pursuant to paragraph (1). (3) The department shall specify a reporting schedule for participating GPP systems to submit an interim yearend report and a final reconciliation report for each GPP program year. The interim yearend report and the final reconciliation report shall identify the services the GPP system provided to the uninsured during the GPP program year, the associated point calculation, and the amount of payments earned by the GPP system before any redistribution. The method and format of the reporting shall be established by the department, consistent with the approved Special Terms and Conditions. (4) Payments shall be made in the manner and within the timeframes as follows, except if one or more GPP systems fail to provide the intergovernmental transfer amount determined pursuant to subdivision (g) by the date specified in this paragraph, the timeframe for the associated payments shall be extended to the extent necessary to allow the department to timely process the payments. In no event, however, shall payment be delayed beyond 21 days after all the necessary intergovernmental transfers have been made. (A) Except as provided in subparagraph (B), for each of the first three quarters of a GPP program year the department shall notify GPP systems of their payment amounts and intergovernmental transfer amounts and make a quarterly interim payment equal to 25 percent of each GPP system’s annual global budget to the GPP system. (i) For quarters ending September 30, the payment amount and intergovernmental transfer amount notice shall be sent by September 15, intergovernmental transfers shall be due by September 22, and payments shall be made by October 15. (ii) For quarters ending December 31, the payment amount and intergovernmental transfer amount notice shall be sent by December 15, intergovernmental transfers shall be due by December 22, and payments shall be made by January 15. (iii) For quarters ending March 31, the payment amount and intergovernmental transfer amount notice shall be sent by March 15, intergovernmental transfers shall be due by March 22, and payments shall be made by April 15. (B) For the 2015–16 GPP program year, the department shall make the quarterly interim payments described in subdivision (a) in a single interim payment for the first three quarters as soon as practicable following approval of the Global Payment Program protocols as part of the Special Terms and Conditions and receipt of the associated intergovernmental transfers. The amount of this interim payment that is otherwise payable to a GPP system shall be reduced by the payments described in paragraph (2) of subdivision (c) of Section 14184.30 that were received by a designated public hospital affiliated with the GPP system. (C) By September 15 following the end of each GPP program year, the department shall determine and notify each GPP system of the amount the GPP system earned for the GPP program year pursuant to paragraph (1) based on its interim yearend report, the amount of additional interim payments necessary to bring the GPP system’s aggregate interim payments for the GPP program year to that amount, and the transfer amounts calculated pursuant to subdivision (g). If the GPP system has earned less than 75 percent of its annual budget, no additional interim payment will be made for the GPP program year. Intergovernmental transfer amounts shall be due by September 22 following the end of the GPP program year, and interim payments shall be made by October 15 following the end of each GPP program year. All interim payments shall be subject to reconciliation after the submission of the final reconciliation report. (D) By June 30 following the end of each GPP program year, the department shall review the final reconciliation reports and determine and notify each GPP system of the final amounts earned by the GPP system for the GPP program year pursuant to paragraph (1), as well as the redistribution amounts, if any, pursuant to paragraph (2), the amount of the payment adjustments or recoupments necessary to reconcile interim payments to those amounts, and the transfer amount pursuant to subdivision (g). Intergovernmental transfer amounts shall be due by July 14 following the notification, and final reconciliation payments for the GPP program year shall be made no later than August 15 following this notification. (e) The Global Payment Program provides a source of funding for GPP systems to support their ability to make health care activities and services available to the uninsured, and shall not constitute or offer health care coverage for individuals receiving services. Global Payment Program payments are not paid on behalf of specific individuals, and participating GPP systems may determine the scope, type, and extent to which services are available, to the extent consistent with the Special Terms and Conditions. The operation of the Global Payment Program shall not decrease, expand, or otherwise alter the scope of a county’s obligations to the medically indigent pursuant to Part 5 (commencing with Section 17000) of Division 9. (f) The nonfederal share of any payments under the Global Payment Program shall consist of voluntary intergovernmental transfers of funds provided by designated public hospitals or affiliated governmental agencies or entities, in accordance with this section or Section 14184.300. (1) The Global Payment Program Special Fund is hereby established in the State Treasury. Notwithstanding Section 13340 of the Government Code, moneys deposited in the Global Payment Program Special Fund shall be continuously appropriated, without regard to fiscal years, to the department for the purposes specified in this section or Section 14184.300. All funds derived pursuant to this section or Section 14184.300 shall be deposited in the State Treasury to the credit of the Global Payment Program Special Fund. (2) The Global Payment Program Special Fund shall consist of moneys that a designated public hospital or affiliated governmental agency or entity elects to transfer to the department for deposit into the fund as a condition of participation in the Global Payment Program, to the extent permitted under Section 433.51 of Title 42 of the Code of Federal Regulations, the Special Terms and Conditions, and any other applicable federal Medicaid laws. Except as otherwise provided in paragraph (3), moneys derived from these intergovernmental transfers in the Global Payment Program Special Fund shall be used as the source for the nonfederal share of Global Payment Program payments authorized under the demonstration project. Any intergovernmental transfer of funds provided for purposes of the Global Payment Program shall be made as specified in this section or Section 14184.300. Upon providing any intergovernmental transfer of funds, each transferring entity shall certify that the transferred funds qualify for federal financial participation pursuant to applicable federal Medicaid laws and the Special Terms and Conditions, and in the form and manner as required by the department. (3) The department shall claim federal financial participation for GPP payments using moneys derived from intergovernmental transfers made pursuant to this section or Section 14184.300, and deposited in the Global Payment Program Special Fund to the full extent permitted by law. The moneys disbursed from the fund, and all associated federal financial participation, shall be distributed only to GPP systems and the governmental agencies or entities to which they are affiliated, as applicable. If federal financial participation is unavailable with respect to a payment under this section or Section 14184.300 and either is not obtained, or results in a recoupment of payments already made, the department shall return any intergovernmental transfer fund amounts associated with the payment for which federal financial participation is unavailable to the applicable transferring entities within 14 days from the date of the associated recoupment or other determination, as applicable. (4) As a condition of participation in the Global Payment Program, each designated public hospital or affiliated governmental agency or entity, agrees to provide intergovernmental transfer of funds necessary to meet the nonfederal share obligation as calculated under subdivision (g) for Global Payment Program payments made pursuant to this section or Section 14184.300 and the Special Terms and Conditions. Any intergovernmental transfer of funds made pursuant to this section or Section 14184.300 shall be considered voluntary for purposes of all federal laws. No state General Fund moneys shall be used to fund the nonfederal share of any Global Payment Program payment. (g) For each scheduled quarterly interim payment, interim yearend payment, and final reconciliation payment pursuant to subdivision (d), the department shall determine the intergovernmental transfer amount for each GPP system as follows: (1) The department shall determine the amount of the quarterly interim payment, interim yearend payment, or final reconciliation payment, as applicable, that is payable to each GPP system pursuant to subdivision (d). For purposes of these determinations, the redistributed amounts described in paragraph (2) of subdivision (d) shall be disregarded. (2) The department shall determine the aggregate amount of intergovernmental transfers necessary to fund the nonfederal share of the quarterly interim payment, interim yearend payment, or final reconciliation payment, as applicable, identified in paragraph (1) for all the GPP systems. (3) With respect to each quarterly interim payment, interim yearend payment, or final yearend reconciliation payment, as applicable, an initial transfer amount shall be determined for each GPP system, calculated as the amount for the GPP system determined in paragraph (1), multiplied by the nonfederal share percentage, as defined in Section 14184.10, and multiplied by the applicable GPP system-specific IGT factor as follows: (A) Los Angeles County Health System: 1.100. (B) Alameda Health System: 1.137. (C) Arrowhead Regional Medical Center: 0.923. (D) Contra Costa Regional Medical Center: 0.502. (E) Kern Medical Center: 0.581. (F) Natividad Medical Center: 1.183. (G) Riverside University Health System-Medical Center: 0.720. (H) San Francisco General Hospital: 0.507. (I) San Joaquin General Hospital: 0.803. (J) San Mateo Medical Center: 1.325. (K) Santa Clara Valley Medical Center: 0.706. (L) Ventura County Medical Center: 1.401. (4) The initial transfer amount for each GPP system determined under paragraph (3) shall be further adjusted as follows to ensure that sufficient intergovernmental transfers are available to make payments to all GPP systems: (A) With respect to each quarterly interim payment, interim yearend payment, or final reconciliation payment, as applicable, the initial transfer amounts for all GPP systems determined under paragraph (3) shall be added together. (B) The sum of the initial transfer amounts in subparagraph (A) shall be subtracted from the aggregate amount of intergovernmental transfers necessary to fund the payments as determined in paragraph (2). The resulting positive or negative amount shall be the aggregate positive or negative intergovernmental transfer adjustment. (C) Each GPP system-specific IGT factor, as specified in subparagraphs (A) to (L), inclusive, of paragraph (3) shall be subtracted from 2.000, yielding an IGT adjustment factor for each GPP system. (D) The IGT adjustment factor calculated in subparagraph (C) for each GPP system shall be multiplied by the positive or negative amount in subparagraph (B), and multiplied by the allocation percentage determined for the GPP system in paragraph (4) of subdivision (c), yielding the amount to be added or subtracted from the initial transfer amount determined in paragraph (3) for the applicable GPP system. (E) The transfer amount to be paid by each GPP system with respect to the applicable quarterly interim payment, interim yearend payment, or final reconciliation payment, shall equal the initial transfer amount determined in paragraph (3) as adjusted by the amount determined in subparagraph (D). (5) Upon the determination of the redistributed amounts described in paragraph (2) of subdivision (d) for the final reconciliation payment, the department shall, with respect to each GPP system that exceeded its respective threshold, determine the associated intergovernmental transfer amount equal to the nonfederal share that is necessary to draw down the additional payment, and shall include this amount in the GPP system’s transfer amount. (h) The department may initiate audits of GPP systems’ data submissions and reports, and may request supporting documentation. Any audits conducted by the department shall be complete within 22 months of the end of the applicable GPP program year to allow for the appropriate finalization of payments to the participating GPP system, but subject to recoupment if it is later determined that federal financial participation is unavailable for any portion of the applicable payments. (i) If the department determines, during the course of the demonstration term and in consultation with participating GPP systems, that the Global Payment Program should be terminated for subsequent years, the department shall terminate the Global Payment Program by notifying the federal Centers for Medicare and Medicaid Services in accordance with the timeframes specified in the Special Terms and Conditions. In the event of this type of termination, the department shall issue a declaration terminating the Global Payment Program and shall work with the federal Centers for Medicare and Medicaid Services to finalize all remaining payments under the Global Payment Program. Subsequent to the effective date for any termination accomplished pursuant to this subdivision, the designated public hospitals that participated in the Global Payment Program shall claim and receive disproportionate share hospital payments, if eligible, as described in subparagraph (D) of paragraph (4) of subdivision (b) of Section 14184.30, but only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized. (j) Commencing January 1, 2021, the Global Payment Program shall be continued as modified pursuant to Section 14184.300. (Amended by Stats. 2021, Ch. 143, Sec. 401. (AB 133) Effective July 27, 2021.)
14184.400.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department must keep implementing the Specialty Mental Health Services Program, and mental health plans contracting with the department must follow applicable CalAIM terms and departmental guidance.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.400. (a) Commencing January 1, 2022, subject to subdivision (f) of Section 14184.102, the department shall continue to implement the Specialty Mental Health Services Program described in part in Chapter 8.9 (commencing with Section 14700), as a component of CalAIM and in accordance with this article and the CalAIM Terms and Conditions. (b) Each mental health plan contracting with the department to provide specialty mental health services pursuant to Chapter 8.9 (commencing with Section 14700) shall comply with all applicable CalAIM Terms and Conditions and any guidance issued by the department pursuant to subdivision (d) of Section 14184.102. (c) (1) As a component of the Specialty Mental Health Services Program described in this section, the department, in consultation with counties and other affected stakeholders, may seek federal approval for a demonstration project under Section 1315(a) of Title 42 of the United States Code, which may include receipt of federal financial participation for services furnished to Medi-Cal beneficiaries during short-term stays for acute care in psychiatric hospitals or residential treatment settings that qualify as institutions for mental diseases. The department may elect to seek approval for this demonstration project to operate on a statewide basis or on a county-by-county basis. (2) Notwithstanding any other law, to the extent that the department receives the necessary federal approvals to implement the demonstration project described in paragraph (1), and subject to approval by the Department of Finance, the department shall implement the demonstration in accordance with the terms of the federal approval and only to the extent that federal financial participation is available and is not otherwise jeopardized. (3) For purposes of this subdivision, “institution for mental diseases” has the same meaning as set forth in Section 1396d(i) of Title 42 of the United States Code. (Amended by Stats. 2022, Ch. 47, Sec. 128. (SB 184) Effective June 30, 2022.)
14184.401.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department must keep operating the DMC-ODS program, and counties that choose to run a DMC-ODS pilot must sign and keep an agreement with the department and follow applicable CalAIM terms and department guidance.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.401. (a) Commencing January 1, 2022, subject to subdivision (f) of Section 14184.102, the department shall continue to implement the Drug Medi-Cal organized delivery system (DMC-ODS) program, previously authorized under the California Medi-Cal 2020 Demonstration pursuant to Article 5.5 (commencing with Section 14184), as a component of CalAIM and in accordance with this article and the CalAIM Terms and Conditions. (b) A county, or consortium of counties in a regional model, that elects to administer, or elects to continue to administer, a DMC-ODS pilot shall enter into and maintain an intergovernmental agreement with the department. Those counties shall comply with all applicable CalAIM Terms and Conditions and any guidance issued by the department pursuant to subdivision (d) of Section 14184.102 as a condition of participation. (c) An election by a county, or consortium of counties in a regional model, to participate as a DMC-ODS pilot shall be considered voluntary for purposes of all state and federal laws. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
14184.402.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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This section sets Medi-Cal behavioral health coverage rules and directs the department to create and possibly require use of screening, transition, and documentation tools.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.402. (a) Notwithstanding any other law, including, but not limited to, the applicable provisions of Chapter 11 (commencing with Section 1810.100) of Division 1 of Title 9, and Chapter 3 (commencing with Section 51000) of Subdivision 1 of Division 3 of Title 22, of the California Code of Regulations, commencing no sooner than January 1, 2022, all medically necessary determinations for covered specialty mental health services and substance use disorder services provided by a Medi-Cal behavioral health delivery system shall be made in accordance with Section 14059.5, except as provided in this section and any written instructions issued by the department pursuant to subdivision (j) until such time that regulations are promulgated or amended. (b) (1) Subject to subdivision (f) of Section 14184.102, the following nonspecialty mental health services shall be covered by a Medi-Cal managed care plan, or available through the Medi-Cal fee-for-service delivery system for beneficiaries not enrolled in a Medi-Cal managed care plan or for services that are carved out from a Medi-Cal managed care plan’s comprehensive risk contract: (A) Individual and group mental health evaluation and treatment, including psychotherapy, family therapy, and dyadic services. (B) Psychological testing, when clinically indicated to evaluate a mental health condition. (C) Outpatient services for the purposes of monitoring drug therapy. (D) Psychiatric consultation. (E) Outpatient laboratory, drugs, supplies, and supplements. (2) Covered nonspecialty mental health services for adult beneficiaries with mild-to-moderate distress or mild-to-moderate impairment of mental, emotional, or behavioral functioning resulting from mental health disorders, as defined by the current edition of the Diagnostic and Statistical Manual of Mental Disorders, shall be provided by a Medi-Cal managed care plan or through the Medi-Cal fee-for-service delivery system. A Medi-Cal managed care plan shall provide medically necessary nonspecialty mental health services to enrolled beneficiaries under 21 years of age as required pursuant to Section 1396d(r) of Title 42 of the United States Code. A Medi-Cal managed care plan shall also be responsible for providing covered nonspecialty mental health services to enrolled beneficiaries with potential mental health disorders not yet diagnosed. (c) For enrolled beneficiaries 21 years of age or older, a county mental health plan shall provide covered specialty mental health services for beneficiaries who meet both of the following criteria: (1) The beneficiary has one or both of the following: (A) Significant impairment, where impairment is defined as distress, disability, or dysfunction in social, occupational, or other important activities. (B) A reasonable probability of significant deterioration in an important area of life functioning. (2) The beneficiary’s condition as described in paragraph (1) is due to either of the following: (A) A diagnosed mental health disorder, according to the criteria of the current editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases and Related Health Problems. (B) A suspected mental disorder that has not yet been diagnosed. (d) For enrolled beneficiaries under 21 years of age, a county mental health plan shall provide all medically necessary specialty mental health services required pursuant to Section 1396d(r) of Title 42 of the United States Code. Covered specialty mental health services shall be provided to enrolled beneficiaries who meet either of the following criteria: (1) The beneficiary has a condition placing them at high risk for a mental health disorder due to experiencing trauma evidenced by scoring in the high-risk range under a trauma screening tool approved by the department, involvement in the child welfare system, juvenile justice involvement, or experiencing homelessness. (2) The beneficiary meets both of the following requirements: (A) The beneficiary has at least one of the following: (i) A significant impairment. (ii) A reasonable probability of significant deterioration in an important area of life functioning. (iii) A reasonable probability of not progressing developmentally as appropriate. (iv) A need for specialty mental health services, regardless of presence of impairment, that are not included within the mental health benefits that a Medi-Cal managed care plan is required to provide. (B) The beneficiary’s condition as described in subparagraph (A) is due to one of the following: (i) A diagnosed mental health disorder, according to the criteria of the current editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases and Related Health Problems. (ii) A suspected mental health disorder that has not yet been diagnosed. (iii) Significant trauma placing the beneficiary at risk of a future mental health condition, based on the assessment of a licensed mental health professional. (e) (1) Covered services provided under a county Drug Medi-Cal Treatment Program or a Drug Medi-Cal organized delivery system shall use criteria adopted by the American Society of Addiction Medicine to determine the appropriate level of care for substance use disorder treatment services. (2) Covered services provided under a county Drug Medi-Cal Treatment Program or a Drug Medi-Cal organized delivery system shall include all medically necessary substance use disorder services for an individual under 21 years of age as required pursuant to Section 1396d(r) of Title 42 of the United States Code. (3) A full assessment utilizing the criteria adopted by the American Society of Addiction Medicine shall not be required for a beneficiary to begin receiving services through a Drug Medi-Cal Treatment Program or a Drug Medi-Cal organized delivery system. (f) (1) This section and Section 14059.5 shall not be construed to exclude coverage for, or reimbursement of, a clinically appropriate and covered mental health or substance use disorder prevention, screening, assessment, treatment, or recovery service under any of the following circumstances: (A) Services were provided prior to determining a diagnosis. (B) The prevention, screening, assessment, treatment, or recovery service was not included in an individual treatment plan. (C) The treated Medi-Cal beneficiary has a co-occurring mental health condition and substance use disorder. (D) For a provider who provides specialty mental health services to a Medi-Cal beneficiary under a contract between the department and a county mental health plan when that beneficiary concurrently receives nonspecialty mental health services from a Medi-Cal managed care plan or under the Medi-Cal fee-for-service delivery system, if those services are coordinated between the specialty and nonspecialty delivery systems and those services are not duplicative. (E) For a provider who provides nonspecialty mental health services to a Medi-Cal beneficiary pursuant to a comprehensive risk contract with a Medi-Cal managed care plan or under the Medi-Cal fee-for-service delivery system when that beneficiary concurrently receives specialty mental health services from a county mental health plan, if those services are coordinated between the nonspecialty and specialty delivery systems and those services are not duplicative. (2) This section and Section 14059.5 shall not be construed to exclude clinically appropriate and covered mental health or substance use disorder services during the assessment process. (g) A dispute between a county mental health plan and a Medi-Cal managed care plan shall not delay the provision of medically necessary services by the county mental health plan or the Medi-Cal managed care plan. (h) (1) The department shall develop, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, mental health and substance use disorder treatment providers, and Medi-Cal managed care plans, standardized screening tools to guide a referral to a Medi-Cal behavioral health delivery system. The department shall develop a standardized screening tool for Medi-Cal beneficiaries who are under 21 years of age and a separate standardized screening tool for those who are 21 years of age or older. The department may require the use of these standardized screening tools by Medi-Cal behavioral health delivery systems and Medi-Cal managed care plans. (2) The department shall develop, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, mental health and substance use disorder treatment providers, and Medi-Cal managed care plans, standardized statewide transition tools to ensure that Medi-Cal beneficiaries requiring transition between delivery systems receive timely coordinated care. The department shall develop a standardized statewide transition tool for Medi-Cal beneficiaries who are under 21 years of age and a separate standardized statewide transition tool for those who are 21 years of age or older. The department may require the use of these standardized statewide transition tools. (3) The department shall develop, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, and mental health and substance use disorders treatment providers, documentation standards and changes to the department’s clinical auditing standards. The department may require the use of these documentation standards by Medi-Cal behavioral health delivery systems, including, but not limited to, restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with Medi-Cal managed care plans and taking into account the need to ensure quality and program integrity and to address equity and disparities. (i) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, and make specific this section and the associated CalAIM terms and conditions by means of all-county letters, plan letters, information notices, or similar instructions, until regulations are promulgated or amended in accordance with paragraph (2). (2) Notwithstanding subdivision (d) of Section 14184.102, the department shall promulgate or amend regulations, as necessary, to implement, interpret, and make specific this section and the associated CalAIM terms and conditions in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code by July 1, 2024. (Added by Stats. 2021, Ch. 143, Sec. 402. (AB 133) Effective July 27, 2021.)
14184.403.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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This section requires Medi-Cal behavioral health delivery systems to follow CalAIM behavioral health payment reform rules starting no earlier than July 1, 2022, and directs the department to set up and manage related reimbursement and fund-transfer processes.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.403. (a) Notwithstanding any other law, commencing no sooner than July 1, 2022, subject to subdivision (f) of Section 14184.102, each Medi-Cal behavioral health delivery system shall comply with the behavioral health payment reform provisions approved in the CalAIM Terms and Conditions and any associated instruction issued by the department pursuant to subdivision (d) of Section 14184.102. (b) As a component of Behavioral Health Payment Reform under CalAIM, the department shall, at a minimum, design and implement an intergovernmental transfer-based reimbursement methodology to replace the use of certified public expenditures for claims associated with covered Specialty Mental Health and Drug Medi-Cal services provided through Medi-Cal behavioral health delivery systems. (c) Notwithstanding any other law, commencing no sooner than July 1, 2022, the nonfederal share of any payments associated with each Medi-Cal behavioral health delivery system shall consist of voluntary intergovernmental transfers of funds provided by eligible governmental agencies or public entities associated with a respective Medi-Cal behavioral health delivery system. Upon providing any intergovernmental transfer of funds, each transferring entity shall certify that the transferred funds qualify for federal financial participation pursuant to Section 433.51 of Title 42 of the Code of Federal Regulations, any other applicable federal Medicaid laws, and the CalAIM Terms and Conditions, and in the form and manner specified by the department. Any intergovernmental transfer of funds made pursuant to this section shall be considered voluntary for purposes of all state and federal laws. Notwithstanding any other law, the department shall not assess the fee described in subdivision (d) of Section 14301.4 or any other similar fee on the intergovernmental transfers made pursuant to this section. The total intergovernmental transfer-funded payment amount, which includes the federal and nonfederal share, paid to a Medi-Cal behavioral health delivery system shall be for the support of behavioral health-related services and activities that benefit patients served by the Medi-Cal behavioral health delivery system, consistent with federal law. (d) (1) The department shall establish and implement prospective reimbursement rate methodologies utilizing past county cost experience for covered Specialty Mental Health and Drug Medi-Cal services provided by Medi-Cal behavioral health delivery systems. Those methodologies shall make use of peer groups whereby counties are grouped according to past cost experience, where the department determines appropriate. The department shall determine the frequency of payments and intergovernmental transfers made pursuant to this section. The department shall consult with the representatives of Medi-Cal behavioral health delivery systems in the development of the rate methodologies, peer groups, and the payment schedule. (2) The department, in consultation with the representatives of Medi-Cal behavioral health delivery systems, shall review and may modify the methodologies annually, including, but not limited to, adjustments to the peer groups or to rates. (e) (1) The Medi-Cal County Behavioral Health Fund is hereby created in the State Treasury. (2) The nonfederal moneys collected by the department pursuant to this section shall be deposited in the Medi-Cal County Behavioral Health Fund. (3) Notwithstanding Section 13340 of the Government Code, the moneys deposited in the Medi-Cal County Behavioral Health Fund are continuously appropriated, without regard to fiscal year, to the department for purposes of implementing this section. (4) (A) Notwithstanding any other law, for counties that elect to participate in the offset and transfer of funds pursuant to this paragraph, moneys from the following sources shall be offset and transferred by the Controller into the Medi-Cal County Behavioral Health Fund pursuant to schedules, in accordance with subparagraph (C), provided by the department and created in consultation with the Department of Finance and applicable counties: (i) The Behavioral Health Subaccount in the Support Services Account in the Local Revenue Fund 2011 established pursuant to subparagraph (B) of paragraph (2) of subdivision (b) of Section 30025 of the Government Code. (ii) The Mental Health Subaccount in the Sales Tax Account in the Local Revenue Fund established pursuant to paragraph (1) of subdivision (b) of Section 17600. (iii) The Mental Health Services Fund established pursuant to Section 5890. (B) To the extent that funds are offset and transferred from the subaccounts or fund listed in subparagraph (A), the use of the funds shall be consistent with, and in furtherance of, the purposes for which they were previously deposited to the subaccounts or fund, as applicable. (C) (i) If the department prepares monthly schedules, it shall provide the schedules to the Controller by the first day of each month. If the department prepares quarterly schedules, it shall provide the schedules to the Controller detailing offsets for each month in that quarter by the first day of each quarter as agreed upon by the department, the Department of Finance, and the Controller. (ii) The department shall provide notifications to the Controller to start, stop, or resume offsetting funds by the first day of the month for changes expected to take effect in the current month. Notifications received by the Controller after the first day of the month shall be processed in the subsequent month. (5) Notwithstanding Section 16305.7 of the Government Code, the Medi-Cal County Behavioral Health Fund shall contain all interest and dividends earned on moneys in the fund and shall be used only for the purpose of implementing this section. (Amended by Stats. 2023, Ch. 42, Sec. 159. (AB 118) Effective July 10, 2023.)
14184.404.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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Starting January 1, 2027, counties must provide covered behavioral health Medi-Cal benefits through a single delivery system contract; if they are in DMC-ODS, they must use a single PIHP.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.404. (a) Notwithstanding any other law, commencing January 1, 2027, subject to subdivision (f) of Section 14184.102, an individual county, or counties acting jointly, shall provide and administer covered behavioral health Medi-Cal benefits under a single Medi-Cal behavioral health delivery system contract and, if participating in the Drug Medi-Cal organized delivery system (DMC-ODS), shall deliver those benefits through a single Prepaid Inpatient Health Plan (PIHP), in accordance with the CalAIM Terms and Conditions. (b) During the CalAIM term, the department, in consultation with counties, shall conduct any planning activities that it deems necessary and issue related guidance pursuant to subdivision (d) of Section 14184.102 to facilitate implementation of subdivision (a). (c) The department may authorize a noncounty organization that it contracts with pursuant to Section 14712 or Section 14124.21 to provide and administer covered behavioral health Medi-Cal benefits under a single Medi-Cal behavioral health delivery system contract, in accordance with the CalAIM Terms and Conditions. (Amended by Stats. 2026, Ch. 27, Sec. 91. (SB 164) Effective June 29, 2026.)
14184.405.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. )
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The department must create and run a Behavioral Health Quality Improvement Program, award grants to qualified Medi-Cal behavioral health delivery systems, and set the grant rules, but only if appropriation and federal participation conditions are satisfied.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.51. California Advancing and Innovating Medi-Cal Act [14184.100 - 14184.900] ( Article 5.51 added by Stats. 2021, Ch. 143, Sec. 402. ) ## 14184.405. (a) Subject to appropriation, the department shall establish, implement, and administer the Behavioral Health Quality Improvement Program to provide grants to qualified Medi-Cal behavioral health delivery systems for purposes of preparing those entities and their contracting health care providers for implementation of CalAIM behavioral health components described in this article and for other purposes related to Medi-Cal behavioral health delivery systems as specified in an annual Budget Act or enacted legislation providing appropriations related to those acts. (b) The department shall, in consultation with representatives of the Medi-Cal behavioral health delivery systems, determine the eligibility criteria, grant application process, and methodology for distribution of the moneys appropriated to the department for the purposes described in this section to Medi-Cal behavioral health delivery systems that the department deems qualified. (c) This section shall be implemented only if, and to the extent that, the department determines that federal financial participation is not jeopardized. (Amended by Stats. 2022, Ch. 47, Sec. 129. (SB 184) Effective June 30, 2022.)
14184.41.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )
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The department must conduct, or arrange for, two evaluations of the Global Payment Program methodology required under the Special Terms and Conditions.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.41. The department shall conduct, or arrange to have conducted, the two evaluations of the Global Payment Program methodology required under the Special Terms and Conditions. (Added by Stats. 2016, Ch. 42, Sec. 2. (AB 1568) Effective July 1, 2016. Operative July 25, 2016, pursuant to Stats. 2016, Ch. 42, Sec. 8, and enactment of SB 815 as Ch. 111.)
14184.50.
## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. )
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This section sets up the PRIME program, requires participating entities to submit project plans and reports, and sets rules for funding, intergovernmental transfers, and payment timing.

## Welfare and Institutions Code - WIC ## DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.98] ( Division 9 added by Stats. 1965, Ch. 1784. ) ## PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771] ( Part 3 added by Stats. 1965, Ch. 1784. ) ## CHAPTER 7. Basic Health Care [14000 - 14199.97] ( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ## ARTICLE 5.5. Medi-Cal 2020 Demonstration Project Act [14184 - 14184.90] ( Article 5.5 added by Stats. 2016, Ch. 111, Sec. 1. ) ## 14184.50. (a) (1) The department shall establish and operate the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program to build upon the foundational delivery system transformation work, expansion of coverage, and increased access to coordinated primary care achieved through the prior California’s “Bridge to Reform” Medicaid demonstration project. The activities supported by the PRIME program are designed to accelerate efforts by participating PRIME entities to change care delivery to maximize health care value and strengthen their ability to successfully perform under risk-based alternative payment models in the long term and consistent with the demonstration’s goals. Participating PRIME entities consist of two types of entities: designated public hospital systems and district and municipal public hospitals. (2) Participating PRIME entities shall be eligible to earn incentive payments by undertaking projects set forth in the Special Terms and Conditions, for which there are required project metrics and targets. Additionally, a minimum number of required projects is specified for each designated public hospital system. (3) The department shall provide participating PRIME entities the opportunity to earn the maximum amount of funds authorized for the PRIME program under the demonstration project. Under the demonstration project, funding is available for the designated public hospital systems and the district and municipal public hospitals through two separate pools. Subject to the Special Terms and Conditions, up to one billion four hundred million dollars ($1,400,000,000) is authorized annually for the designated public hospital systems pool, and up to two hundred million dollars ($200,000,000) is authorized annually for the district and municipal public hospitals pool, during the first three years of the demonstration project, with reductions to these amounts in the fourth and fifth years. Except in those limited instances specifically authorized by the Special Terms and Conditions, the funding that is authorized for each respective pool shall only be available to participating PRIME entities within that pool. (4) PRIME payments shall be incentive payments, and are not payments for services otherwise reimbursable under the Medi-Cal program, nor direct reimbursement for expenditures incurred by participating PRIME entities in implementing reforms. PRIME incentive payments shall not offset payment amounts otherwise payable by the Medi-Cal program, or to and by Medi-Cal managed care plans for services provided to Medi-Cal beneficiaries, or otherwise supplant provider payments payable to PRIME entities. (b) For purposes of this article, the following definitions apply: (1) “Alternative payment methodology” or “APM” means a payment made from a Medi-Cal managed care plan to a designated public hospital system for services covered for a beneficiary assigned to a designated public hospital system that meets the conditions set forth in the Special Terms and Conditions and approved by the department, as applicable. (2) “Designated public hospital system” means a designated public hospital, as listed in the Special Terms and Conditions, and its affiliated governmental providers and contracted governmental and nongovernmental entities that constitute a system with an approved project plan under the PRIME program. A single designated public hospital system may include multiple designated public hospitals under common government ownership. (3) “District and municipal public hospitals” means those nondesignated public hospitals, as listed in the Special Terms and Conditions, that have an approved project plan under the PRIME program. (4) “Participating PRIME entity” means a designated public hospital system or district and municipal public hospital participating in the PRIME program. (5) “PRIME program year” means the state fiscal year beginning on July 1 and ending on June 30 during which the PRIME program is authorized, except that the first PRIME program year shall commence on January 1, 2016, and, as applicable, means each state fiscal year thereafter through the 2019–20 state fiscal year, and any years or partial years during which the PRIME program is authorized under an extension or successor to the demonstration project. (c) (1) Within 30 days following federal approval of the protocols setting forth the PRIME projects, metrics, and funding mechanics, each participating PRIME entity shall submit a five-year PRIME project plan containing the specific elements required in the Special Terms and Conditions. The department shall review all five-year PRIME project plans and take action within 60 days to approve or disapprove each five-year PRIME project plan. (2) Participating PRIME entities may modify projects or metrics in their five-year PRIME project plan, to the extent authorized under the demonstration project and approved by the department. (d) (1) Each participating PRIME entity shall submit reports to the department twice a year demonstrating progress toward required metric targets. A standardized report form shall be developed jointly by the department and participating PRIME entities for this purpose. The mid-year report shall be due March 31 of each PRIME program year, except that, for the 2015–16 project year only, the submission of an acceptable five-year PRIME project plan in accordance with the Special Terms and Conditions shall constitute the submission of the mid-year report. The yearend report shall be due September 30 following each PRIME program year. (2) The submission of the project reports pursuant to paragraph (1) shall constitute a request for payment. Amounts payable to the participating PRIME entity shall be determined based on the achievement of the metric targets included in the mid-year report and yearend report, as applicable. (3) Within 14 days following the submission of the mid-year and yearend reports, the department shall confirm the amounts payable to participating PRIME entities and shall issue requests to each participating PRIME entity for the intergovernmental transfer amounts necessary to draw down the federal funding for the applicable PRIME incentive payment to that entity. (A) Any intergovernmental transfers provided for purposes of this section shall be deposited in the Public Hospital Investment, Improvement, and Incentive Fund established pursuant to Section 14182.4 and retained pursuant to paragraph (1) of subdivision (f). (B) Participating PRIME entities or their affiliated governmental agencies or entities shall make the intergovernmental transfer to the department within seven days of receiving the department’s request. In the event federal approval for a payment is not obtained, the department shall return the intergovernmental transfer funds to the transferring entity within 14 days. (C) PRIME payments to a participating PRIME entity shall be conditioned upon the department’s receipt of the intergovernmental transfer amount from the applicable entity. If the intergovernmental transfer is made within the appropriate timeframe, the incentive payment shall be disbursed in accordance with paragraph (4), otherwise the payment shall be disbursed within 14 days of when the intergovernmental transfer is provided. (4) Subject to paragraph (3), and except with respect to the 2015–16 project year, amounts payable based on the mid-year reports shall be paid no later than April 30, and amounts payable based on the yearend report shall be paid no later than October 31. In the event of insufficient or misreported data, these payment deadlines may be extended up to 60 days to allow time for the reports to be adequately corrected for approval for payment. If corrected data is not submitted to enable payment to be made within the extended timeframe, the participating entity shall not receive PRIME payment for the period in question. For the 2015–16 project year only, 25 percent of the annual allocation for the participating PRIME entity shall be payable within 14 days following the approval of the five-year PRIME project plan. The remaining 75 percent of the participating PRIME entity’s annual allocation shall be available following the 2015–16 yearend report, subject to the requirements in paragraph (2) of subdivision (e). (5) The department shall draw down the federal funding and pay both the nonfederal and federal shares of the incentive payment to the participating PRIME entity, to the extent federal financial participation is available. (e) The amount of PRIME incentive payments payable to a participating PRIME entity shall be determined as follows: (1) The department shall allocate the full amount of annual funding authorized under the PRIME project pools across all domains, projects, and metrics undertaken in the manner set forth in the Special Terms and Conditions. Separate allocations shall be determined for the designated public hospital system pool and the district and municipal hospital pool. The allocations shall determine the aggregate annual amount of funding that may be earned for each domain, project, and metric for all participating PRIME entities within the appropriate pool. (A) The department shall allocate the aggregate annual amounts determined for each project and metric under the designated public hospital system pool among participating designated public hospital systems through an allocation methodology that takes into account available system-specific data, primarily based on the unique number of Medi-Cal beneficiaries treated, consistent with the Special Terms and Conditions. For the 2015−16 project year only, the approval of the five-year PRIME project plans for designated public hospital systems will be considered an appropriate metric target and will equal up to 25 percent of a designated public hospital system’s annual allocation for that year. (B) The department shall allocate the aggregate annual amounts determined for each project and metric under the district and municipal public hospital system pool among participating district and municipal public hospital systems through an allocation methodology that takes into account available system-specific data that includes Medi-Cal and uninsured care, the number of projects being undertaken, and a baseline floor funding amount, consistent with the Special Terms and Conditions. For the 2015–16 project year only, the approval of the five-year PRIME project plans for district and municipal public hospital systems will be considered an appropriate metric target and will equal up to 25 percent of a district and municipal public hospital system’s annual allocation for that year. (2) Amounts payable to each participating PRIME entity shall be determined using the methodology described in the Special Terms and Conditions, based on the participating PRIME entity’s progress toward and achievement of the established metrics and targets, as reflected in the mid-year and yearend reports submitted pursuant to paragraph (1) of subdivision (d). (A) Each participating PRIME entity shall be individually responsible for progress toward and achievement of project specific metric targets during the reporting period. (B) The amounts allocated pursuant to subparagraphs (A) and (B) of paragraph (1) shall represent the amounts the designated public hospital system or district and municipal public hospital, as applicable, may earn through achievement of a designated project metric target for the applicable year, before any redistribution. (C) Participating PRIME entities shall earn reduced payment for partial achievement at both the mid-year and yearend reports, as described in the Special Terms and Conditions. (3) If, at the end of a project year, a project metric target is not fully met by a participating PRIME entity and that entity is not able to fully claim funds that otherwise would have been earned for meeting the metric target, participating PRIME entities shall have the opportunity to earn unclaimed funds under the redistribution methodology established under the Special Terms and Conditions. Amounts earned by a participating PRIME entity through redistribution shall be payable in addition to the amounts earned pursuant to paragraph (2). (f) The nonfederal share of payments under the PRIME program shall consist of voluntary intergovernmental transfers of funds provided by designated public hospitals or affiliated governmental agencies or entities, or district and municipal public hospitals or affiliated governmental agencies or entities, in accordance with this section. (1) The Public Hospital Investment, Improvement, and Incentive Fund, established in the State Treasury pursuant to Section 14182.4, shall be retained during the demonstration term for purposes of making PRIME payments to participating PRIME entities. Notwithstanding Section 13340 of the Government Code, moneys deposited in the Public Hospital Investment, Improvement, and Incentive Fund shall be continuously appropriated, without regard to fiscal years, to the department for the purposes specified in this section. All funds derived pursuant to this section shall be deposited in the State Treasury to the credit of the Public Hospital Investment, Improvement, and Incentive Fund. (2) The Public Hospital Investment, Improvement, and Incentive Fund shall consist of moneys that a designated public hospital or affiliated governmental agency or entity, or a district and municipal public hospital-affiliated governmental agency or entity, elects to transfer to the department for deposit into the fund as a condition of participation in the PRIME program, to the extent permitted under Section 433.51 of Title 42 of the Code of Federal Regulations, the Special Terms and Conditions, and any other applicable federal Medicaid laws. Except as provided in paragraph (3), moneys derived from these intergovernmental transfers in the Public Hospital Investment, Improvement, and Incentive Fund shall be used as the nonfederal share of PRIME program payments authorized under the demonstration project. Any intergovernmental transfer of funds provided for purposes of the PRIME program shall be made as specified in this section. Upon providing any intergovernmental transfer of funds, each transferring entity shall certify that the transferred funds qualify for federal financial participation pursuant to applicable federal Medicaid laws and the Special Terms and Conditions, and in the form and manner as required by the department. (3) The department shall claim federal financial participation for PRIME incentive payments using moneys derived from intergovernmental transfers made pursuant to this section and deposited in the Public Hospital Investment, Improvement, and Incentive Fund to the full extent permitted by law. The moneys disbursed from the fund, and all associated federal financial participation, shall be distributed only to participating PRIME entities and the governmental agencies or entities to which they are affiliated, as applicable. No moneys derived from intergovernmental transfers on behalf of district and municipal public hospitals, including any associated federal financial participation, shall be used to fund PRIME payments to designated public hospital systems, and likewise, no moneys derived from intergovernmental transfers provided by designated public hospitals or their affiliated governmental agencies or entities, including any associated federal financial participation, shall be used to fund PRIME payments to district and municipal public hospitals. In the event federal financial participation is not available with respect to a payment under this section that results in a recoupment of funds from one or more participating PRIME entities, the department shall return any intergovernmental transfer fund amounts associated with the payment for which federal financial participation is not available to the applicable transferring entities within 14 days from the date of the associated recoupment or other determination, as applicable. (4) This section shall not be construed to require a designated public hospital, a district and municipal public hospital, or any affiliated governmental agency or entity to participate in the PRIME program. As a condition of participation in the PRIME program, each designated public hospital or affiliated governmental agency or entity, and each district and municipal public hospital-affiliated governmental agency or entity agrees to provide intergovernmental transfers of funds necessary to meet the nonfederal share obligation for any PRIME payments made pursuant to this section and the Special Terms and Conditions. Any intergovernmental transfers made pursuant to this section shall be considered voluntary for purposes of all federal laws. (g) (1) PRIME incentive payments are intended to support designated public hospital systems in their efforts to change care delivery and strengthen those systems’ ability to participate under an alternate payment methodology (APM). APMs shift some level of risk to participating designated public hospital systems through capitation and other risk-sharing agreements. Contracts entered into, issued, or renewed between managed care plans and participating designated public hospital systems shall include language requiring the designated public hospital system to report on metrics to meet quality benchmark goals and to ensure improved patient outcomes, consistent with the Special Terms and Conditions. (2) In order to promote and increase the level of value-based payments made to designated public hospital systems during the course of the demonstration term, the department shall issue an all-plan letter to Medi-Cal managed care plans that shall promote and encourage positive system transformation. The department shall issue an activities plan supporting designated public hospital system efforts to meet those aggregate APM targets and requirements as provided in the Special Terms and Conditions. (3) (A) Designated public hospital systems shall contract with at least one Medi-Cal managed care plan in the service area where they operate using an APM methodology by January 1, 2018. If a designated public hospital system is unable to meet this requirement and can demonstrate that it has made a good faith effort to contract with a Medi-Cal managed care plan in the service area that it operates in or a gap in contracting period occurs, the department has the discretion to waive this requirement. (B) Each designated public hospital system shall report to the department, in a format determined by the department in consultation with the designated public hospital systems and Medi-Cal managed care plans, a summary of the contracting arrangement the designated public hospital system has with Medi-Cal managed care plans and the scope of services covered under the contract. (C) It is the intent of the Legislature to encourage contracting between designated public hospital systems and multiple Medi-Cal managed care plans so that Medi-Cal members have access to medically necessary and appropriate covered services. (4) Designated public hospital systems and Medi-Cal managed care plans shall seek to strengthen their data and information sharing for purposes of identifying and treating applicable beneficiaries, including the timely sharing and reporting of beneficiary data, assessment, and treatment information. Consistent with the Special Terms and Conditions and the goals of the demonstration project, and notwithstanding any other state law, the department shall provide guidelines, state-level infrastructure, and other mechanisms to support this data and information sharing. (Amended by Stats. 2017, Ch. 561, Sec. 285. (AB 1516) Effective January 1, 2018.)

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