Cal. Code Regs. tit. 22 § 51556

Current through Register 2024 Notice Reg. No. 25, June 21, 2024

Section 51556 - Contracts

(a)

(1) The reimbursement limitation for the noncontract service costs of contracting hospitals which had a valid contract during the entire settlement fiscal period shall be determined by the following method:

Noncontract Reduction = NMCN - TCL

Where:

NMCN = Noncontract Medi-Cal net cost of covered services including third-party liability amounts

TCL = PYNCPD * PDL * SYND

PYNCPD = PYNC/PYND

TCL = Total cost limit exclusive of any reductions for third-party liability

PYNCPD = Prior fiscal period noncontract cost per day

PYNC = Prior fiscal period noncontract costs

PYND = Prior fiscal period noncontract days

PDL = Per diem limit increase which shall be the target as specified in federal regulation CFR 42, Section 413.40(c)(3).

SYND = Settlement fiscal period noncontract days

(2) All AA and appeal issues must pertain to the reason for the increase in the average noncontract costs per day from the prior fiscal period to the settlement fiscal period.

(3) Contracting hospitals with noncontract service costs will also have an ARPDL calculation performed each FPE. The calculation will be used to determine the base period for the next FPE in the event the provider discontinues the contracting program.

(b) The noncontract reimbursement reduction, if any, for partial FPE contracting hospitals, those hospitals which have gone on or off contracting during their settlement fiscal period, shall be determined as follows:

Noncontract Reduction = PRNC * FYR

Where:

PRNC = NMCN/TMCN

PRNC = Proportion of reimbursement not under contract

FYR = Full fiscal period all services reimbursement reduction as determined by the PIRL.

NMCN = Noncontracting Medi-Cal net cost of covered services

TMCN = Total Medi-Cal net cost of covered services for the entire fiscal period for all services.

Cal. Code Regs. Tit. 22, § 51556

1. New section filed 4-23-92; operative 5-25-92 (Register 92, No. 20).
2. Change without regulatory effect amending subsection (b) filed 8-5-97 pursuant to section 100, title 1, California Code of Regulations (Register 97, No. 32).

Note: Authority cited: Sections 10725, 14100.1, 14105, 14105.1, 14106 and 14124.5, Welfare and Institutions Code; and Chapter 1594, Statutes of 1982, Section 87 (SB 2012). Reference: Sections 14105 and 14106, Welfare and Institutions Code.