Section 97449 - Total Health Care Expenditures Data SubmissionIn order for the Office to measure total health care expenditures and per capita total health care expenditures, the reporting requirements for payers and fully integrated delivery systems to submit data and other information are as follows:
(a) Who must submit. A payer or fully integrated delivery system shall be subject to the requirements of this Article if any of the following criteria in subsections (a)(1) through (3) are met: (1) The payer or fully integrated delivery system is a Medi-Cal managed care plan contracted with the State Department of Health Care Services to provide full scope benefits to 40,000 or more Medi-Cal beneficiaries pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code. The number of Medi-Cal beneficiaries shall be calculated as of December 31 of each calendar year prior to the submission year. This subsection (a)(1) is effective beginning with the first annual data file submission as described in subsections (e)(2) and (h)(2).(2) The payer or fully integrated delivery system enrolls or insures 40,000 or more covered lives in Medicare Advantage products under Medicare Part C. The number of covered lives in Medicare Advantage products shall be calculated by adding together all the covered lives in the entity's Medicare Advantage products in California as of December 31 of each calendar year prior to the submission year.(3) The payer or fully integrated delivery system enrolls or insures 40,000 or more covered lives in commercial products. The number of covered lives in commercial products shall be calculated by adding together all the covered lives in the entity's commercial health insurance products and commercial health plan products in California as of December 31 of each calendar year prior to the submission year. For purposes of this paragraph, "commercial" refers to products that are not Medi-Cal or Medicare Advantage products.(b) A payer or fully integrated delivery system that meets any of the criteria in subsection (a) ("required submitter") shall submit data for all required market categories as outlined in the Guide incorporated in section 97445(s), to the extent consistent with federal law.(c) Voluntary Data Submission. To request to become a voluntary submitter, a payer or fully integrated delivery system or their authorized agent shall submit to the Office a written request to participate. Each request shall provide the voluntary submitter's contact information, number of covered lives, and types of coverage offered. The Office shall notify requestors if they are approved to register to submit data.(d) Coordination of Data Submission.(1) Required submitters are responsible for reporting data for all plan members. If a required submitter is the Directly Contracted Plan in a Plan-to-Plan contract, the Directly Contracted Plan shall obtain any necessary data from the Subcontracted Plan and submit the data to the System.(2) Affiliated required submitters are responsible for coordinating data submission amongst their affiliates to ensure compliance with this Article.(e) Registration Deadline. (1) Initial data file submission. All required submitters and approved voluntary submitters shall register in the Data Portal to submit data through the System for the 2022 and 2023 reporting years by April 30, 2024.(2) Annual data file submission. After September 1, 2024, all required submitters and approved voluntary submitters shall register in the Data Portal to submit data through the System annually by May 31st.(f) Registration Process. All required submitters and approved voluntary submitters must register in the Data Portal and provide all required registration information as specified in the Guide.(g) Registration Information Update. Each registered submitter must update registration information in the Data Portal within 15 calendar days of any change in the required registration information as specified in the Guide.(h) Data File Submission Deadline. (1) Initial data file submission. Registered submitters shall submit data files as specified in the Guide through the System for the 2022 and 2023 reporting years by September 1, 2024.(2) Annual data file submission. After September 1, 2024, registered submitters shall submit data files through the System annually by September 1 of the year following each reporting year as specified in the Guide.(i) Data File Technical Requirements. Data files shall comply with file format, technical specifications, and other standards specified in the Guide.(j) Test File Submission. Registered submitters may use the Data Portal to submit test files to confirm and test their ability to create data files meeting the file intake specifications detailed in the Guide. Test files will be identified as specified in the Guide. Test files will not be considered to have been submitted to the Office for reporting purposes.(k) Data Acceptance and Correction.(1) Data files that are submitted to the System but do not meet the file intake specifications detailed in the Guide will be rejected. Registered submitters will be notified within five business days of submission whether a data file has been accepted or rejected. Reasons for rejection include: (A) Invalid file format, file layout, or data types.(B) Incomplete or illogical data.(C) Other technical deficiencies related to file submission, storage, or processing.(2) If the Office determines that a previously accepted file contains initially unidentified errors, the submitter shall be notified through the Data Portal. The submitter shall respond through the Data Portal within three business days of notification by the Office. The Office may make multiple requests for corrections or resubmissions.(l) Requesting a Variance. A submitter that is unable to submit data files meeting the file intake specifications detailed in the Guide may request a temporary variance to those requirements.(1) Variance requests shall be submitted through the Data Portal, and shall clearly identify the issue, the plan for correction, and the anticipated date of correction.(2) The Office shall respond to variance requests within five business days of the date the request was submitted.Cal. Code Regs. Tit. 22, § 97449
Note: Authority cited: Sections 127501, 127501.2 and 127501.4, Health and Safety Code. Reference: Sections 127500.2, 127500.5 and 127501.4, Health and Safety Code.
1. New section filed 3-4-2024 as an emergency; operative 3/4/2024 (Register 2024, No. 10). Pursuant to Health and Safety Code section 127501.2, subdivision (b), this regulation shall be repealed by operation of law on 3-2-2029 unless the adoption, amendment, or repeal of the regulation is promulgated by the office pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of title 2, of the Government Code before that date.