CA Welf & Inst Code Section 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.