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(a) Capital outlier factor means (California fixed loss cost outlier
threshold x geographic adjustment factor x large urban add-on x (capital cost-to-charge
ratio to total cost-to-charge ratio)). The geographic adjustment factor is specified
in the Federal Register of August 1, 2000 at Vol. 65, page 47126, Table 1a,
which document is hereby incorporated by reference and will be made available
upon request to the Administrative Director. The large urban add-on
is indicated by the post-reclassification urban/rural location published in
the Payment Impact File at positions 229-235. As stated in Title 42, Code of
Federal Regulations, Section 412.316(b), as it is in effect on September 29,
2000, the large urban add-on is an additional 3% of what would otherwise
be payable to the health facility.
(b) California fixed loss cost outlier threshold means the factor
calculated by adjusting the Medicare fixed loss cost outlier threshold for California
workers' compensation inpatient admissions. The California fixed loss cost outlier
threshold is $14,500.
(c) Composite factor means the factor calculated by the administrative
director for a health facility by adding the prospective operating costs and
the prospective capital costs for the health facility, excluding the DRG weight
and any applicable outlier payment, as determined by the federal Health Care
Financing Administration for the purpose of determining reimbursement under
Medicare.
(1) Prospective capital costs are determined by the following formula:
Capital standard federal payment rate x capital wage index x large urban add-on
x [1 + capital disproportionate share adjustment factor + capital indirect medical
education adjustment factor]
The capital standard federal payment rate is $382.03 as published
by HCFA in the Federal Register of August 1, 2000, at Vol. 65, page 47127, Table
1d, which document is hereby incorporated by reference and will be made available
upon request to the Administrative Director.
The capital wage index was published in the Payment Impact File
at positions 243-252.
The large urban add-on is indicated by the post-reclassification
urban/rural location published in the Payment Impact File at positions 229-235.
As stated in Title 42, Code of Federal Regulations, Section 412.316(b), as it
is in effect on September 29, 2000, the large urban add-on is an
additional 3% of what would otherwise be payable to the health facility.
The capital disproportionate share adjustment factor was published
in the Payment Impact File at positions 117-126.
The capital indirect medical education adjustment factor (capital
IME adjustment) was published in Payment Impact File at positions 202-211.
(2) Prospective operating costs are determined by the following formula:
[(Labor-related national standardized amount x operating wage index) + nonlabor-related
national standardized amount] x [1 + operating disproportionate share adjustment
factor + operating indirect medical education adjustment]
The labor-related national standardized amount is $2,864.19 for
large urban areas and $2,818.85 for other areas, as published by the federal
Health Care Financing Administration [HCFA] in the Federal Register of August
1, 2000, at Vol. 65, page 47126, Table 1a, which document is hereby incorporated
by reference and will be made available upon request to the Administrative Director.
The labor-related national standardized amount is $2,894.99 for
large urban area sole community hospitals and $2,849.16 for other areas sole
community hospitals, as published by the federal Health Care Financing Administration
[HCFA] in the Federal Register of August 1, 2000, at Vol. 65, page 47127, Table
1e, which document is hereby incorporated by reference and will be made available
upon request to the Administrative Director.
The operating wage index was published in the Payment Impact File
at positions 253-262.
The nonlabor-related national standardized amount is $1,164.21 for
large urban areas and $1,145.78 for other areas, as published by HCFA in the
Federal Register of August 1, 2000, at Vol. 65, page 47126, Table 1a, which
document is hereby incorporated by reference and will be made available upon
request to the Administrative Director. The nonlabor-related national
standardized amount is $1,176.73 for large urban area sole community hospitals
and $1,158.10 for other areas sole community hospitals as published by the federal
Health Care Financing Administration [HCFA] in the Federal Register of August
1, 2000, at Vol. 65, page 47127, Table 1e, which document is hereby incorporated
by reference and will be made available upon request to the administrative director.
The operating disproportionate share adjustment factor was published
in the Payment Impact File at positions 127-136.
The operating indirect medical education adjustment was published
in the Payment Impact File at positions 212-221.
(3) A table of composite factors for each health facility in California is contained
in Appendix A to Section 9792.1.
(d) Costs means the total billed charges for an admission, excluding
non-medical charges such as television and telephone charges, multiplied by
the hospital's total cost-to-charge ratio. For DRGs 496 through 500, for purposes
of determining whether an admission is a cost outlier, costs exclude
implantable hardware and/or instrumentation reimbursed under subsection (7)
of Section 9792.1.
(e) Cost-to-charge ratio means the sum of the hospital specific
operating cost-to-charge ratio and the hospital specific capital cost-to-charge
ratio. The operating cost-to-charge ratio for each hospital was published in
the Payment Impact File at positions 161-168. The capital cost-to-charge ratio
for each hospital was published in the Payment Impact File at positions 99-106.
A table of hospital specific capital cost-to-charge, operating cost-to-charge
and total cost-to-charge ratios for each health facility in California is contained
in Appendix A to Section 9792.1.
(f) Cost outlier case means a hospitalization for which the hospital's
costs, as defined in subdivision (d) above, exceed the Inpatient Hospital Fee
Schedule payment amount by the hospital's outlier factor. If costs exceed the
cost outlier threshold, the case is a cost outlier case.
(g) Cost outlier threshold means the sum of the Inpatient Hospital
Fee Schedule payment amount plus the hospital specific outlier factor.
(h) DRG weight means the weighting factor for a diagnosis-related
group assigned by the Health Care Financing Administration for the purpose of
determining reimbursement under Medicare. A table is contained in Appendix B
to Section 9792.1. Appendix B shows DRG weights as assigned by HCFA and, where
applicable, Revised DRG weights in italics.
(i)(1) Revised DRG weight means the product of the DRG weight multiplied
by the ratio set forth in subsection (i)(2) for 48 specified DRGs to reflect
the different resource usage between the workers' compensation population and
the Medicare population.
(2) The ratios that were applied to the DRG weights are contained in the column
identified as DWC Revised Ratio in Appendix B of Section 9792.1.
(j) Health facility means any facility as defined in Section 1250
of the Health and Safety Code.
(k) Inpatient means a person who has been admitted to a health facility
for the purpose of receiving inpatient services. A person is considered an inpatient
when he or she is formally admitted as an inpatient with the expectation that
he or she will remain at least overnight and occupy a bed, even if it later
develops that such person can be discharged or is transferred to another facility
and does not actually remain overnight.
(l) Inpatient Hospital Fee Schedule payment amount is that amount
determined by multiplying the DRG weight x hospital composite factor x 1.2.
(m) Labor-related portion is that portion of operating costs attributable
to labor costs, as specified in the Federal Register of August 1, 2000 at Vol.
65, page 47126, Table 1a, which document is hereby incorporated by reference
and will be made available upon request to the Administrative Director.
(n) Medical services means those goods and services provided pursuant
to Article 2 (commencing with Section 4600) of Chapter 2 of Part 2 of Division
4 of the Labor Code.
(o) Average length of stay means the geometric mean length of stay
for a diagnosis-related group assigned by the Health Care Financing Administration.
(p) Operating outlier factor means ((California fixed loss cost
outlier threshold x ((labor-related portion x MSA wage index) + nonlabor-related
portion)) x (operating cost-to-charge ratio to total cost-to-charge ratio)).
The MSA wage index is specified at Federal Register of August 1, 2000 at Vol.
65, page 47149, Table 4a, which document is hereby incorporated by reference
and will be made available upon request to the Administrative Director. The
nonlabor-related portion is that portion of operating costs as defined in the
Federal Register of August 1, 2000 at Vol. 65, page 47126, Table 1a, which document
is hereby incorporated by reference and will be made available upon request
to the Administrative Director.
(q) Outlier factor means the sum of the capital outlier factor and
the operating outlier factor. A table of hospital specific outlier factors for
each health facility in California is contained in Appendix A to Section 9792.1.
(r) Payment Impact File means the FY 2001 Prospective Payment System
Payment Impact File (August 2000 Update) (IMPCTF01.EXE) published by the federal
Health Care Financing Administration, which document is hereby incorporated
by reference. The description of the file is found at http://www.hcfa.gov/stats/impctf01.doc.
The file is accessible through http://www.hcfa.gov/stats/pufiles.htm#ppfexmtp.
A paper copy of the Payment Impact File, with explanatory material, is available
from the Administrative Director upon request. An electronic copy is available
from the Administrative Director at http://www.dir.ca.gov.
NOTE
Authority cited: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference:
Sections 4600, 4603.2 and 5307.1, Labor Code.
HISTORY
1. New section filed 10-7-93; operative 1-1-94 (Register 93, No. 41). This
filing is exempt from much of the APA (including OAL review) pursuant to Government
Code section 11351.
2. New subsections (a)-(c)(2), subsection relettering, and new subsection (g)
filed 12-31-96; operative 12-31-96 pursuant to Government Code section 11343.4(d).
Submitted to OAL for printing only pursuant to Government Code section 11351
(Register 97, No. 1).
3. New subsections (a)(1)-(3), amendment of subsections (b) and (c)(2) and new
subsection (h) filed 2-23-99; operative 4-1-99 (Register 99, No. 9).
4. Amendment filed 5-30-2001; operative 6-29-2001. Submitted to OAL for printing
only pursuant to Government Code section 11340.9(g) (Register 2001, No. 23).
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