§ 53820. Maximum Enrollment Levels.

(a) The department shall implement the two-plan model in regions designated by the department, pursuant to section 53800.

(b) For each designated region, the department shall establish a maximum enrollment level of Medi-Cal beneficiaries in the mandatory aid categories for the commercial plan under the two-plan model, which will consider the following factors:

(1) The number of inpatient days qualifying for DSH supplemental payments as the surrogate measure for services provided by all safety net providers in the region.

(2) The impact of the enrollment of Medi-Cal beneficiaries in the commercial plan on supplemental DSH payments, to the extent that inpatient days provided to members of the commercial plan will be diverted from safety net providers.

(3) The number of acute inpatient hospital days attributable to the Medi-Cal beneficiaries not enrolled in prepaid health plans or PCCM plans.

(4) The acute inpatient hospital utilization rate for Medi-Cal beneficiaries in the mandatory aid categories.

(5) The enrollment levels of both plans of the two-plan model necessary to ensure true beneficiary choice between plans and among providers within the two plans.

(6) The hospital inpatient care contracts the commercial plan may have with disproportionate share hospitals.

(7) An agreement between a local initiative and commercial plan in a designated region regarding local initiative minimum and commercial plan maximum enrollment levels.

(c) The process for setting the maximum enrollment level for the commercial plan in any region shall include the following:

(1) The department shall notify the Board(s) of Supervisors of each county included within the region of the proposed maximum enrollment level and the rationale for the proposed level.

(2) The Board(s) of Supervisors shall have 30 days to submit written comments to the department on the proposed maximum enrollment level.

(3) The department shall review and consider any written comments received from the Board(s) of Supervisors within the 30 day comment period and may adjust the maximum enrollment level, if the department determines that an adjustment is warranted, or may set the maximum enrollment level as originally proposed.

(d) The department shall reevaluate the maximum enrollment level at least every two years and revise the level, if appropriate.

(e) If the number of enrollees and the utilization patterns of the commercial plan have significantly reduced or will significantly reduce DSH supplemental payments in the region, the department shall require the commercial plan to contract with disproportionate share hospitals for inpatient care for members.

HISTORY

1. New section filed 5-14-93 as an emergency; operative 5-14-93. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 93, No. 20).

2. New article 3 heading, amendment of subsections (a), (b), (b)(2), (b)(6) and (c), and new subsection (e) filed 7-1-96 as an emergency; operative 7-1-96. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 96, No. 28).

3. Repealer of article 3 heading, section heading, section and Note and new article 3 heading, section heading, section and Note filed 3-4-97; operative 3-4-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 10).

4. New subsection (b)(7) filed 10-1-97 as an emergency; operative 10-1-97. Submitted to OAL for printing only pursuant to Section 147, SB 485 (Ch. 722/92) (Register 97, No. 40).

Note

Note: Authority cited: Sections 10725, 14105, 14124.5 and 14312, Welfare and Institutions Code. Reference: Sections 14087.3, 14087.4, 14105.98 and 14201, Welfare and Institutions Code.