Chapter 2.5. The Maddy Emergency Medical Services Fund 1797.98a-1797.98g of California Health And Safety Code >> Division 2.5. >> Chapter 2.5.
1797.98a. (a) The fund provided for in this chapter shall be known
as the Maddy Emergency Medical Services (EMS) Fund.
(b) (1) Each county may establish an emergency medical services
fund, upon the adoption of a resolution by the board of supervisors.
The moneys in the fund shall be available for the reimbursements
required by this chapter. The fund shall be administered by each
county, except that a county electing to have the state administer
its medically indigent services program may also elect to have its
emergency medical services fund administered by the state.
(2) Costs of administering the fund shall be reimbursed by the
fund in an amount that does not exceed the actual administrative
costs or 10 percent of the amount of the fund, whichever amount is
(3) All interest earned on moneys in the fund shall be deposited
in the fund for disbursement as specified in this section.
(4) Each administering agency may maintain a reserve of up to 15
percent of the amount in the portions of the fund reimbursable to
physicians and surgeons, pursuant to subparagraph (A) of, and to
hospitals, pursuant to subparagraph (B) of, paragraph (5). Each
administering agency may maintain a reserve of any amount in the
portion of the fund that is distributed for other emergency medical
services purposes as determined by each county, pursuant to
subparagraph (C) of paragraph (5).
(5) The amount in the fund, reduced by the amount for
administration and the reserve, shall be utilized to reimburse
physicians and surgeons and hospitals for patients who do not make
payment for emergency medical services and for other emergency
medical services purposes as determined by each county according to
the following schedule:
(A) Fifty-eight percent of the balance of the fund shall be
distributed to physicians and surgeons for emergency services
provided by all physicians and surgeons, except those physicians and
surgeons employed by county hospitals, in general acute care
hospitals that provide basic, comprehensive, or standby emergency
services pursuant to paragraph (3) or (5) of subdivision (f) of
Section 1797.98e up to the time the patient is stabilized.
(B) Twenty-five percent of the fund shall be distributed only to
hospitals providing disproportionate trauma and emergency medical
(C) Seventeen percent of the fund shall be distributed for other
emergency medical services purposes as determined by each county,
including, but not limited to, the funding of regional poison control
centers. Funding may be used for purchasing equipment and for
capital projects only to the extent that these expenditures support
the provision of emergency services and are consistent with the
intent of this chapter.
(c) The source of the moneys in the fund shall be the penalty
assessment made for this purpose, as provided in Section 76000 of the
(d) Any physician and surgeon may be reimbursed for up to 50
percent of the amount claimed pursuant to subdivision (a) of Section
1797.98c for the initial cycle of reimbursements made by the
administering agency in a given year, pursuant to Section 1797.98e.
All funds remaining at the end of the fiscal year in excess of any
reserve held and rolled over to the next year pursuant to paragraph
(4) of subdivision (b) shall be distributed proportionally, based on
the dollar amount of claims submitted and paid to all physicians and
surgeons who submitted qualifying claims during that year.
(e) Of the money deposited into the fund pursuant to Section
76000.5 of the Government Code, 15 percent shall be utilized to
provide funding for all pediatric trauma centers throughout the
county, both publicly and privately owned and operated. The
expenditure of money shall be limited to reimbursement to physicians
and surgeons, and to hospitals for patients who do not make payment
for emergency care services in hospitals up to the point of
stabilization, or to hospitals for expanding the services provided to
pediatric trauma patients at trauma centers and other hospitals
providing care to pediatric trauma patients, or at pediatric trauma
centers, including the purchase of equipment. Local emergency medical
services (EMS) agencies may conduct a needs assessment of pediatric
trauma services in the county to allocate these expenditures.
Counties that do not maintain a pediatric trauma center shall utilize
the money deposited into the fund pursuant to Section 76000.5 of the
Government Code to improve access to, and coordination of, pediatric
trauma and emergency services in the county, with preference for
funding given to hospitals that specialize in services to children,
and physicians and surgeons who provide emergency care for children.
Funds spent for the purposes of this section, shall be known as
Richie's Fund. This subdivision shall remain in effect until January
1, 2017, and shall have no force or effect on or after that date,
unless a later enacted statute, that is chaptered before January 1,
2017, deletes or extends that date.
(f) Costs of administering money deposited into the fund pursuant
to Section 76000.5 of the Government Code shall be reimbursed from
the money collected in an amount that does not exceed the actual
administrative costs or 10 percent of the money collected, whichever
amount is lower. This subdivision shall remain in effect until
January 1, 2017, and shall have no force or effect on or after that
date, unless a later enacted statute, that is chaptered before
January 1, 2017, deletes or extends that date.
1797.98b. (a) Each county establishing a fund, on January 1, 1989,
and on each April 15 thereafter, shall report to the authority on the
implementation and status of the Emergency Medical Services Fund.
Notwithstanding Section 10231.5 of the Government Code, the authority
shall compile and forward a summary of each county's report to the
appropriate policy and fiscal committees of the Legislature. Each
county report, and the summary compiled by the authority, shall cover
the immediately preceding fiscal year, and shall include, but not be
limited to, all of the following:
(1) The total amount of fines and forfeitures collected, the total
amount of penalty assessments collected, and the total amount of
penalty assessments deposited into the Emergency Medical Services
Fund, or, if no moneys were deposited into the fund, the reason or
reasons for the lack of deposits. The total amounts of penalty
assessments shall be listed on the basis of each statute that
provides the authority for the penalty assessment, including Sections
76000, 76000.5, and 76104 of the Government Code, and Section 42007
of the Vehicle Code.
(2) The amount of penalty assessment funds collected under Section
76000.5 of the Government Code that are used for the purposes of
subdivision (e) of Section 1797.98a.
(3) The fund balance and the amount of moneys disbursed under the
program to physicians and surgeons, for hospitals, and for other
emergency medical services purposes, and the amount of money
disbursed for actual administrative costs. If funds were disbursed
for other emergency medical services, the report shall provide a
description of each of those services.
(4) The number of claims paid to physicians and surgeons, and the
percentage of claims paid, based on the uniform fee schedule, as
adopted by the county.
(5) The amount of moneys available to be disbursed to physicians
and surgeons, descriptions of the physician and surgeon claims
payment methodologies, the dollar amount of the total allowable
claims submitted, and the percentage at which those claims were
(6) A statement of the policies, procedures, and regulatory action
taken to implement and run the program under this chapter.
(7) The name of the physician and surgeon and hospital
administrator organization, or names of specific physicians and
surgeons and hospital administrators, contacted to review claims
(8) A description of the process used to solicit input from
physicians and surgeons and hospitals to review payment distribution
methodology as described in subdivision (a) of Section 1797.98e.
(9) An identification of the fee schedule used by the county
pursuant to subdivision (e) of Section 1797.98c.
(10) (A) A description of the methodology used to disburse moneys
to hospitals pursuant to subparagraph (B) of paragraph (5) of
subdivision (b) of Section 1797.98a.
(B) The amount of moneys available to be disbursed to hospitals.
(C) If moneys are disbursed to hospitals on a claims basis, the
dollar amount of the total allowable claims submitted and the
percentage at which those claims were reimbursed to hospitals.
(11) The name and contact information of the entity responsible
for each of the following:
(A) Collection of fines, forfeitures, and penalties.
(B) Distribution of penalty assessments into the Emergency Medical
(C) Distribution of moneys to physicians and surgeons.
(b) (1) Each county, upon request, shall make available to any
member of the public the report provided to the authority under
(2) Each county, upon request, shall make available to any member
of the public a listing of physicians and surgeons and hospitals that
have received reimbursement from the Emergency Medical Services Fund
and the amount of the reimbursement they have received. This listing
shall be compiled on a semiannual basis.
1797.98c. (a) Physicians and surgeons wishing to be reimbursed
shall submit their claims for emergency services provided to patients
who do not make any payment for services and for whom no responsible
third party makes any payment.
(b) If, after receiving payment from the fund, a physician and
surgeon is reimbursed by a patient or a responsible third party, the
physician and surgeon shall do one of the following:
(1) Notify the administering agency, and, after notification, the
administering agency shall reduce the physician and surgeon's future
payment of claims from the fund. In the event there is not a
subsequent submission of a claim for reimbursement within one year,
the physician and surgeon shall reimburse the fund in an amount equal
to the amount collected from the patient or third-party payer, but
not more than the amount of reimbursement received from the fund.
(2) Notify the administering agency of the payment and reimburse
the fund in an amount equal to the amount collected from the patient
or third-party payer, but not more than the amount of the
reimbursement received from the fund for that patient's care.
(c) Reimbursement of claims for emergency services provided to
patients by any physician and surgeon shall be limited to services
provided to a patient who does not have health insurance coverage for
emergency services and care, cannot afford to pay for those
services, and for whom payment will not be made through any private
coverage or by any program funded in whole or in part by the federal
government, with the exception of claims submitted for reimbursement
through Section 1011 of the federal Medicare Prescription Drug,
Improvement and Modernization Act of 2003, and where all of the
following conditions have been met:
(1) The physician and surgeon has inquired if there is a
responsible third-party source of payment.
(2) The physician and surgeon has billed for payment of services.
(3) Either of the following:
(A) At least three months have passed from the date the physician
and surgeon billed the patient or responsible third party, during
which time the physician and surgeon has made two attempts to obtain
reimbursement and has not received reimbursement for any portion of
the amount billed.
(B) The physician and surgeon has received actual notification
from the patient or responsible third party that no payment will be
made for the services rendered by the physician and surgeon.
(4) The physician and surgeon has stopped any current, and waives
any future, collection efforts to obtain reimbursement from the
patient, upon receipt of moneys from the fund.
(d) A listing of patient names shall accompany a physician and
surgeon's submission, and those names shall be given full
confidentiality protections by the administering agency.
(e) Notwithstanding any other restriction on reimbursement, a
county shall adopt a fee schedule and reimbursement methodology to
establish a uniform reasonable level of reimbursement from the county'
s emergency medical services fund for reimbursable services.
(f) For the purposes of submission and reimbursement of physician
and surgeon claims, the administering agency shall adopt and use the
current version of the Physicians' Current Procedural Terminology,
published by the American Medical Association, or a similar
procedural terminology reference.
(g) Each administering agency of a fund under this chapter shall
make all reasonable efforts to notify physicians and surgeons who
provide, or are likely to provide, emergency services in the county
as to the availability of the fund and the process by which to submit
a claim against the fund. The administering agency may satisfy this
requirement by sending materials that provide information about the
fund and the process to submit a claim against the fund to local
medical societies, hospitals, emergency rooms, or other
organizations, including materials that are prepared to be posted in
1797.98e. (a) It is the intent of the Legislature that a
simplified, cost-efficient system of administration of this chapter
be developed so that the maximum amount of funds may be utilized to
reimburse physicians and surgeons and for other emergency medical
services purposes. The administering agency shall select an
administering officer and shall establish procedures and time
schedules for the submission and processing of proposed reimbursement
requests submitted by physicians and surgeons. The schedule shall
provide for disbursements of moneys in the Emergency Medical Services
Fund on at least a quarterly basis to applicants who have submitted
accurate and complete data for payment. When the administering agency
determines that claims for payment for physician and surgeon
services are of sufficient numbers and amounts that, if paid, the
claims would exceed the total amount of funds available for payment,
the administering agency shall fairly prorate, without preference,
payments to each claimant at a level less than the maximum payment
level. Each administering agency may encumber sufficient funds during
one fiscal year to reimburse claimants for losses incurred during
that fiscal year for which claims will not be received until after
the fiscal year. The administering agency may, as necessary, request
records and documentation to support the amounts of reimbursement
requested by physicians and surgeons and the administering agency may
review and audit the records for accuracy. Reimbursements requested
and reimbursements made that are not supported by records may be
denied to, and recouped from, physicians and surgeons. Physicians and
surgeons found to submit requests for reimbursement that are
inaccurate or unsupported by records may be excluded from submitting
future requests for reimbursement. The administering officer shall
not give preferential treatment to any facility, physician and
surgeon, or category of physician and surgeon and shall not engage in
practices that constitute a conflict of interest by favoring a
facility or physician and surgeon with which the administering
officer has an operational or financial relationship. A hospital
administrator of a hospital owned or operated by a county of a
population of 250,000 or more as of January 1, 1991, or a person
under the direct supervision of that person, shall not be the
administering officer. The board of supervisors of a county or any
other county agency may serve as the administering officer. The
administering officer shall solicit input from physicians and
surgeons and hospitals to review payment distribution methodologies
to ensure fair and timely payments. This requirement may be fulfilled
through the establishment of an advisory committee with
representatives comprised of local physicians and surgeons and
hospital administrators. In order to reduce the county's
administrative burden, the administering officer may instead request
an existing board, commission, or local medical society, or
physicians and surgeons and hospital administrators, representative
of the local community, to provide input and make recommendations on
payment distribution methodologies.
(b) Each provider of health services that receives payment under
this chapter shall keep and maintain records of the services
rendered, the person to whom rendered, the date, and any additional
information the administering agency may, by regulation, require, for
a period of three years from the date the service was provided. The
administering agency shall not require any additional information
from a physician and surgeon providing emergency medical services
that is not available in the patient record maintained by the entity
listed in subdivision (f) where the emergency medical services are
provided, nor shall the administering agency require a physician and
surgeon to make eligibility determinations.
(c) During normal working hours, the administering agency may make
any inspection and examination of a hospital's or physician and
surgeon's books and records needed to carry out this chapter. A
provider who has knowingly submitted a false request for
reimbursement shall be guilty of civil fraud.
(d) Nothing in this chapter shall prevent a physician and surgeon
from utilizing an agent who furnishes billing and collection services
to the physician and surgeon to submit claims or receive payment for
(e) All payments from the fund pursuant to Section 1797.98c to
physicians and surgeons shall be limited to physicians and surgeons
who, in person, provide onsite services in a clinical setting,
including, but not limited to, radiology and pathology settings.
(f) All payments from the fund shall be limited to claims for care
rendered by physicians and surgeons to patients who are initially
medically screened, evaluated, treated, or stabilized in any of the
(1) A basic or comprehensive emergency department of a licensed
general acute care hospital.
(2) A site that was approved by a county prior to January 1, 1990,
as a paramedic receiving station for the treatment of emergency
(3) A standby emergency department that was in existence on
January 1, 1989, in a hospital specified in Section 124840.
(4) For the 1991-92 fiscal year and each fiscal year thereafter, a
facility which contracted prior to January 1, 1990, with the
National Park Service to provide emergency medical services.
(5) A standby emergency room in existence on January 1, 2007, in a
hospital located in Los Angeles County that meets all of the
(A) The requirements of subdivision (m) of Section 70413 and
Sections 70415 and 70417 of Title 22 of the California Code of
(B) Reported at least 18,000 emergency department patient
encounters to the Office of Statewide Health Planning and Development
in 2007 and continues to report at least 18,000 emergency department
patient encounters to the Office of Statewide Health Planning and
Development in each year thereafter.
(C) A hospital with a standby emergency department meeting the
requirements of this paragraph shall do both of the following:
(i) Annually provide the State Department of Public Health and the
local emergency medical services agency with certification that it
meets the requirements of subparagraph (A). The department shall
confirm the hospital's compliance with subparagraph (A).
(ii) Annually provide to the State Department of Public Health and
the local emergency medical services agency the emergency department
patient encounters it reports to the Office of Statewide Health
Planning and Development to establish that it meets the requirement
of subparagraph (B).
(g) Payments shall be made only for emergency medical services
provided on the calendar day on which emergency medical services are
first provided and on the immediately following two calendar days.
(h) Notwithstanding subdivision (g), if it is necessary to
transfer the patient to a second facility providing a higher level of
care for the treatment of the emergency condition, reimbursement
shall be available for services provided at the facility to which the
patient was transferred on the calendar day of transfer and on the
immediately following two calendar days.
(i) Payment shall be made for medical screening examinations
required by law to determine whether an emergency condition exists,
notwithstanding the determination after the examination that a
medical emergency does not exist. Payment shall not be denied solely
because a patient was not admitted to an acute care facility. Payment
shall be made for services to an inpatient only when the inpatient
has been admitted to a hospital from an entity specified in
(j) The administering agency shall compile a quarterly and yearend
summary of reimbursements paid to facilities and physicians and
surgeons. The summary shall include, but shall not be limited to, the
total number of claims submitted by physicians and surgeons in
aggregate from each facility and the amount paid to each physician
and surgeon. The administering agency shall provide copies of the
summary and forms and instructions relating to making claims for
reimbursement to the public, and may charge a fee not to exceed the
reasonable costs of duplication.
(k) Each county shall establish an equitable and efficient
mechanism for resolving disputes relating to claims for
reimbursements from the fund. The mechanism shall include a
requirement that disputes be submitted either to binding arbitration
conducted pursuant to arbitration procedures set forth in Chapter 3
(commencing with Section 1282) and Chapter 4 (commencing with Section
1285) of Part 3 of Title 9 of the Code of Civil Procedure, or to a
local medical society for resolution by neutral parties.
(l) Physicians and surgeons shall be eligible to receive payment
for patient care services provided by, or in conjunction with, a
properly credentialed nurse practitioner or physician's assistant for
care rendered under the direct supervision of a physician and
surgeon who is present in the facility where the patient is being
treated and who is available for immediate consultation. Payment
shall be limited to those claims that are substantiated by a medical
record and that have been reviewed and countersigned by the
supervising physician and surgeon in accordance with regulations
established for the supervision of nurse practitioners and physician
assistants in California.
1797.98f. Notwithstanding any other provision of this chapter, an
emergency physician and surgeon, or an emergency physician group,
with a gross billings arrangement with a hospital shall be entitled
to receive reimbursement from the Emergency Medical Services Fund for
services provided in that hospital, if all of the following
conditions are met:
(a) The services are provided in a basic or comprehensive general
acute care hospital emergency department, or in a standby emergency
department in a small and rural hospital as defined in Section
(b) The physician and surgeon is not an employee of the hospital.
(c) All provisions of Section 1797.98c are satisfied, except that
payment to the emergency physician and surgeon, or an emergency
physician group, by a hospital pursuant to a gross billings
arrangement shall not be interpreted to mean that payment for a
patient is made by a responsible third party.
(d) Reimbursement from the Emergency Medical Services Fund is
sought by the hospital or the hospital's designee, as the billing and
collection agent for the emergency physician and surgeon, or an
emergency physician group.
For purposes of this section, a "gross billings arrangement" is an
arrangement whereby a hospital serves as the billing and collection
agent for the emergency physician and surgeon, or an emergency
physician group, and pays the emergency physician and surgeon, or
emergency physician group, a percentage of the emergency physician
and surgeon's or group's gross billings for all patients.
1797.98g. The moneys contained in an Emergency Medical Services
Fund, other than moneys contained in a Physician Services Account
within the fund pursuant to Section 16952 of the Welfare and
Institutions Code, shall not be subject to Article 3.5 (commencing
with Section 16951) of Chapter 5 of Part 4.7 of Division 9 of the
Welfare and Institutions Code.