(e) The department or the Attorney General may bring or intervene in a civil action to collect fines imposed by the department for violations of this article and to recover the state’s enforcement costs, including attorney’s fees, and for appropriate equitable relief.

(f) Fines or other moneys recovered under this section shall first be used to offset any expenses of administering this article, and any moneys beyond those necessary to offset those expenses shall be deposited in the fund.

(a) (1) “Charity care” means the unreimbursed cost to a nonprofit hospital of all of the following:

(A) Providing, funding, or otherwise financially supporting any of the following community benefits, provided that providing, funding, or financial support of the benefits is demonstrated to reduce community health care costs:

(i) Vaccination programs and services for needy individuals.

(ii) Chronic illness prevention programs and services.

(iii) Nursing and caregiver training.

(iv) Home-based health care programs for needy individuals.

(v) Exercise or nutrition programs for needy individuals.

(vi) Community-based mental health outreach and assessment programs for needy individuals.

(B) Providing, funding, or otherwise financially supporting health care services or items on an inpatient or outpatient basis to needy patients.

(C) Providing, funding, or otherwise financially supporting health care services or items provided to needy patients through other outpatient clinics, hospitals, or health care organizations.

(D) Any unreimbursed difference between the reimbursement a nonprofit hospital receives from the Medi-Cal program for providing a health care service or item pursuant to the Medi-Cal program, and the reimbursement the nonprofit hospital would have received from the Medicare program for providing the identical health care service or item had it been eligible for reimbursement from the Medicare program.

(2) For purposes of this definition, charity care does not include the cost to a nonprofit hospital of paying any taxes or other governmental assessments, uncollected fees, or accounts written off as bad debt.

(3) For purposes of this definition, the “cost to a nonprofit hospital” shall be calculated by applying the cost-to-charge ratios, according to the nonprofit hospital’s most recently filed Medicare cost report, to billed charges.

(d) “Fund” means the Nonprofit Hospital Charity Care Penalty Fund established pursuant to Section 127447.25.

(e) (1) “Integrated nonprofit health system” means a nonprofit hospital and an affiliated health care service plan that are owned, operated, or substantially controlled by the same person or persons or other legal entity or entities, including, but not limited to, by a shared corporate parent.

(2) (A) For purposes of this subdivision, “affiliated health care service plan” means a health care service plan licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2) that in a nonprofit hospital’s most recently concluded fiscal year was the primary payer for 5 percent or more of all annual inpatient discharges from the nonprofit hospital on the date of the discharge, excluding inpatient discharges when the primary payer was Medicare, Medi-Cal, or a county indigent program pursuant to Part 5 (commencing with Section 17000) of Division 9 the Welfare and Institutions Code, when the patient was a self-pay patient, as defined in subdivision (f) of Section 127400, or when the care was provided as unreimbursed charity care.

(B) For purposes of this subdivision, “primary payer” means the person or other legal entity, other than the patient, that is or was legally required or responsible to make payment with respect to an item or service provided by a nonprofit hospital to a patient, or any portion thereof, before any other person or other legal entity, other than the patient.

(f) “Needy individual” and “needy patient” shall have the same meaning as the term “financially qualified patient” is defined in Section 127400. If a nonprofit hospital chooses to grant eligibility for its discount payment policy or charity care policies to patients with incomes over 350 percent of the federal poverty level, as permitted by subparagraph (A) of paragraph (1) of subdivision (a) of Section 127405, patients eligible under those policies shall also be deemed “needy individuals” and “needy patients.”

(g) “Net patient revenue” shall be calculated in accordance with generally accepted accounting principles for hospitals, and shall be consistent with information provided by a nonprofit hospital in a compliant Hospital Annual Disclosure Report filed with the Office of Statewide Health Planning and Development pursuant to Section 128735.

(h) “Nonprofit hospital” means any health facility licensed pursuant to subdivision (a) of Section 1250 that is owned or operated or substantially controlled by one or more nonprofit corporations or associations, as defined in Division 2 (commencing with Section 5000) of Title 1 of the Corporations Code, in which no part of the net earnings inures, or may lawfully inure, to the benefit of any private shareholder or individual. “Nonprofit hospital” does not include children’s hospitals, as defined in Section 16996 of the Welfare and Institutions Code, or public hospitals, as defined in paragraph (25) of subdivision (a) of Section 14105.98 of the Welfare and Institutions Code.

(i) “Operating margin” shall be calculated in accordance with generally accepted accounting principles for hospitals, and shall be based on a nonprofit hospital’s operating earnings.

(j) “Unreimbursed costs” means either or in combination the costs a nonprofit hospital incurs for providing individuals inpatient and outpatient services or items for which the nonprofit hospital does not receive reimbursement from any source, and for which the nonprofit hospital has no expectation at the time the services or items are provided that any third-party payer will pay in part or in whole. “Unreimbursed costs” does not include payer discounts or contractual adjustments in reimbursements to third-party payers or costs for which the nonprofit hospital receives any partial payment for the related service, including, but not limited to, third-party insurance payments, Medicare payments, payments from TRICARE or the Civilian Health and Medical Program of the Uniformed Services, state reimbursements for education, payments from pharmaceutical companies to pursue research, grant funds for research, and disproportionate share payments.