Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES
PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES
Section 1151.50 - Payment for out-of-State private psychiatric hospital services

Universal Citation: 55 PA Code ยง 1151.50

Current through Register Vol. 54, No. 44, November 2, 2024

(a) The Department will pay for compensable services furnished by out-of-State private psychiatric hospitals to an eligible Pennsylvania recipient, if one of the following exists:

(1) Residents in a given area generally receive their care in a particular out-of-State private psychiatric hospital; this would apply when the out-of-State private psychiatric hospital is closer to, or substantially more accessible from the residence of the recipient than, the nearest private psychiatric hospital within this Commonwealth which is adequately equipped and is available for the treatment of the individual's illness.

(2) Documentation is provided verifying one of the following:
(i) The recipient required inpatient psychiatric hospital services on an emergency basis, while temporarily out of this Commonwealth.

(ii) An out-of-State private psychiatric hospital is the only facility equipped to provide the type of care that the individual requires.

(b) The payment for inpatient hospital services provided by an out-of-State private psychiatric hospital is the lowest of:

(1) The payment the hospital would receive for the admission under the hospital's home state payment system.

(2) A Statewide days-weighted average per diem rate, times the number of compensable days of inpatient psychiatric care rendered.

(3) The amount of the charges billed by the hospital.

(4) The Medicare deductible or coinsurance, if applicable.

(c) If a recipient is admitted to an out-of-State private psychiatric hospital and discharged within the same calendar day, the Department will pay one half of the per diem rate established under subsection (b)(2). If Medicare is involved, the entire allowable Medicare deductible and coinsurance will be paid.

(d) The Department will pay the amount established in accordance with subsection (b) minus payments from the recipient, a legally responsible relative or a third-party resource for the services a recipient receives while in the hospital.

(e) The Department's payment rate will not be based on costs which are precluded from recognition by the Social Security Act (42 U.S.C.A. §§ 301-1399).

The provisions of this §1151.50 amended under sections 201 and 443.1 of the Public Welfare Code (62 P. S. §§ 201 and 443.1).

This section cited in 55 Pa. Code § 1151.42 (relating to payment methods and rates).

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