Current through Register Vol. 54, No. 44, November 2, 2024
(a) Payment for cost reimbursed inpatient
hospital services is based on the allowable cost for the services in this
section.
(b) Unless clearly
specified to the contrary in this chapter, allowable costs for the MA Program
are computed under Medicare principles under the Social Security Act
(42 U.S.C.A. §§
301-1397f) and Federal regulations and
instructions.
(c) The Department
may not make payment for a service at a rate higher than the hospital's
customary charge. For the purpose of this chapter, the hospital's customary
charge is the usual charge to the general public for a specific
service.
(d) Costs not allowable
under the MA Program are:
(1) Costs exceeding
the limits established by the Department of Health and Human Services under
Medicare regulations set forth at
42 CFR
413.30 (relating to limitations on
reimbursable costs).
(2) Costs
related to the provision of a noncompensable service or item under §
1163.455 (relating to
noncompensable services and items).
(3) Costs related to depreciation and
interest for rehabilitation hospitals unless the hospital was one of the
following:
(i) Constructed prior to July 1,
1983.
(ii) Issued either a Section
1122 approval letter or letter of nonreviewability under 28 Pa. Code Chapter
301 (relating to limitation on Federal participation for capital expenditures)
or a certificate of need or letter of nonreviewability under 28 Pa. Code
Chapter 401 (relating to Certificate of Need Program) for the project by the
Department of Health no later than June 30, 1983. The Department will not
recognize depreciation or interest as an allowable cost if the facility does
not substantially implement the project as defined at 28 Pa. Code §401.5(j)(2)
(relating to Certificate of Need) within the effective period of the original
Section 1122 approval or the original certificate of need.
(4) Costs for legal services relating to
litigation against the Commonwealth, including administrative appeals, if the
litigation is finally decided in favor of the Commonwealth.
(5) Costs for relocating or housing
employes.
(6) Telephone, television
and radio services in patient rooms.
(7) Personal care and maternity
kits.
(8) Costs related to
depreciation and interest for providers reimbursed under this subchapter except
for medical rehabilitation units unless:
(i)
An application for a certificate of need for the new or additional beds has
been approved by the Department of Health, with an effective date of June 30,
1986, or earlier. In order for the facility to receive payment, the project
shall be substantially implemented as defined at 28 Pa. Code §401.5(j)(2)
within the effective period of the certificate of need.
(ii) A letter nonreviewability has been
issued on or before June 30, 1986.
(9) For medical rehabilitation units, costs
related to capital costs for new or additional beds unless one of the following
applies:
(i) The new or additional medical
rehabilitation beds were placed in service prior to July 1, 1988, and are
located in a medical rehabilitation unit which was enrolled in the MA Program
with an effective date no later than July 1, 1988. This includes beds which are
one of the following:
(A) Located in a unit
which has applied to the Medicare Program for exclusion prior to July 1, 1988
and completes its 12-month evaluation period prior to July 1, 1989.
(B) Placed in service during the 12-month
Medicare evaluation period ending prior to July 1, 1989.
(C) Covered in Medicare's initial letter of
exclusion related to those beds.
(ii) Either a Section 1122 approval or letter
of nonreviewability under 28 Pa. Code Chapter 301 or a certificate of need or
letter of nonreviewability under 28 Pa. Code Chapter 401 for the new or
additional medical rehabilitation unit beds was issued by the Department of
Health no later than June 30, 1988. In addition, the project shall have been
substantially implemented as defined at 28 Pa. Code §401.5(j)(2)
within the effective period of the original Section 1122 approval or the
original certificate of need, including one 6-month extension period.
(e) Allowable costs in
addition to those costs allowable under subsection (b) are:
(1) Costs for direct and indirect chaplaincy
expenses related to patient care, excluding training costs associated with the
chaplaincy program.
(2) Costs for
necessary diagnostic services provided to a recipient by another hospital. The
costs may be included by the hospital at which the recipient is an inpatient at
the time of the cost settlement.
(f) For providers reimbursed under this
subchapter, capital costs related to replacement beds will be recognized as
allowable if:
(1) The facility received a
certificate of need or letter of nonreviewability for the replacement
beds.
(2) The replacement beds are
physically replacing beds in the same facility and capital costs related to the
beds being replaced were recognized as allowable.
(3) The project is substantially implemented
as defined at 28 Pa. Code §401.5(j)(2)
within the effective period of the original Section 1122 approval or the
original certificate of need, including one 6-month extension
period.
The provisions of this §1163.453 amended under sections
201 and 443.1(1) of the Public Welfare Code (62 P. S. §§
201 and
443.1(1)).
This section cited in 55 Pa. Code §
1163.451 (relating to general
payment policy); 55 Pa. Code §
1163.452 (relating to payment
methods and rates); and 55 Pa. Code §
1163.457 (relating to payment
policies relating to out-of-State
hospitals).
