Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1163 - INPATIENT HOSPITAL SERVICES
Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES
PAYMENT FOR COST REIMBURSED HOSPITAL SERVICES
Section 1163.457 - Payment policies relating to out-of-State hospitals

Universal Citation: 55 PA Code § 1163.457

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

(a) Payment is made on a per diem basis for out-of-State hospital services if the services are covered by the MA Program and are provided under §§ 1163.451-1163.456 and 1163.458, including the limitations on inpatient days of care as set forth at § 1163.454 (relating to limitations on payment). Out-of-State hospitals shall meet the requirements for rehabilitation hospitals and distinct part units as set forth in § 1163.442 (relating to requirements for reimbursement under this subchapter).

(b) MA recipients are eligible for care provided by an out-of-State hospital only if one of the following occurs:

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

(2) Documentation is provided verifying one of the following:

(i) While temporarily out of this Commonwealth, the recipient required inpatient hospital services on an emergency basis. For the purposes of this chapter, emergency services are those inpatient hospital services that are necessary to prevent the death, or serious impairment of the health of the individual, and which, because of the threat to the life or health of the individual, necessitate the use of the most accessible hospital available that is equipped to furnish the services.

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

(c) The final payment for inpatient hospital services provided by an out-of-State cost related provider is the lowest of:

(1) The hospital's interim per diem rate, if one is established by the Medicaid agency in the hospital's state.

(2) The projected average interim per diem MA rate in this Commonwealth as developed by the Department for the fiscal year.

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

(4) The Medicare deductible or coinsurance, if applicable, under § 1163.456 (relating to third-party liability).

(d) At the discretion of the Department, out-of-State hospitals are subject to the Department's Concurrent Hospital Review (CHR) process in accordance with §§ 1163.471-1163.481 (relating to utilization control).

(e) In no case will the Department's payment rate be based on costs which are precluded from recognition by Title XVIII of the Social Security Act (42 U.S.C.A. §§ 1395-1395XX).

The provisions of this §1163.457 issued 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 § 1163.451 (relating to general payment policy).

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