Current through Register Vol. 54, No. 44, November 2, 2024
(a) Only the following types of providers are
eligible to be reimbursed under this subchapter:
(1) Medical rehabilitation hospitals that
fully comply with the Medicare regulations at
42 CFR
412.23(b) (relating to
excluded hospitals: classifications).
(2) Distinct part drug and alcohol
rehabilitation units of general hospitals that meet the requirements set forth
in subsection (b).
(3) Drug and
alcohol rehabilitation hospitals that meet the requirements set forth in
subsection (d).
(4) Medical
rehabilitation units of general hospitals that meet the requirements in
subsection (e).
(b) To be
considered a drug and alcohol rehabilitation unit for MA purposes, the unit
shall:
(1) Be part of a hospital enrolled in
the MA Program.
(2) Meet the
criteria of a distinct part unit as set forth in subsection (c).
(3) Be approved by the Department of Health,
Office of Drug and Alcohol Programs to provide drug and alcohol treatment and
rehabilitation.
(4) Be enrolled in
the MA Program as a distinct part drug and alcohol treatment/rehabilitation
unit.
(c) To qualify as a
distinct part unit for MA purposes, the unit shall:
(1) Have written admission criteria that are
applied uniformly to both MA patients and non-MA patients.
(2) Have admission and discharge records that
are separately identified from those of the hospital in which it is located and
are readily available.
(3) Have
policies specifying that necessary clinical information is transferred to the
unit when a patient of the hospital is transferred to the unit.
(4) Have utilization review standards
applicable for the type of care offered in the unit.
(5) Have beds physically separate from; that
is, not commingled with the hospital's other beds.
(6) Be treated as a separate cost center for
cost finding and apportionment purposes.
(7) Use an accounting system that properly
allocates costs.
(8) Maintain
adequate statistical data to support the basis of allocation.
(9) Report its costs in the hospital's cost
report covering the same fiscal period and using the same method of
apportionment as the hospital.
(d) For a drug and alcohol rehabilitation
hospital to be eligible for reimbursement under this subchapter, the hospital
shall:
(1) Be enrolled in the MA
Program.
(2) Be approved by the
Department of Health to provide inpatient drug and alcohol rehabilitation
services.
(3) Have treated, during
its most recent 12-month cost reporting period, an inpatient population of
which at least 75% required treatment for drug or alcohol abuse.
(e) To be considered a medical
rehabilitation unit for MA purposes, the unit shall:
(1) Be part of a hospital enrolled in the MA
Program.
(2) Meet the criteria of a
distinct part unit in subsection (c).
(3) Be enrolled or have applied for
enrollment in the Medicare Program as an excluded rehabilitation unit, unless
the unit is located in a non-Medicare participating children's hospital in
which case the unit shall be able to meet the Medicare rehabilitation unit
criteria, but will not be required to enroll in the Medicare Program.
(4) Be enrolled in the MA Program as a
distinct part medical rehabilitation unit.
(5) Be certified by the Commission on
Accreditation of Rehabilitation Facilities (CARF) or the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) and if certified by JCAHO,
also be certified under JCAHO rehabilitation standards.
The provisions of this §1163.442 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 §
1163.457 (relating to payment
policies relating to out-of-State
hospitals).
