Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1181 - NURSING FACILITY CARE
Subchapter A - NURSING FACILITY CARE
PAYMENT FOR NURSING FACILITY CARE
Section 1181.68 - Upper limits of payment

Universal Citation: 55 PA Code ยง 1181.68

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

(a) Maximum rate of payment. Except as provided in this section, the Department's maximum rate of payment to an enrolled facility will be the lower of the following:

(1) The facility's lowest charge to private pay patients for the same level of care.

(2) The facility's Medicare rate, which is either of the following:
(i) As compared to the facility's Medical Assistance interim per diem rate, the facility's Medicare interim per diem rate that is in effect on the date the facility's request for an interim per diem rate is postmarked or, if hand delivered, the date the request is received by the Department as documented by the Department's date stamp.

(ii) As compared to the facility's Medical Assistance final rate, the Medicare interim per diem rate in effect on the day of the facility's exit conference.

(3) The facility's Medical Assistance final per diem rate.

(b) Established ceilings. The established ceilings on net operating costs as published by notice in the Pennsylvania Bulletin are the upper limit, as applicable, on the net operating costs of county and general nursing facilities.

(c) Waiver of application.

(1) A facility participating in Medicare may obtain a waiver of the application of subsection (a)(2) when the following apply:
(i) The facility demonstrates to the Department that the applicable Medicare interim per diem rates are lower than the facility's Medical Assistance per diem rate.

(ii) The grant of the waiver will not cause the Department's estimated aggregate payment for long-term care facility services for the fiscal year involved to exceed the amount that the Department could reasonably estimate would be paid for these services under Medicare principles of reimbursement.

(2) A waiver will not be granted from the application of subsection (a)(2) unless the request for the waiver is received by the Department prior to the expiration of the time limit established by § 1101.84 (relating to provider right of appeal) for filing an appeal of the interim rate or audit report with respect to which the waiver is sought. Additionally, no request for a waiver received after the issuance of an audit report shall stay the collection of any overpayments resulting from the determinations of the audit report pending the adjudication of the waiver request.

(d) Upper limits for State-operated facilities. The upper limits of payment for State-operated intermediate care facilities for the mentally retarded are the full allowable costs as specified in the HIM-15.

(e) Upper limits for non-State operated facilities. The upper limits of payment for non-State operated intermediate care facilities for the mentally retarded are the total projected operating cost or if a waiver is granted under Subchapter C (Reserved) an approved budget level as specified in Subchapter C.

The provisions of this §1181.68 amended under sections 201 and 443.1(2) of the Public Welfare Code (62 P. S. §§ 201 and 443.1 (2)).

This section cited in 55 Pa. Code § 1181.1 (relating to policy); 55 Pa. Code § 1181.2 (relating to definitions); 55 Pa. Code § 1181.52 (relating to payment conditions); 55 Pa. Code § 1181.67 (relating to setting interim per diem rates); 55 Pa. Code §1181.68 (relating to upper limits of payment); 55 Pa. Code § 1181.69 (relating to annual adjustment); 55 Pa. Code § 1181.91 (relating to failure to file a cost report); 55 Pa. Code § 1181.211 (relating to cost reimbursement principles and method); 55 Pa. Code § 1181.221 (relating to determining the interim per diem rate); 55 Pa. Code § 1181.224 (relating to final per diem rate); and 55 Pa. Code § 1181.231 (relating to standards for general and selected costs).

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