Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1181 - NURSING FACILITY CARE
Subchapter B - MANUAL FOR ALLOWABLE COST REIMBURSEMENT FOR SKILLED NURSING AND INTERMEDIATE CARE FACILITIES
RATE DETERMINATIONS
Section 1181.222 - Determining a cost-related prospective rate for certain facilities

(a) As an alternative to having a current interim per diem rate that is subject to annual adjustment to allowable costs under this subchapter, an in-State facility with a monthly average of ten Medical Assistance patients or less may request that the Department determine a prospective per diem rate for the facility. County and hospital-based nursing facilities, special rehabilitation facilities and intermediate care facilities for the mentally retarded may not elect to have a prospective rate.

(b) The prospective rate shall be determined prior to the beginning of the Department's fiscal year and will be based on the facility's projected MA-11 cost report, historical financial statements, and other third-party payor audit reports. The established per diem rate will be effective July 1 and will remain in effect through June 30 of the current fiscal year.

(c) Payments made under a prospective rate may not be subject to annual cost reporting by the facility or to year-end adjustment by the Medical Assistance Program. However, facilities with a prospective rate which render more than 3,650 Medical Assistance patient days may not meet the conditions specified in subsection (a) and will be required to submit a year-end cost report and will be subject to an audit and year-end adjustment by the Department.

(d) The prospective rate, excluding depreciation and interest, may not exceed the applicable group ceiling for the facility. The prospective rate, including depreciation and interest, may not exceed the facility's private payor rate or the facility's Medicare interim rate.

(e) Facilities that request a prospective rate will not be eligible to receive an efficiency incentive.

(f) The costs of facilities with prospective rates will not be included in the costs used to establish ceilings.