Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1187 - NURSING FACILITY SERVICES
Subchapter G - RATE SETTING
Section 1187.94 - Peer grouping for price setting
Current through Register Vol. 54, No. 12, March 23, 2024
To set net operating prices under the case-mix payment system, the Department will classify the nursing facilities participating in the MA Program into 14 mutually exclusive groups as follows:
(1) Nursing facilities participating in the MA Program, except those nursing facilities that meet the definition of a special rehabilitation facility or hospital-based nursing facility, will be classified into 12 mutually exclusive groups based on MSA group classification and nursing facility certified bed complement.
| Peer Group # | MSA Group | # Beds |
| 1 | A | > or = 270 |
| 2 | A | 120-269 |
| 3 | A | 3-119 |
| 4 | B | > or = 270 |
| 5 | B | 120-269 |
| 6 | B | 3-119 |
| 7 | C | > or = 270 |
| 8 | C | 120-269 |
| 9 | C | 3-119 |
| 10 | non-MSA | > or = 270 |
| 11 | non-MSA | 120-269 |
| 12 | non-MSA | 3-119 |
(2) To set net operating prices under the case-mix payment system, the Department will classify the nursing facilities participating in the MA Program that meet the definition of a special rehabilitation facility into one peer group, peer group number 13. Regardless of the number of facilities in this peer group, the Department will not collapse the peer group of special rehabilitation facilities.
(3) To set net operating prices under the case-mix payment system, the Department will classify the nursing facilities participating in the MA Program that meet the definition of a hospital-based nursing facility into one peer group, peer group number 14. Regardless of the number of facilities in this peer group, the Department will not collapse the peer group of hospital-based nursing facilities.
(4) Once nursing facilities have been classified into peer groups for price setting, the nursing facility costs will remain in that peer group until prices are rebased, unless paragraph (5) applies.
(5) Paragraph (3) sunsets on the date that amendments are effective in Chapter 1163 (relating to inpatient hospital services), to allow for the inclusion of costs previously allocated to hospital-based nursing facilities. Subsequent to the effective date of the amendments to Chapter 1163, the Department will classify hospital-based nursing facilities in accordance with paragraph (1).
The provisions of this § 1187.94 amended under sections 201(2), 206(2), 403(b), 443.1 and 454 of the Public Welfare Code (62 P.S. §§ 201(2), 206(2), 403(b), 443.1 and 454).
This section cited in 55 Pa. Code § 1187.97 (relating to rates for new nursing facilities, nursing facilities with a change of ownership, reorganized nursing facilities and former prospective payment nursing facilities); and 55 Pa. Code § 1187.98 (relating to phase-out median determination).
