Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1187 - NURSING FACILITY SERVICES
Subchapter K - EXCEPTIONAL PAYMENT FOR NURSING FACILITY SERVICES
Section 1187.155 - Exceptional DME grants-payment conditions and limitations
Universal Citation: 55 PA Code ยง 1187.155
Current through Register Vol. 53, No. 52, December 30, 2023
(a) Authorization of exceptional payments. Exceptional payments authorized by an exceptional DME grant will be paid as follows:
(1)
Periodic
payments. Unless the grant authorizes a lump sum payment under
paragraph (2), the grant will authorize exceptional payments to the nursing
facility on a specified periodic basis. Authorization for periodic payments
will continue during the term of the nursing facility's grant except during a
period of suspension as specified in §
1187.157 (relating to termination
or suspension of exceptional DME grants and recovery of exceptional
payments).
(2)
Lump sum
payment. The grant may authorize a lump sum exceptional payment to the
nursing facility if the Department determines that a lump sum payment is in the
best interest of the MA Program. The amount of this payment will be based upon
and limited by the necessary, reasonable and prudent costs incurred by the
nursing facility to purchase exceptional DME and related items.
(b) Maximum allowable payment. The maximum allowable exceptional payment authorized by an exceptional DME grant is limited to the lowest of the following:
(1) The lower of the nursing facility's costs
to acquire the exceptional DME and related services and items; or, in the event
the nursing facility is acquiring the exceptional DME or related services and
items from a related party as defined in §
1187.2 (relating to definitions),
the related party's cost to furnish the exceptional DME and related services
and items to the nursing facility.
(2) The applicable MA outpatient fee schedule
amount, if any.
(3) Eighty percent
of the amount, if any, that would be approved by Medicare if the DME or service
or item were a Medicare Part B covered service or item.
(c) Additional conditions and limitations. Exceptional payments made by the Department to a nursing facility under a grant are subject to the following:
(1) The conditions and limitations set forth
in Chapter 1101 (relating to general provisions), including §§
1101.64 and
1101.68 (relating to third-party
medical resources; and invoicing for services).
(2) The terms of the nursing facility's
grant.
This section cited in 55 Pa. Code § 1187.154 (relating to exceptional DME grants-general conditions and limitations).
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