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 1187.157 - Termination or suspension of exceptional DME grants and recovery of exceptional payments
Universal Citation: 55 PA Code ยง 1187.157
Current through Register Vol. 54, No. 12, March 23, 2024
(a) Termination or suspension of an exceptional DME grant.
(1)
Automatic termination.
Any of the following conditions shall cause termination of a nursing facility's
grant without further notice or action by the Department:
(i) The resident dies.
(ii) The resident ceases to be MA
eligible.
(iii) The resident is
transferred or discharged from the nursing facility with no intent to
return.
(iv) The resident's
attending physician notifies the nursing facility that the exceptional DME is
no longer medically necessary.
(v)
The resident notifies the Department or the nursing facility in writing that he
exercises his right to refuse use of the exceptional DME.
(vi) The nursing facility is no longer
enrolled in the MA Program.
(2)
Termination upon notice.
The Department may terminate a grant upon written notice to the nursing
facility if any one or more of the conditions in subparagraphs (i)-(vi) occur.
The Department will simultaneously provide a copy of the written notice to the
resident and the resident's authorized representative, if any.
(i) The Department determines that the
exceptional DME is no longer medically necessary.
(ii) The resident is temporarily discharged
or transferred to a hospital or other health care provider.
(iii) There is a change in state or federal
law or regulations governing payments to MA providers of nursing facility
services.
(iv) Exceptional DME
payments are no longer authorized under the Commonwealth's approved Medicaid
State Plan.
(v) The nursing
facility has violated the terms of the grant.
(vi) The nursing facility changes
ownership.
(3)
Suspension of grant payments. The Department may suspend
payments under a grant upon written notice to the nursing facility if one or
more of the conditions in subparagraphs (i) and (ii) occur. The Department will
simultaneously provide a copy of the written notice to the resident and the
resident's authorized representative, if any.
(i) The resident is temporarily discharged or
transferred to a hospital or other health care provider.
(ii) The resident is absent from the nursing
facility because of therapeutic leave.
(4)
Termination or suspension
date. A termination under paragraph (1) is effective as of the date on
which the condition giving rise to the automatic termination first arises. A
termination under paragraph (2) is effective on the date specified in the
Department's written notice to the nursing facility. A suspension under
paragraph (3) is effective on the date and for the period specified in the
Department's written notice to the nursing facility.
(5)
Effect of termination.
(i) Termination of an exceptional DME grant,
whether automatic or by written notice, terminates the nursing facility's
authorization to obtain exceptional payments for nursing facility services
provided to the resident after the termination date.
(ii) Termination of the grant ends the
nursing facility's grant and the nursing facility's duty and obligation to
comply with the terms of the grant or the requirements of this subchapter,
except as may be otherwise specified in the grant or in this
subchapter.
(iii) Termination of a
grant does not relieve the nursing facility of any of the nursing facility's
duties and obligations relating to services provided to the resident or any
other resident of the nursing facility.
(6)
Effect of suspension.
(i) Suspension of payments under a grant
terminates the nursing facility's authorization to obtain exceptional payments
for nursing facility services provided to the resident for the period specified
in the notice of suspension.
(ii)
Suspension of payments under a grant does not terminate the nursing facility's
grant or the nursing facility's duty and obligation to comply with the terms of
the grant or the requirements of this subchapter.
(iii) Suspension of payments under a grant
does not relieve the nursing facility of any of the nursing facility's duties
and obligations relating to services provided to the resident or any other
resident of the nursing facility.
(b) Recovery of exceptional DME grant payments.
(1) If a grant is
terminated or if payments under a grant are suspended, the Department will
recover any exceptional payments made to the nursing facility for services
provided after the termination date or during the period of
suspension.
(2) If the nursing
facility violates this subchapter or the terms of its grant, the Department may
recover exceptional payments made to the nursing facility in addition to or
instead of terminating the nursing facility's grant.
(c) Rights and remedies. The rights and remedies available to the Department under this section are in addition to any rights, remedies and sanctions otherwise available to the Department under law and regulation.
This section cited in 55 Pa. Code § 1187.154 (relating to exceptional DME grants-general conditions and limitations); 55 Pa. Code § 1187.155 (relating to exceptional DME grants-payment conditions and limitations); and 55 Pa. Code § 1187.158 (relating to appeals).
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