reglab/statecodes huggingface dataset:
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 1187.151 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise:
Exceptional DME grant
or
grant
-Authorization permitting exceptional payments under specified
					 terms to a nursing facility, in addition to the nursing facility's case-mix per
					 diem rate, for nursing facility services that are provided to a specified
					 resident and that involve the use of certain exceptional DME. The amount of the
					 additional payment authorized by a grant is based upon the necessary,
					 reasonable and prudent cost of the exceptional DME and the related services and
					 items specified in the grant.
Resident
-An MA eligible resident of a
					 nursing facility enrolled in the MA Program who, in a request for an
					 exceptional DME grant, is identified as needing exceptional
					 DME.
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 1187.152 - Additional reimbursement of nursing facility services related to exceptional DME

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The necessary,
				  reasonable and prudent costs incurred by a nursing facility related to the
				  purchase or rental, and the use of DME in providing nursing facility services
				  to residents are allowable costs and included in the calculation of the
				  case-mix per diem rates subject to this chapter. Any costs incurred in excess
				  of the costs identified in a grant are not allowable costs under this
				  chapter.
(b) When a nursing
				  facility provides nursing facility services involving exceptional DME to an MA
				  eligible resident, the nursing facility may, in addition to the submission of
				  invoices for payment based upon the nursing facility's case-mix per diem rate,
				  seek authorization for additional payment by requesting a grant from the
				  Department in accordance with §
										1187.153(a)
				  (relating to exceptional DME grants-process).
(c) The Department will issue a grant to a
				  nursing facility if the Department determines that all of the following
				  conditions are met:
(1) The nursing facility's
				  request for the grant complies with all applicable Department
				  instructions.
(2) The specified DME
				  is medically necessary as defined in §
											1101.21 (relating to
				  definitions).
(3) The DME specified
				  in the nursing facility's request is exceptional DME as defined in §
				  1187.2 (relating to definitions).
(4) The nursing facility's physical plant,
				  equipment, staff, program and policies are sufficient to insure the safe,
				  appropriate and effective use of the exceptional DME.
(5) The nursing facility certifies to the
				  Department in writing, on a form designated by the Department, that it has read
				  and understands the terms of the grant.
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 1187.153 - Exceptional DME grants-process

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Requests for exceptional DME
				  grants.
(1) A nursing facility shall
				  request a grant in writing on forms designated by the Department and completed
				  in accordance with all applicable Department instructions. The request shall be
				  accompanied by the necessary supporting documentation specified in the
				  Department's instructions and submitted to the Department within 30 days from
				  the date on which the nursing facility purchases or rents the DME for which the
				  nursing facility is requesting the grant.
(2) The nursing facility shall provide copies
				  of the nursing facility's request to the resident and the resident's authorized
				  representative, if any, when the nursing facility submits the request to the
				  Department.
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 1187.154 - Exceptional DME grants-general conditions and limitations

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Scope and effect of an
				  exceptional DME grant.
(1) A grant
				  authorizes exceptional payments to a nursing facility in addition to the
				  nursing facility's case-mix per diem payment rate for nursing facility services
				  provided to the resident. The amount of the exceptional payments authorized by
				  the grant is deemed to be the necessary, reasonable and prudent cost of the
				  exceptional DME and the related services and items identified in the nursing
				  facility's grant.
(2) A grant does
				  not authorize exceptional payments for nursing facility services that are
				  provided to MA residents other than the resident, nor does it limit costs that
				  are, or must be, incurred by a nursing facility to provide services to any of
				  the nursing facility's residents (including the resident) in accordance with
				  applicable law and regulations.
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

Current through Register Vol. 54, No. 28, July 13, 2024
(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.
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 1187.156 - Exceptional DME notification and reporting requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Status reports.
A
				  nursing facility receiving a grant shall submit periodic status reports to the
				  Department as specified in the nursing facility's grant.
(b)
Notices.
A nursing
				  facility receiving a grant shall notify the Department in writing within 5 days
				  of any of the following occurrences:
(1) The
				  resident dies.
(2) The resident
				  ceases to be MA eligible.
(3) The
				  resident is transferred or discharged from the nursing facility, whether or not
				  there is intent to return.
(4) The
				  nursing facility determines, or is advised by the resident's attending
				  physician, that the exceptional DME is no longer medically necessary.
(5) The resident notifies the nursing
				  facility in writing that he exercises his right to refuse use of the
				  exceptional DME.
(6) The nursing
				  facility ceases to use the exceptional DME or make that DME available to the
				  resident in the course of providing nursing facility services to the
				  resident.
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

Current through Register Vol. 54, No. 28, July 13, 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.
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 1187.158 - Appeals

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Appeals.
An appeal may be filed by the resident or the
				  resident's authorized representative, by the nursing facility, or by both, from
				  the Department's decision to deny, terminate or suspend a grant, subject to the
				  following:
(1) If the Department denies a
				  grant because the DME is not exceptional DME, an appeal of the denial may be
				  filed solely on the basis that the DME is exceptional DME as defined in §
											1187.2 (relating to
				  definitions).
(2) If the Department
				  automatically terminates a grant under §
											1187.157(a)(1) 
				  (relating to termination or suspension of exceptional DME grants and recovery
				  of exceptional payments), an appeal of the termination may be filed solely on
				  the basis that none of the conditions specified in §
				  1187.157(a)(1)(i)-(vi) has occurred.
(3) If a resident appeals the denial,
				  termination or suspension of a grant, Chapter 275 (relating to appeal and fair
				  hearing and administrative disqualification hearings) applies.
(4) If a nursing facility appeals the denial,
				  termination or suspension of a grant, §
											1187.141(b), (d) and
				  (e) (relating to nursing facility's right to
				  appeal and to a hearing) apply.
(5)
				  An appeal from the Department's decision denying a request for a grant shall be
				  received in the Department's Bureau of Hearings and Appeals within 30 days of
				  the date of the Department's written notice.
(6) If the resident or the nursing facility
				  timely appeals the Department's decision to deny, suspend or terminate a grant,
				  the Department's decision is not final until the Department issues a final
				  adjudication on the appeal.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter L - NURSING FACILITY PARTICIPATION REQUIREMENTS AND REVIEW PROCESS › GENERAL PROVISIONS › Section 1187.161 - Applicability

Current through Register Vol. 54, No. 28, July 13, 2024
This subchapter applies to applicants as defined in
						§
											1187.162 (relating to
						definitions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter L - NURSING FACILITY PARTICIPATION REQUIREMENTS AND REVIEW PROCESS › BED REQUESTS › Section 1187.171 - Enrollment in the MA Program and expansion of existing providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) As a condition
					 of participation in the MA Program, an applicant shall submit a bed request to
					 the Department and obtain the Department's advance written approval before
					 increasing the number of MA-certified beds in a subject facility that is a
					 provider, or before applying for the enrollment of a subject facility as a new
					 provider.
(b) As a condition of
					 participation in the MA Program, an applicant shall submit its bed request to
					 the Department prior to beginning a proposed project that involves the
					 construction of a new nursing facility or an expansion of an existing nursing
					 facility.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter L - NURSING FACILITY PARTICIPATION REQUIREMENTS AND REVIEW PROCESS › BED REQUESTS › Section 1187.172 - Contents and submission of bed requests

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Required contents.
An
					 applicant's bed request must contain the following information:
(1)
Ownership information.
(i) The applicant shall provide the name and
					 address of each person who is any of the following:
(A) The applicant and a description of the
					 applicant's involvement in the proposed project.
(B) The legal entity of the subject
					 facility.
(C) An owner of the
					 subject facility.
(D) A related
					 party involved in the proposed project and a description of the related party's
					 involvement with the project.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter L - NURSING FACILITY PARTICIPATION REQUIREMENTS AND REVIEW PROCESS › BED REQUESTS › Section 1187.173 - Review and public process relating to bed requests

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Groups.
Except as
					 specified in subsection (b), the Department will consider bed requests in two
					 groups, as follows:
(1) Group one will consist
					 of bed requests received January 1 through June 30. Subject to subsection (c),
					 the Department will issue decisions on group one by the following December 31.
					 If the Department receives public comments under subsection (d), the Department
					 may extend the review process an additional 90 days.
(2) Group two will consist of bed requests
					 received from July 1 through December 31. Subject to subsection (c), the
					 Department will issue decisions on group two by the following June 30. If the
					 Department receives public comments under subsection (d), the Department may
					 extend the review process an additional 90 days.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter L - NURSING FACILITY PARTICIPATION REQUIREMENTS AND REVIEW PROCESS › BED REQUESTS › Section 1187.174 - Information and data relevant to bed requests

Current through Register Vol. 54, No. 28, July 13, 2024
In reviewing an applicant's bed request, the Department
						will consider the information provided by the applicant and any public comments
						received on the request. In addition, the Department may consider information
						contained in the Department's books and records or obtained from persons other
						than the applicant that is relevant to the applicant's bed request, including
						the following:
(1) Data relating to
					 the overall occupancy rates of MA nursing facilities in the primary service
					 area identified in the bed request, the county in which the subject facility is
					 or will be located and, in the case of a bed transfer request, the county in
					 which the surrendering provider is located.
(2) Data relating to the MA day-one admission
					 rates and the MA occupancy rates of MA nursing facilities in the primary
					 service area identified in the bed request, the county in which the subject
					 facility is or will be located and, in the case of a bed transfer request, the
					 county in which the surrendering provider is located.
(i) The Department will determine the MA
					 day-one admission rate using the most recent MA day-one report completed and
					 posted to the Department's web site prior to January 1 for group one and July 1
					 for group two as provided under §
												1187.173(a)
					 (relating to review and public process relating to bed requests).
(ii) The Department will determine the MA
					 day-one admission rate using the most recent MA day-one report completed and
					 posted to the Department's web site prior to the application date of the bed
					 transfer request.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter L - NURSING FACILITY PARTICIPATION REQUIREMENTS AND REVIEW PROCESS › BED REQUESTS › Section 1187.175 - Criteria for the approval of bed transfer requests

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Upon consideration of the information
					 specified in §
											1187.174 (relating to information
					 and data relevant to bed requests), the Department may approve a bed transfer
					 request only if the following are satisfied:
(1) The bed transfer request contains the
					 information required under §
												1187.172(a)
					 (relating to contents and submission of bed requests).
(2) The receiving provider agrees to achieve
					 and maintain an MA day-one admission rate that is equal to or greater than the
					 surrendering provider's MA day-one admission rate or another MA day-one
					 admission rate as may be agreed to by the Department.
(3) The change in the bed complements of the
					 receiving and surrendering providers will maintain or improve access to
					 medically necessary nursing facility services for MA recipients.
(4) Neither provider will receive an increase
					 in reimbursement as a result of a change in its peer group if the bed transfer
					 request is approved.
(5) If the
					 proposed bed transfer will result in a change in peer group assignments under
					 this chapter for the surrendering or receiving provider, the change will not
					 have a negative effect on the MA Program, on MA recipients or on other
					 facilities which are members of the affected peer group.
(6) Approval of the bed transfer request will
					 not result in increased costs to the MA Program.
(7) None of the circumstances specified in
					 § 1187.172(a)(4) applies.
(8)
					 Both the surrendering provider and the receiving provider agree that the new or
					 additional beds at the receiving provider shall be licensed, MA-certified and
					 available for immediate occupancy before the surrendering provider decertifies
					 and closes a bed.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter L - NURSING FACILITY PARTICIPATION REQUIREMENTS AND REVIEW PROCESS › BED REQUESTS › Section 1187.176 - Criteria for the approval of bed requests other than bed transfer requests

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department
					 may approve a bed request, other than a bed transfer request, only if the
					 following are satisfied:
(1) The bed request
					 contains the information required under §
												1187.172(a)
					 (relating to contents and submission of bed requests).
(2) The additional MA-certified nursing
					 facility beds are needed in the primary service area or the county in which the
					 subject facility is located to maintain or improve MA recipients' access to
					 medically necessary nursing facility services based on any of the following:
(i) The existing MA-certified bed capacity in
					 the primary service area or the county in which the subject facility is or will
					 be located is insufficient to assure that MA recipients have access to
					 medically necessary nursing facility services.
(ii) Systemic barriers prevent MA recipients
					 from accessing the existing MA-certified bed capacity in the primary service
					 area or the county in which the subject facility is or will be
					 located.
(iii) The applicant is
					 proposing to admit and serve MA recipients who require specialized medical
					 services in the subject facility and MA recipients do not have access to the
					 specialized medical services in the existing MA-certified bed capacity in the
					 primary service area or the county in which the subject facility is or will be
					 located.
(3) The legal
					 entity agrees, in a form acceptable to the Department, to the following:
(i) The subject facility will admit and serve
					 MA day-one recipients.
(ii) The
					 subject facility will maintain an MA occupancy rate that equals or exceeds the
					 average MA occupancy rate of MA nursing facilities in the county in which the
					 subject facility is or will be located or, in the case of a subject facility
					 that is proposing to offer specialized medical services, the MA occupancy rate
					 as may be agreed to by the Department.
(iii) The construction and operation of the
					 new or additional beds will be economically and financially feasible without
					 the receipt of MA fixed property capital component payments, and it is not
					 entitled to MA capital component payments for fixed property related to the new
					 or additional beds.
(4)
					 None of the circumstances specified in § 1187.172(a)(4) applies.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter L - NURSING FACILITY PARTICIPATION REQUIREMENTS AND REVIEW PROCESS › BED REQUESTS › Section 1187.177 - Time lines for completion of approved projects

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the Department approves a bed request,
					 the approved project shall be completed in sufficient time so that the beds may
					 be licensed, certified and available for occupancy within 3 years from the date
					 of the Department's decision, or by another date as may be agreed to by the
					 Department.
(b) The provider will
					 make documentation available upon the Department's written request at any time
					 and for so long as the nursing facility is an MA provider, as may be necessary
					 to demonstrate compliance with the terms of the approved exception
					 request.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter L - NURSING FACILITY PARTICIPATION REQUIREMENTS AND REVIEW PROCESS › BED REQUESTS › Appendix A - Resource Utilization Group Index Scores for Case-Mix Adjustment Nursing Facility Reimbursement System

Current through Register Vol. 54, No. 28, July 13, 2024
The following chart is a listing by group of the RUG-III
						index scores that the Department will use to set each nursing facility's 5.01
						resident care rate for the quarter beginning July 1, 2010, and ending September
						30, 2010, as set forth in §
											1187.96 (relating to price- and
						rate-setting computations). The table has one column that is the RUG-III
						nursing CMI scores and a second column that is the RUG-III PA normalized index
						scores.
RUG-III VERSION 5.01 INDEX SCORES
RUG-III Group
RUG-III Nursing CMI
RUG-III PA
								Normalized Index
RLA
1.14
1.13
RLB
1.36
1.35
RMA
1.25
1.24
RMB
1.38
1.37
RMC
2.09
2.07
RHA
1.06
1.05
RHB
1.31
1.30
RHC
1.50
1.49
RHD
1.93
1.91
RVA
0.82
0.81
RVB
1.18
1.17
RVC
1.79
1.77
SE1
1.78
1.76
SE2
2.65
2.62
SE3
3.97
3.93
SSA
1.28
1.27
SSB
1.47
1.46
SSC
1.61
1.59
CA1
0.67
0.66
CA2
0.76
0.75
CB1
0.94
0.93
CB2
1.08
1.07
CC1
1.16
1.15
CC2
1.19
1.18
CD1
1.37
1.36
CD2
1.46
1.45
IA1
0.49
0.49
IA2
0.60
0.59
IB1
0.80
0.79
IB2
0.88
0.87
BA1
0.41
0.41
BA2
0.58
0.57
BB1
0.78
0.77
BB2
0.87
0.86
PA1
0.39
0.39
PA2
0.52
0.51
PB1
0.66
0.65
PB2
0.68
0.67
PC1
0.77
0.76
PC2
0.86
0.85
PD1
1.00
0.99
PD2
1.01
1.00
PE1
1.13
1.12
PE2
1.19
1.18
The following chart is a listing by group of the RUG-III
						index scores that the Department will use to set each nursing facility's 5.12
						resident care rate for rate years 2010-2011, 2011-2012 and 2012-2013 and each
						nursing facility's resident care rate beginning with rate year 2013-2014, and
						thereafter, as set forth in § 1187.96. The table has one column that is
						the RUG-III nursing CMI scores and a second column that is the RUG-III PA
						normalized index scores.
RUG-III VERSION 5.12 INDEX SCORES
RUG-III 44 Grouper
RUG-III Nursing Only CMIs
RUG-III PA
								Normalized Index
RLA
0.87
0.82
RLB
1.22
1.15
RMA
1.06
1.00
RMB
1.20
1.13
RMC
1.48
1.39
RHA
0.96
0.90
RHB
1.16
1.09
RHC
1.30
1.22
RVA
0.89
0.84
RVB
1.14
1.07
RVC
1.24
1.16
RUA
0.85
0.80
RUB
1.05
0.99
RUC
1.43
1.34
SE1
1.28
1.20
SE2
1.52
1.43
SE3
1.86
1.75
SSA
1.11
1.04
SSB
1.15
1.08
SSC
1.24
1.16
CA1
0.82
0.77
CA2
0.91
0.85
CB1
0.92
0.86
CB2
1.00
0.94
CC1
1.08
1.01
CC2
1.23
1.15
IA1
0.58
0.54
IA2
0.63
0.59
IB1
0.73
0.69
IB2
0.76
0.71
BA1
0.52
0.49
BA2
0.61
0.57
BB1
0.71
0.67
BB2
0.75
0.70
PA1
0.51
0.48
PA2
0.53
0.50
PB1
0.55
0.52
PB2
0.56
0.53
PC1
0.70
0.66
PC2
0.72
0.68
PD1
0.73
0.69
PD2
0.78
0.73
PE1
0.84
0.79
PE2
0.86
0.81
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter A - GENERAL PROVISIONS › Section 1189.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This chapter
				  applies to county nursing facilities.
(b) This chapter sets forth conditions of
				  participation for county nursing facilities, identifies the costs incurred by
				  county nursing facilities to provide nursing facility services that will be
				  recognized as allowable MA Program expenditures and specifies the methodology
				  by which rates will be set and payments made to county nursing facilities for
				  services provided to MA residents.
(c) Payment for nursing facility services
				  provided by county nursing facilities is made subject to this chapter and
				  Chapter 1101 (relating to general provisions).
(d) Extensions of time will be as follows:
(1) The time limits established by this
				  chapter for the filing of a cost report, resident assessment data and picture
				  date reporting, or other document or submission to the Department cannot be
				  extended, except as provided in this section.
(2) Extensions of time in addition to the
				  time otherwise prescribed by this chapter may be permitted only upon a showing
				  of fraud, breakdown in the Department's administrative process or an
				  intervening natural disaster making timely compliance impossible or
				  unsafe.
(3) This subsection
				  supersedes 1 Pa. Code §
											31.15 (relating to extensions of
				  time).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter A - GENERAL PROVISIONS › Section 1189.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except for
				  those terms defined in subsection (b), the defined words and terms set forth in
				  §
										1187.2 (relating to definitions),
				  have the same meanings when used in this chapter, unless the context clearly
				  indicates otherwise.
(b) The
				  following words and terms, when used in this chapter, have the following
				  meanings, unless the context clearly indicates otherwise:
Allowable MA Program Expenditure
-A cost
					 incurred by a county nursing facility to provide nursing facility services to
					 MA residents that is allowable under this chapter and that is reported and
					 certified by the county nursing facility in a form and manner specified by the
					 Department.
MA Cost Report
-The package of
					 certifications, schedules and instructions designated by the Department which
					 county nursing facilities shall use to record and report the costs that they
					 incur to provide nursing facility services during a calendar year.
New county nursing facility
-
(i) One of the following:
(A) A newly constructed, licensed and
				  certified county nursing facility.
(B) An existing nursing facility that through
				  a change of ownership, is controlled by the county institution district or by
				  county government if no county institution district exists.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter A - GENERAL PROVISIONS › Section 1189.3 - Compliance with regulations governing noncounty nursing facilities

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Unless a
				  specific provision of this chapter provides to the contrary, the following
				  subchapters of Chapter 1187 (relating to nursing facility services) are
				  applicable to county nursing facilities:
(1)
				  Subchapter B (relating to scope of benefits).
(2) Subchapter C (relating to nursing
				  facility participation).
(3)
				  Subchapter D (relating to data requirements for nursing facility applicants and
				  residents), except for §
											1187.33(b)
				  (relating to resident data and picture data reporting requirements).
(4) Subchapter I (relating to enforcement of
				  compliance for nursing facilities with deficiencies).
(5) Subchapter K (relating to exceptional
				  payment for nursing facility services).
(6) Subchapter L (relating to nursing
				  facility participation requirements and review process).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter B - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1189.51 - Allowable costs

Current through Register Vol. 54, No. 28, July 13, 2024
A cost incurred by a county nursing facility is an
					 allowable cost if the cost was incurred in the course of providing nursing
					 facility services and one of the following applies:
(1) The cost is allowable pursuant to the
				  Medicare Provider Reimbursement Manual (CMS Pub. 15-1).
(2) The cost is not allowable under the CMS
				  Pub. 15-1but is allowable as a net operating cost under Chapter 1187 (relating
				  to nursing facility services).
(3)
				  The cost is identified as an allowable county nursing facility cost in the
				  Commonwealth's approved State Plan.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter B - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1189.52 - Allocating cost centers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  county nursing facility shall allocate costs in accordance with the allocation
				  bases and methodology established by the Department as contained in this
				  chapter and the MA cost report. If the nursing facility has its own more
				  accurate method of allocation basis, it may be used only if the nursing
				  facility receives written approval from the Department prior to the first day
				  of the applicable cost report year.
(b) The absence of documentation to support
				  allocation or the use of other methods which do not properly reflect use of the
				  Department's required allocation bases or approved changes in bases shall
				  result in disallowances being imposed for each affected line item.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter B - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1189.53 - Changes in bed complement during a cost reporting period

Current through Register Vol. 54, No. 28, July 13, 2024
(a) When the county nursing facility's bed
				  complement changes during a cost reporting period, the allocation bases are
				  subject to verification at audit.
(b) The county nursing facility shall keep
				  adequate documentation of the costs related to bed complement changes during a
				  cost reporting period. The county nursing facility shall submit the
				  supplemental schedules as may be required by the Department to identify the
				  costs being allocated by the required statistical methods for each period of
				  change.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter B - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1189.54 - Costs of related parties

Current through Register Vol. 54, No. 28, July 13, 2024
Costs applicable to services, movable property and
					 supplies, furnished to the county nursing facility by organizations related to
					 the county nursing facility by common ownership or control shall be included as
					 an allowable cost of the county nursing facility at the cost to the related
					 organization. This cost may not exceed the price of comparable services,
					 movable property or supplies that could be purchased
					 elsewhere.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter B - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1189.55 - Prudent buyer concept

Current through Register Vol. 54, No. 28, July 13, 2024
The purchase or rental by a county nursing facility of
					 services, movable property and supplies, including pharmaceuticals, may not
					 exceed the cost that a prudent buyer would pay in the open market to obtain
					 these items, as described in the CMS Pub. 15-1.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter C - COST REPORTING AND AUDIT REQUIREMENTS › Section 1189.71 - Cost reporting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  county nursing facility shall submit an acceptable MA cost report to the
				  Department within 120 days following the close of each calendar year in a form
				  and manner specified by the Department. Requests for an extension to file an
				  annual cost report will not be granted except as provided under §
										1189.1 (relating to
				  policy).
(b) An acceptable MA cost
				  report is one that meets the following requirements:
(1) Applicable items are fully completed in
				  accordance with the instructions provided for the cost report including the
				  necessary original signatures on the required number of copies.
(2) Computations carried out on the cost
				  report are accurate and consistent with other related computations.
(3) The treatment of cost conforms to the
				  applicable requirements of this chapter.
(4) Required documentation is
				  included.
(5) The cost report is
				  filed with the Department within the time limits specified.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter C - COST REPORTING AND AUDIT REQUIREMENTS › Section 1189.72 - Cost reporting for Medicare Part B type services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) County nursing facilities shall utilize
				  Medicare as a primary payer resource when appropriate, under §
										1189.102 (relating to utilizing
				  Medicare as a resource).
(b) If
				  Medicare is the primary payer resource, the county nursing facility shall
				  exclude from allowable costs operating costs incurred in or income derived from
				  the provision of Medicare Part B coverable services to nursing facility
				  residents. The county nursing facility shall attach to the MA cost report a
				  copy of the cost report the nursing facility submits to Medicare for the Part B
				  services and, when available, submit a copy of the Medicare final audit,
				  including audit adjustments.
(c) If
				  there is a discrepancy between the costs on the Medicare cost report or, if
				  available, the Medicare audit report, and the adjustments made by the county
				  nursing facility on the MA cost report to exclude Medicare Part B costs, the
				  Department will make the necessary adjustments to conform the county nursing
				  facility's MA cost report to the Medicare report.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter C - COST REPORTING AND AUDIT REQUIREMENTS › Section 1189.73 - Accountability requirements related to resident personal fund management

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A county
				  nursing facility may not require residents to deposit their personal funds with
				  the county nursing facility. A county nursing facility shall hold, safeguard
				  and account for a resident's personal funds upon written authorization from the
				  resident in accordance with this section and other applicable provisions in
				  State and Federal law.
(b) A
				  resident's personal funds may not be commingled with county nursing facility
				  funds or with the funds of a person other than another resident.
(c) A resident's personal funds in excess of
				  $50 shall be maintained in an interest bearing account, and interest earned
				  shall be credited to that account.
(d) A resident's personal funds that do not
				  exceed $50 may be maintained in a noninterest bearing account, interest bearing
				  account or petty cash fund.
(e)
				  Statements regarding a resident's financial record shall be available upon
				  request to the resident or to the resident's legal representative.
(f) The county nursing facility shall notify
				  each resident that receives MA benefits when the amount in the resident's
				  personal fund account reaches $200 less than the SSI resource limit for one
				  person.
(g) Within 60 days of the
				  death of a resident, the county nursing facility shall convey the resident's
				  funds and a final accounting of those funds to the individual or probate
				  jurisdiction administering the resident's estate.
(h) The county nursing facility may not
				  impose a charge against the personal funds of a resident for an item or service
				  for which payment is made under MA or Medicare.
(i) The county nursing facility shall
				  maintain records relating to its management of residents' personal funds for a
				  minimum of 4 years. These records shall be available to Federal and State
				  representatives upon request.
(j)
				  The county nursing facility shall purchase a surety bond or otherwise provide
				  assurances of the security of personal funds of the residents deposited with
				  the county nursing facility.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter C - COST REPORTING AND AUDIT REQUIREMENTS › Section 1189.74 - Auditing requirements related to resident personal fund management

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department
				  will periodically audit residents' personal fund accounts.
(b) If discrepancies are found at audit, the
				  county nursing facility shall make restitution to the residents for funds
				  improperly handled, accounted for or disbursed. The Department may sanction the
				  nursing facility in accordance with Chapter 1187, Subchapter I (relating to
				  enforcement of compliance for nursing facility services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter C - COST REPORTING AND AUDIT REQUIREMENTS › Section 1189.75 - Auditing requirements related to MA cost report

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will conduct an audit of
				  each acceptable MA cost report with an end date of December 31, 2005, and
				  thereafter to determine the county nursing facility's allowable MA Program
				  expenditures for the calendar year.
(b) To determine the county nursing
				  facility's audited allowable MA Program expenditures for a calendar year, the
				  Department will audit the county nursing facility's MA cost report for
				  compliance with:
(1) This chapter.
(2) Chapter 1101 (relating to general
				  provisions).
(3) The schedules and
				  instructions included in the MA cost report.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter D - RATE SETTING › Section 1189.91 - Per diem rates for county nursing facilities

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For the rate year 2006-2007, the per diem
				  rate paid to a county nursing facility for a rate year will be the facility's
				  April 1, 2006, case-mix per diem rate as calculated under Chapter 1187,
				  Subchapter G (relating to rate setting) multiplied by a budget adjustment
				  factor determined in accordance with subsection (d).
(b) For each rate year beginning on or after
				  July 1, 2007, the per diem rate paid to a county nursing facility for a rate
				  year will be the facility's prior rate year per diem rate multiplied by a
				  budget adjustment factor determined in accordance with subsection
				  (d).
(c) The Department, at its
				  discretion, may revise the per diem rates for county nursing facilities by
				  calculating updated case-mix per diem rates in accordance with Chapter 1187,
				  Subchapter G or under an alternative method specified in the Commonwealth's
				  approved State Plan.
(d) The budget
				  adjustment factor for the rate year will be determined in accordance with the
				  formula in the Commonwealth's approved State Plan.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter D - RATE SETTING › Section 1189.92 - Per diem rates for new county nursing facilities

Current through Register Vol. 54, No. 28, July 13, 2024
The per diem rate for a new county nursing facility will be
					 the Statewide average of all other county nursing facilities' per diem rates
					 for the same rate year established in accordance with §
										1189.91 (relating to per diem
					 rates for county nursing facilities).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter E - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1189.101 - General payment policy for county nursing facilities

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payment for nursing facility services
				  provided by a county nursing facility will be made subject to the following
				  conditions and limitations:
(1) This chapter
				  and Chapter 1101 (relating to general provisions).
(2) Applicable State statutes.
(3) Applicable Federal statutes and
				  regulations and the Commonwealth's approved State Plan.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter E - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1189.102 - Utilizing Medicare as a resource

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An eligible resident who is a Medicare
				  beneficiary, is receiving care in a Medicare certified county nursing facility
				  and is authorized by the Medicare Program to receive county nursing facility
				  services shall utilize available Medicare benefits before payment will be made
				  by the MA Program. If the Medicare payment is less than the county nursing
				  facility's MA per diem rate for nursing facility services, the Department will
				  participate in payment of the coinsurance charge to the extent that the total
				  of the Medicare payment and the Department's and other coinsurance payments do
				  not exceed the MA per diem rate for the county nursing facility. The Department
				  will not pay more than the maximum coinsurance amount.
(b) If a resident has Medicare Part B
				  coverage, the county nursing facility shall use available Medicare Part B
				  resources for Medicare Part B services before payment is made by the MA
				  Program.
(c) The county nursing
				  facility may not seek or accept payment from a source other than Medicare for
				  any portion of the Medicare coinsurance amount that is not paid by the
				  Department on behalf of an eligible resident because of the limit of the county
				  nursing facility's MA per diem rate.
(d) The Department will recognize the
				  Medicare payment as payment in full for each day that a Medicare payment is
				  made during the Medicare-only benefit period.
(e) The cost of providing Medicare Part B
				  type services to MA residents not eligible for Medicare Part B services which
				  are otherwise allowable costs under this part are reported in accordance with
				  §
										1189.72 (relating to cost
				  reporting for Medicare Part B type services).
This section cited in 55 Pa. Code §
												1189.72 (relating to cost
						reporting for Medicare Part B type
						services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter E - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1189.104 - Limitations on payment during strike or disaster situations requiring resident evacuation

Current through Register Vol. 54, No. 28, July 13, 2024
Payment may continue to be made to a county nursing
					 facility that has temporarily transferred residents, as the result or threat of
					 a strike or disaster situation, to the closest medical institution able to meet
					 the residents' needs, if the institution receiving the residents is licensed
					 and certified to provide the required services. If the county nursing facility
					 transferring the residents can demonstrate that there is no certified nursing
					 facility available for the safe and orderly transfer of the residents, the
					 payments may be made so long as the institution receiving the residents is
					 certifiable and licensed to provide the services required. The resident
					 assessment submissions for the transferring nursing facility residents shall be
					 maintained under the transferring county nursing facility provider number as
					 long as the transferring county nursing facility is receiving payment for those
					 residents. If the nursing facility to which the residents are transferred has a
					 different per diem rate, the transferring county nursing facility shall be
					 reimbursed at the lower rate. The per diem rate established on the date of
					 transfer will not be adjusted during the period that the residents are
					 temporarily transferred. The county nursing facility shall immediately notify
					 the Department in writing of an impending strike or a disaster situation and
					 follow with a listing of MA residents and the nursing facility to which they
					 will be or were transferred.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1189 - COUNTY NURSING FACILITY SERVICES › Subchapter E - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1189.105 - Incentive payments

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Disproportionate share incentive payment.
(1) A disproportionate share incentive
				  payment will be made based on MA paid days of care times the per diem incentive
				  to facilities meeting the following criteria for a 12-month facility cost
				  reporting period:
(i) The county nursing
				  facility shall have an annual overall occupancy rate of at least 90% of the
				  total available bed days.
(ii) The
				  county nursing facility shall have an MA occupancy rate of at least 80%. The MA
				  occupancy rate is calculated by dividing the MA days of care paid by the
				  Department by the total actual days of care.