Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › PAYMENT FOR COST REIMBURSED HOSPITAL SERVICES › Section 1163.452 - Payment methods and rates

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Subject to the per diem cap on interim
					 and final payment specified in subsection (f), the Department's payment
					 policies relating to interim payments for cost reimbursed services are as
					 follows:
(1) The Department will pay an
					 interim per diem rate for inpatient hospital care provided by freestanding
					 licensed rehabilitation hospitals, general hospital distinct part medical
					 rehabilitation units and distinct part units of general hospitals that are
					 approved by the Department of Health to provide both detoxification and
					 rehabilitation services.
(2) The
					 amount of the Department's interim payment for services provided to each MA
					 recipient per admission will be the hospital's or the unit's interim per diem
					 rate as specified in this section multiplied by the number of compensable days
					 minus payment owed by the recipient, a legally responsible relative or a
					 third-party payor. Medicare Part B payments and other resources available to
					 the patient to meet the cost of inpatient hospital care also are deducted from
					 the interim payment.
(3) For Fiscal
					 Years 1991-92-1994-95, for existing freestanding rehabilitation hospitals and
					 medical rehabilitation units, the Department will determine the interim payment
					 rate as described in subparagraphs (i)-(iv). "Existing" refers to hospitals and
					 units which have submitted an MA cost report covering the 12-month cost
					 reporting period ending June 30, 1988.
(i) The
					 Department will use Fiscal Year 1987-88 as the base year for determining the
					 interim payment rate.
(ii) The
					 Department will use the following inflation factors in the interim rate
					 calculation:
(A) 5.6% from Fiscal Year 1987-88
					 to 1988-89.
(B) 5.0% from Fiscal
					 Year 1988-89 to 1989-90.
(C) 5.3%
					 from Fiscal Year 1989-90 to 1990-91.
(D) 5.2% from Fiscal Year 1990-91 to
					 1991-92.
(E) 4.6% from Fiscal Year
					 1991-92 to 1992-93.
(F) 4.3% from
					 Fiscal Year 1992-93 to 1993-94 to be applied as follows:
(I) Hospitals and units that qualified for a
					 disproportionate share payment other than a supplemental disproportionate share
					 payment for Fiscal Year 1992-93 will receive the 4.3% inflation factor
					 effective July 1, 1993.
(II)
					 Hospitals and units that did not qualify for a disproportionate share payment
					 other than a supplemental disproportionate share payment for Fiscal Year
					 1992-93 will receive the 4.3% inflation factor effective January 1,
					 1994.
(G) For Fiscal Year
					 1994-95, effective January 1, 1995, hospitals and units will receive an
					 inflation factor equal to the prospective payment system type hospital market
					 basket moving average inflation factor published by DRI/McGraw-Hill in the
					 fourth calendar quarter of 1993 for the second calendar quarter of
					 1995.
(iii) For
					 freestanding rehabilitation hospitals, the Department will determine the
					 interim rate as follows:
(A) The Department
					 will identify the audited MA per diem cost without ceiling adjustments for
					 Fiscal Year 1987-88 and later.
(B)
					 If the audited MA per diem cost for Fiscal Year 1987-88 or thereafter is not
					 available, the Department will use the reported MA per diem cost for Fiscal
					 Year 1987-88 in the calculation.
(C) The Department will inflate each per diem
					 cost identified under clause (A) or (B), as applicable, by the applicable
					 inflation factors in subparagraph (ii).
(D) The Department will establish the interim
					 per diem rate at the lowest of the rates calculated under clause (C).
(iv) For medical rehabilitation
					 units, the Department will determine the interim rate as follows:
(A) The Department will identify audited MA
					 per diem costs without ceiling adjustment for all fiscal years and MA reported
					 per diem costs for unaudited years.
(B) The Department will inflate each per diem
					 identified under clause (A) by the applicable inflation factors in subparagraph
					 (ii).
(C) The Department will
					 establish the interim rate at the lowest of the rates calculated under clause
					 (B).
(4) For
					 Fiscal Years 1991-92-1994-95, for new freestanding rehabilitation hospitals and
					 medical rehabilitation units, the Department will determine the interim payment
					 rate as described in subparagraphs (i)-(iii). "New" refers to facilities which
					 had not completed a 12-month cost report for the period ending June 30, 1988.
(i) For the first fiscal year of operation,
					 the Department will base the interim per diem rate on a projected budget
					 submitted to, and accepted by, the Department for the forthcoming fiscal
					 year.
(ii) For subsequent fiscal
					 years except as provided under subparagraph (iii), the Department will base the
					 interim per diem rate on the projected budget submitted to the Department for
					 the first fiscal year of operation, adjusted for inflation by the applicable
					 inflation factors specified in paragraph (3)(ii).
(iii) When a full fiscal year cost report is
					 submitted to the Department by a new hospital or unit, covered under this
					 paragraph, the interim per diem rate paid by the Department will be based on
					 the full fiscal year reported cost, adjusted for inflation by the applicable
					 inflation factors under paragraph (3)(ii).
(5) The MA Program recognizes only one
					 interim per diem rate for a hospital at one time.
(6) If the patient pay amount plus the
					 insurance payment for hospital care equals or exceeds the hospital's interim
					 per diem rate multiplied by the number of compensable days, the Department will
					 not make payment for the hospital care.
(7) For Fiscal Years 1993-94 to 1994-95, for
					 existing drug and alcohol units, the Department will determine the interim
					 payment rate as described in subparagraphs (i)-(iii). "Existing" refers to
					 hospitals and units which have submitted an MA cost report covering the
					 12-month cost reporting period ending June 30, 1990.
(i) The Department will identify the
					 following per diem rates for each facility:
(A) The Fiscal Year 1989-90 audited MA per
					 diem cost without ceiling adjustment.
(B) The latest MA final audited per diem
					 payment rate, subsequent to Fiscal Year 1989-90.
(C) The reported MA per diem costs for
					 unaudited Fiscal Years 1989-90 or later.
(ii) The Department will inflate each per
					 diem rate identified under subparagraph (i) to the forthcoming fiscal year by
					 the applicable inflation factors in paragraph (3)(ii).
(iii) The Department will establish the
					 interim rate at the lowest of the per diem rates calculated under subparagraph
					 (ii).
(8) For Fiscal
					 Years 1993-94 and 1994-95, for new drug and alcohol units, the Department will
					 determine the interim payment rate as described in subparagraphs (i)-(iii).
					 "New" refers to units which have not submitted an MA cost report covering the
					 12-month cost reporting period ending June 30, 1990.
(i) For the first fiscal year, the Department
					 will base the interim per diem rate on a projected budget submitted to, and
					 accepted by, the Department for the forthcoming fiscal year of
					 operation.
(ii) Except as provided
					 under subparagraph (iii), for subsequent fiscal years, the Department will base
					 the interim per diem rate on the projected budget submitted to the Department
					 for the first fiscal year of operation adjusted for inflation by the applicable
					 inflation factors specified in paragraph (3)(ii).
(iii) When a full fiscal year cost report is
					 submitted to the Department for a unit covered under this paragraph, the
					 interim per diem rate paid by the Department will be based on the full fiscal
					 year reported cost adjusted for inflation by the applicable factors under
					 paragraph (3)(ii).