reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter E - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1187.60 - Prudent buyer concept

Current through Register Vol. 54, No. 28, July 13, 2024
The purchase or rental by a 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
Medicare Provider Reimbursement Manual
(CMS Pub. 15-1).
This section cited in 55 Pa. Code §
												1187.61 (relating to movable
						property cost policies).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter F - COST REPORTING AND AUDIT REQUIREMENTS › Section 1187.71 - Cost reporting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  nursing facility shall report costs to the MA Program by filing an acceptable
				  MA-11 with the Department. Costs in the MA-11 are:
(1)
Resident care costs.
(i) Nursing.
(ii) Director of nursing.
(iii) Related clerical staff.
(iv) Practitioners.
(v) Medical director.
(vi) Utilization and medical
				  review.
(vii) Social
				  services.
(viii) Resident
				  activities.
(ix) Volunteer
				  services.
(x) Pharmacy-prescription
				  drugs.
(xi) Over-the-counter
				  drugs.
(xii) Medical
				  supplies.
(xiii) Laboratory and
				  X-rays.
(xiv) Physical,
				  occupational and speech therapy.
(xv) Oxygen.
(xvi) Beauty and barber services.
(xvii) Minor movable property.
(xviii) Other supplies and other resident
				  care costs.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter F - COST REPORTING AND AUDIT REQUIREMENTS › Section 1187.72 - Cost reporting for Medicare Part B type services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Nursing facilities shall utilize Medicare
				  as a primary payor resource when appropriate, under §
										1187.102 (relating to utilizing
				  Medicare as a resource).
(b) If
				  Medicare is the primary payor resource, the 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 nursing facility shall attach to the MA-11 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 nursing facility on the
				  MA-11 to exclude Medicare Part B costs, the Department will make the necessary
				  adjustments to conform to the Medicare report.
This section cited in 55 Pa. Code §
												1187.102 (relating to utilizing
						Medicare as a resource).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter F - COST REPORTING AND AUDIT REQUIREMENTS › Section 1187.73 - Annual reporting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  fiscal year, for purposes of the MA Program for nursing facilities, shall be
				  either January 1 through December 31 or July 1 through June 30 as designated by
				  the nursing facility. The fiscal year designated by the nursing facility may
				  not be changed except in the event of the sale of the nursing facility to a new
				  owner.
(b) A nursing facility shall
				  submit an acceptable MA-11 to the Department within 120 days following the June
				  30 or December 31 close of each fiscal year as designated by the nursing
				  facility. An acceptable MA-11 is one that meets the requirements in §
										1187.71(e)
				  (relating to cost reporting). No request for an extension to file an annual
				  cost report will be granted except in accordance with §
										1187.1(d)(2)
				  (relating to policy). The report shall be prepared using the accrual basis of
				  accounting and shall cover a fiscal period of 12 consecutive months.
This section cited in 55 Pa. Code §
												1187.22 (relating to ongoing
						responsibilities of nursing facilities); and 55 Pa. Code §
												1187.71 (relating to cost
						reporting).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter F - COST REPORTING AND AUDIT REQUIREMENTS › Section 1187.75 - Final reporting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  nursing facility that enters into a termination agreement or an agreement of
				  sale, or is otherwise undergoing a change of ownership or is withdrawing or
				  being terminated as a nursing facility, shall file an acceptable final MA-11
				  cost report as well as outstanding annual cost reports with the Department
				  within 90 days of the effective date of the termination, transfer, withdrawal
				  or change of ownership and shall provide financial and statistical records to
				  the Department for auditing. An acceptable MA-11 is one that meets the
				  requirements in §
										1187.71(e)
				  (relating to cost reporting).
(b) A
				  nursing facility may request an extension to file its final cost reports as
				  required by subsection (a) of up to 30 days from the date the cost reports are
				  due if the nursing facility's request is received by the Department prior to
				  the expiration of the 60th day of the 90-day period specified in subsection
				  (a); the reasons for the extension request and the amount of time requested are
				  specified; and the requirements of §
										1187.1(d)
				  (relating to policy) are met. Further extensions will not be granted. The
				  denial of a request for an extension is an adverse action appealable in
				  accordance with §
										1187.141 (relating to nursing
				  facility's right to appeal and to a hearing). Failure to appeal a denial within
				  the time period provided precludes any appeal or challenge relating to the
				  denial in another proceeding.
This section cited in 55 Pa. Code §
												1187.22 (relating to ongoing
						responsibilities of nursing facilities); and 55 Pa. Code §
												1187.71 (relating to cost
						reporting).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter F - COST REPORTING AND AUDIT REQUIREMENTS › Section 1187.76 - Reporting for new nursing facilities

Current through Register Vol. 54, No. 28, July 13, 2024
Nursing facilities beginning operations during a fiscal
					 period shall prepare an MA-11 from the date of certification for participation
					 to the end of the nursing facility's fiscal year.
This section cited in 55 Pa. Code §
												1187.71 (relating to cost
						reporting).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter F - COST REPORTING AND AUDIT REQUIREMENTS › Section 1187.77 - Auditing requirements related to cost report

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will audit acceptable cost
				  reports filed to verify nursing facility compliance with:
(1) This chapter.
(2) Chapter 1101 (relating to general
				  provisions).
(3) The schedules and
				  instructions attached to the MA-11.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter F - COST REPORTING AND AUDIT REQUIREMENTS › Section 1187.78 - Accountability requirements related to resident personal fund management

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A nursing
				  facility may not require residents to deposit their personal funds with the
				  nursing facility. A 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 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 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 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 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 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 nursing facility shall purchase a surety bond or otherwise provide
				  assurances of the security of personal funds of the residents deposited with
				  the nursing facility.
This section cited in 55 Pa. Code §
												1187.22 (relating to ongoing
						responsibilities of nursing
						facilities).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter F - COST REPORTING AND AUDIT REQUIREMENTS › Section 1187.79 - 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
				  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 Subchapter I (relating to enforcement of compliance
				  for nursing facilities with deficiencies).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter F - COST REPORTING AND AUDIT REQUIREMENTS › Section 1187.80 - Failure to file an MA-11

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Failure by the nursing facility to file a timely MA-11, other than a final
				  MA-11 and annual MA-11s due along with a final MA-11, may result in termination
				  of the nursing facility's provider agreement and will result in adjustment of
				  the nursing facility's per diem rate as provided in this subsection. An MA-11
				  is considered timely filed if the MA-11 is received within 120 days following
				  the June 30 or December 31 close of each fiscal year as designated by the
				  nursing facility, or if an extension has been granted, within the additional
				  time allowed by the extension. The Department may also seek injunctive relief
				  to require proper filing, as the Department may deem is in the best interest of
				  the efficient and economic administration of the MA program.
(1)
Cost report periods prior to
				  January 1, 2001.
(i) If an MA-11 is
				  not timely filed, the nursing facility's per diem rate will be adjusted
				  downward by 5% beginning the first day of the next month and will remain in
				  effect until the date that an acceptable MA-11 is filed with the
				  Department.
(ii) If an MA-11 is
				  timely filed and is unacceptable, the Department will return the MA-11 to the
				  nursing facility for correction. If an acceptable MA-11 is not filed by the end
				  of the 30th day from the date of the letter returning the unacceptable MA-11
				  from the Department, the nursing facility's per diem rate will be adjusted
				  downward by 5% beginning the first day of the next month and will remain in
				  effect until the date that an acceptable MA-11 is filed with the
				  Department.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter G - RATE SETTING › Section 1187.91 - Database

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will set rates for the case-mix payment
					 system based on the following data:
(1)
Net operating costs
.
(i) The net operating prices will be
				  established based on the following:
(A)
				  Audited nursing facility costs for the 3 most recent years available in the NIS
				  database adjusted for inflation. This database includes audited MA-11 cost
				  reports that are issued by the Department on or before March 31 of each July 1
				  price setting period.
(B) If a
				  nursing facility that has participated in the MA Program for 3 or more
				  consecutive years has fewer than three audited cost reports in the NIS database
				  that are issued by the Department on or before March 31 of each July 1 price
				  setting period, the Department will use reported costs, as adjusted to conform
				  to Department regulations, for those years not audited within 15 months of the
				  date of acceptance, until audits have been completed and are available in the
				  NIS database for price setting.
(C)
				  If a nursing facility, that has not participated in the MA Program for 3 or
				  more consecutive years, has fewer than three audited cost reports in the NIS
				  database that are issued by the Department on or before March 31 of each July 1
				  price setting period, the Department will use all available audited cost
				  reports in the NIS database.
(D)
				  For net operating prices effective on or after July 1, 2001, the Department
				  will revise the audited costs specified in clauses (A)-(C) by disregarding
				  audit adjustments disallowing or reclassifying to capital costs, the costs of
				  minor movable property (as defined in §
												1187.2 (relating to definitions),
				  effective on July 1, 2001) or linens reported as net operating costs on cost
				  reports for fiscal periods beginning prior to January 1, 2001. The Department
				  will not adjust the audited statistics when revising the nursing facility
				  audited resident care, other resident care and administrative allowable costs
				  to disregard the adjustments relating to minor movable property and linen
				  costs. After revising the audited costs to disregard these adjustments, the
				  Department will recalculate the maximum allowable administrative cost, and will
				  disallow administrative costs in excess of the 12% limitation as specified in
				  §
												1187.56(1)(i)
				  (relating to selected administrative cost policies).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter G - RATE SETTING › Section 1187.92 - Resident classification system

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will use the RUG-III to
				  adjust payment for resident care services based on the classification of
				  nursing facility residents into 44 groups.
(b) Each resident shall be included in the
				  RUG-III category with the highest numeric CMI for which the resident
				  qualifies.
(c) The Department will
				  use the RUG-III nursing CMI scores normalized across all this Commonwealth's
				  nursing facility residents.
(d) The
				  Department will announce, by notice submitted for recommended publication in
				  the
Pennsylvania Bulletin
and suggested codification in the
Pennsylvania Code
as Appendix A, the RUG-III nursing CMI
				  scores and the PA normalized RUG-III index scores.
(e) The PA normalized RUG-III index scores
				  will remain in effect until a subsequent notice is published in the
Pennsylvania Bulletin
.
(f) Resident data for RUG-III classification
				  purposes shall be reported by each nursing facility under §
										1187.33 (relating to resident data
				  reporting requirements).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter G - RATE SETTING › Section 1187.93 - CMI calculations

Current through Register Vol. 54, No. 28, July 13, 2024
The Pennsylvania Case-Mix Payment System uses the following
					 CMI calculations:
(1) An individual
				  resident's CMI shall be assigned to the resident according to the RUG-III
				  classification system.
(2) The
				  facility MA CMI shall be the arithmetic mean of the individual CMIs for MA
				  residents identified on the nursing facility's CMI report for the picture date.
				  The facility MA CMI shall be used for rate determination under §
										1187.96(a)(5)
				  (relating to price and rate-setting computations.) If there are no MA residents
				  identified on the CMI report for a picture date, the Statewide average MA CMI
				  shall be substituted for rate determination under §
				  1187.96(a)(5).
(3) The total
				  facility CMI is the arithmetic mean of the individual resident CMIs for all
				  residents, regardless of payor, identified on the nursing facility's CMI report
				  for the picture date. The total facility CMI for the February 1 picture date
				  shall be used for price and rate setting computations as specified in §
				  1187.96(a)(1)(i).
(4) Picture dates
				  that are used for rate setting beginning July 1, 2010, and thereafter will be
				  calculated based on the RUG versions and CMIs set forth in Appendix
				  A.
The provisions of this §
												1187.93 amended under sections
						201(2), 206(2), 403(b) and 443.1(5) of the Public Welfare Code (62 P.S.
						§§
													201(2),
						206(2), 403(b) and
						443.1(5)).
This section cited in 55 Pa. Code §
												1187.96 (relating to price- and
						rate-setting computations).
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. 28, July 13, 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.
(i) Effective for rate setting periods
				  commencing July 1, 2004, the Department will use the MSA group classification
				  published by the Federal Office of Management and Budget in the OMB Bulletin
				  No. 99-04 (relating to revised definitions of Metropolitan Areas and guidance
				  on uses of Metropolitan Area definitions), to classify each nursing facility
				  into one of three MSA groups or one non-MSA group.
(ii) The Department will use the bed
				  complement of the nursing facility on the final day of the reporting period of
				  the most recent audited MA-11 used in the NIS database to classify nursing
				  facilities into one of three bed complement groups.
(iii) The Department will classify each
				  nursing facility into one of the following 12 peer groups:
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
(iv) A peer group with fewer than seven
				  nursing facilities will be collapsed into the adjacent peer group with the same
				  bed size. If the peer group with fewer than seven nursing facilities is a peer
				  group in MSA B or MSA C and there is a choice of two peer groups with which to
				  merge, the peer group with fewer than seven nursing facilities will be
				  collapsed into the peer group with the larger population MSA group.
(v) For rate years 2009-2010, 2010-2011 and
				  2011-2012, county nursing facilities will be included when determining the
				  number of nursing facilities in a peer group in accordance with subparagraph
				  (iv).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter G - RATE SETTING › Section 1187.95 - General principles for rate and price setting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Prices will be set prospectively on an
				  annual basis during the second quarter of each calendar year and be in effect
				  for the subsequent July 1 through June 30 period.
(1) Peer group prices will be established for
				  resident care costs, other resident related costs and administrative
				  costs.
(2) If a peer group has an
				  even number of nursing facilities, the median peer group price determined will
				  be the arithmetic mean of the costs of the two nursing facilities holding the
				  middle position in the peer group array.
(3) If a nursing facility changes bed size or
				  MSA group, the nursing facility will be reassigned from the peer group used for
				  price setting to peer group based on bed certification and MSA group as of
				  April 1, for rate setting.
(4) The
				  Department will announce, by notice submitted for recommended publication in
				  the
Pennsylvania Bulletin
and suggested codification in the
Pennsylvania Code
as Appendix B, the peer group prices for
				  each peer group.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter G - RATE SETTING › Section 1187.96 - Price- and rate-setting computations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Using the NIS database in accordance with
				  this subsection and §
										1187.91 (relating to database),
				  the Department will set prices for the resident care cost category.
(1) The Department will use each nursing
				  facility's cost reports in the NIS database to make the following computations:
(i) The total resident care cost for each
				  cost report will be divided by the total facility CMI from the available
				  February 1 picture date closest to the midpoint of the cost report period to
				  obtain case-mix neutral total resident care cost for the cost report
				  year.
(ii) The case-mix neutral
				  total resident care cost for each cost report will be divided by the total
				  actual resident days for the cost report year to obtain the case-mix neutral
				  resident care cost per diem for the cost report year.
(iii) The Department will calculate the
				  3-year arithmetic mean of the case-mix neutral resident care cost per diem for
				  each nursing facility to obtain the average case-mix neutral resident care cost
				  per diem of each nursing facility.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter G - RATE SETTING › Section 1187.97 - Rates for new nursing facilities, nursing facilities with a change of ownership, reorganized nursing facilities and former prospective payment nursing facilities

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will establish rates for new nursing
					 facilities, nursing facilities with a change of ownership, reorganized nursing
					 facilities and former prospective payment nursing facilities as follows:
(1)
New nursing
				  facilities.
(i) The net operating
				  portion of the case-mix rate is determined as follows:
(A) A new nursing facility will be assigned
				  the Statewide average MA CMI until assessment data submitted by the nursing
				  facility under §
												1187.33 (relating to resident data
				  and picture date reporting requirements) is used in a rate determination under
				  §
												1187.96(a)(5)
				  (relating to price- and rate-setting computations). Beginning, July 1, 2010,
				  the Statewide average MA CMI assigned to a new nursing facility will be
				  calculated using the RUG-III version 5.12 44 group values in Appendix A and the
				  most recent classifiable assessments of any type. When a new nursing facility
				  has submitted assessment data under §
												1187.33, the CMI values used to
				  determine the new nursing facility's total facility CMIs and MA CMI will be the
				  RUG-III version 5.12 44 group values and the resident assessment that will be
				  used for each resident will be the most recent classifiable assessment of any
				  type.
(B) The nursing facility will
				  be assigned to the appropriate peer group. The peer group price for resident
				  care, other resident related and administrative costs will be assigned to the
				  nursing facility until there is at least one audited nursing facility cost
				  report used in the rebasing process. Beginning July 1, 2010, a new nursing
				  facility will be assigned the peer group price for resident care that will be
				  calculated using the RUG-III version 5.12 44 group values in Appendix A and the
				  most recent classifiable assessments of any type.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter G - RATE SETTING › Section 1187.98 - Phase-out median determination

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For rate years 2006-2007 and 2007-2008,
				  the Department will determine a phase-out median for each net operating cost
				  center for each peer group to calculate a peer group price. The Department will
				  establish the phase-out median as follows:
(1) Peer groups will be established in
				  accordance with §§
											1187.91 and
				  1187.94 (relating to database; and
				  peer grouping for price setting).
(2) County nursing facilities will be
				  included when determining the number of nursing facilities in a peer group in
				  accordance with § 1187.94(1)(iv).
(3) Audited county nursing facilities' costs
				  from the 3 most recent audited cost reports audited in accordance with this
				  chapter, will be included in the established peer groups when determining a
				  median in accordance with §
											1187.96 (relating to price- and
				  rate-setting computations).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.101 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Payment for nursing facility services will be 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 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.102 - 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 nursing facility and is
				  authorized by the Medicare Program to receive 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 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 nursing facility. The Department will not pay more
				  than the maximum coinsurance amount.
(b) If a resident has Medicare Part B
				  coverage, the nursing facility shall use available Medicare Part B resources
				  for Medicare Part B services before payment is made by the MA
				  Program.
(c) The 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 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 recipients not eligible for Medicare Part B
				  services which are otherwise allowable costs under this part are reported in
				  accordance with §
										1187.72 (relating to cost
				  reporting for Medicare Part B type services).
This section cited in 55 Pa. Code §
												1187.72 (relating to cost
						reporting for Medicare Part B type
						services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.103 - Cost finding and allocation of costs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A nursing facility shall use the direct
				  allocation method of cost finding. The costs will be apportioned directly to
				  the nursing facility and residential or other facility, based on appropriate
				  financial and statistical data.
(b)
				  Allowable operating cost for nursing facilities will be determined subject to
				  this chapter and the
Medicare Provider Reimbursement Manual
,
				  CMS Pub. 15-1, except that if this chapter and CMS Pub. 15-1 differ, this
				  chapter applies.
The provisions of this §
												1187.103 amended under sections
						201(2), 206(2), 403(b) and 443.1(5) of the Public Welfare Code (62 P.S.
						§§
													201(2),
						206(2), 403(b) and 443.1(5)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.105 - Limitations on payment for prescription drugs

Current through Register Vol. 54, No. 28, July 13, 2024
The Department's per diem rate for nursing facility
					 services does not include prescription drugs. Prescribed drugs for the
					 categorically needy and medically needy are reimbursable directly to a licensed
					 pharmacy in accordance with Chapter 1121 (relating to pharmaceutical
					 services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.106 - 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 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 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 nursing facility provider number as long as
					 the transferring 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 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
					 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 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.107 - Limitations on resident care and other resident related cost centers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department
				  will set a limit on the resident care peer group price for each nursing
				  facility for each year, using the NIS database as specified in §
										1187.91 (relating to database), to
				  the lower of:
(1) The nursing facility
				  resident care peer group price.
(2)
				  One hundred three percent of the nursing facility's average case-mix
				  neutralized resident care cost per diem plus 30% of the difference between the
				  103% calculation and the nursing facility resident care peer group
				  price.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.108 - Gross adjustments to nursing facility payments

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The case-mix payment system is a
				  prospective system. There is no cost settlement under the case-mix payment
				  system.
(b) Certain adjustments may
				  be made which increase or decrease the payment which a nursing facility may
				  have otherwise received. Gross adjustments to nursing facility payments are
				  based on one or more of the following general provisions:
(1) If audit findings result in changing the
				  peer group median and the peer group price, a retrospective gross adjustment is
				  made for each nursing facility in the peer group where the change
				  occurred.
(2) If a nursing
				  facility's MA CMI changes as a result of UMR resident assessment audit
				  adjustments, retrospective gross adjustments shall be made for the nursing
				  facility involved.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.109 - Medicare upper limit on payment

Current through Register Vol. 54, No. 28, July 13, 2024
Nursing facilities shall submit Medicare information on the
					 MA-11. MA payments will not exceed in the aggregate the comparable amount that
					 Medicare would have paid had the Medicare Program reimbursed for the services
					 rendered.
This section cited in 55 Pa. Code §
												1187.108 (relating to gross
						adjustments to nursing facility
						payments).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.110 - Private pay rate adjustment

Current through Register Vol. 54, No. 28, July 13, 2024
The MA rate is limited by the nursing facility's private
					 pay rate for the comparable rate period.
This section cited in 55 Pa. Code §
												1187.108 (relating to gross
						adjustments to nursing facility
						payments).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.111 - Disproportionate share incentive payments

Current through Register Vol. 54, No. 28, July 13, 2024
(a) 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:
(1) The nursing facility
				  shall have an annual overall occupancy rate of at least 90% of the total
				  available bed days.
(2) The 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.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.112 - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
This section cited in 55 Pa. Code §
												1187.108 (relating to gross
						adjustments to nursing facility
						payments).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.113 - Capital component payment limitation

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Conditions.
The capital
				  component payment for fixed property is subject to the following conditions:
(1) The Department will make the capital
				  component payment for fixed property on new or additional beds only if one of
				  the following applies:
(i) The nursing
				  facility was issued either a Section 1122 approval or letter of
				  nonreviewability under 28 Pa. Code Chapter 301 (relating to limitation on
				  Federal participation for capital expenditures) or a Certificate of Need or
				  letter of nonreviewability under 28 Pa. Code Chapter 401 (relating to
				  Certificate of Need Program) for the project by the Department of Health by
				  August 31, 1982.
(ii) The nursing
				  facility was issued a Certificate of Need or letter of nonreviewability under
				  28 Pa. Code Chapter 401 for the construction of a nursing facility and there
				  was no nursing facility located within the county.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.113a - Nursing facility replacement beds-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Scope.
This section
				  applies to any participating provider of nursing facility services that intends
				  to seek capital component payments under this chapter for replacement beds
				  constructed, licensed or certified after November 29, 1997.
(b)
Purpose.
(1) Department regulations relating to
				  capital component payments for nursing facilities enrolled and participating in
				  the Commonwealth's Medical Assistance (MA) Program state that capital component
				  payments for replacement beds are allowed only if the nursing facility was
				  "issued a Certificate of Need or a letter of nonreviewability for the project
				  by the Department of Health." See §
											1187.113(a)(3)
				  (relating to capital component payment limitations).
(2) Chapter 7 and all other portions of the
				  Health Care Facilities Act (35 P. S. §§
												448.701-448.712) pertaining to Certificates
				  of Need (CON) sunsetted on December 18, 1996. To allow the Department to
				  continue to make capital component payments for replacement beds for which a
				  nursing facility does not have a CON or letter of nonreviewability, the
				  Department will amend its regulations to specify the conditions under which it
				  will recognize beds as replacement beds for purposes of making capital
				  component payments. Pending the promulgation of these regulations, the
				  Department has issued this section to specify instances in which the Department
				  will make capital component payments for replacement beds.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.113b - Capital cost reimbursement waivers-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Scope.
This section
				  applies to any participating provider of nursing facility services that intends
				  to seek capital component payments under this chapter for existing
				  postmoratorium beds in a nursing facility. This section also applies to
				  participating providers who were granted moratorium waivers under Chapter 1181
				  (relating to nursing facility care).
(b)
Purpose.
The purpose of
				  this section is to announce the criteria that the Department will apply to
				  evaluate and approve applications for capital cost reimbursement waivers of
				  §
										1187.113(a)
				  (relating to capital component payment limitation) and to reaffirm that nursing
				  facilities that were granted waivers under Chapter 1181 continue to receive
				  capital component payments under this chapter. Waivers of §
										1187.113(a) will
				  not otherwise be granted except as provided in this section.
(c)
Submission and content of
				  applications.
(1) An applicant
				  seeking a waiver of §
											1187.113(a) shall
				  submit a written application and two copies to the Department at the following
				  address:
Department of Human Services
Bureau of Long Term Care Programs
P. O. Box 2675
Harrisburg, PA 17105-2675
ATTN: MORATORIUM WAIVER REVIEW
(2) The written application shall address the
				  criteria in subsections (d) and (e). If necessary, the application should
				  include supporting documentation.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.114 - Adjustments relating to sanctions and fines

Current through Register Vol. 54, No. 28, July 13, 2024
Nursing facility payments shall be withheld, offset,
					 reduced or recouped as a result of sanctions and fines in accordance with
					 Subchapter I (relating to enforcement of compliance for nursing facilities with
					 deficiencies).
This section cited in 55 Pa. Code §
												1187.108 (relating to gross
						adjustments to nursing facility
						payments).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.115 - Adjustments relating to errors and corrections of nursing facility payments

Current through Register Vol. 54, No. 28, July 13, 2024
Nursing facility payments shall be withheld, offset,
					 increased, reduced or recouped as a result of errors, fraud and abuse or
					 appeals under Subchapter I (relating to enforcement of compliance for nursing
					 facilities with deficiencies) and §
										1187.141 (relating to nursing
					 facility's right to appeal and to a hearing).
This section cited in 55 Pa. Code §
												1187.108 (relating to gross
						adjustments to nursing facility
						payments).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter H - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS › Section 1187.117 - Supplemental ventilator care and tracheostomy care payments

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Supplemental ventilator care
				  payments.
(1) A supplemental
				  ventilator care payment will be made each calendar quarter, effective July 1,
				  2012, through June 30, 2014, to nursing facilities subject to the following:
(i) To qualify for the supplemental
				  ventilator care payment, the nursing facility shall satisfy both of the
				  following threshold criteria on the applicable picture date:
(A) The nursing facility shall have a minimum
				  of ten MA-recipient residents who receive medically necessary ventilator
				  care.
(B) The nursing facility
				  shall have a minimum of 10% of their MA-recipient resident population receiving
				  medically necessary ventilator care.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter I - ENFORCEMENT OF COMPLIANCE FOR NURSING FACILITIES WITH DEFICIENCIES › Section 1187.121 - Applicability

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This subchapter
				  addresses the application of remedies established by Federal law to be
				  effective July 1, 1995.
(b) The
				  remedies will be applied on the basis of noncompliance found during surveys
				  conducted by the survey agency or audits, reviews or inspections conducted by
				  the Department or the Auditor General's Office.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter I - ENFORCEMENT OF COMPLIANCE FOR NURSING FACILITIES WITH DEFICIENCIES › Section 1187.122 - Requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department
				  incorporates by reference 42
				  CFR 488.400-488.456 (published in
				  59 FR 56243-56250 (November 10, 1994)) or as amended, as the enforcement of
				  compliance regulations for nursing facilities with deficiencies.
(b) Directed in-service training as contained
				  in 42 CFR
				  488.406 and
				  488.425 (relating to available
				  remedies; and directed inservice training) or, as amended, may be imposed as a
				  remedy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter J - NURSING FACILITY RIGHT OF APPEAL › Section 1187.141 - Nursing facility's right to appeal and to a hearing

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A nursing facility has a right to appeal
				  and have a hearing if the nursing facility does not agree with the Department's
				  decision regarding:
(1) The peer group prices
				  established annually by the Department for the peer group in which the nursing
				  facility is included. The nursing facility may appeal the peer group prices
				  only as to the issue of whether the peer group prices were calculated in
				  accordance with §
											1187.96 (relating to price and
				  rate setting computations).
(i) A nursing
				  facility may not challenge the validity or accuracy of any adjustment (except
				  as provided in §
												1187.141(10)) or
				  any desk or field audit findings relating to the database or total facility
				  CMIs used by the Department in calculating the peer group prices as a basis for
				  its appeal of the peer group prices.
(ii) If more than one nursing facility in a
				  peer group appeals the peer group prices established by the Department, the
				  Office of Hearings and Appeals may consolidate for hearing the appeals relating
				  to each peer group.