55 Pa. Code § 1128.51 - General payment policy

(a) Payment is made as set forth in this section, for support services and items related to procedures provided by participating dialysis facilities if full payment for the services and items is not available through Medicare, other financial resources or health insurance programs. Payment is subject to the conditions and limitations established in this chapter, Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program Fee Schedule.

(b) A fee determined by the Department is paid for support services provided to an eligible recipient during the course of a dialysis procedure.

(c) The dialysis facility is considered the provider regardless of whether the facility is operated directly by the enrolled provider or through contract between the provider and other organizations or individuals. The enrolled provider is responsible for the delivery of service and for billings.

(d) The Department will pay for the unsatisfied portion of the Medicare deductible and remaining 20% coinsurance up to the amount of the MA fee, if the Medicare 80% payment and the amount billed to MA does not exceed the maximum MA fee.

(e) Payment is made for dialysis services provided at the site of a facility or in a patient's home.

(f) The fee paid to the facility includes, but is not limited to, the following:

(1) Nursing, technician and related services.

(2) Use of the facility.

(3) The maintenance of medical records as required by the Department of Health and under § 1101.51 (relating to ongoing responsibilities of providers.)

(4) Drugs, biologicals, surgical dressings, supplies, blood, intravenous fluids, diagnostic studies and equipment directly related to the provision of a dialysis procedure.

(5) Ongoing evaluation of patients receiving home dialysis services.

(6) Dietary, social services and other related services.

(7) Administrative and housekeeping items and services.

(g) The fees paid for procedures are applicable to staff-assisted dialysis, self dialysis and home dialysis.

(h) Payment is made in accordance with the MA Program Fee Schedule for installation of equipment and modification of a home to the extent necessary for home dialysis services.

(i) The dialysis facility shall submit invoices to the Department in accordance with the instructions in the Provider Handbook.

(j) The Department will pay the lesser of the dialysis facility's charge to the general public or the amount determined as the rate that the facility is eligible to bill.

(k) If the dialysis facility has a fee schedule based on the patient's ability to pay, the Department will consider the provider's usual and customary charge to the general public to be the most frequent charge to the self-paying public for the same service in the preceding calendar month.

(l) The Department's payment for dialysis services shall be considered payment in full as specified under § 1101.63 (relating to payment in full).

(m) If a dialysis facility voluntarily terminates the provider agreement, payment is made for services provided prior to the effective date of the termination of the provider agreement. Payment shall be made in accordance with § 1128.52 (relating to payment criteria).

(n) Payment is made for services provided to Commonwealth MA recipients by an out-of-State dialysis facility only if residents in a given area generally receive their care in that particular facility. This would apply when the out-of-State facility is closer to, or substantially more accessible from, the residence of the recipient than the nearest facility within this Commonwealth that is adequately equipped to deal with, and is available for the treatment of, the individual's illness.

Notes

55 Pa. Code § 1128.51

This section cited in 55 Pa. Code § 1128.53 (relating to limitations on payment).