55 Pa. Code § 1163.51 - General payment policy
(a)
Except for services provided in a hospital unit excluded from the DRG
prospective payment system, the Department will pay a prospective rate for
inpatient hospital services compensable under the MA Program. See §
1163.2 (relating to definitions)
for the definition of "inpatient hospital services." The Department will base
the prospective payment on the DRG into which the patient is classified and on
the prospective payment rate assigned to a hospital.
(b) In addition to the DRG prospective
payment made by the Department for a patient discharged from the hospital, the
Department will reimburse a participating hospital for:
(1) Costs for depreciation and interest for
buildings and fixtures under §
1163.53a (relating to prospective
capital reimbursement system).
(2)
Costs for direct medical education under §
1163.55 (relating to payments for
direct medical education for Fiscal Years 1993-94 and 1994-95).
(c) If a hospital stay meets the
requirements for outliers in §
1163.56 (relating to outliers),
the prospective payment amount is adjusted under that section.
(d) A hospital that qualifies for
disproportionate share payments under §
1163.67 (relating to
disproportionate share payments) receives monthly payments as provided under
that section.
(e) When provided to
an inpatient, the Department makes separate payment to a hospital for:
(1) Direct care services provided by a
practitioner as defined in Chapter 1101 (relating to general provisions) who is
under salary or contract with the hospital. The Department pays for the
services in accordance with Chapters 1141, 1143, 1145, 1147 and 1149 which
govern payment for the practitioner.
(2) Direct care services provided by a
midwife as defined in Chapter 1142 (relating to midwives' services) who is
under salary or contract with the hospital . The services are paid under Chapter
1142.
(f) The Department
does not pay for an admission that it determines is not medically
necessary.
(g) The Department 's
prospective payment amount is payment in full for compensable inpatient
hospital services. Compensable services provided to an inpatient are covered by
the Department 's payment, except for direct care services provided by salaried
practitioners and midwives.
(h)
Except as specified in subsection (i), no payment for inpatient hospital
services is made until the recipient is discharged from the hospital. A
recipient is considered discharged from the hospital if one of the following
occurs:
(1) The recipient is formally released
from the hospital, except if the recipient is transferred to another hospital
covered under the MA prospective payment system. See §
1163.58 (relating to payment
policy for transfers).
(2) The
recipient dies in the hospital.
(3)
The recipient is transferred to a private psychiatric hospital, public
psychiatric hospital, rehabilitation hospital, drug and alcohol rehabilitation
hospital or other facility not covered by the MA prospective payment
system.
(4) The recipient is
transferred to a hospital unit that is excluded from the MA prospective payment
system as specified in §
1163.32 (relating to hospital
units excluded from the DRG prospective payment system).
(i) A hospitalization for a continuous period
of 90 days or longer may be billed, and paid, on an interim basis. Specific
procedures for interim billing and payment are specified in the
Inpatient Hospital Handbook issued to providers by the
Department .
(j) Payment for
emergency room services provided to patients admitted to the hospital is
included in the payment for inpatient hospital services. The hospital may not
submit a separate bill for these services.
(k) A hospital may not bill an MA recipient
for care related to a noncovered service unless the recipient was informed,
prior to receiving the service, that the service and the inpatient care
relating to it were not covered under the MA Program .
(l) A hospital may not bill the MA Program
for services provided to a person who has made application for MA benefits
unless the CAO has notified the hospital that the person is eligible for MA
benefits.
(m) If a hospital
voluntarily terminates the provider agreement, payment for inpatient hospital
services is made for MA patients admitted prior to the effective date of the
termination of the provider agreement.
(n) If a hospital provides services to a
recipient with a psychiatric principal diagnosis but the hospital does not have
a psychiatric unit that is excluded from the prospective payment system under
§
1163.32, the Department pays a
2-day per diem amount for the hospital stay. The 2-day per diem amount is
determined by dividing the normal payment rate for the DRG by the Statewide
average length of stay for the DRG and multiplying the result by two.
(o) If a hospital provides services to a
recipient with a psychiatric principal diagnosis and the hospital has a
psychiatric unit that is excluded from the prospective payment system under
§ 1163.32, the Department makes payment for these services under
Subchapter B (relating to hospitals and hospital units under cost reimbursement
principles). The Department makes no payment for the hospital stay under the
DRG prospective payment system unless an emergency situation exists and the
psychiatric unit is full, in which case the Department will make a 2-day per
diem payment determined by dividing the payment rate for the DRG by the
Statewide average length of stay for the DRG and multiplying the result by
two.
(p) If a hospital provides
services to a recipient with a drug or alcohol principal diagnosis but the
hospital's drug and alcohol services have not been approved by the Department
of Health, Office of Drug and Alcohol Programs, the Department pays a 2-day per
diem amount for the hospital stay. The 2-day per diem amount is determined by
dividing the normal payment rate for the DRG by the Statewide average length of
stay for the DRG and multiplying the result by two.
(q) Except as specified in subsection (r), if
a hospital provides services to a recipient with a drug and alcohol principal
diagnosis and the hospital has been approved by the Department of Health,
Office of Drug and Alcohol Programs to provide detoxification services, the
Department pays the full DRG rate for the hospital stay.
(r) If a hospital provides services to a
recipient with a drug or alcohol principal diagnosis and the hospital has a
drug and alcohol rehabilitation unit that is excluded from the prospective
payment system under § 1163.32, the Department makes no payment for the
hospital stay under the DRG prospective payment system. For these hospitals,
payment for services provided to a recipient with a drug or alcohol principal
diagnosis is made under Subchapter B.
(s) The Department will not pay an acute care
hospital for medical rehabilitation services which are not provided in
conjunction with acute care services. For recipients receiving only medical
rehabilitation services and requiring no acute care services, payment is made
only to distinct part medical rehabilitation units or freestanding medical
rehabilitation hospitals enrolled in the MA Program under Subchapter
B.
(t) Payment for inpatient
hospital services, including acute care general hospitals and their distinct
part units, private psychiatric hospitals and freestanding rehabilitation
hospitals, will not be made in excess of the amount which would be paid in the
aggregate for those services under Medicare principles of reimbursement in 42
CFR Part 413 (relating to principles of reasonable cost reimbursement; payment
for end-stage renal disease services).
(u) Capital and operating costs related to
new or additional beds are nonallowable for purposes of this subchapter unless
a Certificate of Need or letter of nonreviewability related to those beds was
issued by the Department of Health prior to July 1, 1993.
(v) The Department will not make a separate
APR-DRG payment for inpatient acute care general hospital services of a normal
newborn.
Notes
The provisions of this § 1163.51 amended under sections 201, 403(b), 403.1 and 443.1(1) of the Public Welfare Code (62 P. S. §§ 201, 403(b), 403.1 and 443.1(1)).
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