(a)
Maximum rate of payment. Except as provided in this section,
the
Department's maximum rate of payment to an enrolled facility will be the
lower of the following:
(1) The facility's
lowest charge to private pay patients for the same level of care.
(2) The facility's Medicare rate, which is
either of the following:
(i) As compared to
the facility's Medical Assistance interim per diem rate, the facility's
Medicare interim per diem rate that is in effect on the date the facility's
request for an interim per diem rate is postmarked or, if hand delivered, the
date the request is received by the Department as documented by the
Department's date stamp.
(ii) As
compared to the facility's Medical Assistance final rate, the Medicare interim
per diem rate in effect on the day of the facility's exit conference.
(3) The facility's Medical
Assistance final per diem rate.
(b)
Established ceilings.
The established ceilings on net operating costs as published by notice in the
Pennsylvania Bulletin are the upper limit, as applicable, on
the net operating costs of county and general nursing facilities.
(c)
Waiver of application.
(1) A facility participating in Medicare may
obtain a waiver of the application of subsection (a)(2) when the following
apply:
(i) The facility demonstrates to the
Department that the applicable Medicare interim per diem rates are lower than
the facility's Medical Assistance per diem rate.
(ii) The grant of the waiver will not cause
the Department's estimated aggregate payment for long-term care facility
services for the fiscal year involved to exceed the amount that the Department
could reasonably estimate would be paid for these services under Medicare
principles of reimbursement.
(2) A waiver will not be granted from the
application of subsection (a)(2) unless the request for the waiver is received
by the
Department prior to the expiration of the time limit established by
§
1101.84 (relating to
provider
right of appeal) for filing an appeal of the interim rate or audit report with
respect to which the waiver is sought. Additionally, no request for a waiver
received after the issuance of an audit report shall stay the collection of any
overpayments resulting from the determinations of the audit report pending the
adjudication of the waiver request.
(d)
Upper limits for State-operated
facilities. The upper limits of payment for State-operated
intermediate care facilities for the mentally retarded are the full allowable
costs as specified in the HIM-15.
(e)
Upper limits for non-State
operated facilities. The upper limits of payment for non-State
operated intermediate care facilities for the mentally retarded are the total
projected operating cost or if a waiver is granted under Subchapter C
(Reserved) an approved budget level as specified in Subchapter C.
Notes
The
provisions of this § 1181.68 codified July 24, 1981,
effective 7/25/1981, 11 Pa.B.
2610; amended July 2, 1982, effective 7/1/1982, 12 Pa.B. 2070; amended August 5, 1983,
effective 7/1/1983, 13 Pa.B.
2402; amended May 3, 1985, effective retroactively to July 1, 1984, 15 Pa.B.
1629; amended September 6, 1985, effective 9/7/1985, except the groups and ceilings shall
be effective and apply at audit to costs of services rendered from July 1, 1984
through December 31, 1984; corrected August 7, 1987, effective
9/7/1985, 17 Pa.B. 3327; amended
March 10, 1989, effective immediately and applies retroactively to January 1,
1989, 19 Pa.B. 1005.
The provisions of this § 1181.68 amended under sections 201
and 443.1(2) of the Public Welfare Code (62 P. S. §§
201 and
443.1
(2)).
This section cited in 55 Pa. Code §
1181.1 (relating to policy); 55
Pa. Code §
1181.2 (relating to definitions);
55 Pa. Code §
1181.52 (relating to payment
conditions); 55 Pa. Code §
1181.67 (relating to setting
interim per diem rates); 55 Pa. Code § 1181.68 (relating to upper limits
of payment); 55 Pa. Code §
1181.69 (relating to annual
adjustment); 55 Pa. Code §
1181.91 (relating to failure to
file a cost report); 55 Pa. Code §
1181.211 (relating to cost
reimbursement principles and method); 55 Pa. Code §
1181.221 (relating to determining
the interim per diem rate); 55 Pa. Code §
1181.224 (relating to final per
diem rate); and 55 Pa. Code §
1181.231 (relating to standards
for general and selected costs).
