55 Pa. Code § 1187.94 - Peer grouping for price setting
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).
(2) To set net
operating prices under the case-mix payment system, the Department will
classify the nursing facilities participating in the MA Program that meet the
definition of a special rehabilitation facility into one peer group, peer group
number 13. Regardless of the number of facilities in this peer group, the
Department will not collapse the peer group of special rehabilitation
facilities.
(i) Effective November 1, 2011,
the Department will establish peer group medians and prices for facilities
classified as special rehabilitation facilities on or before July 1, 2000, by
using data from only the nursing facilities classified as special
rehabilitation facilities on or before July 1, 2000.
(ii) Effective November 1, 2011, the
Department will establish peer group medians and prices for facilities
classified as special rehabilitation facilities after July 1, 2000, by using
data from all nursing facilities classified as special rehabilitation
facilities.
(3) To set net
operating prices under the case-mix payment system, the Department will
classify the nursing facilities participating in the MA Program that meet the
definition of a hospital-based nursing facility into one peer group, peer group
number 14. Regardless of the number of facilities in this peer group, the
Department will not collapse the peer group of hospital-based nursing
facilities.
(4) Once nursing
facilities have been classified into peer groups for price setting, the nursing
facility costs will remain in that peer group until prices are rebased, unless
paragraph (5) applies.
(5) Paragraph
(3) sunsets on the date that amendments are effective in Chapter 1163 (relating
to inpatient hospital services), to allow for the inclusion of costs previously
allocated to hospital-based nursing facilities. Subsequent to the effective
date of the amendments to Chapter 1163, the Department will classify
hospital-based nursing facilities in accordance with paragraph
(1).
Notes
The provisions of this § 1187.94 amended under sections 201(2), 206(2), 403(b), 443.1 and 454 of the Public Welfare Code (62 P.S. §§ 201(2), 206(2), 403(b), 443.1 and 454).
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