§ 1127.52. Payment criteria.
(a) The Department will establish maximum reimbursement fees for birth centers based on the following criteria:
(1) The level of reimbursement will be consistent with efficiency, economy and quality of care.
(2) The level of reimbursement will be sufficient to assure availability of services.
(b) Total payment to a birth center will be made at 70% of the overall Statewide average hospital prospective payment rate in effect on July 1, 1986, plus a component to cover midwife prenatal visits and the delivery fee. The total prenatal visit amount will be based on 12 visits. The visit and delivery fee component will be calculated in accordance with Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule in effect as of July 1, 1986.
(c) Payment will be made on a trimester basis at a rate of 25%, 25% and 50% of the total fee.
(d) If, during prenatal care, birth center services are terminated for any reason, including changes in the recipient’s eligibility, payment is made to the birth center for visits with professional staff provided during the course of the last trimester in which the patient received services. The Department will also pay for other services the facility has provided for which it is eligible to bill on a fee for service basis. The birth center visit fee shall be the amount equal to that of the midwives’ or physicians’ visit fee under the MA Program fee schedule. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day constitute a single visit.
(e) If, due to complications that develop during labor, it is necessary to transfer a birth center patient to a hospital, one payment will be made to the birth center for services provided during the third trimester including services provided during labor. The amount of the payment is 50% of the third trimester rate of payment. Midwives or physicians attending the delivery on an inpatient basis may bill a fee under the Medical Assistance program fee schedule.
Source The provisions of this § 1127.52 adopted January 16, 1987, effective retroactively to July 1, 1986, 17 Pa.B. 267; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (114408) and (117353).
Cross References This section cited in 55 Pa. Code § 1127.51 (relating to general payment policy).
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