§ 1151.46. Payment rate calculations for Fiscal Years 1993-94 and 1994-95.
(a) The amount of the Department’s payment for services provided to an MA recipient is the inpatient psychiatric facility’s per diem rate established under this section multiplied by the number of compensable days of service rendered minus payment made by a third-party payor, the recipient or a legally responsible relative. The Department will also deduct from the payment Medicare Part B payments and other resources available to the patient to meet the cost of the inpatient psychiatric care.
(b) The per diem rate includes payments for capital costs and for direct medical education costs, but does not include disproportionate share payments.
(c) The method for determining the per diem payment rates under this section depends upon the status of the inpatient psychiatric provider as being ‘‘existing’’ or ‘‘new,’’ as follows:
(1) An ‘‘existing’’ provider is an inpatient psychiatric facility that was enrolled in the MA Program for the entire period from July 1, 1989, to June 30, 1990, including each inpatient psychiatric facility which changed ownership after July 1, 1989, and elected to retain the rate of the prior entity, which had submitted a full cost report for Fiscal Year 1989-90.
(2) A ‘‘new’’ provider is an inpatient psychiatric facility that enrolled in the MA Program after July 1, 1989, including each inpatient psychiatric facility which changed ownership between July 1, 1989, and June 30, 1993, and elected to have its payment rate rebased.
(d) Subject to the limits specified in subsection (i), the per diem payment rate for an existing provider is the facility’s MA per diem cost as reported on the Fiscal Year 1989-90 MA Cost Report (MA 336) reduced by the over reporting factor of 1.69% and inflated by the appropriate inflation factors specified under subsection (h).
(e) The payment rates established for existing providers shall be considered final payment rates, without regard to audit, unless the facility is eligible for additional capital payment under § 1151.52 (relating to payment for capital costs not included in the base year).
(f) Subject to the limits specified under subsection (i), the interim and final per diem payment rates for new providers are determined as follows:
(1) The interim per diem payment rate is based on the MA per diem cost as reported on the MA Cost Report (MA 336) for the first full fiscal year of operation in the MA Program, or, until the first full cost report is available, a projected budget is submitted by the provider and approved by the Department.
(2) The interim per diem payment rate is the amount determined under paragraph (1), reduced by the over-reporting factor of 1.69% and inflated by the appropriate inflation factors specified under subsection (h).
(3) The final per diem payment rate is the audited MA per diem cost of the facility’s first full fiscal year of operation in the MA Program, inflated by the appropriate inflation factors specified under subsection (h).
(g) New providers will be subject to cost settlement for a difference between the interim and final payment rates determined under this section.
(h) To calculate per diem payment rates, the Department will use the following inflation factors, as applicable:
(1) 5.3% to account for Fiscal Year 1990-91 inflation.
(2) 5.2% to account for Fiscal Year 1991-92 inflation.
(3) 4.6% to account for Fiscal Year 1992-93 inflation.
(4) 4.3% to account for Fiscal Year 1993-94 inflation, to be applied as follows:
(i) Inpatient psychiatric facilities that received a Fiscal Year 1992-93 disproportionate share rate enhancement will receive the 4.3% inflation factor effective July 1, 1993.
(ii) Inpatient psychiatric facilities that did not receive a Fiscal Year 1992-93 disproportionate share rate enhancement will receive the 4.3% inflation factor effective January 1, 1994.
(5) For Fiscal Year 1994-95 effective January 1, 1995, inpatient psychiatric facilities will receive an inflation factor equal to the prospective payment system type hospital market basket moving average inflation factor, published by DRI/McGraw-Hill in the fourth quarter of 1993 for the second calendar quarter of 1995.
(i) The Department will limit per diem rates as follows:
(1) For Fiscal Year 1993-94, an inpatient psychiatric facility’s per diem rate may not exceed $950.
(2) For Fiscal Year 1994-95, an inpatient psychiatric facility’s per diem rate may not exceed $950 increased effective January 1, 1995, for inflation by the prospective payment system type hospital market basket moving average inflation factor, published by DRI/McGraw-Hill in the fourth calendar quarter of 1993 for the second calendar quarter of 1995.
(j) The Department will establish payment rates for inpatient psychiatric facilities which change ownership on or after July 1, 1993, under § 1151.34 (relating to changes of ownership or control).
Authority The provisions of this § 1151.46 amended under sections 201 and 443.1(1) and (4) of the Public Welfare Code (62 P. S. § § 201 and 443.1(1) and (4)).
Source The provisions of this § 1151.46 adopted September 30, 1983, effective July 1, 1983, 13 Pa.B. 2796; amended October 10, 1986, effective retroactively to July 1, 1984, 16 Pa.B. 3828; amended November 7, 1986, effective July 1, 1986, 16 Pa.B. 4384; amended June 1, 1990, effective retroactively to July 1, 1988, 20 Pa.B. 2913; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917; amended October 29, 1993, effective July 1, 1993, 23 Pa.B. 5241. Immediately preceding text appears at serial pages (181781) to (181782).
Cross References This section cited in 55 Pa. Code § 1151.41 (relating to general payment policy); and 55 Pa. Code § 1151.52 (relating to payment for capital costs not included in the base year).
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