§ 1181.60. Utilizing Medicare as a resource.
(a) An eligible recipient who is a Medicare beneficiary, is receiving care in a Medicare certified facility and is authorized by the Medicare Program to receive skilled nursing care benefits shall utilize these benefits before payment will be made by the MA Program. For each benefit period, the Medicare Program makes full payment for the first 20 days of skilled nursing care and pays all but a specified coinsurance amount for days 21 through 100. If the Medicare payment for days 21 through 100 is less than the facility’s MA interim per diem rate for skilled nursing care, the Department will participate in payment of the coinsurance charge to the extent that the total of the Medicare payment and the Department’s coinsurance payment does not exceed the MA skilled interim per diem rate for the facility. The Department will not pay more than the maximum coinsurance amount.
(b) The facility may not seek or accept payment from a source other than Medicare for any portion of the Medicare coinsurance amount that is not paid by the Department on behalf of an eligible recipient because of the limit of the facility’s MA skilled interim per diem rate.
(c) The Medicare payment will be recognized as payment in full for each day that a Medicare payment is made during the first 20 days of a benefit period.
(d) If a recipient either has purchased Medicare Part B coverage or the coverage has been purchased for the recipient, the facility shall use available Medicare Part B resources for Medicare Part B services.
(e) The amendments to this section as published in Annex A at 20 Pa.B. 6175 (December 15, 1990), and corrected at 21 Pa.B. 228 (January 19, 1991), required by the Medicare Catastrophic Coverage Act of 1988 (Pub. L. No. 100-360 (Repealed)) are in effect for the period from January 1, 1989 to December 31, 1989.
Source The provisions of this § 1181.60 codified July 24, 1981, effective July 25, 1981, 11 Pa.B. 2610; deleted August 5, 1983, effective July 1, 1983, 13 Pa.B. 2402; amended August 19, 1983, effective July 1, 1983, 13 Pa.B. 2554; amended March 10, 1989, effective immediately and applies retroactively to January 1, 1989, 19 Pa.B. 1005; amended December 14, 1990, effective immediately and apply retroactively to January 1, 1989, 20 Pa.B. 6172; amended December 14, 1990, effective immediately and apply retroactively to January 1, 1990, 20 Pa.B. 6172; corrected December 21, 1990, effective immediately and apply retroactively to January 1, 1990, 20 Pa.B. 6269; corrected January 18, 1991, effective immediately and apply retroactively to January 1, 1990, 21 Pa.B. 228. Immediately preceding text appears at serial page (135899).
Cross References This section cited in 55 Pa. Code § 1181.52 (relating to payment conditions).
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