§ 1181.69. Annual adjustment.
(a) An annual payment adjustment will be made by the Department or facility based on total audited costs related to the total Department interim claims for services for the fiscal year and any interim cost settlement for the fiscal years paid under subsection (c).
(b) For cost reporting periods ending on or after October 1, 1985, if the total amount of MA payment for interim claims for services during the fiscal year exceeds the total audited costs, the Department will recover the overpaid amount from the provider under § 1101.69(b) (relating to overpayment—underpayment).
(c) During Fiscal Years 1992-1993, 1993-1994 and 1994-1995, the Department will pay facilities interim cost settlements on acceptable year-end cost reports as follows:
(1) A facility’s interim cost settlement will be equal to 90% of the amount by which the facility’s total adjusted allowable costs for MA reported in the facility’s acceptable fiscal year-end cost report exceed the amount of MA interim payments received by the facility attributable to the fiscal period covered by the cost report.
(2) For the purpose of paragraph (1), ‘‘adjusted allowable costs’’ means the facility’s total reported costs for MA as adjusted for the following limitations:
(i) The applicable ceiling on net operating costs, as stated in § 1181.68(b) (relating to upper limits of payment).
(ii) The per bed ceiling on allowable depreciation and interest costs as stated in § § 1181.259(s) and 1181.260(k) (relating to depreciation allowance; and interest allowance) in effect on February 1, 1993, or in effect during the cost report period, whichever is greater.
(iii) The moratorium on reimbursement of depreciation and interest costs as stated in § § 1181.259(r) and 1181.260(a).
(iv) The Medicare rate and private pay rate upper limitations on payment, as stated in § 1181.68(a)(1) and (2). In adjusting the facility’s reported costs for the Medicare rate and the private pay rate limitations, the Department will apply the facility’s most recent Medicare and private pay rates reported on the MA 58 form filed with the fiscal year end cost report on which the interim cost settlement is based.
(3) Interim cost settlements will not be paid on the basis of interim or final cost reports.
(4) An interim cost settlement will not be paid to a facility which has filed an interim cost report for the fiscal period covered by the interim cost settlement unless the facility waives its rights to a revised interim rate for the fiscal period.
Authority The provisions of this § 1181.69 amended under sections 201, 403 and 443.1(2) and (3) of the Public Welfare Code (62 P. S. § § 201, 403 and 443.1(2) and (3)).
Source The provisions of this § 1181.69 codified July 24, 1981, effective July 25, 1981, 11 Pa.B. 2610; amended February 5, 1988, effective February 6, 1988, 18 Pa.B. 556; amended July 21, 1995, effective immediately and apply retroactively to July 1, 1992, and sunsetted on June 30, 1995, 25 Pa.B. 2893. Immediately preceding text appears at serial page (193425). (Editor’s Note: See 22 Pa.B. 3749 (July 18, 1992) for nursing home pooling provisions.)
Cross References This section cited in 55 Pa. Code § 1181.52 (relating to payment conditions); and 55 Pa. Code § 1181.101 (relating to facility’s right to a hearing).
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