§ 1187.155. Exceptional DME grants—payment conditions and limitations.
(a) Authorization of exceptional payments. Exceptional payments authorized by an exceptional DME grant will be paid as follows:
(1) Periodic payments. Unless the grant authorizes a lump sum payment under paragraph (2), the grant will authorize exceptional payments to the nursing facility on a specified periodic basis. Authorization for periodic payments will continue during the term of the nursing facility’s grant except during a period of suspension as specified in § 1187.157 (relating to termination or suspension of exceptional DME grants and recovery of exceptional payments).
(2) Lump sum payment. The grant may authorize a lump sum exceptional payment to the nursing facility if the Department determines that a lump sum payment is in the best interest of the MA Program. The amount of this payment will be based upon and limited by the necessary, reasonable and prudent costs incurred by the nursing facility to purchase exceptional DME and related items.
(b) Maximum allowable payment. The maximum allowable exceptional payment authorized by an exceptional DME grant is limited to the lowest of the following:
(1) The lower of the nursing facility’s costs to acquire the exceptional DME and related services and items; or, in the event the nursing facility is acquiring the exceptional DME or related services and items from a related party as defined in § 1187.2 (relating to definitions), the related party’s cost to furnish the exceptional DME and related services and items to the nursing facility.
(2) The applicable MA outpatient fee schedule amount, if any.
(3) Eighty percent of the amount, if any, that would be approved by Medicare if the DME or service or item were a Medicare Part B covered service or item.
(c) Additional conditions and limitations. Exceptional payments made by the Department to a nursing facility under a grant are subject to the following:
(1) The conditions and limitations set forth in Chapter 1101 (relating to general provisions), including § § 1101.64 and 1101.68 (relating to third-party medical resources; and invoicing for services).
(2) The terms of the nursing facility’s grant.
Cross References This section cited in 55 Pa. Code § 1187.154 (relating to exceptional DME grants—general conditions and limitations).
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