§ 1163.442. Requirements for reimbursement under this subchapter.
(a) Only the following types of providers are eligible to be reimbursed under this subchapter:
(1) Medical rehabilitation hospitals that fully comply with the Medicare regulations at 42 CFR 412.23(b) (relating to excluded hospitals: classifications).
(2) Distinct part drug and alcohol rehabilitation units of general hospitals that meet the requirements set forth in subsection (b).
(3) Drug and alcohol rehabilitation hospitals that meet the requirements set forth in subsection (d).
(4) Medical rehabilitation units of general hospitals that meet the requirements in subsection (e).
(b) To be considered a drug and alcohol rehabilitation unit for MA purposes, the unit shall:
(1) Be part of a hospital enrolled in the MA Program.
(2) Meet the criteria of a distinct part unit as set forth in subsection (c).
(3) Be approved by the Department of Health, Office of Drug and Alcohol Programs to provide drug and alcohol treatment and rehabilitation.
(4) Be enrolled in the MA Program as a distinct part drug and alcohol treatment/rehabilitation unit.
(c) To qualify as a distinct part unit for MA purposes, the unit shall:
(1) Have written admission criteria that are applied uniformly to both MA patients and non-MA patients.
(2) Have admission and discharge records that are separately identified from those of the hospital in which it is located and are readily available.
(3) Have policies specifying that necessary clinical information is transferred to the unit when a patient of the hospital is transferred to the unit.
(4) Have utilization review standards applicable for the type of care offered in the unit.
(5) Have beds physically separate from; that is, not commingled with the hospital’s other beds.
(6) Be treated as a separate cost center for cost finding and apportionment purposes.
(7) Use an accounting system that properly allocates costs.
(8) Maintain adequate statistical data to support the basis of allocation.
(9) Report its costs in the hospital’s cost report covering the same fiscal period and using the same method of apportionment as the hospital.
(d) For a drug and alcohol rehabilitation hospital to be eligible for reimbursement under this subchapter, the hospital shall:
(1) Be enrolled in the MA Program.
(2) Be approved by the Department of Health to provide inpatient drug and alcohol rehabilitation services.
(3) Have treated, during its most recent 12-month cost reporting period, an inpatient population of which at least 75% required treatment for drug or alcohol abuse.
(e) To be considered a medical rehabilitation unit for MA purposes, the unit shall:
(1) Be part of a hospital enrolled in the MA Program.
(2) Meet the criteria of a distinct part unit in subsection (c).
(3) Be enrolled or have applied for enrollment in the Medicare Program as an excluded rehabilitation unit, unless the unit is located in a non-Medicare participating children’s hospital in which case the unit shall be able to meet the Medicare rehabilitation unit criteria, but will not be required to enroll in the Medicare Program.
(4) Be enrolled in the MA Program as a distinct part medical rehabilitation unit.
(5) Be certified by the Commission on Accreditation of Rehabilitation Facilities (CARF) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and if certified by JCAHO, also be certified under JCAHO rehabilitation standards.
Authority The provisions of this § 1163.442 amended under sections 201 and 443.1(1) of the Public Welfare Code (62 P. S. § § 201 and 443.1(1)).
Source The provisions of this § 1163.442 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185; amended October 9, 1986, effective retroactively to July 1, 1984, 16 Pa.B. 3828; amended June 16, 1989, effective immediately and applies retroactively to July 1, 1988, 19 Pa.B. 2563; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917. Immediately preceding text appears at serial pages (177190) to (177191) and (150151) to (150152).
Cross References This section cited in 55 Pa. Code § 1163.457 (relating to payment policies relating to out-of-State hospitals).
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