RULES AND REGULATIONS
Title 55--PUBLIC WELFARE
DEPARTMENT OF PUBLIC WELFARE
[55 PA. CODE CH. 1150]
Medical Assistance Program Payment Policies
[34 Pa.B. 3596] The Department of Public Welfare (Department), by this order, adopts § 1150.51 (relating to general payment policies) to read set forth in Annex A, under sections 201(2) and 443.3(2)(ii) of the Public Welfare Code (62 P. S. §§ 201(2) and 443.3(2)(ii)) (code).
Omission of Proposed Rulemaking
Notice of proposed rulemaking is omitted under section 204(1)(iv) and (3) of the act of July 31, 1968 (P. L. 769, No. 240) (45 P. S. § 1204(1)(iv) and (3)), known as the Commonwealth Documents Law (CDL), and 1 Pa. Code § 7.4(1)(iv) and (3). The Department may omit proposed rulemaking because the amendment relates to Commonwealth grants and benefits. The Department also finds that notice of proposed rulemaking is, under the circumstances, unnecessary and contrary to the public interest because access to some medical services by Medical Assistance (MA) recipients may be jeopardized if the Department delays taking action to increase payment rates for selected medical services available under the MA Program.
Purpose
The purpose of this final-omitted rulemaking is to revise the current MA maximum reimbursement limit for services provided by a practitioner during any one period of hospitalization, retroactive to January 1, 2004, to allow for the same exception to the limit that exists for services provided on an outpatient basis.
Need for the Final-Omitted Rulemaking
The current regulatory limit for payment to a practitioner for services rendered during a single hospitalization has been in place since 1985. See 15 Pa.B. 1436 (April 20, 1985) and 18 Pa.B. 2212 (May 14, 1988). It currently has the unintended effect of discouraging practitioners from treating MA recipients. To avoid harm to MA recipients as a result of this unintended consequence, the Department has determined that it is necessary and proper to revise the current cap on payments made to a practitioner during a single period of hospitalization.
Background
Under current regulations, the Department limits payment to practitioners to $1,000 per inpatient stay. See § 1150.51(e). By contrast, payment for services in an outpatient setting is limited to $500 per day, unless the MA fee for an outpatient procedure is more than $500, in which case the daily limit is the MA fee for that outpatient procedure. See § 1150.51(f). In 1985, when the limit for services in an inpatient setting was set at $1,000, fees for individual practitioners' services were well below the regulatory limit. Various fee increases in the intervening years have resulted in the fees for many procedure codes on the MA Fee Schedule being equal to the limit. The maximum reimbursement limit was never intended to constrain the Department's ability to set payment rates for individual procedures. Nonetheless, the current effect of the limit is to keep fees for select procedure codes artificially depressed so as not to exceed the limit. In addition to increasing the Department's flexibility to modify payment rates as needed to continue to assure recipient access to services, the final-form rulemaking will make the payment limit for services provided during a hospitalization consistent in principle with the payment limit for services provided in an outpatient setting.
Requirements
Section 1150.51(e) is amended to revise the maximum reimbursement limit for services provided by a practitioner during a single period of hospitalization to allow for an exception to the existing $1,000 limit if the fee for a particular procedure rendered during the hospitalization is higher than $1,000.
Affected Individuals and Organizations
Practitioners who provide services to hospitalized patients will be affected by the change, which revises the current cap on payment for services provided during an inpatient admission.
Accomplishments and Benefits
This final-omitted rulemaking revises the current MA reimbursement limit for services provided by a practitioner during a hospital stay. The anticipated effect is to provide greater incentive for physicians to remain in this Commonwealth as well as to attract physicians to this Commonwealth. In addition, MA recipients should benefit by continuing to have access to needed health care.
Fiscal Impact
There is no fiscal impact associated with this final-omitted rulemaking. Any fiscal impact would be addressed in the public notice issued under § 1150.61(a) (relating to guidelines for fee schedule changes), announcing the Department's decision to increase the payment rate for a particular procedure code.
Paperwork Requirements
No new or additional paperwork requirements result from the adoption of this final-omitted rulemaking.
Public Comment
Although this final-omitted rulemaking is being adopted without publication as proposed rulemaking, interested persons are invited to submit written comments, suggestions or objections regarding it to John Hummel, Regulations Coordinator, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, 515 Health and Welfare Building, Harrisburg, PA 17120. Comments will be reviewed and considered in any subsequent revision of the section.
Persons with a disability who require an auxiliary aid or service may submit comments by using the AT&T Relay Service at (800)-654-5984 (TDD users) or (800) 654-5988 (voice users).
Sunset Date
There is no sunset date.
Regulatory Review Act
Under section 5.1(c) of the Regulatory Review Act (71 P. S. § 745.5.1(c)), on May 14, 2004, the Department submitted a copy of this final-omitted rulemaking to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the House Committee on Health and Human Services and the Senate Committee on Public Health and Welfare. On the same date, the final-omitted rulemaking was submitted to the Office of the Attorney General for review and approval under Commonwealth Attorneys Act (71 P. S. §§ 731-101--732-506).
Under section 5.1(j.1) and (j.2) of the Regulatory Review Act, this final-omitted rulemaking was deemed approved by the Committees on June 23, 2004. IRRC met on June 24, 2004, and approved the final-omitted rulemaking.
In addition to submitting the final-omitted rulemaking, the Department has provided IRRC and the Committees with a copy of a Regulatory Analysis Form prepared by the Department. A copy of this form is available to the public upon request.
Findings
The Department finds that:
(a) Notice of proposed rulemaking is omitted in accordance with section 204(1)(iv) and (3) of the CDL and 1 Pa. Code § 7.4(1)(iv) and (3) because the regulation relates to Commonwealth grants and benefits and notice of proposed rulemaking is unnecessary and contrary to the public interest.
(b) Adoption of this final-omitted rulemaking in the manner provided by this order is necessary and appropriate for the administration and enforcement of the code.
Order
The Department, acting under the code, orders that:
(a) The regulations of the Department, 55 Pa. Code Chapter 1150, are amended by amending § 1150.51 to read as set forth in Annex A.
(b) The Secretary of the Department shall submit this order and Annex A to the Offices of General Counsel and Attorney General for approval as to legality and form as required by law.
(c) The Secretary of the Department shall certify and deposit this order and Annex A with the Legislative Reference Bureau as required by law.
(d) This order shall take effect upon publication and applies retroactively to January 1, 2004.
ESTELLE B. RICHMAN,
Secretary(Editor's Note: For the text of the order of the Independent Regulatory Review Commission relating to this document, see 34 Pa.B. (July 10, 2004.))
Fiscal Note: 14-484. No fiscal impact; (8) recommends adoption. There are currently no procedure codes that exceed the $1,000 cap. Any fiscal impact would be addressed in separate public notices announcing the Department's decision to increase the payment for a particular procedure code.
Annex A
TITLE 55. PUBLIC WELFARE
PART III. MEDICAL ASSISTANCE MANUAL
CHAPTER 1150. MA PROGRAM PAYMENT POLICIES
PAYMENT FOR SERVICES § 1150.51. General payment policies.
(a) Payment will be made to providers. Payment may be made to practitioners' professional corporations or partnerships if the professional corporation or partnership is composed of like practitioners. Payment will be made directly to practitioners if they are members of professional corporations or partnerships composed of unlike practitioners. Practitioners who render services at eligible provider hospitals, either through direct employment or through contract, may direct that payment be made to the eligible provider hospital. Payment will be made for medical services or items covered by the program, furnished by enrolled providers subject to the conditions and limitations established in this chapter, Chapter 1101 (relating to general provisions) and the specific chapters for each provider type. Payment will not be made for a covered medical service or item if payment is available from another agency or another insurance or health program. Payment will not be made for services that are not medically necessary.
(b) To the extent that this chapter conflicts with the regulations that relate to reimbursement for various services or items contained in the specific MA provider chapters which were in effect on January 1, 1983, this chapter controls. To the extent that this chapter does not address a reimbursement question answered by a regulation contained in a specific provider chapter, the regulation in the specific provider chapter controls.
(c) This chapter shall be used by practitioners, hospitals providing outpatient and emergency room services, facilities and practitioners rendering services which require a PSR or second opinion, or both; independent clinics; and other noninstitutional providers including medical supplies, independent laboratories, ambulance companies, pharmacies, portable X-ray providers, funeral directors and home health agencies.
(d) Each section of the MA Program Fee Schedule which is contained in the Provider's Handbook includes the following:
(1) An all-inclusive listing of covered services and items.
(2) The provider type eligible under MA to bill for each service and item.
(3) The appropriate procedure code for each service or item.
(4) The appropriate type of service for each procedure code.
(5) The applicable limitations for each service or item.
(6) The maximum allowable fee for each service or item.
(7) For surgical and obstetrical procedures, the allowable number of postoperative or postpartum days during which no additional payment will be made for office or home visits for a purpose other than early and periodic screening, diagnosis and treatment visits to the practitioner who performed the procedure. This policy does not apply to other members of a group practice of a different specialty.
(8) The maximum allowable fee for anesthesia for each procedure.
(e) The maximum payment made to a practitioner for all services provided to a patient during any one period of hospitalization will be the lowest of:
(1) The practitioner's usual charge to the general public for the same service.
(2) The MA maximum allowable fee.
(3) A maximum reimbursement limit of $1,000 unless a procedure provided during the hospitalization has a fee which exceeds $1,000, in which case that fee is the maximum reimbursement for the period of hospitalization.
(f) Maximum payments to various categories shall be as follows:
(1) The maximum payment made to a provider or practitioner, or their professional corporation or partnership, or a clinic for outpatient procedures provided to a nonhospitalized patient for treatment during 1 day will be the lowest of:
(i) The usual charge to the general public for the same service.
(ii) The MA maximum allowable fee.
(iii) A maximum reimbursement limit of $500 per day unless the outpatient procedure has a fee which exceeds $500, in which case the fee is the maximum reimbursement on a daily basis, for that day only.
(2) The maximum payment made to a dentist, medical supplier or pharmacy, or their professional corporation or partnership, or a clinic for outpatient procedures provided to a nonhospitalized patient for treatment during 1 day will be the lower of:
(i) The usual charge to the general public for the same service.
(ii) The MA maximum allowable fee.
(g) Services shall be performed in an efficient and economical manner.
(h) No payment will be made to a provider:
(1) For physical therapy except when provided and billed as an integral part of hospital inpatient, hospital outpatient, rural health clinic, home health agency or nursing home services.
(2) For a surgical procedure and an office or clinic visit for the same patient on the same day.
(3) For standby services except to practitioners for Cesarean sections and high risk deliveries.
(4) For an emergency room visit and a hospital clinic visit for the same patient on the same day for the same condition.
(5) For the removal of sutures and casts.
(6) For procedures not listed in the MA Program Fee Schedule, except as specified in § 1150.63 (relating to waivers).
[Pa.B. Doc. No. 04-1236. Filed for public inspection July 9, 2004, 9:00 a.m.]
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