§ 1151.50. Payment for out-of-State private psychiatric hospital services.
(a) The Department will pay for compensable services furnished by out-of-State private psychiatric hospitals to an eligible Pennsylvania recipient, if one of the following exists:
(1) Residents in a given area generally receive their care in a particular out-of-State private psychiatric hospital; this would apply when the out-of-State private psychiatric hospital is closer to, or substantially more accessible from the residence of the recipient than, the nearest private psychiatric hospital within this Commonwealth which is adequately equipped and is available for the treatment of the individuals illness.
(2) Documentation is provided verifying one of the following:
(i) The recipient required inpatient psychiatric hospital services on an emergency basis, while temporarily out of this Commonwealth.
(ii) An out-of-State private psychiatric hospital is the only facility equipped to provide the type of care that the individual requires.
(b) The payment for inpatient hospital services provided by an out-of-State private psychiatric hospital is the lowest of:
(1) The payment the hospital would receive for the admission under the hospitals home state payment system.
(2) A Statewide days-weighted average per diem rate, times the number of compensable days of inpatient psychiatric care rendered.
(3) The amount of the charges billed by the hospital.
(4) The Medicare deductible or coinsurance, if applicable.
(c) If a recipient is admitted to an out-of-State private psychiatric hospital and discharged within the same calendar day, the Department will pay one half of the per diem rate established under subsection (b)(2). If Medicare is involved, the entire allowable Medicare deductible and coinsurance will be paid.
(d) The Department will pay the amount established in accordance with subsection (b) minus payments from the recipient, a legally responsible relative or a third-party resource for the services a recipient receives while in the hospital.
(e) The Departments payment rate will not be based on costs which are precluded from recognition by the Social Security Act (42 U.S.C.A. § § 3011399).
The provisions of this § 1151.50 amended under sections 201 and 443.1 of the Public Welfare Code (62 P. S. § § 201 and 443.1).
The provisions of this § 1151.50 adopted September 30, 1983, effective July 1, 1983, 13 Pa.B. 2796; amended February 28, 1986 effective March 2, 1986, 16 Pa.B. 600; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917; amended October 29, 1993, effective July 1, 1993, 23 Pa.B. 5241. Immediately preceding text appears at serial pages (181787) to (181788).
Notes of Decisions
Court Order Committing Juvenile Delinquents to Out-of-State Hospital Did Not Preclude In-State Placement
Court order committing juvenile delinquents to out-of-State hospital on grounds that such placement was best suited to their needs did not establish that hospital was the only facility equipped to provide the type of care the juveniles required, which would necessitate the Department of Public Welfare to pay the costs of the out-of-State placements. Department of Public Welfare v. Devereux Hospital Texas Treatment Network (K.C.), 855 A.2d 842, 847 (Pa. 2004)
This section cited in 55 Pa. Code § 1151.42 (relating to payment methods and rates).
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