Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 2336 (April 27, 2024).

55 Pa. Code § 1243.53. Limitations on payment.

§ 1243.53. Limitations on payment.

 (a)  The fees listed in the MA Program fee schedule are the maximum fees allowed under the MA Program.

 (b)  Section 1903(i)(1) of Title XIX of the Social Security Act (42 U.S.C.A. §  1396(i)(1)) provides that charges allowed for medical services, supplies, and equipment under Medicare Part B and Medicaid that, in the judgment of the Secretary of Health and Human Services (HHS) do not generally vary significantly from one provider to another, may not exceed the lowest charge levels at which the items and services are widely and consistently available in a locality. Certain laboratory procedures are presently subject to lowest charge levels. Other procedures shall be added to the list by HHS from time to time. For those selected procedures established by both Medicare and Medicaid, the lowest charge level adopted by the Medicare carrier shall control. For those selected procedures furnished only under Medicaid, the Department will set lowest charge levels according to the procedures used by Medicare. Medical Assistance maximum fees for laboratory procedures shall be periodically adjusted and published in the Pennsylvania Bulletin under the act of July 31, 1968 (P. L. 769, No. 240) (45 P. S. § §  1102, 1201—1208 and 1602); and 45 Pa.C.S. Chapters 5, 7 and 9, known as the Commonwealth Documents Law.


   The provisions of this §  1243.53 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4614; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (117515) to (117516).

Cross References

   This section cited in 55 Pa. Code §  1243.51 (relating to general payment policy).

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