§ 1163.65. Payment for out-of-State hospital services.
(a) The Department pays for compensable inpatient hospital services furnished by an out-of-State hospital to an eligible Pennsylvania recipient if one of the following occurs:
(1) Residents in a given area generally receive their care in a particular out-of-State hospital. This would apply when the out-of-State hospital is closer to, or substantially more accessible from, the residence of the recipient than the nearest hospital within this Commonwealth that is adequately equipped and is available for the treatment of the individuals illness.
(2) Documentation is provided verifying one of the following:
(i) While temporarily out-of-State, the recipient required inpatient hospital services on an emergency basis. For the purpose of this chapter, emergency services are those inpatient hospital services that are necessary to prevent the death, or serious impairment of the health of the individual, and which, because of the threat to the life or health of the individual, require the use of the most accessible hospital available that is equipped to furnish the services.
(ii) An out-of-State hospital is the only facility equipped to provide the type of care that the individual requires.
(b) Payment for inpatient hospital services provided by out-of-State hospitals is subject to the limitations and conditions set forth in this chapter.
(c) The Departments payment for services provided by an out-of-State hospital is the lower of:
(1) The amount of the charges billed by the hospital.
(2) The Statewide average DRG payment rate, excluding capital, increased by 7.1% to account for capital-related costs for buildings and fixtures and, if applicable, an outlier payment as determined under § 1163.56 (relating to outliers).
(d) The Department pays the rate established under subsection (c) minus payments from the recipient, a legally responsible relative or a third-party resource for the services a recipient receives while in the hospital.
The provisions of this § 1163.65 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185; amended June 1, 1990, effective retroactively to July 1, 1987, 20 Pa.B. 2913. Immediately preceding text appears at serial pages (90735) to (90736).
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