Reimbursement

Skilled Nursing Facility MA Reimbursement

Nursing facilities that participate in the Medical Assistance (MA) program are reimbursed a daily per diem rate for days of services provided to MA residents by the Department of Human Services (DHS). In addition to the daily per diem rate, nursing facilities that meet certain criteria are eligible to receive supplementary payments from the Department. This section provides links and other information related to nursing facility payments.

Nursing Facility MA Per Diem Rates

Nursing Facility Case-Mix Per Diem Rates

The Department of Human Services calculates payment rates for nursing facilities participating in the MA program based on the rate setting methodology contained in 55 Pa. Code Chapter 1187. Proposed rate files and final rate files for each MA nursing facility can be found using this link.

Statewide Average Total Facility and MA Case-Mix Indices (CMIs)

The Department calculates each MA nursing facility’s total facility CMI and MA CMI for use in determining a nursing facilities case-mix rate. The CMI statewide averages for all MA nursing facilities, excluding county nursing homes are posted by the Department on the website. The CMIs can be found using this link.

Peer Groups and Peer Group Prices

On an annual basis the Department calculates net operating peer group medians and prices calculated prospectively during the second quarter for nursing facilities participating in the Medical Assistance program. These prices are effective for the subsequent July 1 through June 30 period. This link provides documents that describe the process and information on the cost reporting periods in the database, the facilities in each median peer group, and the medians and prices for the Resident Care, Other Resident Care, and Administrative Cost categories.

Nursing Facility Frequently Asked PROMISe Questions

Nursing Facility frequently asked questions to assist nursing facilities with the submission of invoices to the Department for the Medical Assistance residents they serve.

MA Pass Through/Incentive Payments

HAI Surcharge Pass-Through Payments

The Department of Health annual health-care associated infection (HAI) surcharge on a nursing facility’s licensing fee is an allowable cost under the MA Program. The MA portion of the HAI surcharge is reimbursed as a pass-through payment on an annual basis.

Disproportionate Share Incentive Payments

Disproportionate Share Incentive Payments are made annually by the Department to nursing facilities that meet established occupancy criteria during the facility’s cost reporting period: overall occupancy percent of at least 90% and MA occupancy percent of at least 80%.

Non-Public Medical Assistance Day One Incentive (MDOI) Payments

For fiscal years 2013-2014 and 2014-2015 the Department made MDOI payments to qualified nonpublic nursing facilities. To qualify for a payment, the facility had to be a nonpublic nursing facility during the entire Resident Day quarter used to obtain the resident days for calculating the payment, submit their resident days by the deadline, have an overall occupancy rate of at least 85% and an MA occupancy rate of at least 65%.

MA Nursing Facility Assessment

Nursing Facility Assessment Program

The Nursing Facility Assessment Program was authorized by the General Assembly in 2003. For each fiscal year in which the Program is authorized the Department of Human Services collects an assessment fee from all licensed nursing facilities (with limited exceptions) operating in Pennsylvania. The revenue from this assessment is used to maintain Medical Assistance (MA) rates and provide additional reimbursement to MA participating nursing facilities. Information related to the Nursing Facility Assessment Program including: Important Dates document; Public Notices related to assessment fees; Nursing Facility Assessment End User Manual and Signature on File form can be found on this page.

Nursing Facility Assessment Supplemental Payment Calculations

A portion of the revenues from the NF Assessment Program are used to pay qualified nursing facilities a supplemental payment. Each qualifying nursing facility’s supplemental payment is determined by multiplying the facility’s MA days as reported by the facility for the corresponding assessment quarter by a per diem rate. The supplemental per diem rates for each fiscal year in which the NF Assessment program has been in effect can be found on this page.

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