Current through Register Vol. 54, No. 49, December 7, 2024
Section 1187.157 - Termination or suspension of exceptional DME grants and recovery of exceptional payments(a)Termination or suspension of an exceptional DME grant.(1)Automatic termination. Any of the following conditions shall cause termination of a nursing facility's grant without further notice or action by the Department: (ii) The resident ceases to be MA eligible.(iii) The resident is transferred or discharged from the nursing facility with no intent to return.(iv) The resident's attending physician notifies the nursing facility that the exceptional DME is no longer medically necessary.(v) The resident notifies the Department or the nursing facility in writing that he exercises his right to refuse use of the exceptional DME.(vi) The nursing facility is no longer enrolled in the MA Program.(2)Termination upon notice. The Department may terminate a grant upon written notice to the nursing facility if any one or more of the conditions in subparagraphs (i)-(vi) occur. The Department will simultaneously provide a copy of the written notice to the resident and the resident's authorized representative, if any. (i) The Department determines that the exceptional DME is no longer medically necessary.(ii) The resident is temporarily discharged or transferred to a hospital or other health care provider.(iii) There is a change in state or federal law or regulations governing payments to MA providers of nursing facility services.(iv) Exceptional DME payments are no longer authorized under the Commonwealth's approved Medicaid State Plan.(v) The nursing facility has violated the terms of the grant.(vi) The nursing facility changes ownership.(3)Suspension of grant payments. The Department may suspend payments under a grant upon written notice to the nursing facility if one or more of the conditions in subparagraphs (i) and (ii) occur. The Department will simultaneously provide a copy of the written notice to the resident and the resident's authorized representative, if any. (i) The resident is temporarily discharged or transferred to a hospital or other health care provider.(ii) The resident is absent from the nursing facility because of therapeutic leave.(4)Termination or suspension date. A termination under paragraph (1) is effective as of the date on which the condition giving rise to the automatic termination first arises. A termination under paragraph (2) is effective on the date specified in the Department's written notice to the nursing facility. A suspension under paragraph (3) is effective on the date and for the period specified in the Department's written notice to the nursing facility.(5)Effect of termination.(i) Termination of an exceptional DME grant, whether automatic or by written notice, terminates the nursing facility's authorization to obtain exceptional payments for nursing facility services provided to the resident after the termination date.(ii) Termination of the grant ends the nursing facility's grant and the nursing facility's duty and obligation to comply with the terms of the grant or the requirements of this subchapter, except as may be otherwise specified in the grant or in this subchapter.(iii) Termination of a grant does not relieve the nursing facility of any of the nursing facility's duties and obligations relating to services provided to the resident or any other resident of the nursing facility.(6)Effect of suspension.(i) Suspension of payments under a grant terminates the nursing facility's authorization to obtain exceptional payments for nursing facility services provided to the resident for the period specified in the notice of suspension.(ii) Suspension of payments under a grant does not terminate the nursing facility's grant or the nursing facility's duty and obligation to comply with the terms of the grant or the requirements of this subchapter.(iii) Suspension of payments under a grant does not relieve the nursing facility of any of the nursing facility's duties and obligations relating to services provided to the resident or any other resident of the nursing facility.(b)Recovery of exceptional DME grant payments.(1) If a grant is terminated or if payments under a grant are suspended, the Department will recover any exceptional payments made to the nursing facility for services provided after the termination date or during the period of suspension.(2) If the nursing facility violates this subchapter or the terms of its grant, the Department may recover exceptional payments made to the nursing facility in addition to or instead of terminating the nursing facility's grant.(c)Rights and remedies. The rights and remedies available to the Department under this section are in addition to any rights, remedies and sanctions otherwise available to the Department under law and regulation. This section cited in 55 Pa. Code § 1187.154 (relating to exceptional DME grants-general conditions and limitations); 55 Pa. Code § 1187.155 (relating to exceptional DME grants-payment conditions and limitations); and 55 Pa. Code § 1187.158 (relating to appeals).