(a) Scope. This section applies to rates set by the agency to pay for inpatient services furnished by hospitals, NFs, and ICFs/IID within one of the following categories:
(1) State government-owned or operated facilities (that is, all facilities that are either owned or operated by the State).
(2) Non-State government-owned or operated facilities (that is, all government facilities that are neither owned nor operated by the State).
(3) Privately-owned and operated facilities.
(b) General rules. (1) Upper payment limit refers to a reasonable estimate of the amount that would be paid for the services furnished by the group of facilities under Medicare payment principles in subchapter B of this chapter.
(2) Except as provided for in paragraph (c) of this section, aggregate Medicaid payments to a group of facilities within one of the categories described in paragraph (a) of this section may not exceed the upper payment limit described in paragraph (b)(1) of this section.
(c) Exceptions—(1) Indian Health Services and tribal facilities. The limitation in paragraph (b) of this section does not apply to Indian Health Services facilities and tribal facilities that are funded through the Indian Self-Determination and Education Assistance Act (Pub. L. 93-638).
(2) Disproportionate share hospitals. The limitation in paragraph (b) of this section does not apply to payment adjustments made under section 1923 of the Act that are made under a State plan to hospitals found to serve a disproportionate number of low-income patients with special needs as provided in section 1902(a)(13)(A)(iv) of the Act. Disproportionate share hospital (DSH) payments are subject to the following limits:
(i) The aggregate DSH limit using the Federal share of the DSH limit under section 1923(f) of the Act.
(ii) The hospital-specific DSH limit in section 1923(g) of the Act.
(iii) The aggregate DSH limit for institutions for mental disease (IMDs) under section 1923(h) of the Act.
(d) Compliance dates. Except as permitted under paragraph (e) of this section, a State must comply with the upper payment limit described in paragraph (b) of this section by one of the following dates:
(1) For non-State government owned or operated hospitals,—March 19, 2002.
(2) For all other facilities—March 13, 2001.
[66 FR 3175, Jan. 12, 2001, as amended at 66 FR 46399, Sept. 5, 2001; 67 FR 2610, Jan. 18, 2002; 72 FR 29834, May 29, 2007; 75 FR 73975, Nov. 30, 2010; 77 FR 31512, May 29, 2012]
Notes of Decisions
Ashley Cnty. Med. Ctr. v. Thompson, 205 F. Supp. 2d 1026 (E.D. Ark. 2002).
· cites it 4× “1 These regulations — codified at 42 C.F.R. §§ 447.272 and 42 C.F.R. 447.321 — are known collectively as the 2002 Upper Payment Limit Rule.”
Dickinson Nursing Ctr. v. North Dakota Dep't of Human Servs., 353 N.W.2d 754 (N.D. 1984).
· cites it 2× “” [ 42 C.F.R. § 447.272 (a) (1983)]. 2 Thus the Department’s payment-rate regulations are closely patterned after the corresponding principles governing reimbursement for long-term-care services rendered under Medicare, Title XVIII of the Social Security Act, 42 U.”
Multicare Med. Ctr. v. State of Wash., 768 F. Supp. 1349 (W.D. Wash. 1991).
“” 42 C.F.R. § 447.272 . DSHS must, whenever it makes a change in its methods and standards, but not less often than annually, make a finding that proposed payment rates will not exceed the upper payment limits.”
Alabama Nursing Home Ass'n v. Harris, 617 F.2d 388 (5th Cir. 1980).
“The applicable federal regulations have been recodified and currently appear at 42 C.F.R. §§ 447.272 to .316 (1979). This opinion refers to the regulations as they appeared at the time Alabama’s proposed reimbursement methodology was being formulated and approved.”
Connecticut Hosp. Ass'n v. Weicker, 46 F.3d 211 (2d Cir. 1995).
· cites it 2× “” 42 C.F.R. § 447.272 . Because the Medicare principles are used to compute the upper limit for payments to any particular group of providers, and because Medicaid plans approved under these principles were “subjected to a more rigorous statutory standard,” the Secretary has…”
Connecticut Hosp. Ass'n v. O'Neill, 793 F. Supp. 47 (D. Conn. 1992).
“The Magistrate Judge determined that regulations promulgated by the Secretary in 1983, specifically 42 C.F.R. § 447.272 , limited Medicaid payments by states to a reasonable estimation of what Medicare payments would have been for similar services.”
SSM Healthcare Sys. v. Reagen, 681 F. Supp. 625 (W.D. Mo. 1988).
“In response to the enactment of § 1396a(h), which was effective retroactively as if it was included in the Omnibus Budget Reconstruction Act of 1981, HCFA issued a revised version of its upper limit test set forth in 42 C.F.R. § 447.272 , which became effective on July 28, 1987,…”
Lewis v. Hegstrom, 581 F. Supp. 183 (D. Or. 1983).
“-252, 42 C.F.R. § 447.272 , 42 C.F.R. part 405, subpt.”
— 42 C.F.R. § 447.272(b) — 2 cases
— 42 C.F.R. § 447.272(c)(2) — 1 case
Ashley Cnty. Med. Ctr. v. Thompson, 205 F. Supp. 2d 1026 (E.D. Ark. 2002).
“1 These regulations — codified at 42 C.F.R. §§ 447.272 and 42 C.F.R. 447.321 — are known collectively as the 2002 Upper Payment Limit Rule.”
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