Payment Limits Applicable to Provider-Based RHCs in a

70.2.2 – Payment Limits Applicable to Provider-Based RHCs in a Hospital with Less than 50 Beds (Rev. 11803; Issued: 01-26-23; Effective: 01-01-23; Implementation: 02-27-23) Beginning April 1, 2021, provider-based RHCs that meet a specified criteria are entitled to special payment rules that establish a payment limit based on the provider-based RHC’s per visit payment amount (or AIR) instead of the national statutory payment limit. For purposes of this section of the manual, we use the term “specified” interchangeably with the term “grandfathered” since those RHCs that meet the specified criteria are considered to be “grandfathered” into the establishment of their payment limit per visit. The specified criteria that an RHC must meet in order to be eligible for the special payment rules are as follows: • As of December 31, 2020, was in a hospital with less than 50 beds (not taking into account any increase in the number of beds pursuant to a waiver during the Public Health Emergency (PHE) for COVID-19); and one of the following circumstances: o As of December 31, 2020, was enrolled in Medicare (including temporary enrollment during the PHE for COVID-19); or o Submitted an application for enrollment in Medicare (or a request for temporary enrollment during the PHE for COVID-19) that was received not later than December 31, 2020. Medicare Administrative Contractors (MACs) will calculate the payment limit per visit for specified provider-based RHCs (that is, grandfathered RHCs) as discussed in sections 70.2.2.1 and 70.2.2.2 below. A grandfathered provider-based RHC will lose this designation if the hospital does not continue to have less than 50 beds. If this occurs, the provider-based RHC will be subject to the statutory payment limit per visit applicable for such year for RHCs discussed in section 70.2.1 of this manual.