Outpatient hospital and clinic services: Application of upper payment limits
(a)Scope. This section applies to rates set by the agency…#
(a) Scope. This section applies to rates set by the agency to pay for outpatient services furnished by hospitals and clinics within one of the following categories:
(1) State government-owned or operated facilities (that is, all facilities that are owned or operated by the State.)
(2) Non-State government owned or operated facilities (that is, all government operated facilities that are neither owned nor operated by the State).
(3) Privately-owned and operated facilities.
(b)General rules.#
(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 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.