SENATE AMENDED
PRIOR PRINTER'S NOS. 2385, 2500, 4127 PRINTER'S NO. 4179
No. 1788 Session of 2007
INTRODUCED BY McILVAINE SMITH, BELFANTI, BLACKWELL, CARROLL,
DeLUCA, GIBBONS, GINGRICH, GOODMAN, HENNESSEY, JOSEPHS,
KOTIK, KULA, LEACH, MANDERINO, McGEEHAN, R. MILLER, MILNE,
MOUL, MUNDY, MURT, PARKER, PETRONE, REICHLEY, RUBLEY,
K. SMITH, STABACK, SURRA, WALKO, YOUNGBLOOD, FRANKEL, KORTZ,
FREEMAN, SIPTROTH AND CALTAGIRONE, AUGUST 1, 2007
SENATOR ARMSTRONG, APPROPRIATIONS, IN SENATE, RE-REPORTED AS
AMENDED, JULY 2, 2008
AN ACT
1 Requiring the Department of Public Welfare to prepare and submit <--
2 a report on licensing of personal care homes.
3 AMENDING THE ACT OF JUNE 13, 1967 (P.L.31, NO.21), ENTITLED "AN <--
4 ACT TO CONSOLIDATE, EDITORIALLY REVISE, AND CODIFY THE PUBLIC
5 WELFARE LAWS OF THE COMMONWEALTH," PROVIDING FOR PERSONAL <--
6 CARE HOME INFORMATION. IN PUBLIC ASSISTANCE, FURTHER <--
7 PROVIDING FOR MEDICAL ASSISTANCE PAYMENTS FOR INSTITUTIONAL
8 CARE; PROVIDING FOR PAYMENTS FOR HOSPITAL READMISSIONS AND
9 FOR MAXIMUM PAYMENT TO PRACTITIONERS FOR INPATIENT
10 HOSPITALIZATION; FURTHER PROVIDING FOR PHARMACEUTICAL AND
11 THERAPEUTICS COMMITTEE; PROVIDING FOR DRUG UTILIZATION REVIEW
12 BOARD; FURTHER PROVIDING FOR MEDICAID MANAGED CARE
13 ORGANIZATION ASSESSMENTS; IN ASSESSMENTS FOR INTERMEDIATE
14 CARE FACILITIES FOR MENTALLY RETARDED PERSONS, FURTHER
15 PROVIDING FOR TIME PERIODS; PROVIDING FOR HOSPITAL
16 ASSESSMENTS; IN DEPARTMENTAL POWERS AND DUTIES AS TO
17 LICENSING, PROVIDING FOR PERSONAL CARE HOME INFORMATION; IN
18 FRAUD AND ABUSE CONTROL, FURTHER PROVIDING FOR THIRD-PARTY
19 LIABILITY; PROVIDING FOR FEDERAL LAW RECOVERY OF MEDICAL
20 ASSISTANCE REIMBURSEMENT; AND FURTHER PROVIDING FOR DATA
21 MATCHING.
22 The General Assembly of the Commonwealth of Pennsylvania
23 hereby enacts as follows:
24 Section 1. Short title. <--
1 This act shall be known and may be cited as the Personal Care
2 Homes Licensing and Inspection Reporting Act.
3 Section 2. Definitions.
4 The following words and phrases when used in this act shall
5 have the meanings given to them in this section unless the
6 context clearly indicates otherwise:
7 "Department." The Department of Public Welfare of the
8 Commonwealth.
9 "Personal care home." As defined in section 1001 of the act
10 of June 13, 1967 (P.L.31, No.21), known as the Public Welfare
11 Code.
12 "Relative." As defined in section 1001 of the act of June
13 13, 1967 (P.L.31, No.21), known as the Public Welfare Code.
14 Section 3. Report to Governor and General Assembly.
15 By March 1, the department shall submit an annual report
16 relating to the licensing and inspection of personal care homes
17 to the Governor, the Chief Clerk of the Senate and the Chief
18 Clerk of the House of Representatives. The report shall include
19 the following information covering the preceding calendar year:
20 (1) Number of licensed personal care homes.
21 (2) Number of residents in licensed personal care homes.
22 (3) Number of personal care homes which have received an
23 annual inspection.
24 (4) Number of licensing inspectors, Statewide and by
25 region, as defined by the department to identify counties.
26 (5) Ratio of licensing staff per licensed personal care
27 home.
28 (6) Number of personal care homes operating with a
29 provisional license, Statewide and by county.
30 (7) Number of personal care homes operating with a full
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1 license, Statewide and by county.
2 (8) Number of personal care homes which the department
3 has closed or taken legal action to close.
4 (9) Description of violations of Article X of the act of
5 June 13, 1967 (P.L.31, No.21), known as the Public Welfare
6 Code, classification of violations under section 1085 of the
7 Public Welfare Code and frequency of violations.
8 (10) Extent to which the department assessed financial
9 penalties against licensed personal care homes as provided
10 for in Article X of the Public Welfare Code.
11 (11) Specific plans of the department to ensure
12 compliance with the Public Welfare Code regarding inspection
13 of licensed personal care homes and enforcement of
14 regulations.
15 (12) Other information the department deems pertinent.
16 Section 4. Effective date.
17 This act shall take effect in 60 days.
18 SECTION 1. THE ACT OF JUNE 13, 1967 (P.L.31, NO.21), KNOWN <--
19 AS THE PUBLIC WELFARE CODE, IS AMENDED BY ADDING A SECTION TO
20 READ:
21 SECTION 1088. PERSONAL CARE HOME INFORMATION.--THE
22 DEPARTMENT SHALL POST INFORMATION ON ITS INTERNET WEBSITE
23 RELATING TO THE LICENSURE AND INSPECTION OF PERSONAL CARE HOMES.
24 THE INFORMATION SHALL BE UPDATED AT LEAST ANNUALLY. THE
25 INFORMATION SHALL INCLUDE THE FOLLOWING:
26 (1) NUMBER OF LICENSED PERSONAL CARE HOMES.
27 (2) NUMBER OF RESIDENTS IN LICENSED PERSONAL CARE HOMES.
28 (3) NUMBER OF PERSONAL CARE HOMES WHICH HAVE RECEIVED AN
29 ANNUAL INSPECTION.
30 (4) NUMBER OF PERSONAL CARE HOME INSPECTORS STATEWIDE AND BY
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1 REGION.
2 (5) RATIO OF DEPARTMENT STAFF RESPONSIBLE FOR THE LICENSURE
3 AND INSPECTION OF PERSONAL CARE HOMES DIVIDED BY THE TOTAL
4 NUMBER OF LICENSED PERSONAL CARE HOMES.
5 (6) NUMBER OF PERSONAL CARE HOMES OPERATING WITH A
6 PROVISIONAL LICENSE, STATEWIDE AND BY COUNTY.
7 (7) NUMBER OF PERSONAL CARE HOMES OPERATING WITH A FULL
8 LICENSE, STATEWIDE AND BY COUNTY.
9 (8) NUMBER OF PERSONAL CARE HOMES WHICH THE DEPARTMENT HAS
10 CLOSED OR TAKEN LEGAL ACTION TO CLOSE.
11 (9) FOR EACH PERSONAL CARE HOME, A LICENSING INSPECTION
12 SUMMARY WHICH LISTS ANY VIOLATION UNDER THIS ARTICLE.
13 (10) SUMMARY OF TYPES OF VIOLATIONS WHICH ARE LISTED IN
14 LICENSING INSPECTION SUMMARIES, IN ACCORDANCE WITH THE
15 CLASSIFICATION OF VIOLATIONS SET FORTH UNDER THIS ARTICLE.
16 (11) UPON IMPLEMENTATION OF A FINANCIAL PENALTY PROGRAM, THE
17 INTERNET WEBSITE SHALL INCLUDE INFORMATION RELATING TO ASSESSED
18 FINANCIAL PENALTIES AGAINST LICENSED PERSONAL CARE HOMES AS
19 PROVIDED FOR IN THIS ARTICLE.
20 (12) A SUMMARY OF THE SPECIFIC PLANS OF THE DEPARTMENT TO
21 ENSURE COMPLIANCE WITH THIS ARTICLE REGARDING INSPECTION OF
22 LICENSED PERSONAL CARE HOMES AND ENFORCEMENT OF REGULATIONS.
23 (13) OTHER INFORMATION THE DEPARTMENT DEEMS PERTINENT.
24 SECTION 2. THIS ACT SHALL TAKE EFFECT IN 60 DAYS.
25 SECTION 1. SECTION 443.1(7) OF THE ACT OF JUNE 13, 1967 <--
26 (P.L.31, NO.21), KNOWN AS THE PUBLIC WELFARE CODE, IS AMENDED BY
27 ADDING A SUBCLAUSE TO READ:
28 SECTION 443.1. MEDICAL ASSISTANCE PAYMENTS FOR INSTITUTIONAL
29 CARE.--THE FOLLOWING MEDICAL ASSISTANCE PAYMENTS SHALL BE MADE
30 IN BEHALF OF ELIGIBLE PERSONS WHOSE INSTITUTIONAL CARE IS
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1 PRESCRIBED BY PHYSICIANS:
2 * * *
3 (7) AFTER JUNE 30, 2007, PAYMENTS TO COUNTY AND NONPUBLIC
4 NURSING FACILITIES ENROLLED IN THE MEDICAL ASSISTANCE PROGRAM AS
5 PROVIDERS OF NURSING FACILITY SERVICES SHALL BE DETERMINED IN
6 ACCORDANCE WITH THE METHODOLOGIES FOR ESTABLISHING PAYMENT RATES
7 FOR COUNTY AND NONPUBLIC NURSING FACILITIES SPECIFIED IN THE
8 DEPARTMENT'S REGULATIONS AND THE COMMONWEALTH'S APPROVED TITLE
9 XIX STATE PLAN FOR NURSING FACILITY SERVICES IN EFFECT AFTER
10 JUNE 30, 2007. THE FOLLOWING SHALL APPLY:
11 * * *
12 (III) SUBJECT TO FEDERAL APPROVAL OF SUCH AMENDMENTS AS MAY
13 BE NECESSARY TO THE COMMONWEALTH'S APPROVED TITLE XIX STATE
14 PLAN, THE DEPARTMENT SHALL DO ALL OF THE FOLLOWING:
15 (A) FOR EACH FISCAL YEAR BETWEEN JULY 1, 2008, AND JUNE 30,
16 2011, THE DEPARTMENT SHALL APPLY A REVENUE ADJUSTMENT NEUTRALITY
17 FACTOR TO COUNTY AND NONPUBLIC NURSING FACILITY PAYMENT RATES.
18 FOR EACH SUCH FISCAL YEAR, THE REVENUE ADJUSTMENT NEUTRALITY
19 FACTOR SHALL LIMIT THE ESTIMATED AGGREGATE INCREASE IN THE
20 STATEWIDE DAY-WEIGHTED AVERAGE PAYMENT RATE SO THAT THE
21 AGGREGATE PERCENTAGE RATE OF INCREASE FOR THE PERIOD THAT BEGINS
22 ON JULY 1, 2005, AND ENDS ON THE LAST DAY OF THE FISCAL YEAR IS
23 LIMITED TO THE AMOUNT PERMITTED BY THE FUNDS APPROPRIATED BY THE
24 GENERAL APPROPRIATIONS ACT FOR THOSE FISCAL YEARS.
25 (B) IN CALCULATING RATES FOR NONPUBLIC NURSING FACILITIES
26 FOR FISCAL YEAR 2008-2009, THE DEPARTMENT SHALL CONTINUE TO
27 INCLUDE COSTS INCURRED BY COUNTY NURSING FACILITIES IN THE RATE-
28 SETTING DATABASE, AS SPECIFIED IN THE DEPARTMENT'S REGULATIONS
29 IN EFFECT ON JULY 1, 2007.
30 (C) THE DEPARTMENT SHALL PROPOSE REGULATIONS THAT PHASE OUT
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1 THE USE OF COUNTY NURSING FACILITY COSTS AS AN INPUT IN THE
2 PROCESS OF SETTING PAYMENT RATES OF NONPUBLIC NURSING
3 FACILITIES. THE FINAL REGULATIONS SHALL BE EFFECTIVE JULY 1,
4 2009, AND SHALL PHASE OUT THE USE OF THESE COSTS IN RATE-SETTING
5 OVER A PERIOD OF THREE RATE YEARS, BEGINNING FISCAL YEAR 2009-
6 2010 AND ENDING ON JUNE 30, 2012.
7 (D) THE DEPARTMENT SHALL PROPOSE REGULATIONS THAT ESTABLISH
8 MINIMUM OCCUPANCY REQUIREMENTS AS A CONDITION FOR BED HOLD
9 PAYMENTS. THE FINAL REGULATIONS SHALL BE EFFECTIVE JULY 1, 2009,
10 AND SHALL PHASE IN THESE REQUIREMENTS OVER A PERIOD OF TWO RATE
11 YEARS, BEGINNING FISCAL YEAR 2009-2010.
12 * * *
13 SECTION 2. THE ACT IS AMENDED BY ADDING SECTIONS TO READ:
14 SECTION 443.9. PAYMENTS FOR READMISSION TO A HOSPITAL PAID
15 THROUGH DIAGNOSIS-RELATED GROUPS.--ALL OF THE FOLLOWING SHALL
16 APPLY TO ELIGIBLE RECIPIENTS READMITTED TO A HOSPITAL WITHIN
17 FOURTEEN DAYS OF THE DATE OF DISCHARGE:
18 (1) IF THE READMISSION IS FOR THE TREATMENT OF CONDITIONS
19 THAT COULD OR SHOULD HAVE BEEN TREATED DURING THE PREVIOUS
20 ADMISSION, THE DEPARTMENT SHALL MAKE NO PAYMENT IN ADDITION TO
21 THE HOSPITAL'S ORIGINAL DIAGNOSIS-RELATED GROUP PAYMENT. IF THE
22 COMBINED HOSPITAL STAY QUALIFIES AS AN OUTLIER, AS SET FORTH
23 UNDER THE DEPARTMENT'S REGULATIONS, AN OUTLIER PAYMENT SHALL BE
24 MADE.
25 (2) IF THE READMISSION IS DUE TO COMPLICATIONS OF THE
26 ORIGINAL DIAGNOSIS AND THE RESULT IS A DIFFERENT DIAGNOSIS-
27 RELATED GROUP WITH A HIGHER PAYMENT, THE DEPARTMENT SHALL PAY
28 THE HIGHER DIAGNOSIS-RELATED GROUP PAYMENT RATHER THAN THE
29 ORIGINAL DIAGNOSIS-RELATED GROUP PAYMENT.
30 (3) IF THE READMISSION IS DUE TO CONDITIONS UNRELATED TO THE
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1 PREVIOUS ADMISSION, THE DEPARTMENT SHALL CONSIDER THE
2 READMISSION AS A NEW ADMISSION FOR PAYMENT PURPOSES.
3 SECTION 443.10. MAXIMUM PAYMENT TO PRACTITIONERS FOR
4 INPATIENT HOSPITALIZATION.--THE MAXIMUM PAYMENT MADE TO A
5 PRACTITIONER FOR ALL SERVICES PROVIDED TO AN ELIGIBLE RECIPIENT
6 DURING ANY ONE PERIOD OF INPATIENT HOSPITALIZATION SHALL BE THE
7 LOWEST OF THE FOLLOWING:
8 (1) THE PRACTITIONER'S USUAL CHARGE TO THE GENERAL PUBLIC
9 FOR THE SAME SERVICE.
10 (2) THE MEDICAL ASSISTANCE MAXIMUM ALLOWABLE FEE FOR THE
11 SERVICE.
12 (3) A MAXIMUM PAYMENT LIMIT, PER RECIPIENT PER THE PERIOD OF
13 INPATIENT HOSPITALIZATION, ESTABLISHED BY THE MEDICAL ASSISTANCE
14 PROGRAM AND PUBLISHED AS A NOTICE IN THE PENNSYLVANIA BULLETIN.
15 IF THE FEE FOR THE ACTUAL SERVICE EXCEEDS THE MAXIMUM PAYMENT
16 LIMIT, THE FEE FOR THE ACTUAL PROCEDURE SHALL BE THE MAXIMUM
17 PAYMENT FOR THE PERIOD OF INPATIENT HOSPITALIZATION.
18 SECTION 3. SECTION 460 OF THE ACT, ADDED JUNE 30, 2007
19 (P.L.49, NO.16), IS AMENDED TO READ:
20 SECTION 460. PHARMACEUTICAL AND THERAPEUTICS COMMITTEE.--(A)
21 ANY COMMONWEALTH PHARMACY PROGRAM THAT ESTABLISHES OR MAINTAINS
22 A PREFERRED DRUG LIST [AND RECEIVES] FOR THE PURPOSE OF
23 RECEIVING SUPPLEMENTAL REBATES [UNDER] CONSISTENT WITH SECTION
24 [1927] 1927(D)(4) OF THE SOCIAL SECURITY ACT (49 STAT. 620, 42
25 U.S.C. § [1396R-8] 1396R-8(D)(4)) SHALL ESTABLISH A
26 PHARMACEUTICAL AND THERAPEUTICS COMMITTEE[. THE PHARMACEUTICAL
27 AND THERAPEUTICS COMMITTEE SHALL] THAT SHALL SERVE IN AN
28 ADVISORY CAPACITY TO THE DEPARTMENT AND TO THE SECRETARY FOR THE
29 PURPOSE OF DEVELOPING AND MAINTAINING A PREFERRED DRUG LIST [AND
30 DEVELOPING AND MAINTAINING DRUG UTILIZATION REVIEW CONTROLS FOR
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1 PRESCRIPTION DRUGS AND MEDICAL DEVICES].
2 (B) THE COMMITTEE SHALL PUBLICIZE [THEIR] ITS MEETINGS
3 PURSUANT TO 65 PA.C.S. CH. 7 (RELATING TO OPEN MEETINGS)[, AND
4 THE]. THE COMMITTEE'S DELIBERATIONS, RECOMMENDATIONS AND
5 DECISIONS [SHALL BE CONSIDERED OFFICIAL ACTION AND] SHALL BE
6 OPEN TO THE PUBLIC EXCEPT AS LIMITED BY 65 PA.C.S. §§ 707
7 (RELATING TO EXCEPTIONS TO OPEN MEETINGS) AND 708 (RELATING TO
8 EXECUTIVE SESSIONS).
9 SECTION 4. THE ACT IS AMENDED BY ADDING A SECTION TO READ:
10 SECTION 460.1. DRUG UTILIZATION REVIEW BOARD.--(A) THE DRUG
11 UTILIZATION REVIEW BOARD SHALL BE ESTABLISHED BY THE DEPARTMENT
12 CONSISTENT WITH SECTION 1927(G)(3) OF THE SOCIAL SECURITY ACT
13 (42 U.S.C. § 1396R-8(G)(3)). THE BOARD SHALL HAVE THE FOLLOWING
14 POWERS AND DUTIES:
15 (1) TO ADVISE THE DEPARTMENT AND THE SECRETARY ON THE DRUG
16 UTILIZATION REVIEW CONTROLS FOR PRESCRIPTION DRUGS AS REQUIRED
17 BY SECTION 1927(G)(3) OF THE SOCIAL SECURITY ACT, INCLUDING
18 APPROPRIATE UTILIZATION PROTOCOLS FOR INDIVIDUAL MEDICATIONS AND
19 FOR THERAPEUTIC CATEGORIES AND PRIOR AUTHORIZATION GUIDELINES.
20 (2) TO SERVE IN AN ADVISORY CAPACITY TO THE SECRETARY FOR
21 THE PURPOSE OF DEVELOPING AND MAINTAINING DRUG UTILIZATION
22 REVIEW CONTROLS FOR PRESCRIPTION DRUGS AND SERVE TO PROMOTE
23 PATIENT SAFETY BY AN INCREASED REVIEW AND AWARENESS OF
24 OUTPATIENT PRESCRIBED DRUGS IN THE DEPARTMENT'S MEDICAL
25 ASSISTANCE PROGRAM.
26 (B) THE BOARD SHALL PUBLICIZE ITS MEETINGS PURSUANT TO 65
27 PA.C.S. CH. 7 (RELATING TO OPEN MEETINGS). THE COMMITTEE'S
28 DELIBERATIONS, RECOMMENDATIONS AND DECISIONS SHALL BE OPEN TO
29 THE PUBLIC, EXCEPT AS LIMITED BY 65 PA.C.S. §§ 707 (RELATING TO
30 EXCEPTIONS TO OPEN MEETINGS) AND 708 (RELATING TO EXECUTIVE
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1 SESSIONS).
2 SECTION 5. ARTICLE VIII-B OF THE ACT IS REPEALED:
3 [ARTICLE VIII-B
4 MEDICAID MANAGED CARE ORGANIZATION ASSESSMENTS
5 SECTION 801-B. DEFINITIONS.
6 THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS ARTICLE
7 SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE
8 CONTEXT CLEARLY INDICATES OTHERWISE:
9 "ASSESSMENT PERCENTAGE." THE RATE ASSESSED PURSUANT TO THIS
10 ARTICLE ON EVERY MEDICAID MANAGED CARE ORGANIZATION.
11 "ASSESSMENT PERIOD." THE TIME PERIOD IDENTIFIED IN THE
12 CONTRACT.
13 "ASSESSMENT PROCEEDS." THE STATE REVENUE COLLECTED FROM THE
14 ASSESSMENT PROVIDED FOR IN THIS ARTICLE, ANY FEDERAL FUNDS
15 RECEIVED BY THE COMMONWEALTH AS A DIRECT RESULT OF THE
16 ASSESSMENT AND ANY PENALTIES AND INTEREST RECEIVED UNDER SECTION
17 810-B.
18 "CONTRACT." THE AGREEMENT BETWEEN A MEDICAID MANAGED CARE
19 ORGANIZATION AND THE DEPARTMENT OF PUBLIC WELFARE.
20 "COUNTY MEDICAID MANAGED CARE ORGANIZATION." A COUNTY, OR AN
21 ENTITY ORGANIZED AND CONTROLLED DIRECTLY OR INDIRECTLY BY A
22 COUNTY OR A CITY OF THE FIRST CLASS, THAT IS A PARTY TO A
23 MEDICAID MANAGED CARE CONTRACT WITH THE DEPARTMENT OF PUBLIC
24 WELFARE.
25 "DEPARTMENT." THE DEPARTMENT OF PUBLIC WELFARE OF THE
26 COMMONWEALTH.
27 "MEDICAID." THE PROGRAM ESTABLISHED UNDER TITLE XIX OF THE
28 SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. § 1396 ET SEQ.).
29 "MEDICAID MANAGED CARE ORGANIZATION." A MEDICAID MANAGED
30 CARE ORGANIZATION AS DEFINED IN SECTION 1903(M)(1)(A) OF THE
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1 SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. § 1396B(M)(1)(A))
2 THAT IS A PARTY TO A MEDICAID MANAGED CARE CONTRACT WITH THE
3 DEPARTMENT OF PUBLIC WELFARE. THE TERM SHALL INCLUDE A COUNTY
4 MEDICAID MANAGED CARE ORGANIZATION AND A PERMITTED ASSIGNEE OF A
5 MEDICAID MANAGED CARE CONTRACT BUT SHALL NOT INCLUDE AN ASSIGNOR
6 OF A MEDICAID MANAGED CARE CONTRACT.
7 "SECRETARY." THE SECRETARY OF PUBLIC WELFARE OF THE
8 COMMONWEALTH.
9 "SOCIAL SECURITY ACT." 49 STAT. 620, 42 U.S.C. § 301 ET SEQ.
10 SECTION 802-B. AUTHORIZATION.
11 THE DEPARTMENT SHALL IMPLEMENT AN ASSESSMENT ON EACH MEDICAID
12 MANAGED CARE ORGANIZATION, SUBJECT TO THE CONDITIONS AND
13 REQUIREMENTS SPECIFIED IN THIS ARTICLE.
14 SECTION 803-B. IMPLEMENTATION.
15 THE ASSESSMENT SHALL BE IMPLEMENTED ON AN ANNUAL BASIS,
16 THROUGH PERIODIC SUBMISSIONS NOT TO EXCEED FIVE TIMES PER YEAR
17 BY MEDICAID MANAGED CARE ORGANIZATIONS, AS A HEALTH CARE-RELATED
18 FEE AS DEFINED IN SECTION 1903(W)(3)(B) OF THE SOCIAL SECURITY
19 ACT, OR ANY AMENDMENTS THERETO, AND MAY BE IMPOSED AND IS
20 REQUIRED TO BE PAID ONLY TO THE EXTENT THAT THE REVENUES
21 GENERATED FROM THE ASSESSMENT QUALIFY AS THE STATE SHARE OF
22 PROGRAM EXPENDITURES ELIGIBLE FOR FEDERAL FINANCIAL
23 PARTICIPATION.
24 SECTION 804-B. ASSESSMENT PERCENTAGE.
25 (A) AMOUNT.--THE ASSESSMENT PERCENTAGE SHALL BE UNIFORM FOR
26 ALL MEDICAID MANAGED CARE ORGANIZATIONS, DETERMINED IN
27 ACCORDANCE WITH THIS SECTION AND IMPLEMENTED BY THE DEPARTMENT
28 AS APPROVED BY THE GOVERNOR AFTER NOTIFICATION TO AND IN
29 CONSULTATION WITH THE MEDICAID MANAGED CARE ORGANIZATIONS. THE
30 ASSESSMENT PERCENTAGE SHALL BE SUBJECT TO THE MAXIMUM AGGREGATE
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1 AMOUNT THAT MAY BE ASSESSED PURSUANT TO 42 CFR 433.68(F)(3)(I)
2 (RELATING TO PERMISSIBLE HEALTH CARE-RELATED TAXES AFTER THE
3 TRANSITION PERIOD) OR ANY SUBSEQUENT MAXIMUM ESTABLISHED BY
4 FEDERAL LAW.
5 (B) NOTICE.--SUBJECT TO THE PROVISIONS OF SUBSECTION (C),
6 THE DEPARTMENT SHALL NOTIFY EACH MEDICAID MANAGED CARE
7 ORGANIZATION OF A PROPOSED ASSESSMENT PERCENTAGE. MEDICAID
8 MANAGED CARE ORGANIZATIONS SHALL HAVE 30 DAYS FROM THE DATE OF
9 THE PROPOSED ASSESSMENT PERCENTAGE NOTICE TO PROVIDE WRITTEN
10 COMMENTS TO THE DEPARTMENT REGARDING THE PROPOSED ASSESSMENT.
11 UPON EXPIRATION OF THE 30-DAY COMMENT PERIOD, THE DEPARTMENT,
12 AFTER CONSIDERATION OF THE COMMENTS, SHALL PROVIDE EACH MEDICAID
13 MANAGED CARE ORGANIZATION WITH A SECOND NOTICE ANNOUNCING THE
14 ASSESSMENT PERCENTAGE. ONCE EFFECTIVE, AN ASSESSMENT PERCENTAGE
15 WILL REMAIN IN EFFECT UNTIL THE DEPARTMENT NOTIFIES EACH
16 MEDICAID MANAGED CARE ORGANIZATION OF A NEW ASSESSMENT
17 PERCENTAGE IN ACCORDANCE WITH THE NOTICE PROVISIONS CONTAINED IN
18 THIS SECTION.
19 (C) INITIAL ASSESSMENT.--THE INITIAL ASSESSMENT PERCENTAGE
20 MAY BE IMPOSED RETROACTIVELY TO THE BEGINNING OF AN ASSESSMENT
21 PERIOD BEGINNING ON OR AFTER JULY 1, 2004. ONCE EFFECTIVE, THE
22 INITIAL ASSESSMENT PERCENTAGE WILL REMAIN IN EFFECT UNTIL THE
23 DEPARTMENT NOTIFIES EACH MEDICAID MANAGED CARE ORGANIZATION OF A
24 NEW ASSESSMENT PERCENTAGE IN ACCORDANCE WITH THE NOTICE
25 PROVISIONS CONTAINED IN THIS SECTION.
26 SECTION 805-B. CALCULATION AND PAYMENT.
27 USING THE ASSESSMENT PERCENTAGE ESTABLISHED UNDER SECTION
28 804-B, EACH MEDICAID MANAGED CARE ORGANIZATION SHALL CALCULATE
29 THE ASSESSMENT AMOUNT FOR EACH ASSESSMENT PERIOD ON A REPORT
30 FORM SPECIFIED BY THE CONTRACT AND SHALL SUBMIT THE COMPLETED
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1 REPORT FORM AND TOTAL AMOUNT OWED TO THE DEPARTMENT ON A DUE
2 DATE SPECIFIED BY THE CONTRACT. THE MEDICAID MANAGED CARE
3 ORGANIZATION SHALL REPORT NET OPERATING REVENUE FOR PURPOSES OF
4 THE ASSESSMENT CALCULATION AS SPECIFIED IN THE CONTRACT.
5 SECTION 806-B. USE OF ASSESSMENT PROCEEDS.
6 NO MEDICAID MANAGED CARE ORGANIZATION SHALL BE GUARANTEED A
7 REPAYMENT OF ITS ASSESSMENT IN DEROGATION OF 42 CFR 433.68(F),
8 PROVIDED, HOWEVER, IN EACH FISCAL YEAR IN WHICH AN ASSESSMENT IS
9 IMPLEMENTED, THE DEPARTMENT SHALL USE THE ASSESSMENT PROCEEDS TO
10 MAINTAIN ACTUARIALLY SOUND RATES AS DEFINED IN THE CONTRACT FOR
11 THE MEDICAID MANAGED CARE ORGANIZATIONS TO THE EXTENT
12 PERMISSIBLE UNDER FEDERAL AND STATE LAW OR REGULATION AND
13 WITHOUT CREATING A GUARANTEE TO HOLD HARMLESS, AS THOSE TERMS
14 ARE USED IN 42 CFR 433.68(F) (RELATING TO PERMISSIBLE HEALTH
15 CARE-RELATED TAXES AFTER THE TRANSITION PERIOD).
16 SECTION 807-B. RECORDS.
17 UPON WRITTEN REQUEST BY THE DEPARTMENT, A MEDICAID MANAGED
18 CARE ORGANIZATION SHALL FURNISH TO THE DEPARTMENT SUCH RECORDS
19 AS THE DEPARTMENT MAY SPECIFY IN ORDER TO DETERMINE THE AMOUNT
20 OF ASSESSMENT DUE FROM THE MEDICAID MANAGED CARE ORGANIZATION OR
21 TO VERIFY THAT THE MEDICAID MANAGED CARE ORGANIZATION HAS
22 CALCULATED AND PAID THE CORRECT AMOUNT DUE. THE REQUESTED
23 RECORDS SHALL BE PROVIDED TO THE DEPARTMENT WITHIN 30 DAYS FROM
24 THE DATE OF THE MEDICAID MANAGED CARE ORGANIZATION'S RECEIPT OF
25 THE WRITTEN REQUEST UNLESS REQUIRED AT AN EARLIER DATE FOR
26 PURPOSES OF THE DEPARTMENT'S COMPLIANCE WITH A REQUEST FROM A
27 FEDERAL OR ANOTHER STATE AGENCY.
28 SECTION 808-B. PAYMENT OF ASSESSMENT.
29 IN THE EVENT THAT THE DEPARTMENT DETERMINES THAT A MEDICAID
30 MANAGED CARE ORGANIZATION HAS FAILED TO PAY AN ASSESSMENT OR
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1 THAT IT HAS UNDERPAID AN ASSESSMENT, THE DEPARTMENT SHALL
2 PROVIDE WRITTEN NOTIFICATION TO THE MEDICAID MANAGED CARE
3 ORGANIZATION WITHIN 180 DAYS OF THE ORIGINAL DUE DATE OF THE
4 AMOUNT DUE, INCLUDING INTEREST, AND THE DATE ON WHICH THE AMOUNT
5 DUE MUST BE PAID, WHICH SHALL NOT BE LESS THAN 30 DAYS FROM THE
6 DATE OF THE NOTICE. IN THE EVENT THAT THE DEPARTMENT DETERMINES
7 THAT A MEDICAID MANAGED CARE ORGANIZATION HAS OVERPAID AN
8 ASSESSMENT, THE DEPARTMENT SHALL NOTIFY THE MEDICAID MANAGED
9 CARE ORGANIZATION IN WRITING OF THE OVERPAYMENT, AND, WITHIN 30
10 DAYS OF THE DATE OF THE NOTICE OF THE OVERPAYMENT, THE MEDICAID
11 MANAGED CARE ORGANIZATION SHALL ADVISE THE DEPARTMENT TO EITHER
12 AUTHORIZE A REFUND OF THE AMOUNT OF THE OVERPAYMENT OR OFFSET
13 THE AMOUNT OF THE OVERPAYMENT AGAINST ANY AMOUNT THAT MAY BE
14 OWED TO THE DEPARTMENT BY THE MEDICAID MANAGED CARE
15 ORGANIZATION.
16 SECTION 809-B. APPEAL RIGHTS.
17 A MEDICAID MANAGED CARE ORGANIZATION THAT IS AGGRIEVED BY A
18 DETERMINATION OF THE DEPARTMENT RELATING TO THE ASSESSMENT MAY
19 FILE A REQUEST FOR REVIEW OF THE DECISION OF THE DEPARTMENT BY
20 THE BUREAU OF HEARINGS AND APPEALS WITHIN THE DEPARTMENT, WHICH
21 SHALL HAVE EXCLUSIVE PRIMARY JURISDICTION IN SUCH MATTERS. THE
22 PROCEDURES AND REQUIREMENTS OF 67 PA.C.S. CH. 11 (RELATING TO
23 MEDICAL ASSISTANCE HEARINGS AND APPEALS) SHALL APPLY TO REQUESTS
24 FOR REVIEW FILED PURSUANT TO THIS SECTION EXCEPT THAT, IN ANY
25 SUCH REQUEST FOR REVIEW, A MEDICAID MANAGED CARE ORGANIZATION
26 MAY NOT CHALLENGE THE ASSESSMENT PERCENTAGE DETERMINED BY THE
27 DEPARTMENT PURSUANT TO SECTION 804-B.
28 SECTION 810-B. ENFORCEMENT.
29 IN ADDITION TO ANY OTHER REMEDY PROVIDED BY LAW, THE
30 DEPARTMENT MAY ENFORCE THIS ARTICLE BY IMPOSING ONE OR MORE OF
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1 THE FOLLOWING REMEDIES:
2 (1) WHEN A MEDICAID MANAGED CARE ORGANIZATION FAILS TO
3 PAY AN ASSESSMENT OR PENALTY IN THE AMOUNT OR ON THE DATE
4 REQUIRED BY THIS ARTICLE, THE DEPARTMENT MAY ADD INTEREST AT
5 THE RATE PROVIDED IN SECTION 806 OF THE ACT OF APRIL 9, 1929
6 (P.L.343, NO.176), KNOWN AS THE FISCAL CODE, TO THE UNPAID
7 AMOUNT OF THE ASSESSMENT OR PENALTY FROM THE DATE PRESCRIBED
8 FOR ITS PAYMENT UNTIL THE DATE IT IS PAID.
9 (2) WHEN A MEDICAID MANAGED CARE ORGANIZATION FAILS TO
10 SUBMIT A REPORT FORM CONCERNING THE CALCULATION OF THE
11 ASSESSMENT OR TO FURNISH RECORDS TO THE DEPARTMENT AS
12 REQUIRED BY THIS ARTICLE, THE DEPARTMENT MAY IMPOSE A PENALTY
13 AGAINST THE MEDICAID MANAGED CARE ORGANIZATION IN THE AMOUNT
14 OF $1,000 PER DAY FOR EACH DAY THE REPORT FORM OR REQUIRED
15 RECORDS ARE NOT SUBMITTED OR FURNISHED TO THE DEPARTMENT. IF
16 THE $1,000 PER DAY PENALTY IS IMPOSED, IT SHALL COMMENCE ON
17 THE FIRST DAY AFTER THE DATE FOR WHICH A REPORT FORM OR
18 RECORDS ARE DUE.
19 (3) WHEN A MEDICAID MANAGED CARE ORGANIZATION FAILS TO
20 PAY ALL OR PART OF AN ASSESSMENT OR PENALTY WITHIN 30 DAYS OF
21 THE DATE THAT PAYMENT IS DUE, THE DEPARTMENT MAY DEDUCT THE
22 UNPAID ASSESSMENT OR PENALTY AND ANY INTEREST OWED FROM ANY
23 CAPITATION PAYMENTS DUE TO THE MEDICAID MANAGED CARE
24 ORGANIZATION UNTIL THE FULL AMOUNT IS RECOVERED. ANY
25 DEDUCTION SHALL BE MADE ONLY AFTER WRITTEN NOTICE TO THE
26 MEDICAID MANAGED CARE ORGANIZATION.
27 (4) UPON WRITTEN REQUEST BY A MEDICAID MANAGED CARE
28 ORGANIZATION TO THE SECRETARY, THE SECRETARY MAY WAIVE ALL OR
29 PART OF THE INTEREST OR PENALTIES ASSESSED AGAINST A MEDICAID
30 MANAGED CARE ORGANIZATION PURSUANT TO THIS ARTICLE FOR GOOD
20070H1788B4179 - 14 -
1 CAUSE AS SHOWN BY THE MEDICAID MANAGED CARE ORGANIZATION.
2 SECTION 811-B. TIME PERIODS.
3 THE ASSESSMENT AUTHORIZED IN THIS ARTICLE SHALL NOT BE
4 IMPOSED OR PAID PRIOR TO JULY 1, 2004, OR IN THE ABSENCE OF
5 FEDERAL FINANCIAL PARTICIPATION AS DESCRIBED IN SECTION 803-B.
6 THE ASSESSMENT SHALL CEASE ON JUNE 30, 2008, OR EARLIER IF
7 REQUIRED BY LAW.]
8 SECTION 6. SECTION 811-C OF THE ACT, AMENDED NOVEMBER 29,
9 2004 (P.L.1272, NO.154), IS AMENDED TO READ:
10 SECTION 811-C. TIME PERIODS.
11 [THE ASSESSMENT AUTHORIZED IN THIS ARTICLE SHALL NOT BE
12 IMPOSED PRIOR TO JULY 1, 2003, FOR PRIVATE ICFS/MR AND JULY 1,
13 2004, FOR PUBLIC ICFS/MR AND SHALL CEASE ON JUNE 30, 2009, OR
14 EARLIER IF REQUIRED BY LAW.]
15 (A) IMPOSITION.--THE ASSESSMENT AUTHORIZED UNDER THIS
16 ARTICLE SHALL NOT BE IMPOSED AS FOLLOWS:
17 (1) PRIOR TO JULY 1, 2003, FOR PRIVATE ICFS/MR.
18 (2) PRIOR TO JULY 1, 2004, FOR PUBLIC ICFS/MR.
19 (3) IN THE ABSENCE OF FEDERAL FINANCIAL PARTICIPATION AS
20 DESCRIBED UNDER SECTION 803-C.
21 (B) CESSATION.--THE ASSESSMENT AUTHORIZED UNDER THIS ARTICLE
22 SHALL CEASE JUNE 30, 2013, OR EARLIER, IF REQUIRED BY LAW.
23 SECTION 7. THE ACT IS AMENDED BY ADDING ARTICLES TO READ:
24 ARTICLE VIII-E
25 HOSPITAL ASSESSMENTS
26 SECTION 801-E. DEFINITIONS.
27 THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS ARTICLE
28 SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE
29 CONTEXT CLEARLY INDICATES OTHERWISE:
30 "ASSESSMENT." THE FEE AUTHORIZED TO BE IMPLEMENTED UNDER
20070H1788B4179 - 15 -
1 THIS ARTICLE ON EVERY GENERAL ACUTE CARE HOSPITAL WITHIN A
2 MUNICIPALITY.
3 "BAD DEBT EXPENSE." THE COST OF CARE FOR WHICH A HOSPITAL
4 EXPECTED PAYMENT FROM THE PATIENT OR A THIRD-PARTY PAYOR, BUT
5 WHICH THE HOSPITAL SUBSEQUENTLY DETERMINES TO BE UNCOLLECTIBLE,
6 AS FURTHER DESCRIBED IN THE MEDICARE PROVIDER REIMBURSEMENT
7 MANUAL PUBLISHED BY THE UNITED STATES DEPARTMENT OF HEALTH AND
8 HUMAN SERVICES.
9 "CHARITY CARE EXPENSE." THE COST OF CARE FOR WHICH A
10 HOSPITAL ORDINARILY CHARGES A FEE BUT WHICH IS PROVIDED FREE OR
11 AT A REDUCED RATE TO PATIENTS WHO CANNOT AFFORD TO PAY BUT WHO
12 ARE NOT ELIGIBLE FOR PUBLIC PROGRAMS, AND FROM WHOM THE HOSPITAL
13 DID NOT EXPECT PAYMENT IN ACCORDANCE WITH THE HOSPITAL'S CHARITY
14 CARE POLICY, AS FURTHER DESCRIBED IN THE MEDICARE PROVIDER
15 REIMBURSEMENT MANUAL PUBLISHED BY THE UNITED STATES DEPARTMENT
16 OF HEALTH AND HUMAN SERVICES.
17 "CONTRACTUAL ALLOWANCE." THE DIFFERENCE BETWEEN WHAT A
18 HOSPITAL CHARGES FOR SERVICES AND THE AMOUNTS THAT CERTAIN
19 PAYERS HAVE AGREED TO PAY FOR THE SERVICES AS FURTHER DESCRIBED
20 IN THE MEDICARE PROVIDER REIMBURSEMENT MANUAL PUBLISHED BY THE
21 UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES.
22 "EXEMPT HOSPITAL." A HOSPITAL THAT THE SECRETARY OF PUBLIC
23 WELFARE HAS DETERMINED MEETS ONE OF THE FOLLOWING:
24 (1) IS EXCLUDED UNDER 42 CFR § 412.23(A), (B), (D) AND
25 (F) (RELATING TO EXCLUDED HOSPITALS: CLASSIFICATION) AS OF
26 MARCH 20, 2008, FROM REIMBURSEMENT OF CERTAIN FEDERAL FUNDS
27 UNDER THE PROSPECTIVE PAYMENT SYSTEM DESCRIBED BY 42 CFR PT.
28 412 (RELATING TO PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT
29 HOSPITAL SERVICES).
30 (2) IS A FEDERAL VETERANS' AFFAIRS HOSPITAL.
20070H1788B4179 - 16 -
1 (3) IS PART OF AN INSTITUTION WITH STATE-RELATED STATUS
2 AS THAT TERM IS DEFINED IN 22 PA.CODE § 31.2 (RELATING TO
3 DEFINITIONS) AND PROVIDES OVER 100,000 DAYS OF CARE TO
4 MEDICAL ASSISTANCE PATIENTS ANNUALLY.
5 (4) PROVIDES CARE, INCLUDING INPATIENT HOSPITAL
6 SERVICES, TO ALL PATIENTS FREE OF CHARGE.
7 "GENERAL ACUTE CARE HOSPITAL." A HOSPITAL OTHER THAN AN
8 EXEMPT HOSPITAL.
9 "HOSPITAL." A FACILITY LICENSED AS A HOSPITAL UNDER 28 PA.
10 CODE PT. IV SUBPT. B (RELATING TO GENERAL AND SPECIAL HOSPITALS)
11 AND LOCATED WITHIN A MUNICIPALITY.
12 "MUNICIPALITY." A CITY OF THE FIRST CLASS.
13 "NET OPERATING REVENUE." GROSS CHARGES FOR FACILITIES LESS
14 ANY DEDUCTED AMOUNTS FOR BAD DEBT EXPENSE, CHARITY CARE EXPENSE
15 AND CONTRACTUAL ALLOWANCES.
16 "PROGRAM." THE COMMONWEALTH'S MEDICAL ASSISTANCE PROGRAM AS
17 AUTHORIZED UNDER ARTICLE IV.
18 SECTION 802-E. AUTHORIZATION.
19 IN ORDER TO GENERATE ADDITIONAL REVENUES FOR THE PURPOSE OF
20 ASSURING THAT MEDICAL ASSISTANCE RECIPIENTS HAVE ACCESS TO
21 HOSPITAL SERVICES, AND THAT ALL CITIZENS HAVE ACCESS TO
22 EMERGENCY DEPARTMENT SERVICES, A MUNICIPALITY MAY, BY ORDINANCE,
23 IMPOSE A MONETARY ASSESSMENT ON THE NET OPERATING REVENUE
24 REDUCED BY ALL REVENUES RECEIVED FROM MEDICARE OF EACH GENERAL
25 ACUTE CARE HOSPITAL LOCATED IN THE MUNICIPALITY SUBJECT TO THE
26 CONDITIONS AND REQUIREMENTS SPECIFIED UNDER THIS ARTICLE. THE
27 ORDINANCE MAY INCLUDE APPROPRIATE ADMINISTRATIVE PROVISIONS
28 INCLUDING, WITHOUT LIMITATION, PROVISIONS FOR THE COLLECTION OF
29 INTEREST AND PENALTIES. IN EACH YEAR IN WHICH THE ASSESSMENT IS
30 IMPLEMENTED, THE ASSESSMENT SHALL BE SUBJECT TO THE MAXIMUM
20070H1788B4179 - 17 -
1 AGGREGATE AMOUNT THAT MAY BE ASSESSED UNDER 42 CFR §
2 433.68(F)(3)(I) (RELATING TO PERMISSIBLE HEALTH CARE-RELATED
3 TAXES AFTER THE TRANSITION PERIOD) OR ANY OTHER MAXIMUM
4 ESTABLISHED UNDER FEDERAL LAW.
5 SECTION 803-E. IMPLEMENTATION.
6 THE ASSESSMENT AUTHORIZED UNDER THIS ARTICLE, ONCE IMPOSED,
7 SHALL BE IMPLEMENTED AS A HEALTH-CARE RELATED FEE AS DEFINED
8 UNDER SECTION 1903(W)(3)(B) OF THE SOCIAL SECURITY ACT (49 STAT.
9 620, 42 U.S.C. § 1396B(W)(3)(B)) OR ANY AMENDMENTS THERETO AND
10 MAY BE COLLECTED ONLY TO THE EXTENT AND FOR THE PERIODS THAT THE
11 SECRETARY DETERMINES THAT REVENUES GENERATED BY THE ASSESSMENT
12 WILL QUALIFY AS THE STATE SHARE OF PROGRAM EXPENDITURES ELIGIBLE
13 FOR FEDERAL FINANCIAL PARTICIPATION.
14 SECTION 804-E. ADMINISTRATION.
15 (A) REMITTANCE.--UPON COLLECTION OF THE FUNDS GENERATED BY
16 THE ASSESSMENT AUTHORIZED UNDER THIS ARTICLE, THE MUNICIPALITY
17 SHALL REMIT A PORTION OF THE FUNDS TO THE COMMONWEALTH FOR THE
18 PURPOSES SET FORTH UNDER SECTION 802-E, EXCEPT THAT THE
19 MUNICIPALITY MAY RETAIN FUNDS IN AN AMOUNT NECESSARY TO
20 REIMBURSE IT FOR ITS REASONABLE COSTS IN THE ADMINISTRATION AND
21 COLLECTION OF THE ASSESSMENT AS SET FORTH IN AN AGREEMENT TO BE
22 ENTERED INTO BETWEEN THE MUNICIPALITY AND THE COMMONWEALTH
23 ACTING THROUGH THE SECRETARY.
24 (B) ESTABLISHMENT.--THERE IS ESTABLISHED A RESTRICTED
25 ACCOUNT IN THE GENERAL FUND FOR THE RECEIPT AND DEPOSIT OF FUNDS
26 UNDER SUBSECTION (A). FUNDS IN THE ACCOUNT ARE HEREBY
27 APPROPRIATED TO THE DEPARTMENT FOR PURPOSES OF MAKING
28 SUPPLEMENTAL OR INCREASED MEDICAL ASSISTANCE PAYMENTS FOR
29 EMERGENCY DEPARTMENT SERVICES TO GENERAL ACUTE CARE HOSPITALS
30 WITHIN THE MUNICIPALITY AND TO MAINTAIN OR INCREASE OTHER
20070H1788B4179 - 18 -
1 MEDICAL ASSISTANCE PAYMENTS TO HOSPITALS WITHIN THE
2 MUNICIPALITY, AS SPECIFIED IN THE COMMONWEALTH'S APPROVED TITLE
3 XIX STATE PLAN.
4 SECTION 805-E. NO HOLD HARMLESS.
5 NO GENERAL ACUTE CARE HOSPITAL SHALL BE DIRECTLY GUARANTEED A
6 REPAYMENT OF ITS ASSESSMENT IN DEROGATION OF 42 CFR 433.68(F)
7 (RELATING TO PERMISSIBLE HEALTH CARE-RELATED TAXES AFTER THE
8 TRANSITION PERIOD), EXCEPT THAT IN EACH FISCAL YEAR IN WHICH AN
9 ASSESSMENT IS IMPLEMENTED, THE DEPARTMENT SHALL USE A PORTION OF
10 THE FUNDS RECEIVED UNDER SECTION 804-E(A) FOR THE PURPOSES
11 OUTLINED UNDER SECTION 804-E(B) TO THE EXTENT PERMISSIBLE UNDER
12 FEDERAL AND STATE LAW OR REGULATION AND WITHOUT CREATING AN
13 INDIRECT GUARANTEE TO HOLD HARMLESS, AS THOSE TERMS ARE USED
14 UNDER 42 CFR 433.68(F)(I). THE SECRETARY SHALL SUBMIT ANY STATE
15 MEDICAID PLAN AMENDMENTS TO THE UNITED STATES DEPARTMENT OF
16 HEALTH AND HUMAN SERVICES THAT ARE NECESSARY TO MAKE THE
17 PAYMENTS AUTHORIZED UNDER SECTION 804-E(B).
18 SECTION 806-E. FEDERAL WAIVER.
19 TO THE EXTENT NECESSARY IN ORDER TO IMPLEMENT THIS ARTICLE,
20 THE DEPARTMENT SHALL SEEK A WAIVER UNDER 42 CFR 433.68(E)
21 (RELATING TO PERMISSIBLE HEALTH CARE-RELATED TAXES AFTER THE
22 TRANSITION PERIOD) FROM THE CENTERS FOR MEDICARE AND MEDICAID
23 SERVICES OF THE UNITED STATES DEPARTMENT OF HEALTH AND HUMAN
24 SERVICES.
25 SECTION 807-E. TAX EXEMPTION.
26 NOTWITHSTANDING ANY EXEMPTIONS GRANTED BY ANY OTHER FEDERAL,
27 STATE OR LOCAL TAX OR OTHER LAW, INCLUDING SECTION 204(A)(3) OF
28 THE ACT OF MAY 22, 1933 (P.L.853, NO.155), KNOWN AS THE GENERAL
29 COUNTY ASSESSMENT LAW, NO GENERAL ACUTE CARE HOSPITAL IN THE
30 MUNICIPALITY SHALL BE EXEMPT FROM THE ASSESSMENT.
20070H1788B4179 - 19 -
1 SECTION 808-E. CESSATION.
2 THE ASSESSMENT AUTHORIZED UNDER THIS ARTICLE SHALL CEASE JUNE
3 30, 2013.
4 ARTICLE VIII-F
5 MEDICAID MANAGED CARE ORGANIZATION ASSESSMENTS
6 SECTION 801-F. DEFINITIONS.
7 THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS ARTICLE
8 SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE
9 CONTEXT CLEARLY INDICATES OTHERWISE:
10 "ASSESSMENT PERCENTAGE." THE RATE ASSESSED PURSUANT TO THIS
11 ARTICLE ON EVERY MEDICAID MANAGED CARE ORGANIZATION.
12 "ASSESSMENT PERIOD." THE TIME PERIOD IDENTIFIED IN THE
13 CONTRACT.
14 "ASSESSMENT PROCEEDS." THE STATE REVENUE COLLECTED FROM THE
15 ASSESSMENT PROVIDED FOR IN THIS ARTICLE, ANY FEDERAL FUNDS
16 RECEIVED BY THE COMMONWEALTH AS A DIRECT RESULT OF THE
17 ASSESSMENT AND ANY PENALTIES AND INTEREST RECEIVED UNDER SECTION
18 810-F.
19 "CONTRACT." THE AGREEMENT BETWEEN A MEDICAID MANAGED CARE
20 ORGANIZATION AND THE DEPARTMENT OF PUBLIC WELFARE.
21 "COUNTY MEDICAID MANAGED CARE ORGANIZATION." A COUNTY, OR AN
22 ENTITY ORGANIZED AND CONTROLLED DIRECTLY OR INDIRECTLY BY A
23 COUNTY OR A CITY OF THE FIRST CLASS, THAT IS A PARTY TO A
24 MEDICAID MANAGED CARE CONTRACT WITH THE DEPARTMENT OF PUBLIC
25 WELFARE.
26 "DEPARTMENT." THE DEPARTMENT OF PUBLIC WELFARE OF THE
27 COMMONWEALTH.
28 "MEDICAID." THE PROGRAM ESTABLISHED UNDER TITLE XIX OF THE
29 SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. § 1396 ET SEQ.).
30 "MEDICAID MANAGED CARE ORGANIZATION." A MEDICAID MANAGED
20070H1788B4179 - 20 -
1 CARE ORGANIZATION AS DEFINED IN SECTION 1903(M)(1)(A) OF THE
2 SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. § 1396B(M)(1)(A))
3 THAT IS A PARTY TO A MEDICAID MANAGED CARE CONTRACT WITH THE
4 DEPARTMENT OF PUBLIC WELFARE. THE TERM SHALL INCLUDE A COUNTY
5 MEDICAID MANAGED CARE ORGANIZATION AND A PERMITTED ASSIGNEE OF A
6 MEDICAID MANAGED CARE CONTRACT BUT SHALL NOT INCLUDE AN ASSIGNOR
7 OF A MEDICAID MANAGED CARE CONTRACT.
8 "SECRETARY." THE SECRETARY OF PUBLIC WELFARE OF THE
9 COMMONWEALTH.
10 "SOCIAL SECURITY ACT." 49 STAT. 620, 42 U.S.C. § 301 ET SEQ.
11 SECTION 802-F. AUTHORIZATION.
12 THE DEPARTMENT SHALL IMPLEMENT AN ASSESSMENT ON EACH MEDICAID
13 MANAGED CARE ORGANIZATION, SUBJECT TO THE CONDITIONS AND
14 REQUIREMENTS SPECIFIED IN THIS ARTICLE.
15 SECTION 803-F. IMPLEMENTATION.
16 THE ASSESSMENT SHALL BE IMPLEMENTED ON AN ANNUAL BASIS,
17 THROUGH PERIODIC SUBMISSIONS NOT TO EXCEED FIVE TIMES PER YEAR
18 BY MEDICAID MANAGED CARE ORGANIZATIONS, AS A HEALTH CARE-RELATED
19 FEE AS DEFINED IN SECTION 1903(W)(3)(B) OF THE SOCIAL SECURITY
20 ACT, OR ANY AMENDMENTS THERETO, AND MAY BE IMPOSED AND IS
21 REQUIRED TO BE PAID ONLY TO THE EXTENT THAT THE REVENUES
22 GENERATED FROM THE ASSESSMENT QUALIFY AS THE STATE SHARE OF
23 PROGRAM EXPENDITURES ELIGIBLE FOR FEDERAL FINANCIAL
24 PARTICIPATION.
25 SECTION 804-F. ASSESSMENT PERCENTAGE.
26 (A) AMOUNT.--THE ASSESSMENT PERCENTAGE SHALL BE UNIFORM FOR
27 ALL MEDICAID MANAGED CARE ORGANIZATIONS, DETERMINED IN
28 ACCORDANCE WITH THIS SECTION AND IMPLEMENTED BY THE DEPARTMENT
29 AS APPROVED BY THE GOVERNOR AFTER NOTIFICATION TO AND IN
30 CONSULTATION WITH THE MEDICAID MANAGED CARE ORGANIZATIONS. THE
20070H1788B4179 - 21 -
1 ASSESSMENT PERCENTAGE SHALL BE SUBJECT TO THE MAXIMUM AGGREGATE
2 AMOUNT THAT MAY BE ASSESSED PURSUANT TO 42 CFR 433.68(F)(3)(I)
3 (RELATING TO PERMISSIBLE HEALTH CARE-RELATED TAXES AFTER THE
4 TRANSITION PERIOD) OR ANY SUBSEQUENT MAXIMUM ESTABLISHED BY
5 FEDERAL LAW.
6 (B) NOTICE.--SUBJECT TO THE PROVISIONS OF SUBSECTION (C),
7 THE DEPARTMENT SHALL NOTIFY EACH MEDICAID MANAGED CARE
8 ORGANIZATION OF A PROPOSED ASSESSMENT PERCENTAGE. MEDICAID
9 MANAGED CARE ORGANIZATIONS SHALL HAVE 30 DAYS FROM THE DATE OF
10 THE PROPOSED ASSESSMENT PERCENTAGE NOTICE TO PROVIDE WRITTEN
11 COMMENTS TO THE DEPARTMENT REGARDING THE PROPOSED ASSESSMENT.
12 UPON EXPIRATION OF THE 30-DAY COMMENT PERIOD, THE DEPARTMENT,
13 AFTER CONSIDERATION OF THE COMMENTS, SHALL PROVIDE EACH MEDICAID
14 MANAGED CARE ORGANIZATION WITH A SECOND NOTICE ANNOUNCING THE
15 ASSESSMENT PERCENTAGE. ONCE EFFECTIVE, AN ASSESSMENT PERCENTAGE
16 WILL REMAIN IN EFFECT UNTIL THE DEPARTMENT NOTIFIES EACH
17 MEDICAID MANAGED CARE ORGANIZATION OF A NEW ASSESSMENT
18 PERCENTAGE IN ACCORDANCE WITH THE NOTICE PROVISIONS CONTAINED IN
19 THIS SECTION.
20 (C) INITIAL ASSESSMENT.--THE INITIAL ASSESSMENT PERCENTAGE
21 MAY BE IMPOSED RETROACTIVELY TO THE BEGINNING OF AN ASSESSMENT
22 PERIOD BEGINNING ON OR AFTER JULY 1, 2004. ONCE EFFECTIVE, THE
23 INITIAL ASSESSMENT PERCENTAGE WILL REMAIN IN EFFECT UNTIL THE
24 DEPARTMENT NOTIFIES EACH MEDICAID MANAGED CARE ORGANIZATION OF A
25 NEW ASSESSMENT PERCENTAGE IN ACCORDANCE WITH THE NOTICE
26 PROVISIONS CONTAINED IN THIS SECTION.
27 SECTION 805-F. CALCULATION AND PAYMENT.
28 USING THE ASSESSMENT PERCENTAGE ESTABLISHED UNDER SECTION
29 804-F, EACH MEDICAID MANAGED CARE ORGANIZATION SHALL CALCULATE
30 THE ASSESSMENT AMOUNT FOR EACH ASSESSMENT PERIOD ON A REPORT
20070H1788B4179 - 22 -
1 FORM SPECIFIED BY THE CONTRACT AND SHALL SUBMIT THE COMPLETED
2 REPORT FORM AND TOTAL AMOUNT OWED TO THE DEPARTMENT ON A DUE
3 DATE SPECIFIED BY THE CONTRACT. THE MEDICAID MANAGED CARE
4 ORGANIZATION SHALL REPORT NET OPERATING REVENUE FOR PURPOSES OF
5 THE ASSESSMENT CALCULATION AS SPECIFIED IN THE CONTRACT.
6 SECTION 806-F. USE OF ASSESSMENT PROCEEDS.
7 NO MEDICAID MANAGED CARE ORGANIZATION SHALL BE GUARANTEED A
8 REPAYMENT OF ITS ASSESSMENT IN DEROGATION OF 42 CFR 433.68(F),
9 PROVIDED, HOWEVER, IN EACH FISCAL YEAR IN WHICH AN ASSESSMENT IS
10 IMPLEMENTED, THE DEPARTMENT SHALL USE THE ASSESSMENT PROCEEDS TO
11 MAINTAIN ACTUARIALLY SOUND RATES AS DEFINED IN THE CONTRACT FOR
12 THE MEDICAID MANAGED CARE ORGANIZATIONS TO THE EXTENT
13 PERMISSIBLE UNDER FEDERAL AND STATE LAW OR REGULATION AND
14 WITHOUT CREATING A GUARANTEE TO HOLD HARMLESS, AS THOSE TERMS
15 ARE USED IN 42 CFR 433.68(F) (RELATING TO PERMISSIBLE HEALTH
16 CARE-RELATED TAXES AFTER THE TRANSITION PERIOD).
17 SECTION 807-F. RECORDS.
18 UPON WRITTEN REQUEST BY THE DEPARTMENT, A MEDICAID MANAGED
19 CARE ORGANIZATION SHALL FURNISH TO THE DEPARTMENT SUCH RECORDS
20 AS THE DEPARTMENT MAY SPECIFY IN ORDER TO DETERMINE THE AMOUNT
21 OF ASSESSMENT DUE FROM THE MEDICAID MANAGED CARE ORGANIZATION OR
22 TO VERIFY THAT THE MEDICAID MANAGED CARE ORGANIZATION HAS
23 CALCULATED AND PAID THE CORRECT AMOUNT DUE. THE REQUESTED
24 RECORDS SHALL BE PROVIDED TO THE DEPARTMENT WITHIN 30 DAYS FROM
25 THE DATE OF THE MEDICAID MANAGED CARE ORGANIZATION'S RECEIPT OF
26 THE WRITTEN REQUEST UNLESS REQUIRED AT AN EARLIER DATE FOR
27 PURPOSES OF THE DEPARTMENT'S COMPLIANCE WITH A REQUEST FROM A
28 FEDERAL OR ANOTHER STATE AGENCY.
29 SECTION 808-F. PAYMENT OF ASSESSMENT.
30 IN THE EVENT THAT THE DEPARTMENT DETERMINES THAT A MEDICAID
20070H1788B4179 - 23 -
1 MANAGED CARE ORGANIZATION HAS FAILED TO PAY AN ASSESSMENT OR
2 THAT IT HAS UNDERPAID AN ASSESSMENT, THE DEPARTMENT SHALL
3 PROVIDE WRITTEN NOTIFICATION TO THE MEDICAID MANAGED CARE
4 ORGANIZATION WITHIN 180 DAYS OF THE ORIGINAL DUE DATE OF THE
5 AMOUNT DUE, INCLUDING INTEREST, AND THE DATE ON WHICH THE AMOUNT
6 DUE MUST BE PAID, WHICH SHALL NOT BE LESS THAN 30 DAYS FROM THE
7 DATE OF THE NOTICE. IN THE EVENT THAT THE DEPARTMENT DETERMINES
8 THAT A MEDICAID MANAGED CARE ORGANIZATION HAS OVERPAID AN
9 ASSESSMENT, THE DEPARTMENT SHALL NOTIFY THE MEDICAID MANAGED
10 CARE ORGANIZATION IN WRITING OF THE OVERPAYMENT, AND, WITHIN 30
11 DAYS OF THE DATE OF THE NOTICE OF THE OVERPAYMENT, THE MEDICAID
12 MANAGED CARE ORGANIZATION SHALL ADVISE THE DEPARTMENT TO EITHER
13 AUTHORIZE A REFUND OF THE AMOUNT OF THE OVERPAYMENT OR OFFSET
14 THE AMOUNT OF THE OVERPAYMENT AGAINST ANY AMOUNT THAT MAY BE
15 OWED TO THE DEPARTMENT BY THE MEDICAID MANAGED CARE
16 ORGANIZATION.
17 SECTION 809-F. APPEAL RIGHTS.
18 A MEDICAID MANAGED CARE ORGANIZATION THAT IS AGGRIEVED BY A
19 DETERMINATION OF THE DEPARTMENT RELATING TO THE ASSESSMENT MAY
20 FILE A REQUEST FOR REVIEW OF THE DECISION OF THE DEPARTMENT BY
21 THE BUREAU OF HEARINGS AND APPEALS WITHIN THE DEPARTMENT, WHICH
22 SHALL HAVE EXCLUSIVE PRIMARY JURISDICTION IN SUCH MATTERS. THE
23 PROCEDURES AND REQUIREMENTS OF 67 PA.C.S. CH. 11 (RELATING TO
24 MEDICAL ASSISTANCE HEARINGS AND APPEALS) SHALL APPLY TO REQUESTS
25 FOR REVIEW FILED PURSUANT TO THIS SECTION EXCEPT THAT, IN ANY
26 SUCH REQUEST FOR REVIEW, A MEDICAID MANAGED CARE ORGANIZATION
27 MAY NOT CHALLENGE THE ASSESSMENT PERCENTAGE DETERMINED BY THE
28 DEPARTMENT PURSUANT TO SECTION 804-F.
29 SECTION 810-F. ENFORCEMENT.
30 IN ADDITION TO ANY OTHER REMEDY PROVIDED BY LAW, THE
20070H1788B4179 - 24 -
1 DEPARTMENT MAY ENFORCE THIS ARTICLE BY IMPOSING ONE OR MORE OF
2 THE FOLLOWING REMEDIES:
3 (1) WHEN A MEDICAID MANAGED CARE ORGANIZATION FAILS TO
4 PAY AN ASSESSMENT OR PENALTY IN THE AMOUNT OR ON THE DATE
5 REQUIRED BY THIS ARTICLE, THE DEPARTMENT MAY ADD INTEREST AT
6 THE RATE PROVIDED IN SECTION 806 OF THE ACT OF APRIL 9, 1929
7 (P.L.343, NO.176), KNOWN AS THE FISCAL CODE, TO THE UNPAID
8 AMOUNT OF THE ASSESSMENT OR PENALTY FROM THE DATE PRESCRIBED
9 FOR ITS PAYMENT UNTIL THE DATE IT IS PAID.
10 (2) WHEN A MEDICAID MANAGED CARE ORGANIZATION FAILS TO
11 SUBMIT A REPORT FORM CONCERNING THE CALCULATION OF THE
12 ASSESSMENT OR TO FURNISH RECORDS TO THE DEPARTMENT AS
13 REQUIRED BY THIS ARTICLE, THE DEPARTMENT MAY IMPOSE A PENALTY
14 AGAINST THE MEDICAID MANAGED CARE ORGANIZATION IN THE AMOUNT
15 OF $1,000 PER DAY FOR EACH DAY THE REPORT FORM OR REQUIRED
16 RECORDS ARE NOT SUBMITTED OR FURNISHED TO THE DEPARTMENT. IF
17 THE $1,000 PER DAY PENALTY IS IMPOSED, IT SHALL COMMENCE ON
18 THE FIRST DAY AFTER THE DATE FOR WHICH A REPORT FORM OR
19 RECORDS ARE DUE.
20 (3) WHEN A MEDICAID MANAGED CARE ORGANIZATION FAILS TO
21 PAY ALL OR PART OF AN ASSESSMENT OR PENALTY WITHIN 30 DAYS OF
22 THE DATE THAT PAYMENT IS DUE, THE DEPARTMENT MAY DEDUCT THE
23 UNPAID ASSESSMENT OR PENALTY AND ANY INTEREST OWED FROM ANY
24 CAPITATION PAYMENTS DUE TO THE MEDICAID MANAGED CARE
25 ORGANIZATION UNTIL THE FULL AMOUNT IS RECOVERED. ANY
26 DEDUCTION SHALL BE MADE ONLY AFTER WRITTEN NOTICE TO THE
27 MEDICAID MANAGED CARE ORGANIZATION.
28 (4) UPON WRITTEN REQUEST BY A MEDICAID MANAGED CARE
29 ORGANIZATION TO THE SECRETARY, THE SECRETARY MAY WAIVE ALL OR
30 PART OF THE INTEREST OR PENALTIES ASSESSED AGAINST A MEDICAID
20070H1788B4179 - 25 -
1 MANAGED CARE ORGANIZATION PURSUANT TO THIS ARTICLE FOR GOOD
2 CAUSE AS SHOWN BY THE MEDICAID MANAGED CARE ORGANIZATION.
3 SECTION 811-F. TIME PERIODS.
4 THE ASSESSMENT AUTHORIZED IN THIS ARTICLE SHALL NOT BE
5 IMPOSED OR PAID PRIOR TO JULY 1, 2004, OR IN THE ABSENCE OF
6 FEDERAL FINANCIAL PARTICIPATION AS DESCRIBED IN SECTION 803-F.
7 THE ASSESSMENT SHALL CEASE ON JUNE 30, 2013, OR EARLIER IF
8 REQUIRED BY LAW.
9 SECTION 8. THE ACT IS AMENDED BY ADDING A SECTION TO READ:
10 SECTION 1088. PERSONAL CARE HOME INFORMATION.--THE
11 DEPARTMENT SHALL POST INFORMATION ON ITS INTERNET WEBSITE
12 RELATING TO THE LICENSURE AND INSPECTION OF PERSONAL CARE HOMES.
13 THE INFORMATION SHALL BE UPDATED AT LEAST ANNUALLY. THE
14 INFORMATION SHALL INCLUDE THE FOLLOWING:
15 (1) NUMBER OF LICENSED PERSONAL CARE HOMES.
16 (2) NUMBER OF RESIDENTS IN LICENSED PERSONAL CARE HOMES.
17 (3) NUMBER OF PERSONAL CARE HOMES WHICH HAVE RECEIVED AN
18 ANNUAL INSPECTION.
19 (4) NUMBER OF PERSONAL CARE HOME INSPECTORS STATEWIDE AND BY
20 REGION.
21 (5) RATIO OF DEPARTMENT STAFF RESPONSIBLE FOR THE LICENSURE
22 AND INSPECTION OF PERSONAL CARE HOMES DIVIDED BY THE TOTAL
23 NUMBER OF LICENSED PERSONAL CARE HOMES.
24 (6) NUMBER OF PERSONAL CARE HOMES OPERATING WITH A
25 PROVISIONAL LICENSE, STATEWIDE AND BY COUNTY.
26 (7) NUMBER OF PERSONAL CARE HOMES OPERATING WITH A FULL
27 LICENSE, STATEWIDE AND BY COUNTY.
28 (8) NUMBER OF PERSONAL CARE HOMES WHICH THE DEPARTMENT HAS
29 CLOSED OR TAKEN LEGAL ACTION TO CLOSE.
30 (9) FOR EACH PERSONAL CARE HOME, A LICENSING INSPECTION
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1 SUMMARY WHICH LISTS ANY VIOLATION UNDER THIS ARTICLE.
2 (10) SUMMARY OF TYPES OF VIOLATIONS WHICH ARE LISTED IN
3 LICENSING INSPECTION SUMMARIES, IN ACCORDANCE WITH THE
4 CLASSIFICATION OF VIOLATIONS SET FORTH UNDER THIS ARTICLE.
5 (11) UPON IMPLEMENTATION OF A FINANCIAL PENALTY PROGRAM, THE
6 INTERNET WEBSITE SHALL INCLUDE INFORMATION RELATING TO ASSESSED
7 FINANCIAL PENALTIES AGAINST LICENSED PERSONAL CARE HOMES AS
8 PROVIDED FOR IN THIS ARTICLE.
9 (12) A SUMMARY OF THE SPECIFIC PLANS OF THE DEPARTMENT TO
10 ENSURE COMPLIANCE WITH THIS ARTICLE REGARDING INSPECTION OF
11 LICENSED PERSONAL CARE HOMES AND ENFORCEMENT OF REGULATIONS.
12 (13) OTHER INFORMATION THE DEPARTMENT DEEMS PERTINENT.
13 SECTION 9. SECTION 1409 OF THE ACT, AMENDED OR ADDED JULY
14 10, 1980 (P.L.493, NO.105), JUNE 16, 1994 (P.L.319, NO.49) AND
15 JULY 7, 2005 (P.L.177, NO.42), IS AMENDED TO READ:
16 SECTION 1409. THIRD PARTY LIABILITY.--(A) (1) NO PERSON
17 HAVING PRIVATE HEALTH CARE COVERAGE SHALL BE ENTITLED TO RECEIVE
18 THE SAME HEALTH CARE FURNISHED OR PAID FOR BY A PUBLICLY FUNDED
19 HEALTH CARE PROGRAM. FOR THE PURPOSES OF THIS SECTION, "PUBLICLY
20 FUNDED HEALTH CARE PROGRAM" SHALL MEAN CARE FOR SERVICES
21 RENDERED BY A STATE OR LOCAL GOVERNMENT OR ANY FACILITY THEREOF,
22 HEALTH CARE SERVICES FOR WHICH PAYMENT IS MADE UNDER THE MEDICAL
23 ASSISTANCE PROGRAM ESTABLISHED BY THE DEPARTMENT OR BY ITS
24 FISCAL INTERMEDIARY, OR BY AN INSURER OR ORGANIZATION WITH WHICH
25 THE DEPARTMENT HAS CONTRACTED TO FURNISH SUCH SERVICES OR TO PAY
26 PROVIDERS WHO FURNISH SUCH SERVICES. FOR THE PURPOSES OF THIS
27 SECTION, "PRIVATELY FUNDED HEALTH CARE" MEANS MEDICAL CARE
28 COVERAGE CONTAINED IN ACCIDENT AND HEALTH INSURANCE POLICIES OR
29 SUBSCRIBER CONTRACTS ISSUED BY HEALTH PLAN CORPORATIONS AND
30 NONPROFIT HEALTH SERVICE PLANS, CERTIFICATES ISSUED BY FRATERNAL
20070H1788B4179 - 27 -
1 BENEFIT SOCIETIES, AND ALSO ANY MEDICAL CARE BENEFITS PROVIDED
2 BY SELF INSURANCE PLAN INCLUDING SELF INSURANCE TRUST, AS
3 OUTLINED IN PENNSYLVANIA INSURANCE LAWS AND RELATED STATUTES.
4 (2) IF SUCH A PERSON RECEIVES HEALTH CARE FURNISHED OR PAID
5 FOR BY A PUBLICLY FUNDED HEALTH CARE PROGRAM, THE INSURER OF HIS
6 PRIVATE HEALTH CARE COVERAGE SHALL REIMBURSE THE PUBLICLY FUNDED
7 HEALTH CARE PROGRAM, THE COST INCURRED IN RENDERING SUCH CARE TO
8 THE EXTENT OF THE BENEFITS PROVIDED UNDER THE TERMS OF THE
9 POLICY FOR THE SERVICES RENDERED.
10 (3) EACH PUBLICLY FUNDED HEALTH CARE PROGRAM THAT FURNISHES
11 OR PAYS FOR HEALTH CARE SERVICES TO A RECIPIENT HAVING PRIVATE
12 HEALTH CARE COVERAGE SHALL BE ENTITLED TO BE SUBROGATED TO THE
13 RIGHTS THAT SUCH PERSON HAS AGAINST THE INSURER OF SUCH COVERAGE
14 TO THE EXTENT OF THE HEALTH CARE SERVICES RENDERED. SUCH ACTION
15 MAY BE BROUGHT WITHIN FIVE YEARS FROM THE DATE THAT SERVICE WAS
16 RENDERED SUCH PERSON.
17 (4) WHEN HEALTH CARE SERVICES ARE PROVIDED TO A PERSON UNDER
18 THIS SECTION WHO AT THE TIME THE SERVICE IS PROVIDED HAS ANY
19 OTHER CONTRACTUAL OR LEGAL ENTITLEMENT TO SUCH SERVICES, THE
20 SECRETARY OF THE DEPARTMENT SHALL HAVE THE RIGHT TO RECOVER FROM
21 THE PERSON, CORPORATION, OR PARTNERSHIP WHO OWES SUCH
22 ENTITLEMENT, THE AMOUNT WHICH WOULD HAVE BEEN PAID TO THE PERSON
23 ENTITLED THERETO, OR TO A THIRD PARTY IN HIS BEHALF, OR THE
24 VALUE OF THE SERVICE ACTUALLY PROVIDED, IF THE PERSON ENTITLED
25 THERETO WAS ENTITLED TO SERVICES. THE ATTORNEY GENERAL MAY, TO
26 RECOVER UNDER THIS SECTION, INSTITUTE AND PROSECUTE LEGAL
27 PROCEEDINGS AGAINST THE PERSON, CORPORATION, HEALTH SERVICE PLAN
28 OR FRATERNAL SOCIETY OWING SUCH ENTITLEMENT IN THE APPROPRIATE
29 COURT IN THE NAME OF THE SECRETARY OF THE DEPARTMENT.
30 (5) THE COMMONWEALTH OF PENNSYLVANIA SHALL NOT REIMBURSE ANY
20070H1788B4179 - 28 -
1 LOCAL GOVERNMENT OR ANY FACILITY THEREOF, UNDER MEDICAL
2 ASSISTANCE OR UNDER ANY OTHER HEALTH PROGRAM WHERE THE
3 COMMONWEALTH PAYS PART OR ALL OF THE COSTS, FOR CARE PROVIDED TO
4 A PERSON COVERED UNDER ANY DISABILITY INSURANCE, HEALTH
5 INSURANCE OR PREPAID HEALTH PLAN.
6 (6) IN LOCAL PROGRAMS FULLY OR PARTIALLY FUNDED BY THE
7 COMMONWEALTH, COMMONWEALTH PARTICIPATION SHALL BE REDUCED IN THE
8 AMOUNT PROPORTIONATE TO THE COST OF SERVICES PROVIDED TO A
9 PERSON.
10 (7) WHEN HEALTH CARE SERVICES ARE PROVIDED TO A DEPENDENT OF
11 A LEGALLY RESPONSIBLE RELATIVE, INCLUDING BUT NOT LIMITED TO A
12 SPOUSE OR A PARENT OF AN UNEMANCIPATED CHILD, SUCH LEGALLY
13 RESPONSIBLE RELATIVE SHALL BE LIABLE FOR THE COST OF HEALTH CARE
14 SERVICES FURNISHED TO THE INDIVIDUAL ON WHOSE BEHALF THE DUTY OF
15 SUPPORT IS OWED. THE DEPARTMENT SHALL HAVE THE RIGHT TO RECOVER
16 FROM SUCH LEGALLY RESPONSIBLE RELATIVE THE CHARGES FOR SUCH
17 SERVICES FURNISHED UNDER THE MEDICAL ASSISTANCE PROGRAM.
18 (B) (1) WHEN BENEFITS ARE PROVIDED OR WILL BE PROVIDED TO A
19 BENEFICIARY UNDER THIS SECTION BECAUSE OF AN INJURY FOR WHICH
20 ANOTHER PERSON IS LIABLE, OR FOR WHICH AN INSURER IS LIABLE IN
21 ACCORDANCE WITH THE PROVISIONS OF ANY POLICY OF INSURANCE ISSUED
22 PURSUANT TO PENNSYLVANIA INSURANCE LAWS AND RELATED STATUTES THE
23 DEPARTMENT SHALL HAVE THE RIGHT TO RECOVER FROM SUCH PERSON OR
24 INSURER THE REASONABLE VALUE OF BENEFITS SO PROVIDED. THE
25 ATTORNEY GENERAL OR HIS DESIGNEE MAY, AT THE REQUEST OF THE
26 DEPARTMENT, TO ENFORCE SUCH RIGHT, INSTITUTE AND PROSECUTE LEGAL
27 PROCEEDINGS AGAINST THE THIRD PERSON OR INSURER WHO MAY BE
28 LIABLE FOR THE INJURY IN AN APPROPRIATE COURT, EITHER IN THE
29 NAME OF THE DEPARTMENT OR IN THE NAME OF THE INJURED PERSON, HIS
30 GUARDIAN, PERSONAL REPRESENTATIVE, ESTATE OR SURVIVORS.
20070H1788B4179 - 29 -
1 (2) THE DEPARTMENT MAY:
2 (I) COMPROMISE, OR SETTLE AND RELEASE ANY SUCH CLAIMS; OR
3 (II) WAIVE ANY SUCH CLAIM, IN WHOLE OR IN PART, OR IF THE
4 DEPARTMENT DETERMINES THAT COLLECTION WOULD RESULT IN UNDUE
5 HARDSHIP UPON THE PERSON WHO SUFFERED THE INJURY, OR IN A
6 WRONGFUL DEATH ACTION UPON THE HEIRS OF THE DECEASED.
7 (3) NO ACTION TAKEN IN BEHALF OF THE DEPARTMENT PURSUANT TO
8 THIS SECTION OR ANY JUDGMENT RENDERED IN SUCH ACTION SHALL BE A
9 BAR TO ANY ACTION UPON THE CLAIM OR CAUSE OF ACTION OF THE
10 BENEFICIARY, HIS GUARDIAN, PERSONAL REPRESENTATIVE, ESTATE,
11 DEPENDENTS OR SURVIVORS AGAINST THE THIRD PERSON WHO MAY BE
12 LIABLE FOR THE INJURY, OR SHALL OPERATE TO DENY TO THE
13 BENEFICIARY THE RECOVERY FOR THAT PORTION OF ANY DAMAGES NOT
14 COVERED HEREUNDER.
15 (4) (I) WHERE AN ACTION IS BROUGHT BY THE DEPARTMENT
16 PURSUANT TO THIS SECTION, IT SHALL BE COMMENCED WITHIN [FIVE]
17 SEVEN YEARS OF THE DATE THE CAUSE OF ACTION ARISES:
18 (II) NOTWITHSTANDING SUBCLAUSE (I), IF A BENEFICIARY HAS
19 COMMENCED AN ACTION TO RECOVER DAMAGES FOR AN INJURY FOR WHICH
20 BENEFITS ARE PROVIDED OR WILL BE PROVIDED AND IF THE DEPARTMENT
21 WAS NOT PROVIDED WITH ADEQUATE NOTICE UNDER THIS SECTION OR
22 SECTION 1409.1, THE DEPARTMENT MAY COMMENCE AN ACTION UNDER THIS
23 SECTION WITHIN THE LATER OF SEVEN YEARS OF THE DATE THE CAUSE OF
24 ACTION ARISES OR TWO YEARS FROM THE DATE THE DEPARTMENT
25 DISCOVERS THE SETTLEMENT OR JUDGMENT. NOTICE SHALL BE ADEQUATE
26 IF ALL OF THE FOLLOWING NOTICES HAVE BEEN PROVIDED TO THE
27 DEPARTMENT, IF REQUIRED:
28 (A) NOTICE OF SUIT UNDER CLAUSE (5)(I) FROM EITHER THE
29 BENEFICIARY OR ANY THIRD PARTY OR INSURER.
30 (B) NOTICE OF ANY ELECTION FROM THE BENEFICIARY UNDER CLAUSE
20070H1788B4179 - 30 -
1 (5)(III).
2 (C) NOTICE OF SETTLEMENT UNDER CLAUSE (5)(IV) FROM EITHER
3 THE BENEFICIARY OR ANY THIRD PARTY OR INSURER.
4 (D) NOTICE OF ANY ALLOCATION PROCEEDING UNDER SECTION
5 1409.1(B)(3).
6 (III) THE FOLLOWING SHALL APPLY:
7 [(I)] (A) THE DEATH OF THE BENEFICIARY DOES NOT ABATE ANY
8 RIGHT OF ACTION ESTABLISHED BY THIS SECTION.
9 [(II)] (B) WHEN AN ACTION OR CLAIM IS BROUGHT BY PERSONS
10 ENTITLED TO BRING SUCH ACTIONS OR ASSERT SUCH CLAIMS AGAINST A
11 THIRD PARTY WHO MAY BE LIABLE FOR CAUSING THE DEATH OF A
12 BENEFICIARY, ANY SETTLEMENT, JUDGMENT OR AWARD OBTAINED IS
13 SUBJECT TO THE DEPARTMENT'S CLAIMS FOR REIMBURSEMENT OF THE
14 BENEFITS PROVIDED TO THE BENEFICIARY UNDER THE MEDICAL
15 ASSISTANCE PROGRAM.
16 [(III)] (C) WHERE THE ACTION OR CLAIM IS BROUGHT BY THE
17 BENEFICIARY ALONE AND THE BENEFICIARY INCURS A PERSONAL
18 LIABILITY TO PAY ATTORNEY'S FEES AND COSTS OF LITIGATION, THE
19 DEPARTMENT'S CLAIM FOR REIMBURSEMENT OF THE BENEFITS PROVIDED TO
20 THE BENEFICIARY SHALL BE LIMITED TO THE AMOUNT OF THE MEDICAL
21 EXPENDITURES FOR THE SERVICES TO THE BENEFICIARY.
22 (D) WHERE BENEFITS ARE PROVIDED OR WILL BE PROVIDED FOR A
23 MINOR'S CARE, ANY STATUTE OF LIMITATION OR REPOSE APPLICABLE TO
24 AN ACTION OR CLAIM IN WHICH THE MINOR'S MEDICAL EXPENSES MAY BE
25 SOUGHT SHALL BE TOLLED UNTIL THE MINOR REACHES THE AGE OF
26 MAJORITY. THE PERIOD OF MINORITY SHALL NOT BE DEEMED A PORTION
27 OF THE TIME PERIOD WITHIN WHICH THE ACTION MUST BE COMMENCED. AS
28 USED IN THIS PARAGRAPH, THE TERM "MINOR" SHALL MEAN ANY
29 INDIVIDUAL WHO HAS NOT YET ATTAINED THE AGE OF 18.
30 (5) IF EITHER THE BENEFICIARY OR THE DEPARTMENT BRINGS AN
20070H1788B4179 - 31 -
1 ACTION OR CLAIM AGAINST SUCH THIRD PARTY OR INSURER, THE
2 BENEFICIARY OR THE DEPARTMENT SHALL WITHIN THIRTY DAYS OF FILING
3 THE ACTION GIVE TO THE OTHER WRITTEN NOTICE BY PERSONAL
4 SERVICE[,] OR BY CERTIFIED OR REGISTERED MAIL OF THE ACTION OR
5 CLAIM. [PROOF OF SUCH NOTICE SHALL BE FILED IN SUCH ACTION OR
6 CLAIM. IF AN ACTION OR CLAIM IS BROUGHT BY EITHER THE DEPARTMENT
7 OR BENEFICIARY, THE OTHER MAY, AT ANY TIME BEFORE TRIAL ON THE
8 FACTS, BECOME A PARTY TO, OR SHALL CONSOLIDATE HIS ACTION OR
9 CLAIM WITH THE OTHER IF BROUGHT INDEPENDENTLY.] ANY THIRD PARTY
10 OR INSURER THAT HAS RECEIVED INFORMATION INDICATING THAT THE
11 BENEFICIARY RECEIVED BENEFITS UNDER THE MEDICAL ASSISTANCE
12 PROGRAM SHALL GIVE WRITTEN NOTICE TO THE DEPARTMENT BY PERSONAL
13 SERVICE OR BY CERTIFIED OR REGISTERED MAIL OF THE ACTION OR
14 CLAIM. PROOF OF THE NOTICES SHALL BE FILED IN THE ACTION OR
15 CLAIM.
16 (I) IF A BENEFICIARY FILES AN ACTION OR CLAIM THAT DOES NOT
17 SEEK RECOVERY OF EXPENSES FOR WHICH BENEFITS UNDER THE MEDICAL
18 ASSISTANCE PROGRAM ARE PROVIDED, THE BENEFICIARY SHALL INCLUDE
19 IN THE NOTICE TO THE DEPARTMENT A STATEMENT THAT THE ACTION OR
20 CLAIM DOES NOT SEEK RECOVERY OF THE EXPENSES.
21 (II) IF A PARENT FILES AN ACTION OR CLAIM THAT DOES NOT SEEK
22 RECOVERY OF A MINOR'S MEDICAL EXPENSES PAID BY THE MEDICAL
23 ASSISTANCE PROGRAM, THE PARENT SHALL INCLUDE IN THE NOTICE TO
24 THE DEPARTMENT A STATEMENT THAT THE ACTION OR CLAIM DOES NOT
25 SEEK THE RECOVERY OF THE EXPENSES.
26 (III) IF A BENEFICIARY FILES AN ACTION OR CLAIM THAT SEEKS
27 THE RECOVERY OF EXPENSES FOR WHICH BENEFITS UNDER THE MEDICAL
28 ASSISTANCE PROGRAM ARE PROVIDED AND LATER ELECTS NOT TO SEEK
29 RECOVERY OF THE EXPENSES, THE BENEFICIARY SHALL PROVIDE
30 REASONABLE NOTICE TO THE DEPARTMENT BY PERSONAL SERVICE OR BY
20070H1788B4179 - 32 -
1 CERTIFIED OR REGISTERED MAIL. NOTICE SHALL BE REASONABLE IF IT
2 ALLOWS THE DEPARTMENT SUFFICIENT TIME TO PETITION TO INTERVENE
3 IN THE ACTION AND PROSECUTE ITS CLAIM.
4 (IV) NOTICE OF ANY SETTLEMENT SHALL BE PROVIDED TO THE
5 DEPARTMENT BY THE BENEFICIARY AND ANY THIRD PARTY OR INSURER
6 WITHIN THIRTY DAYS OF THE SETTLEMENT. WHERE JUDICIAL APPROVAL OF
7 THE SETTLEMENT IS REQUIRED, REASONABLE NOTICE OF THE SETTLEMENT
8 SHALL BE PROVIDED TO THE DEPARTMENT BEFORE A JUDICIAL HEARING
9 FOR APPROVAL OF THE SETTLEMENT. NOTICE IS REASONABLE IF IT
10 ALLOWS THE DEPARTMENT SUFFICIENT TIME TO INTERVENE IN THE ACTION
11 AND PROSECUTE ITS CLAIM.
12 (V) IF AN ACTION OR CLAIM IS BROUGHT BY EITHER THE
13 DEPARTMENT OR BENEFICIARY, THE OTHER MAY, AT ANY TIME BEFORE
14 TRIAL ON THE FACTS, BECOME A PARTY TO, OR SHALL CONSOLIDATE HIS
15 ACTION OR CLAIM WITH, THE OTHER IF BROUGHT INDEPENDENTLY.
16 (VI) THE BENEFICIARY MAY INCLUDE AS PART OF HIS CLAIM THE
17 AMOUNT OF BENEFITS THAT HAVE BEEN OR WILL BE PROVIDED BY THE
18 MEDICAL ASSISTANCE PROGRAM.
19 (6) IF AN ACTION OR CLAIM IS BROUGHT BY THE DEPARTMENT
20 PURSUANT TO SUBSECTION [(A)] (B)(1), WRITTEN NOTICE TO THE
21 BENEFICIARY[, GUARDIAN, PERSONAL REPRESENTATIVE, ESTATE OR
22 SURVIVOR] GIVEN PURSUANT TO THIS SECTION SHALL ADVISE HIM OF HIS
23 RIGHT TO INTERVENE IN THE PROCEEDING[,] AND HIS RIGHT TO RECOVER
24 THE REASONABLE VALUE OF THE BENEFITS PROVIDED.
25 (7) [IN] EXCEPT AS PROVIDED UNDER SECTION 1409.1, IN THE
26 EVENT OF JUDGMENT, AWARD OR SETTLEMENT IN A SUIT OR CLAIM
27 AGAINST SUCH THIRD PARTY OR INSURER:
28 (I) IF THE ACTION OR CLAIM IS PROSECUTED BY THE BENEFICIARY
29 ALONE, THE COURT OR AGENCY SHALL FIRST ORDER PAID FROM ANY
30 JUDGMENT OR AWARD THE REASONABLE LITIGATION EXPENSES, AS
20070H1788B4179 - 33 -
1 DETERMINED BY THE COURT, INCURRED IN PREPARATION AND PROSECUTION
2 OF SUCH ACTION OR CLAIM, TOGETHER WITH REASONABLE ATTORNEY'S
3 FEES, WHEN AN ATTORNEY HAS BEEN RETAINED. AFTER PAYMENT OF SUCH
4 EXPENSES AND ATTORNEY'S FEES THE COURT OR AGENCY SHALL, ON THE
5 APPLICATION OF THE DEPARTMENT, ALLOW AS A FIRST LIEN AGAINST THE
6 AMOUNT OF SUCH JUDGMENT OR AWARD, THE AMOUNT OF THE EXPENDITURES
7 FOR THE BENEFIT OF THE BENEFICIARY UNDER THE MEDICAL ASSISTANCE
8 PROGRAM.
9 (II) IF THE ACTION OR CLAIM IS PROSECUTED BOTH BY THE
10 BENEFICIARY AND THE DEPARTMENT, THE COURT OR AGENCY SHALL FIRST
11 ORDER PAID FROM ANY JUDGMENT OR AWARD, THE REASONABLE LITIGATION
12 EXPENSES INCURRED IN PREPARATION AND PROSECUTION OF SUCH ACTION
13 OR CLAIM, TOGETHER WITH REASONABLE ATTORNEY'S FEES BASED SOLELY
14 ON THE SERVICES RENDERED FOR THE BENEFIT OF THE BENEFICIARY.
15 AFTER PAYMENT OF SUCH EXPENSES AND ATTORNEY'S FEES, THE COURT OR
16 AGENCY SHALL APPLY OUT OF THE BALANCE OF SUCH JUDGMENT OR AWARD
17 AN AMOUNT OF BENEFITS PAID ON BEHALF OF THE BENEFICIARY UNDER
18 THE MEDICAL ASSISTANCE PROGRAM.
19 (III) WITH RESPECT TO CLAIMS AGAINST THIRD PARTIES FOR THE
20 COST OF MEDICAL ASSISTANCE SERVICES DELIVERED THROUGH A MANAGED
21 CARE ORGANIZATION CONTRACT, THE DEPARTMENT SHALL RECOVER THE
22 ACTUAL PAYMENT TO THE HOSPITAL OR OTHER MEDICAL PROVIDER FOR THE
23 SERVICE. IF NO SPECIFIC PAYMENT IS IDENTIFIED BY THE MANAGED
24 CARE ORGANIZATION FOR THE SERVICE, THE DEPARTMENT SHALL RECOVER
25 ITS FEE SCHEDULE AMOUNT FOR THE SERVICE.
26 (8) [UPON] EXCEPT AS PROVIDED UNDER SECTION 1409.1, UPON
27 APPLICATION OF THE DEPARTMENT, THE COURT OR AGENCY SHALL ALLOW A
28 LIEN AGAINST ANY THIRD PARTY PAYMENT OR TRUST FUND RESULTING
29 FROM A JUDGMENT, AWARD OR SETTLEMENT IN THE AMOUNT OF ANY
30 EXPENDITURES IN PAYMENT OF ADDITIONAL BENEFITS ARISING OUT OF
20070H1788B4179 - 34 -
1 THE SAME CAUSE OF ACTION OR CLAIM PROVIDED ON BEHALF OF THE
2 BENEFICIARY UNDER THE MEDICAL ASSISTANCE PROGRAM, WHEN SUCH
3 BENEFITS WERE PROVIDED OR BECAME PAYABLE SUBSEQUENT TO THE DATE
4 OF THE JUDGMENT, AWARD OR SETTLEMENT.
5 (9) UNLESS OTHERWISE DIRECTED BY THE DEPARTMENT, NO PAYMENT
6 OR DISTRIBUTION SHALL BE MADE TO A CLAIMANT OR A CLAIMANT'S
7 DESIGNEE OF THE PROCEEDS OF ANY ACTION, CLAIM OR SETTLEMENT
8 WHERE THE DEPARTMENT HAS AN INTEREST WITHOUT FIRST SATISFYING OR
9 ASSURING SATISFACTION OF THE INTEREST OF THE COMMONWEALTH. ANY
10 PERSON WHO, AFTER RECEIVING NOTICE OF THE DEPARTMENT'S INTEREST,
11 KNOWINGLY FAILS TO COMPLY WITH THE OBLIGATIONS ESTABLISHED UNDER
12 THIS CLAUSE SHALL BE LIABLE TO THE DEPARTMENT, AND THE
13 DEPARTMENT MAY SUE TO RECOVER FROM THE PERSON.
14 (10) WHEN THE DEPARTMENT HAS PERFECTED A LIEN UPON A
15 JUDGMENT OR AWARD IN FAVOR OF A BENEFICIARY AGAINST ANY THIRD
16 PARTY FOR AN INJURY FOR WHICH THE BENEFICIARY HAS RECEIVED
17 BENEFITS UNDER THE MEDICAL ASSISTANCE PROGRAM, THE DEPARTMENT
18 SHALL BE ENTITLED TO A WRIT OF EXECUTION AS LIEN CLAIMANT TO
19 ENFORCE PAYMENT OF SAID LIEN AGAINST SUCH THIRD PARTY WITH
20 INTEREST AND OTHER ACCRUING COSTS AS IN THE CASE OF OTHER
21 EXECUTIONS. IN THE EVENT THE AMOUNT OF SUCH JUDGMENT OR AWARD SO
22 RECOVERED HAS BEEN PAID TO THE BENEFICIARY, THE DEPARTMENT SHALL
23 BE ENTITLED TO A WRIT OF EXECUTION AGAINST SUCH BENEFICIARY TO
24 THE EXTENT OF THE DEPARTMENT'S LIEN, WITH INTEREST AND OTHER
25 ACCRUING COSTS AS IN THE COST OF OTHER EXECUTIONS.
26 (11) EXCEPT AS OTHERWISE PROVIDED IN THIS ACT,
27 NOTWITHSTANDING ANY OTHER PROVISION OF LAW, THE ENTIRE AMOUNT OF
28 ANY SETTLEMENT OF THE INJURED BENEFICIARY'S ACTION OR CLAIM,
29 WITH OR WITHOUT SUIT, IS SUBJECT TO THE DEPARTMENT'S CLAIM FOR
30 REIMBURSEMENT OF THE BENEFITS PROVIDED ANY LIEN FILED PURSUANT
20070H1788B4179 - 35 -
1 THERETO, BUT IN NO EVENT SHALL THE DEPARTMENT'S CLAIM EXCEED
2 ONE-HALF OF THE BENEFICIARY'S RECOVERY AFTER DEDUCTING FOR
3 ATTORNEY'S FEES, LITIGATION COSTS, AND MEDICAL EXPENSES RELATING
4 TO THE INJURY PAID FOR BY THE BENEFICIARY.
5 (12) IN THE EVENT THAT THE BENEFICIARY, HIS GUARDIAN,
6 PERSONAL REPRESENTATIVE, ESTATE OR SURVIVORS OR ANY OF THEM
7 BRINGS AN ACTION AGAINST THE THIRD PERSON WHO MAY BE LIABLE FOR
8 THE INJURY, NOTICE OF INSTITUTION OF LEGAL PROCEEDINGS, NOTICE
9 OF SETTLEMENT AND ALL OTHER NOTICES REQUIRED BY THIS ACT SHALL
10 BE GIVEN TO THE SECRETARY (OR HIS DESIGNEE) IN HARRISBURG EXCEPT
11 IN CASES WHERE THE SECRETARY SPECIFIES THAT NOTICE SHALL BE
12 GIVEN TO THE ATTORNEY GENERAL. [ALL SUCH NOTICES SHALL BE GIVEN
13 BY THE] THE BENEFICIARY'S OBLIGATIONS UNDER THIS SUBSECTION
14 SHALL BE MET BY THE ATTORNEY RETAINED TO ASSERT THE
15 BENEFICIARY'S CLAIM, OR BY THE INJURED PARTY BENEFICIARY, HIS
16 GUARDIAN, PERSONAL REPRESENTATIVE, ESTATE OR SURVIVORS, IF NO
17 ATTORNEY IS RETAINED.
18 (13) THE FOLLOWING SPECIAL DEFINITIONS APPLY TO THIS
19 SUBSECTION [(B)]:
20 "BENEFICIARY" MEANS ANY PERSON WHO HAS RECEIVED BENEFITS OR
21 WILL BE PROVIDED BENEFITS UNDER THIS ACT BECAUSE OF AN INJURY
22 FOR WHICH ANOTHER PERSON MAY BE LIABLE. IT INCLUDES SUCH
23 BENEFICIARY'S GUARDIAN, CONSERVATOR, OR OTHER PERSONAL
24 REPRESENTATIVE, HIS ESTATE OR SURVIVORS.
25 "INSURER" INCLUDES ANY INSURER AS DEFINED IN THE ACT OF MAY
26 17, 1921 (P.L.789, NO.285), KNOWN AS "THE INSURANCE DEPARTMENT
27 ACT OF ONE THOUSAND NINE HUNDRED AND TWENTY-ONE," INCLUDING ANY
28 INSURER AUTHORIZED UNDER THE LAWS OF THIS COMMONWEALTH TO INSURE
29 PERSONS AGAINST LIABILITY OR INJURIES CAUSED TO ANOTHER, AND
30 ALSO ANY INSURER PROVIDING BENEFITS UNDER A POLICY OF BODILY
20070H1788B4179 - 36 -
1 INJURY LIABILITY INSURANCE COVERING LIABILITY ARISING OUT OF
2 OWNERSHIP, MAINTENANCE OR USE OF A MOTOR VEHICLE WHICH PROVIDES
3 UNINSURED MOTORIST ENDORSEMENT OF COVERAGE PURSUANT TO THE ACT
4 OF JULY 19, 1974 (P.L.489, NO.176), KNOWN AS THE "PENNSYLVANIA
5 NO-FAULT MOTOR VEHICLE INSURANCE ACT."
6 (C) FOLLOWING NOTICE AND HEARING, THE DEPARTMENT MAY
7 ADMINISTRATIVELY IMPOSE A PENALTY OF UP TO FIVE THOUSAND DOLLARS
8 ($5,000) PER VIOLATION UPON ANY PERSON WHO WILFULLY FAILS TO
9 COMPLY WITH THE OBLIGATIONS IMPOSED UNDER THIS SECTION.
10 SECTION 10. THE ACT IS AMENDED BY ADDING A SECTION TO READ:
11 SECTION 1409.1. FEDERAL LAW RECOVERY OF MEDICAL ASSISTANCE
12 REIMBURSEMENT.--(A) TO THE EXTENT THAT FEDERAL LAW LIMITS THE
13 DEPARTMENT'S RECOVERY OF MEDICAL ASSISTANCE REIMBURSEMENT TO THE
14 MEDICAL PORTION OF A BENEFICIARY'S JUDGMENT, AWARD OR SETTLEMENT
15 IN A CLAIM AGAINST A THIRD PARTY, THE PROVISIONS OF THIS SECTION
16 SHALL APPLY.
17 (B) IN THE EVENT OF JUDGMENT, AWARD OR SETTLEMENT IN A SUIT
18 OR CLAIM AGAINST A THIRD PARTY OR INSURER:
19 (1) IF THE ACTION OR CLAIM IS PROSECUTED BY THE BENEFICIARY
20 ALONE, THE COURT OR AGENCY SHALL FIRST ORDER PAID FROM ANY
21 JUDGMENT OR AWARD THE REASONABLE LITIGATION EXPENSES, AS
22 DETERMINED BY THE COURT, INCURRED IN PREPARATION AND PROSECUTION
23 OF THE ACTION OR CLAIM, TOGETHER WITH REASONABLE ATTORNEY FEES.
24 AFTER PAYMENT OF THE EXPENSES AND ATTORNEY FEES, THE COURT OR
25 AGENCY SHALL ALLOCATE THE JUDGMENT OR AWARD BETWEEN THE MEDICAL
26 PORTION AND OTHER DAMAGES AND SHALL ALLOW THE DEPARTMENT A FIRST
27 LIEN AGAINST THE MEDICAL PORTION OF THE JUDGMENT OR AWARD, THE
28 AMOUNT OF THE EXPENDITURES FOR THE BENEFIT OF THE BENEFICIARY
29 UNDER THE MEDICAL ASSISTANCE PROGRAM.
30 (2) IF THE ACTION OR CLAIM IS PROSECUTED BOTH BY THE
20070H1788B4179 - 37 -
1 BENEFICIARY AND THE DEPARTMENT, THE COURT OR AGENCY SHALL FIRST
2 ORDER PAID FROM ANY JUDGMENT OR AWARD THE REASONABLE LITIGATION
3 EXPENSES INCURRED IN PREPARATION AND PROSECUTION OF THE ACTION
4 OR CLAIM, TOGETHER WITH REASONABLE ATTORNEY FEES BASED SOLELY ON
5 THE SERVICES RENDERED FOR THE BENEFIT OF THE BENEFICIARY. AFTER
6 PAYMENT OF THE EXPENSES AND ATTORNEY FEES, THE COURT OR AGENCY
7 SHALL ALLOCATE THE JUDGMENT OR AWARD BETWEEN THE MEDICAL PORTION
8 AND OTHER DAMAGES AND SHALL MAKE AN AWARD TO THE DEPARTMENT OUT
9 OF THE MEDICAL PORTION OF THE JUDGMENT OR AWARD THE AMOUNT OF
10 BENEFITS PAID ON BEHALF OF THE BENEFICIARY UNDER THE MEDICAL
11 ASSISTANCE PROGRAM.
12 (3) THE DEPARTMENT SHALL BE GIVEN REASONABLE ADVANCE NOTICE
13 BEFORE THE COURT MAKES ANY ALLOCATION OF A JUDGMENT OR AWARD
14 UNDER THIS SECTION.
15 (4) THE PROVISIONS OF SECTION 1409(B)(7)(III) SHALL APPLY TO
16 THIS SECTION.
17 SECTION 11. SECTION 1413 OF THE ACT, ADDED JULY 7, 2005
18 (P.L.177, NO.42), IS AMENDED TO READ:
19 SECTION 1413. DATA MATCHING.--(A) ALL ENTITIES PROVIDING
20 HEALTH INSURANCE OR HEALTH CARE COVERAGE TO INDIVIDUALS RESIDING
21 WITHIN THIS COMMONWEALTH SHALL PROVIDE SUCH INFORMATION ON
22 COVERAGE AND BENEFITS, AS THE DEPARTMENT MAY SPECIFY, FOR ANY
23 RECIPIENT OF MEDICAL ASSISTANCE OR CHILD SUPPORT SERVICES
24 IDENTIFIED BY THE DEPARTMENT BY NAME AND EITHER POLICY NUMBER OR
25 SOCIAL SECURITY NUMBER. THE INFORMATION THE DEPARTMENT MAY
26 SPECIFY IN ITS REQUEST MAY INCLUDE INFORMATION NEEDED TO
27 DETERMINE DURING WHAT PERIOD INDIVIDUALS OR THEIR SPOUSES OR
28 THEIR DEPENDENTS MAY BE OR MAY HAVE BEEN COVERED BY THE ENTITY
29 AND THE NATURE OF THE COVERAGE THAT IS OR WAS PROVIDED BY THE
30 ENTITY, INCLUDING THE NAME, ADDRESS AND IDENTIFYING NUMBER OF
20070H1788B4179 - 38 -
1 THE PLAN.
2 (B) ALL ENTITIES PROVIDING HEALTH INSURANCE OR HEALTH CARE
3 COVERAGE TO INDIVIDUALS RESIDING WITHIN THIS COMMONWEALTH SHALL
4 ACCEPT THE DEPARTMENT'S RIGHT OF RECOVERY AND THE ASSIGNMENT TO
5 THE DEPARTMENT OF ANY RIGHT OF AN INDIVIDUAL OR ANY OTHER ENTITY
6 TO PAYMENT FOR AN ITEM OR SERVICE FOR WHICH PAYMENT HAS BEEN
7 MADE BY THE MEDICAL ASSISTANCE PROGRAM AND SHALL RECEIVE,
8 PROCESS AND PAY CLAIMS FOR REIMBURSEMENT SUBMITTED BY THE
9 DEPARTMENT OR ITS AUTHORIZED CONTRACTOR WITH RESPECT TO MEDICAL
10 ASSISTANCE RECIPIENTS WHO HAVE COVERAGE FOR SUCH CLAIMS.
11 (C) TO THE MAXIMUM EXTENT PERMITTED BY FEDERAL LAW AND
12 NOTWITHSTANDING ANY POLICY OR PLAN PROVISION TO THE CONTRARY, A
13 CLAIM BY THE DEPARTMENT FOR REIMBURSEMENT OF MEDICAL ASSISTANCE
14 SHALL BE DEEMED TIMELY FILED WITH THE ENTITY PROVIDING HEALTH
15 INSURANCE OR HEALTH CARE COVERAGE AND SHALL NOT BE DENIED SOLELY
16 ON THE BASIS OF THE DATE OF SUBMISSION OF THE CLAIM, THE TYPE OR
17 FORMAT OF THE CLAIM OR A FAILURE TO PRESENT PROPER DOCUMENTATION
18 AT THE POINT OF SALE THAT IS THE BASIS OF THE CLAIM, IF IT IS
19 FILED AS FOLLOWS:
20 (1) WITHIN FIVE YEARS OF THE DATE OF SERVICE FOR ALL DATES
21 OF SERVICE OCCURRING ON OR BEFORE JUNE 30, 2007; OR
22 (2) WITHIN THREE YEARS OF THE DATE OF SERVICE FOR ALL DATES
23 OF SERVICE OCCURRING ON OR AFTER JULY 1, 2007.
24 (C.1) ANY ACTION BY THE DEPARTMENT TO ENFORCE ITS RIGHTS
25 WITH RESPECT TO A CLAIM SUBMITTED BY THE DEPARTMENT UNDER THIS
26 SECTION MUST BE COMMENCED WITHIN SIX YEARS OF THE DEPARTMENT'S
27 SUBMISSION OF THE CLAIM. ALL ENTITIES PROVIDING HEALTH CARE
28 COVERAGE WITHIN THIS COMMONWEALTH SHALL RESPOND WITHIN FORTY-
29 FIVE DAYS TO ANY INQUIRY BY THE DEPARTMENT REGARDING A CLAIM FOR
30 PAYMENT FOR ANY HEALTH CARE ITEM OR SERVICE THAT IS SUBMITTED
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1 NOT LATER THAN THREE YEARS AFTER THE DATE OF PROVISION OF THE
2 HEALTH CARE ITEM OR SERVICE.
3 (D) THE DEPARTMENT IS AUTHORIZED TO ENTER INTO AGREEMENTS
4 WITH ENTITIES PROVIDING HEALTH INSURANCE AND HEALTH CARE
5 COVERAGE FOR THE PURPOSE OF CARRYING OUT THE PROVISIONS OF THIS
6 SECTION. THE AGREEMENT SHALL PROVIDE FOR THE ELECTRONIC EXCHANGE
7 OF DATA BETWEEN THE PARTIES AT A MUTUALLY AGREED-UPON FREQUENCY,
8 BUT NO LESS FREQUENTLY THAN [ONCE EVERY TWO MONTHS] MONTHLY, AND
9 MAY ALSO ALLOW FOR PAYMENT OF A FEE BY THE DEPARTMENT TO THE
10 ENTITY PROVIDING HEALTH INSURANCE OR HEALTH CARE COVERAGE.
11 (E) FOLLOWING NOTICE AND HEARING, THE DEPARTMENT MAY IMPOSE
12 A PENALTY OF UP TO ONE THOUSAND DOLLARS ($1,000) PER VIOLATION
13 UPON ANY ENTITY THAT WILFULLY FAILS TO COMPLY WITH THE
14 OBLIGATIONS IMPOSED BY THIS SECTION.
15 (E.1) IT IS A CONDITION OF DOING BUSINESS IN THIS
16 COMMONWEALTH THAT EVERY ENTITY SUBJECT TO THIS SECTION COMPLY
17 WITH THE PROVISIONS OF THIS SECTION AND AGREE NOT TO DENY A
18 CLAIM SUBMITTED BY THE DEPARTMENT ON THE BASIS OF A PLAN OR
19 CONTRACT PROVISION THAT IS INCONSISTENT WITH SUBSECTION (C).
20 (F) THIS SECTION SHALL APPLY TO EVERY ENTITY PROVIDING
21 HEALTH INSURANCE OR HEALTH CARE COVERAGE WITHIN THIS
22 COMMONWEALTH, INCLUDING, BUT NOT LIMITED TO, PLANS, POLICIES,
23 CONTRACTS OR CERTIFICATES ISSUED BY:
24 (1) A STOCK INSURANCE COMPANY INCORPORATED FOR ANY OF THE
25 PURPOSES SET FORTH IN SECTION 202(C) OF THE ACT OF MAY 17, 1921
26 (P.L.682, NO.284), KNOWN AS "THE INSURANCE COMPANY LAW OF 1921."
27 (2) A MUTUAL INSURANCE COMPANY INCORPORATED FOR ANY OF THE
28 PURPOSES SET FORTH IN SECTION 202(D) OF "THE INSURANCE COMPANY
29 LAW OF 1921."
30 (3) A PROFESSIONAL HEALTH SERVICES PLAN CORPORATION AS
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1 DEFINED IN 40 PA.C.S. CH. 63 (RELATING TO PROFESSIONAL HEALTH
2 SERVICES PLAN CORPORATIONS).
3 (4) A HEALTH MAINTENANCE ORGANIZATION AS DEFINED IN THE ACT
4 OF DECEMBER 29, 1972 (P.L.1701, NO.364), KNOWN AS THE "HEALTH
5 MAINTENANCE ORGANIZATION ACT."
6 (5) A FRATERNAL BENEFIT SOCIETY AS DEFINED IN SECTION 2403
7 OF "THE INSURANCE COMPANY LAW OF 1921."
8 (6) A PERSON WHO SELLS OR ISSUES CONTRACTS OR CERTIFICATES
9 OF INSURANCE WHICH MEET THE REQUIREMENTS OF THIS ACT.
10 (7) A HOSPITAL PLAN CORPORATION AS DEFINED IN 40 PA.C.S. CH.
11 61 (RELATING TO HOSPITAL PLAN CORPORATIONS).
12 (8) HEALTH CARE PLANS SUBJECT TO THE EMPLOYEE RETIREMENT
13 INCOME SECURITY ACT OF 1974 (PUBLIC LAW 93-406, 88 STAT. 829),
14 SELF-INSURED PLANS, SERVICE BENEFIT PLANS, MANAGED CARE
15 ORGANIZATIONS, PHARMACY BENEFIT MANAGERS AND EVERY OTHER
16 ORGANIZATION THAT IS, BY STATUTE, CONTRACT OR AGREEMENT, LEGALLY
17 RESPONSIBLE FOR THE PAYMENT OF A CLAIM FOR A HEALTH CARE SERVICE
18 OR ITEM TO THE MAXIMUM EXTENT PERMITTED BY FEDERAL LAW.
19 SECTION 12. (1) THE ADDITION OF ARTICLE VIII-F OF THE ACT
20 SHALL APPLY RETROACTIVELY TO JULY 1, 2008.
21 (2) THE AMENDMENT OR ADDITION OF SECTIONS 1409 AND 1409.1 OF
22 THE ACT SHALL APPLY TO ACTIONS FILED ON OR AFTER THE EFFECTIVE
23 DATE OF THIS SECTION.
24 SECTION 13. THIS ACT SHALL TAKE EFFECT AS FOLLOWS:
25 (1) THE FOLLOWING PROVISIONS SHALL TAKE EFFECT
26 IMMEDIATELY:
27 (I) THE AMENDMENT OR ADDITION OF SECTIONS 443.1(7),
28 460, 811-C, AND ARTICLE VIII-E OF THE ACT.
29 (II) THIS SECTION.
30 (III) SECTION 12 OF THIS ACT.
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1 (2) THE ADDITION OF SECTION 1088 OF THE ACT SHALL TAKE
2 EFFECT DECEMBER 31, 2008.
3 (3) THE REMAINDER OF THIS ACT SHALL TAKE EFFECT IN 60
4 DAYS.
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