PRINTER'S NO. 1684
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1354
Session of
2017
INTRODUCED BY GROVE, McGINNIS, BARRAR, ORTITAY, WARD, PICKETT,
PHILLIPS-HILL, DUSH, NELSON, SCHEMEL, HENNESSEY, O'NEILL,
TOOHIL, EVERETT, SAYLOR, FRITZ, RYAN, DAY, WHEELAND, CUTLER
AND MOUL, MAY 9, 2017
REFERRED TO COMMITTEE ON HEALTH, MAY 9, 2017
AN ACT
Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
act to consolidate, editorially revise, and codify the public
welfare laws of the Commonwealth," in public assistance,
further providing for income for the community spouse, for
medical assistance payments for institutional care, for
medical assistance payments for home health care, for other
medical assistance payments and for medical assistance
benefit packages and coverage, copayments, premiums and
rates; and providing for the Office of Independent Medicaid
Director.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Section 441.7(a) of the act of June 13, 1967
(P.L.31, No.21), known as the Human Services Code, is amended to
read:
Section 441.7. Income for the Community Spouse.--(a) When a
community spouse has income below the monthly maintenance needs
allowance as determined under the [department's] regulations
[and] adopted by the Office of Independent Medicaid Director for
the Commonwealth approved State plan under Title XIX of the
Social Security Act (49 Stat. 620, 42 U.S.C. § 1396 et seq.),
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the institutionalized spouse may transfer additional resources
to the community spouse only in accordance with this section.
* * *
Section 2. Section 443.1 of the act, amended December 28,
2015 (P.L.500, No.92) and July 8, 2016 (P.L.480, No.76), is
amended to read:
Section 443.1. Medical Assistance Payments for Institutional
Care.--The following medical assistance payments shall be made
on behalf of eligible persons whose institutional care is
prescribed by physicians:
(1) Payments as determined by the [department] Office of
Independent Medicaid Director for inpatient hospital care
consistent with Title XIX of the Social Security Act (49 Stat.
620, 42 U.S.C. § 1396 et seq.). To be eligible for such
payments, a hospital must be qualified to participate under
Title XIX of the Social Security Act and have entered into a
written agreement with the [department] Office of Independent
Medicaid Director regarding matters designated by the secretary
as necessary to efficient administration, such as hospital
utilization, maintenance of proper cost accounting records and
access to patients' records. Such efficient administration shall
require the [department] Office of Independent Medicaid Director
to permit participating hospitals to utilize the same fiscal
intermediary for this Title XIX program as such hospitals use
for the Title XVIII program.
(1.1) Subject to section 813-G, for inpatient hospital
services provided during a fiscal year in which an assessment is
imposed under Article VIII-G, payments under the medical
assistance fee-for-service program shall be determined in
accordance with the [department's] regulations adopted by the
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Office of Independent Medicaid Director, except as follows:
(i) If the Commonwealth's approved Title XIX State Plan for
inpatient hospital services in effect for the period of July 1,
2010, through June 30, 2018, specifies a methodology for
calculating payments that is different from the department's
regulations or authorizes additional payments not specified in
the department's regulations, such as inpatient disproportionate
share payments and direct medical education payments, the
department shall follow the methodology or make the additional
payments as specified in the approved Title XIX State Plan.
(ii) Subject to Federal approval of an amendment to the
Commonwealth's approved Title XIX State Plan, in making medical
assistance fee-for-service payments to acute care hospitals for
inpatient services provided on or after July 1, 2010, the
[department] Office of Independent Medicaid Director shall use
payment methods and standards that provide for all of the
following:
(A) Use of the All Patient Refined-Diagnosis Related Group
(APR/DRG) system for the classification of inpatient stays into
DRGs.
(B) Calculation of base DRG rates, based upon a Statewide
average cost, which are adjusted to account for a hospital's
regional labor costs, teaching status, capital and medical
assistance patient levels and such other factors as the
[department] Office of Independent Medicaid Director determines
may significantly impact the costs that a hospital incurs in
delivering inpatient services and which may be adjusted based on
the assessment revenue collected under Article VIII-G.
(C) Adjustments to payments for outlier cases where the
costs of the inpatient stays either exceed or are below cost
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thresholds established by the [department] Office of
Independent Medicaid Director.
(iii) Notwithstanding subparagraph (i), the [department]
Office of Independent Medicaid Director may make additional
changes to its payment methods and standards for inpatient
hospital services consistent with Title XIX of the Social
Security Act, including changes to supplemental payments
currently authorized in the State plan based on the availability
of Federal and State funds.
(1.2) Subject to section 813-G, for inpatient acute care
hospital services provided under the physical health medical
assistance managed care program during State fiscal year 2010-
2011, the following shall apply:
(i) For inpatient hospital services provided under a
participation agreement between an inpatient acute care hospital
and a medical assistance managed care organization in effect as
of June 30, 2010, the medical assistance managed care
organization shall pay, and the hospital shall accept as payment
in full, amounts determined in accordance with the payment terms
and rate methodology specified in the agreement and in effect as
of June 30, 2010, during the term of that participation
agreement. If a participation agreement in effect as of June 30,
2010, uses the [department] fee for service DRG rate methodology
in determining payment amounts, the medical assistance managed
care organization shall pay, and the hospital shall accept as
payment in full, amounts determined in accordance with the fee
for service payment methodology in effect as of June 30, 2010,
including, without limitation, continuation of the same grouper,
outlier methodology, base rates and relative weights, during the
term of that participation agreement.
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(ii) Nothing in subparagraph (i) shall prohibit payment
rates for inpatient acute care hospital services provided under
a participation agreement to change from the rates in effect as
of June 30, 2010, if the change in payment rates is authorized
by the terms of the participation agreement between the
inpatient acute care hospital and the medical assistance managed
care organization. For purposes of this act, any contract
provision that provides that payment rates and changes to
payment rates shall be calculated based upon the department's
fee for service DRG payment methodology shall be interpreted to
mean the [department's] fee for service medical assistance DRG
methodology in place on June 30, 2010.
(iii) If a participation agreement between a hospital and a
medical assistance managed care organization terminates during a
fiscal year in which an assessment is imposed under Article
VIII-G prior to the expiration of the term of the participation
agreement, payment for services, other than emergency services,
covered by the medical assistance managed care organization and
rendered by the hospital shall be made at the rate in effect as
of the termination date, as adjusted in accordance with
subparagraphs (i) and (ii), during the period in which the
participation agreement would have been in effect had the
agreement not terminated. The hospital shall receive the
supplemental payment in accordance with subparagraph (v).
(iv) If a hospital and a medical assistance managed care
organization do not have a participation agreement in effect as
of June 30, 2010, the medical assistance managed care
organization shall pay, and the hospital shall accept as payment
in full, for services, other than emergency services, covered by
the medical assistance managed care organization and rendered
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during a fiscal year in which an assessment is imposed under
Article VIII-G, an amount equal to the rates payable for the
services by the medical assistance fee for service program as of
June 30, 2010. The hospital shall receive the supplemental
payment in accordance with subparagraph (v).
(v) The [department] Office of Independent Medicaid
Director shall make enhanced capitation payments to medical
assistance managed care organizations if necessary exclusively
for the purpose of making supplemental payments to hospitals in
order to promote continued access to quality care for medical
assistance recipients. Medical assistance managed care
organizations shall use the enhanced capitation payments
received pursuant to this section solely for the purpose of
making supplemental payments to hospitals and shall provide
documentation to the [department] Office of Independent Medicaid
Director certifying that all funds received in this manner are
used in accordance with this section. The supplemental payments
to hospitals made pursuant to this subsection are in lieu of
increased or additional payments for inpatient acute care
services from medical assistance managed care organizations
resulting from the [department's] Office of Independent Medicaid
Director's implementation of payments under paragraph (1.1)(ii).
Medical assistance managed care organizations shall in no event
be obligated under this section to make supplemental or other
additional payments to hospitals that exceed the enhanced
capitation payments made to the medical assistance managed care
organization under this section. Medical assistance managed care
organizations shall not be required to advance the supplemental
payments to hospitals authorized by this subsection and shall
only make the supplemental payments to hospitals once medical
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assistance managed care organizations have received the enhanced
capitation payments from the [department] Office of Independent
Medicaid Director.
(vi) Nothing in this subsection shall prohibit an inpatient
acute care hospital and a medical assistance managed care
organization from executing a new participation agreement or
amending an existing participation agreement on or after July 1,
2010, in which they agree to payment terms that would result in
payments that are different than the payments determined in
accordance with subparagraphs (i), (ii), (iii) and (iv).
(1.3) Subject to section 813-G, the [department] Office of
Independent Medicaid Director may adjust its capitation payments
to medical assistance managed care organizations under the
physical health medical assistance managed care program during
State fiscal year 2011-2012 to provide additional funds for
inpatient hospital services to mitigate the impact, if any, to
the managed care organizations that may result from the changes
to the [department's] Office of Independent Medicaid Director's
payment methods and standards specified in paragraph (1.1)(ii).
If the [department] Office of Independent Medicaid Director
adjusts a medical assistance managed care organization's
capitation payments pursuant to this paragraph, the following
shall apply:
(i) The medical assistance managed care organization shall
provide documentation to the [department] Office of Independent
Medicaid Director identifying how the additional funds received
pursuant to this subsection were used by the medical assistance
managed care organization.
(ii) If the medical assistance managed care organization
uses all of the additional funds received pursuant to this
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subsection to make additional payments to hospitals, the
following shall apply:
(A) For inpatient hospital services provided under a
participation agreement between an inpatient acute care hospital
and the medical assistance managed care organization in effect
as of June 30, 2010, the medical assistance managed care
organization shall pay, and the hospital shall accept as payment
in full, amounts determined in accordance with the payment terms
and rate methodology specified in the agreement and in effect as
of June 30, 2010, during the term of that participation
agreement. If a participation agreement in effect as of June 30,
2010, uses the [department] fee-for-service DRG rate methodology
in determining payment amounts, the medical assistance managed
care organization shall pay, and the hospital shall accept as
payment in full, amounts determined in accordance with the fee-
for-service payment methodology in effect as of June 30, 2010,
including, without limitation, continuation of the same grouper,
outlier methodology, base rates and relative weights during the
term of that participation agreement.
(B) Nothing in clause (A) shall prohibit payment rates for
inpatient acute care hospital services provided under a
participation agreement to change from the rates in effect as of
June 30, 2010, if the change in payment rates is authorized by
the terms of the participation agreement between the inpatient
acute care hospital and the medical assistance managed care
organization. For purposes of this act, any contract provision
that provides that payment rates and changes to payment rates
shall be calculated based upon the [department's] fee-for-
service DRG payment methodology shall be interpreted to mean the
department's fee-for-service medical assistance DRG methodology
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in place on June 30, 2010.
(C) For an out-of-network inpatient discharge of a recipient
enrolled in a medical assistance managed care organization that
occurs in State fiscal year 2011-2012, the medical assistance
managed care organization shall pay, and the hospital shall
accept as payment in full, the amount that the [department's]
fee-for-service program would have paid for the discharge if the
recipient were enrolled in the [department's] fee-for-service
program and the discharge occurred on June 30, 2010.
(D) Nothing in this subparagraph shall prohibit an inpatient
acute care hospital and a medical assistance managed care
organization from executing a new participation agreement or
amending an existing participation agreement on or after July 1,
2010, in which they agree to payment terms that would result in
payments that are different from the payments determined in
accordance with clauses (A), (B) and (C).
(1.4) Subject to section 813-G, for inpatient hospital
services provided under the physical health medical assistance
managed care program during State fiscal years 2012-2013, 2013-
2014, 2014-2015, 2015-2016, 2016-2017 and 2017-2018, the
following shall apply:
(A) The [department] Office of Independent Medicaid Director
may adjust its capitation payments to medical assistance managed
care organizations to provide additional funds for inpatient and
outpatient hospital services.
(B) For an out-of-network inpatient discharge of a recipient
enrolled in a medical assistance managed care organization that
occurs in State fiscal year 2012-2013, 2013-2014, 2014-2015,
2015-2016, 2016-2017 and 2017-2018, the medical assistance
managed care organization shall pay, and the hospital shall
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accept as payment in full, the amount that the [department's]
fee-for-service program would have paid for the discharge if the
recipient was enrolled in the [department's] fee-for-service
program.
(C) Nothing in this paragraph shall prohibit an inpatient
acute care hospital and a medical assistance managed care
organization from executing a new participation agreement or
amending an existing participation agreement on or after July 1,
2013.
(1.5) As used in paragraphs (1.2), (1.3) and (1.4), the
following terms shall have the following meanings:
(i) "Emergency services" means emergency services as defined
in section 1932(b) of the Social Security Act (49 Stat. 620, 42
U.S.C. § 1396u-2(b)(2)(B)). The term shall not include
poststabilization care services as defined in 42 CFR 438.114(a)
(1) (relating to emergency and poststabilization services).
(ii) "Medical assistance managed care organization" means a
Medicaid managed care organization as defined in section 1903(m)
(1)(a) of the Social Security Act (49 Stat. 620, 42 U.S.C. §
1396b(m)(1)(a)) that is a party to a Medicaid managed care
contract with the [department] Office of Independent Medicaid
Director, other than a behavioral health managed care
organization that is a party to a medical assistance managed
care contract with the [department] Office of Independent
Medicaid Director.
(1.6) Notwithstanding any other provision of law or
departmental regulation to the contrary, the [department] Office
of Independent Medicaid Director shall make separate fee-for-
service APR/DRG payments for medically necessary inpatient acute
care general hospital services provided for normal newborn care
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and for mothers' obstetrical delivery.
(2) The cost of skilled nursing and intermediate nursing
care in State-owned geriatric centers, institutions for the
mentally retarded, institutions for the mentally ill, and the
cost of skilled and intermediate nursing care provided prior to
June 30, 2004, in county homes which meet the State and Federal
requirements for participation under Title XIX of the Social
Security Act and which are approved by the [department] Office
of Independent Medicaid Director. This cost in county homes
shall be as specified by the regulations of the [department]
Officer of Independent Medicaid Director adopted under Title XIX
of the Social Security Act and certified to the department by
the Auditor General; elsewhere the cost shall be determined by
the [department] Office of Independent Medicaid Director;
(3) Rates on a cost-related basis established by the
department for skilled nursing home or intermediate care in a
non-public nursing home, when furnished by a nursing home
licensed or approved by the department and qualified to
participate under Title XIX of the Social Security Act and
provided prior to June 30, 2004;
(4) Payments as determined by the department for inpatient
psychiatric care consistent with Title XIX of the Social
Security Act. To be eligible for such payments, a hospital must
be qualified to participate under Title XIX of the Social
Security Act and have entered into a written agreement with the
department regarding matters designated by the secretary as
necessary to efficient administration, such as hospital
utilization, maintenance of proper cost accounting records and
access to patients' records. Care in a private mental hospital
provided under the fee for service delivery system shall be
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limited to thirty days in any fiscal year for recipients aged
twenty-one years or older who are eligible for medical
assistance under Title XIX of the Social Security Act and for
recipients aged twenty-one years or older who are eligible for
general assistance-related medical assistance. Exceptions to the
thirty-day limit may be granted under section 443.3. Only
persons aged twenty-one years or under and aged sixty-five years
or older shall be eligible for care in a public mental hospital.
This cost shall be as specified by regulations of the
[department] Office of Independent Medicaid Director adopted
under Title XIX of the Social Security Act and certified to the
department by the Auditor General for county and non-public
institutions;
(5) After June 30, 2004, and before June 30, 2007, payments
to county and nonpublic nursing facilities enrolled in the
medical assistance program as providers of nursing facility
services shall be calculated and made as specified in the
[department's] regulations in effect on July 1, 2003, except
that if the Commonwealth's approved Title XIX State Plan for
nursing facility services in effect for the period of July 1,
2004, through June 30, 2007, specifies a methodology for
calculating county and nonpublic nursing facility payment rates
that is different than the department's regulations in effect on
July 1, 2003, the [department] Office of Independent Medicaid
Director shall follow the methodology in the Federally approved
Title XIX State plan.
(6) For public nursing home care provided on or after July
1, 2005, the [department] Office of Independent Medicaid
Director may recognize the costs incurred by county nursing
facilities to provide services to eligible persons as medical
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assistance program expenditures to the extent the costs qualify
for Federal matching funds and so long as the costs are
allowable as determined by the department and reported and
certified by the county nursing facilities in a form and manner
specified by the department. Expenditures reported and certified
by county nursing facilities shall be subject to periodic review
and verification by the department or the Auditor General.
Notwithstanding this paragraph, county nursing facilities shall
be paid based upon rates determined in accordance with
paragraphs (5) and (7).
(7) After June 30, 2007, payments to county and nonpublic
nursing facilities enrolled in the medical assistance program as
providers of nursing facility services shall be determined in
accordance with the methodologies for establishing payment rates
for county and nonpublic nursing facilities specified in the
[department's] Office of Independent Medicaid Director's
regulations and the Commonwealth's approved Title XIX State Plan
for nursing facility services in effect after June 30, 2007. The
following shall apply:
(i) For the fiscal year 2007-2008, the [department] Office
of Independent Medicaid Director shall apply a revenue
adjustment neutrality factor and make adjustments to county and
nonpublic nursing facility payment rates for medical assistance
nursing facility services. The revenue adjustment factor shall
limit the estimated aggregate increase in the Statewide day-
weighted average payment rate over the three-year period
commencing July 1, 2005, and ending June 30, 2008, from the
Statewide day-weighted average payment rate for medical
assistance nursing facility services in fiscal year 2004-2005 to
6.912% plus any percentage rate of increase permitted by the
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amount of funds appropriated for nursing facility services in
the General Appropriation Act of 2007. Application of the
revenue adjustment neutrality factor shall be subject to Federal
approval of any amendments as may be necessary to the
Commonwealth's approved Title XIX State Plan for nursing
facility services.
(ii) The [department] Office of Independent Medicaid
Director may make additional changes to its methodologies for
establishing payment rates for county and nonpublic nursing
facilities enrolled in the medical assistance program consistent
with Title XIX of the Social Security Act, except that if during
a fiscal year an assessment is implemented under Article VIII-A,
the department shall not make a change under this subparagraph
unless it adopts regulations as provided under section 814-A.
(iii) Subject to Federal approval of such amendments as may
be necessary to the Commonwealth's approved Title XIX State
Plan, the department shall do all of the following:
(A) For each fiscal year between July 1, 2008, and June 30,
2011, the department shall apply a revenue adjustment neutrality
factor to county and nonpublic nursing facility payment rates.
For each such fiscal year, the revenue adjustment neutrality
factor shall limit the estimated aggregate increase in the
Statewide day-weighted average payment rate so that the
aggregate percentage rate of increase for the period that begins
on July 1, 2005, and ends on the last day of the fiscal year is
limited to the amount permitted by the funds appropriated by the
General Appropriations Act for those fiscal years.
(B) In calculating rates for nonpublic nursing facilities
for fiscal year 2008-2009, the department shall continue to
include costs incurred by county nursing facilities in the rate-
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setting database, as specified in the department's regulations
in effect on July 1, 2007.
(C) The department shall propose regulations that phase out
the use of county nursing facility costs as an input in the
process of setting payment rates of nonpublic nursing
facilities. The final regulations shall be effective July 1,
2009, and shall phase out the use of these costs in rate-setting
over a period of three rate years, beginning fiscal year 2009-
2010 and ending on June 30, 2012.
(D) The department shall propose regulations that establish
minimum occupancy requirements as a condition for bed-hold
payments. The final regulations shall be effective July 1, 2009,
and shall phase in these requirements over a period of two rate
years, beginning fiscal year 2009-2010.
(iv) Subject to Federal approval of such amendments as may
be necessary to the Commonwealth's approved Title XIX State
Plan, for each fiscal year beginning on or after July 1, 2011,
the [department] Office of Independent Medicaid Director shall
apply a revenue adjustment neutrality factor to county and
nonpublic nursing facility payment rates so that the estimated
Statewide day-weighted average payment rate in effect for that
fiscal year is limited to the amount permitted by the funds
appropriated by the General Appropriation Act for the fiscal
year. The revenue adjustment neutrality factor shall remain in
effect until the sooner of June 30, 2019, or the date on which a
new rate-setting methodology for medical assistance nursing
facility services which replaces the rate-setting methodology
codified in 55 Pa. Code Chs. 1187 (relating to nursing facility
services) and 1189 (relating to county nursing facility
services) takes effect.
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(v) Subject to Federal approval of such amendments as may be
necessary to the Commonwealth's approved Title XIX State Plan,
for fiscal year 2013-2014, the [department] Office of
Independent Medicaid Director shall make quarterly medical
assistance day-one incentive payments to qualified nonpublic
nursing facilities. The [department] Office of Independent
Medicaid Director shall determine the nonpublic nursing
facilities that qualify for the quarterly medical assistance
day-one incentive payments and calculate the payments using the
total Pennsylvania medical assistance (PA MA) days and total
resident days as reported by nonpublic nursing facilities under
Article VIII-A. The [department's] Office of Independent
Medicaid Director's determination and calculations under this
subparagraph shall be based on the nursing facility assessment
quarterly resident day reporting forms available on October 31,
January 31, April 30 and July 31. The [department] Office of
Independent Medicaid Director shall not retroactively revise a
medical assistance day-one incentive payment amount based on a
nursing facility's late submission or revision of its report
after these dates. The [department] Office of Independent
Medicaid Director, however, may recoup payments based on an
audit of a nursing facility's report. The following shall apply:
(A) A nonpublic nursing facility shall meet all of the
following criteria to qualify for a medical assistance day-one
incentive payment:
(I) The nursing facility shall have an overall occupancy
rate of at least 85% during the resident day quarter. For
purposes of determining a nursing facility's overall occupancy
rate, a nursing facility's total resident days, as reported by
the facility under Article VIII-A, shall be divided by the
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product of the facility's licensed bed capacity, at the end of
the quarter, multiplied by the number of calendar days in the
quarter.
(II) The nursing facility shall have a medical assistance
occupancy rate of at least 65% during the resident day quarter.
For purposes of determining a nursing facility's medical
assistance occupancy rate, the nursing facility's total PA MA
days shall be divided by the nursing facility's total resident
days, as reported by the facility under Article VIII-A.
(III) The nursing facility shall be a nonpublic nursing
facility for a full resident day quarter prior to the applicable
quarterly reporting due dates of October 31, January 31, April
30 and July 31.
(B) The [department] Office of Independent Medicaid
Director shall calculate a qualified nonpublic nursing
facility's medical assistance day-one incentive quarterly
payment as follows:
(I) The total funds appropriated for payments under this
subparagraph shall be divided by four.
(II) To establish the quarterly per diem rate, the amount
under subclause (I) shall be divided by the total PA MA days, as
reported by all qualifying nonpublic nursing facilities under
Article VIII-A.
(III) To determine a qualifying nonpublic nursing facility's
quarterly medical assistance day-one incentive payment, the
quarterly per diem rate shall be multiplied by a nonpublic
nursing facility's total PA MA days, as reported by the facility
under Article VIII-A.
(C) For fiscal year 2013-2014, the State funds available for
the nonpublic nursing facility medical assistance day-one
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incentive payments shall equal eight million dollars
($8,000,000).
(vi) Subject to Federal approval of such amendments as may
be necessary to the Commonwealth's approved Title XIX State
Plan, for fiscal years 2015-2016 and 2016-2017, the [department]
Office of Independent Medicaid Director shall make up to four
medical assistance day-one incentive payments to qualified
nonpublic nursing facilities. The department shall determine the
nonpublic nursing facilities that qualify for the medical
assistance day-one incentive payments and calculate the payments
using the total Pennsylvania medical assistance (PA MA) days and
total resident days as reported by nonpublic nursing facilities
under Article VIII-A. The department's determination and
calculations under this subparagraph shall be based on the
nursing facility assessment quarterly resident day reporting
forms, as determined by the department. The department shall not
retroactively revise a medical assistance day-one incentive
payment amount based on a nursing facility's late submission or
revision of the department's report after the dates designated
by the department. The department, however, may recoup payments
based on an audit of a nursing facility's report. The following
shall apply:
(A) A nonpublic nursing facility shall meet all of the
following criteria to qualify for a medical assistance day-one
incentive payment:
(I) The nursing facility shall have an overall occupancy
rate of at least eighty-five percent during the resident day
quarter. For purposes of determining a nursing facility's
overall occupancy rate, a nursing facility's total resident
days, as reported by the facility under Article VIII-A, shall be
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divided by the product of the facility's licensed bed capacity,
at the end of the quarter, multiplied by the number of calendar
days in the quarter.
(II) The nursing facility shall have a medical assistance
occupancy rate of at least sixty-five percent during the
resident day quarter. For purposes of determining a nursing
facility's medical assistance occupancy rate, the nursing
facility's total PA MA days shall be divided by the nursing
facility's total resident days, as reported by the facility
under Article VIII-A.
(III) The nursing facility shall be a nonpublic nursing
facility for a full resident day quarter prior to the applicable
quarterly reporting due dates, as determined by the department.
(B) The department shall calculate a qualified nonpublic
nursing facility's medical assistance day-one incentive payment
as follows:
(I) The total funds appropriated for payments under this
subparagraph shall be divided by the number of payments, as
determined by the department.
(II) To establish the per diem rate for a payment, the
amount under subclause (I) shall be divided by the total PA MA
days, as reported by all qualifying nonpublic nursing facilities
under Article VIII-A for that payment.
(III) To determine a qualifying nonpublic nursing facility's
medical assistance day-one incentive payment, the per diem rate
calculated for the payment shall be multiplied by a nonpublic
nursing facility's total PA MA days, as reported by the facility
under Article VIII-A for the payment.
(C) For fiscal years 2015-2016 and 2016-2017, the State
funds available for the nonpublic nursing facility medical
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assistance day-one incentive payments shall equal eight million
dollars ($8,000,000).
(8) As a condition of participation in the medical
assistance program, before any county or nonpublic nursing
facility increases the number of medical assistance certified
beds in its facility or in the medical assistance program,
whether as a result of an increase in beds in an existing
facility or the enrollment of a new provider, the facility must
seek and obtain advance written approval of the increase in
certified beds from the department. The following shall apply:
(i) Before July 1, 2009, the department shall propose
regulations that would establish the process and criteria to be
used to review and respond to requests for increases in medical
assistance certified beds, including whether an increase in the
number of certified beds is necessary to assure that long-term
living care and services under the medical assistance program
will be provided in a manner consistent with applicable Federal
and State law, including Title XIX of the Social Security Act.
(ii) Pending adoption of regulations, a nursing facility's
request for advance written approval for an increase in medical
assistance certified beds shall be submitted and reviewed in
accordance with the process and guidelines contained in the
statement of policy published in 28 Pa.B. 138.
(iii) The [department] Office of Independent Medicaid
Director may publish amendments to the statement of policy if
the department determines that changes to the process and
guidelines for reviewing and responding to requests for approval
of increases in medical assistance certified beds will
facilitate access to medically necessary nursing facility
services or are required to assure that long-term living care
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and services under the medical assistance program will be
provided in a manner consistent with applicable Federal and
State law, including Title XIX of the Social Security Act. The
[department] Office of Independent Medicaid Director shall
publish the proposed amendments in the Pennsylvania Bulletin and
solicit public comments for thirty days. After consideration of
the comments it receives, the [department] Office of
Independent Medicaid Director may proceed to adopt the
amendments by publishing an amended statement of policy in the
Pennsylvania Bulletin which shall include its responses to the
public comments that it received concerning the proposed
amendments.
Section 3. Section 443.2 of the act is amended to read:
Section 443.2. Medical Assistance Payments for Home Health
Care.--The following medical assistance payments shall be made
in behalf of eligible persons whose care in the home has been
prescribed by a physician, chiropractor or podiatrist:
(1) Rates established by the [department] Office of
Independent Medicaid Director for post-hospital home care, as
specified by regulations of the [department] Office of
Independent Medicaid Director adopted under Title XIX of the
Federal Social Security Act for not more than one hundred eighty
days following a period of hospitalization, if such care is
related to the reason the person was hospitalized and if given
by a hospital as comprehensive, hospital type care in a
patient's home;
(2) Rates established by the [department] Office of
Independent Medicaid Director for home health care services if
such services are furnished by a voluntary or governmental
health agency.
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Section 4. Section 443.3 of the act, amended December 28,
2015 (P.L.500, No.92), is amended to read:
Section 443.3. Other Medical Assistance Payments.--(a)
Payments on behalf of eligible persons shall be made for other
services, as follows:
(1) Rates established by the [department] Office of
Independent Medicaid Director for outpatient services as
specified by regulations of the department adopted under Title
XIX of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1396
et seq.) consisting of preventive, diagnostic, therapeutic,
rehabilitative or palliative services; furnished by or under the
direction of a physician, chiropractor or podiatrist, by a
hospital or outpatient clinic which qualifies to participate
under Title XIX of the Social Security Act, to a patient to whom
such hospital or outpatient clinic does not furnish room, board
and professional services on a continuous, twenty-four hour a
day basis.
(1.1) Rates established by the [department] Office of
Independent Medicaid Director for observation services provided
by or furnished under the direction of a physician and furnished
by a hospital. Payment for observation services shall be made in
an amount specified by the [department] Office of Independent
Medicaid Director by notice in the Pennsylvania Bulletin and
shall be effective for dates of service on or after July 1,
2016. Payment for observation services shall be subject to
conditions specified in the [department's] Office of Independent
Medicaid Director regulations, including regulations adopted by
the [department] Office of Independent Medicaid Director to
implement this paragraph. Pending adoption of regulations
implementing this paragraph, the conditions for payment of
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observation services shall be specified in a medical assistance
bulletin.
(2) Rates established by the [department] Office of
Independent Medicaid Director for (i) other laboratory and X-ray
services prescribed by a physician, chiropractor or podiatrist
and furnished by a facility other than a hospital which is
qualified to participate under Title XIX of the Social Security
Act, (ii) physician's services consisting of professional care
by a physician, chiropractor or podiatrist in his office, the
patient's home, a hospital, a nursing facility or elsewhere,
(iii) the first three pints of whole blood, (iv) remedial eye
care, as provided in Article VIII consisting of medical or
surgical care and aids and services and other vision care
provided by a physician skilled in diseases of the eye or by an
optometrist which are not otherwise available under this
Article, (v) special medical services for school children, as
provided in the Public School Code of 1949, consisting of
medical, dental, vision care provided by a physician skilled in
diseases of the eye or by an optometrist or surgical care and
aids and services which are not otherwise available under this
article.
(3) Notwithstanding any other provision of law, for
recipients aged twenty-one years or older receiving services
under the fee for service delivery system who are eligible for
medical assistance under Title XIX of the Social Security Act
and for recipients aged twenty-one years or older receiving
services under the fee-for-service delivery system who are
eligible for general assistance-related categories of medical
assistance, the following medically necessary services:
(i) Psychiatric outpatient clinic services not to exceed
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five hours or ten one-half-hour sessions per thirty consecutive
day period.
(ii) Psychiatric partial hospitalization not to exceed five
hundred forty hours per fiscal year.
(b) The [department] Office of Independent Medicaid Director
may grant exceptions to the limits specified in this section,
section 443.1(4) or the department's regulations when any of the
following circumstances applies:
(1) The [department] Office of Independent Medicaid Director
determines that the recipient has a serious chronic systemic
illness or other serious health condition and denial of the
exception will jeopardize the life of or result in the rapid,
serious deterioration of the health of the recipient.
(2) The [department] Office of Independent Medicaid Director
determines that granting a specific exception to a limit is a
cost-effective alternative for the medical assistance program.
(3) The [department] Office of Independent Medicaid Director
determines that granting an exception to a limit is necessary in
order to comply with Federal law.
(c) The [Secretary of Public Welfare] Office of Independent
Medicaid Director shall promulgate regulations pursuant to
section 204(1)(iv) of the act of July 31, 1968 (P.L.769,
No.240), referred to as the Commonwealth Documents Law, to
implement this section. Notwithstanding any other provision of
law, the promulgation of regulations under this subsection
shall, until December 31, 2005, be exempt from all of the
following:
(1) Section 205 of the Commonwealth Documents Law.
(2) Section 204(b) of the act of October 15, 1980 (P.L.950,
No.164), known as the "Commonwealth Attorneys Act."
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(3) The act of June 25, 1982 (P.L.633, No.181), known as the
"Regulatory Review Act."
Section 5. Section 454(a) and (c) of the act are amended to
read:
Section 454. Medical Assistance Benefit Packages; Coverage,
Copayments, Premiums and Rates.--(a) Notwithstanding any other
provision of law to the contrary, the [department] Office of
Independent Medicaid Director shall promulgate regulations as
provided in subsection (b) to establish provider payment rates;
the benefit packages and any copayments for adults eligible for
medical assistance under Title XIX of the Social Security Act
(49 Stat 620, 42 U.S.C. § 1396 et seq.) and adults eligible for
medical assistance in general assistance-related categories; and
the premium or copayment requirements for disabled children
whose family income is above two hundred percent of the Federal
poverty income limit. Subject to such Federal approval as may be
necessary, the regulations shall authorize and describe the
available benefit packages and any copayments and premiums,
except that the [department] Office of Independent Medicaid
Director shall set forth the copayment and premium schedule for
disabled children whose family income is above two hundred
percent of the Federal poverty income limit by publishing a
notice in the Pennsylvania Bulletin. The [department] Office of
Independent Medicaid Director may adjust such copayments and
premiums for disabled children by notice published in the
Pennsylvania Bulletin. The regulations shall also specify the
effective date for provider payment rates.
* * *
(c) The [department] Office of Independent Medicaid Director
is authorized to grant exceptions to any limits specified in the
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benefit packages adopted under this section or when any of the
following circumstances applies:
(1) The [department] Office of Independent Medicaid Director
determines the recipient has a serious chronic systemic illness
or other serious health condition and denial of the exception
will jeopardize the life of or result in the rapid, serious
deterioration of the health of the recipient.
(2) The [department] Office of Independent Medicaid Director
determines that granting a specific exception to a limit is a
cost-effective alternative for the medical assistance program.
(3) The department determines that granting an exception to
a limit is necessary in order to comply with Federal law.
* * *
Section 6. The act is amended by adding an article to read:
ARTICLE IV-A
OFFICE OF INDEPENDENT MEDICAID DIRECTOR
Section 401-A. Declaration of purpose.
The General Assembly finds and declares that the intent of
this article is to ensure that the Commonwealth's current
Medicaid programs provide all of the following:
(1) Budget stability and predictability through defined
outcomes, performance and accountability.
(2) A balance of quality, patient satisfaction,
financial measures and self-sufficiency.
(3) The most efficient and cost-effective services,
administrative systems and structures.
(4) A sustainable and uniform delivery system across the
Commonwealth's departments and agencies.
(5) Services are offered to assist recipients attain
independence or self-care.
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Section 402-A. Definitions.
The following words and phrases when used in this article
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Director." The Director of the Office of Independent
Medicaid Director.
"Medicaid program." A State program or funding source which
is connected, whether by funding or approval, to the Centers for
Medicare and Medicaid Services of the United States Department
of Health and Human Services.
Section 403-A. Office of Independent Medicaid Director.
The Office of Independent Medicaid Director is established
within the department for budgetary purposes.
Section 404-A. Director of the Office of Independent Medicaid
Director.
(a) Appointment.--The Governor shall appoint the Director of
the Office of Independent Medicaid Director from the list
submitted by the Selection and Organization Committee under
subsection (c) for a term of six years and subject to
confirmation by the Senate. The initial term of office for the
director shall commence upon confirmation by the Senate and
shall expire June 30, 2022. After June 30, 2022, the term of
office for the director shall be four years and shall commence
on July 1 after the date of confirmation.
(b) Committee.--The Selection and Organization Committee is
established for the purpose of comprising a list of potential
nominees for director. The committee shall consist of the
following:
(1) The chair and minority chair of the Appropriations
Committee of the Senate and the chair and minority chair of
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the Appropriations Committee of the House of Representatives.
(2) The Majority Leader and the Minority Leader of the
Senate and the Majority Leader and the Minority Leader of the
House of Representatives.
(3) The President pro tempore of the Senate and the
Speaker of the House of Representatives.
(5) The chair and minority chair of the Health and Human
Services Committee of the Senate.
(6) The chair and minority chair of the Health Committee
of the House of Representatives.
(c) Nomination.--The following shall apply:
(1) The Selection and Organization Committee shall
submit no more than three potential nominees to the Governor
within 30 days of a vacancy.
(2) The Governor shall submit a nominee from the list
submitted under paragraph (1) for director to the Senate for
confirmation no later than May 1 of the year when the term of
office expires.
(3) If the Governor fails to submit a nominee under
paragraph (2) by May 1 of the year when the term of office
expires, the President pro tempore of the Senate and the
Speaker of the House of Representatives shall jointly submit
a nominee to the Senate on or before May 15 of the same year
by resolution. The resolution shall include all of the
following:
(i) The name of the nominee.
(ii) The effective date of the appointment.
(iii) The date of expiration of the term of office.
(iv) The residence of the nominee.
(v) A clause providing that the nominee is submitted
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upon joint recommendation of the President pro tempore of
the Senate and the Speaker of the House of
Representatives.
(4) If a nominee for director is not confirmed within 30
days of submission to the Senate, a new nominee for director
shall be submitted to the Senate.
(d) Vacancy.--The following shall apply if the position of
director is vacant:
(1) If the vacancy occurs before the director's term of
office expires, the Governor shall submit a nominee from the
list submitted by the Selection and Organization Committee
under subsection (c) for director to the Senate no later than
60 days after the vacancy occurs.
(2) If the vacancy occurs when the General Assembly is
not in session, the Governor shall appoint an acting director
to serve the remainder of the unexpired term. An acting
director may not serve for more than three months without
confirmation by the Senate.
Section 405-A. Powers and duties of director.
The director shall have the following powers and duties:
(1) Administering Medicaid programs in a manner in which
the total expenditures, net of agency receipts, do not exceed
the authorized budget for the Medicaid programs.
(2) Employing clerical and professional staff for the
Office of Independent Medicaid Director, including
consultants, actuaries and legal counsel, for the purpose of
administering Medicaid programs. The director may offer
employment contracts for specified terms and set compensation
for the employees, which may include performance-based
bonuses based on meeting budget or other targets.
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(3) Notwithstanding any other provisions of law,
entering into and managing contracts for the administration
of Medicaid programs, which shall include all of the
following:
(i) Expected outcomes to improve the health and
well-being of residents of this Commonwealth.
(ii) Value-based purchasing.
(iii) The use of evidence-based programs.
(iv) Performance incentives for exceeding outcomes.
(v) Uniformed coordination of services.
(vi) Cost containment provisions.
(vii) Maximizing the amount of Federal funds.
(4) Establishing and adjusting all components of
Medicaid programs within the appropriated and allocated
budget.
(5) Adopting rules and regulations relating to Medicaid
programs in accordance with Executive Order 1996-1.
(6) Developing mid-year budget correction plans and
strategies and taking mid-year budget corrective actions as
necessary to keep Medicaid programs within budget.
(7) Approving or disapproving and overseeing all
expenditures to be allocated to Medicaid programs.
(8) Developing and providing to the Office of the
Budget, the Appropriations Committee of the Senate and the
Appropriations Committee of the House of Representatives by
January 1, 2018, and each year thereafter, the following
information about Medicaid programs:
(i) A detailed four-year forecast of expected
changes to enrollment growth and enrollment demographics.
(ii) Changes that will be implemented by the
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department in order to stay within the existing budget
based on the next fiscal year's forecasted enrollment
growth and enrollment demographics.
(iii) The cost to maintain the current level of
services based on the next fiscal year's forecasted
enrollment growth and enrollment demographics.
(9) Creating a publicly accessible Internet website for
the Office of Independent Medicaid Director and updating the
website on at least a monthly basis with the following
information about the Medicaid programs:
(i) Enrollment by Medicaid program aid category by
county.
(ii) Per member, per month spending by category of
service.
(iii) Spending and receipts by fund, including a
detailed variance analysis.
(iv) A comparison of the figures specified under
subparagraphs (i), (ii) and (iii) to the amounts
forecasted and budgeted for the corresponding time
period.
(10) Developing performance measures and outcomes for
programs under the director's jurisdiction and programs which
are billed against Medicaid programs.
(11) Making recommendations to the Governor and the
General Assembly to streamline programs to provide better
services for residents of this Commonwealth at a lower cost
to taxpayers.
(12) Serving at the pleasure of the residents of this
Commonwealth in an independent manner.
(13) Developing and implementing policies to address
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excessive utilization of health care services.
(14) Ensuring that services are coordinated throughout
Commonwealth agencies, including physical health, behavioral
health, long-term services and supports and third-party
insurances.
Section 406-A. Amendments to State plan for Medicaid programs.
(a) Amendments.--The director may take all necessary action
to amend the State plan for Medicaid programs in order to keep
Medicaid programs within the certified budget, including State
plan amendments, waivers and waiver amendments.
(b) Submission.--An amendment to the State plan for Medicaid
programs shall be submitted by the director in accordance with
the following:
(1) A law of this Commonwealth mandating that the
director submit an amendment to the State plan for Medicaid
programs.
(2) A law of this Commonwealth which changes Medicaid
programs and requires approval from the Federal Government.
(3) A change in Federal law which requires an amendment
to the State plan for Medicaid programs.
(4) An order of a court of competent jurisdiction if the
amendment to the State plan for Medicaid programs is
necessary to implement the order.
(5) In a manner as required to maintain Federal funding
for Medicaid programs.
(c) Notice.--No less than 30 days before submitting an
amendment to the State plan for Medicaid programs to the Federal
Government, the director shall post the amendment on the Office
of Independent Medicaid Director's publicly accessible Internet
website and notify the members of the General Assembly and the
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Independent Fiscal Office that the amendment has been posted.
The notice requirement under this subsection shall not apply to
a draft or proposed amendment submitted to the Federal
Government for comments and not for approval.
Section 407-A. Use of funds.
The Office of Independent Medicaid Director shall use
encumbered funds appropriated to the department to implement
this article.
Section 408-A. Legislative oversight powers.
The Appropriations Committee of the Senate and the
Appropriations Committee of House of Representatives, while in
discharge of official duties, shall have access to any document
and may compel the attendance of an employee or secure any
evidence.
Section 409-A. Duties of Commonwealth agencies.
The following shall apply:
(1) A Commonwealth agency shall not interfere with the
duties of the director or withhold information requested by
the director.
(2) A Commonwealth agency shall coordinate with the
director to ensure the residents of this Commonwealth have a
continuity of care.
Section 410-A. Construction.
Nothing in this article shall be construed to limit the
budget authority of the Office of the Budget under Article VI of
the act of April 9, 1929 (P.L.177, No.175), known as The
Administrative Code of 1929.
Section 7. All acts and parts of acts are repealed insofar
as they are inconsistent with this act.
Section 8. This act shall take effect July 1, 2017, or
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immediately, whichever is later.
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