PRINTER'S NO. 1234
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
912
Session of
2017
INTRODUCED BY BROOKS, STREET, WHITE, BREWSTER, GREENLEAF,
MENSCH, COSTA, HAYWOOD, BROWNE, VULAKOVICH, SCHWANK, MARTIN,
BAKER, HUGHES, LEACH AND VOGEL, OCTOBER 5, 2017
REFERRED TO HEALTH AND HUMAN SERVICES, OCTOBER 5, 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,
providing for a medical assistance presumptive eligibility
program for home care and home health services.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of June 13, 1967 (P.L.31, No.21), known
as the Human Services Code, is amended by adding a section to
read:
Section 443.12. Medical Assistance Presumptive Eligibility
Program for Home Care and Home Health Services.--(a) The
department shall establish a presumptive eligibility program for
home care services and home health services to prevent the
unnecessary and costly institutionalization of individuals who
are eligible for medical assistance nursing facility services
and wish to receive care in a less restrictive setting.
(b) The program shall:
(1) Be designed to provide home care services and home
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health services only for individuals who are sixty years of age
or older and are nursing facility clinically eligible. An
individual is considered nursing facility clinically eligible if
all of the following criteria are met:
(i) The individual has an illness, injury, disability or
medical condition diagnosed by a physician.
(ii) As a result of that diagnosed illness, injury,
disability or medical condition the individual requires care and
services above the level of room and board.
(iii) A physician certifies that the individual is nursing
facility clinically eligible.
(iv) The care and services are either skilled nursing or
rehabilitation services as specified by the Medicare program
under 42 CFR §§ 409.31(a) and (b)(1) and (3) (relating to level
or care requirement), 409.32 (relating to criteria for skilled
services and the need for skilled services), 409.33 (relating to
examples of skilled nursing and rehabilitation services), 409.34
(relating to criteria for "daily basis") and 409.35 (relating to
criteria for "practical matter"), or health-related care and
services that may not be as inherently complex as skilled
nursing or rehabilitation services but which are needed and
provided on a regular basis in the context of a planned program
of health care and management and were previously available only
through institutional facilities.
(2) Permit a qualified entity to submit an application for
medical assistance on behalf of individuals.
(3) Permit an individual who is applying for medical
assistance to declare income and assets on an application form
and attest to the accuracy of the income and assets provided on
the application form.
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(4) Permit a qualified entity to determine the presumptive
eligibility of an individual to receive medical assistance and
submit an application to receive medical assistance on behalf of
the individual to the department.
(c) The following shall apply:
(1) If a qualified entity determines that an individual is
presumptively eligible to receive medical assistance under
subsection (b)(4), the individual may begin receiving home care
services and home health services from a medical assistance
provider immediately. As authorized under Federal law, the
department shall apply a final determination of medical
assistance eligibility for an individual presumed eligible as of
the date that presumptive eligibility is established by the
qualified entity.
(2) If an individual determined to be presumptively eligible
under subsection (b)(4) is subsequently determined to be
ineligible for home care services or home health services by the
department, the qualified entity which made the determination
under subsection (b)(4) shall not be reimbursed by the
Commonwealth for the cost of home care services or home health
services provided during the period of presumed eligibility. If
the individual provided fraudulent information under this
section, the qualified entity may seek reimbursement from the
individual for the cost of home care services and home health
services provided during the period of presumed eligibility.
(3) Once the department makes a final determination of
eligibility, it shall authorize medical assistance payment for
home care services and home health services provided during the
period of presumed eligibility as of the date that the qualified
entity established presumed eligibility under subsection (b)(4).
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(4) Within sixty days of the submission of an application
under this section, the department shall verify the information
on the application and make a final determination of medical
assistance eligibility. The department may request additional
information from an applicant for the purpose of completing the
verification process under this clause.
(d) The department shall provide to an organization upon
request relevant State policies, procedures and information on
how to fulfill responsibilities in determining an individual
presumptively eligible for home care services or home health
services.
(e) The department shall issue a medical assistance bulletin
with State policies and procedures to implement this section,
the publication of which shall not delay the implementation of
this section.
(f) The department shall apply for any necessary Federal
waivers and maximize the use of Federal money for the program.
(g) The department shall issue any revisions to the State
medical assistance plan as required under Title XIX of the
Social Security Act (49 Stat. 620, 42 U.S.C. § 1396 et seq.)
before implementing the program.
(h) On or before January 1 of each year, the department
shall issue a report to the General Assembly with the following
information about the program:
(1) The number of individuals who participated in the
program.
(2) The average cost for each individual in the program.
(3) The number of qualified entities in the program.
(4) The administrative costs of the program.
(5) The estimated savings achieved through the program.
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(i) As used in this section, the following words and phrases
shall have the meanings given to them in this subsection:
"Home care services" means the term as defined under 28 Pa.
Code § 611.5 (relating to definitions).
"Home health services" means part-time, intermittent skilled
nursing and therapy services provided in an individual's place
of residence by a home health care agency as defined under 28
Pa. Code § 601.6 (relating to definitions).
"Nursing facility services" means nursing facility services
under 42 CFR 440.40 (relating to nursing facility services for
individuals age 21 or older (other than services in an
institution for mental disease), EPSDT, and family planning
services and supplies) or 42 CFR 440.155 (relating to nursing
facility services, other than in institutions for mental
diseases).
"Program" means the presumptive eligibility program for home
care services and home health services established under
subsection (a).
"Qualified entity" means a home care agency as defined under
28 Pa. Code § 611.5 or a home health care agency as defined
under 28 Pa. Code § 601.6.
Section 2. This act shall take effect in 60 days.
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