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A02434
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,
MOUL, GILLEN AND ZIMMERMAN, MAY 9, 2017
AS REPORTED FROM COMMITTEE ON HEALTH, HOUSE OF REPRESENTATIVES,
AS AMENDED, JUNE 26, 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 GENERAL POWERS AND
DUTIES OF THE DEPARTMENT, FURTHER PROVIDING FOR STATE
PARTICIPATION IN COOPERATIVE FEDERAL PROGRAMS; 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 MEDICAL ASSISTANCE Director.; AND MAKING
AN EDITORIAL CHANGE.
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 1. ARTICLE II HEADING AND SECTIONS 201 AND 441.7(A)
OF THE ACT OF JUNE 13, 1967 (P.L.31, NO.21), KNOWN AS THE HUMAN
SERVICES CODE, ARE AMENDED TO READ:
ARTICLE II
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GENERAL POWERS AND DUTIES
OF THE DEPARTMENT OF [PUBLIC WELFARE] HUMAN SERVICES
SECTION 201. STATE PARTICIPATION IN COOPERATIVE FEDERAL
PROGRAMS.--THE DEPARTMENT, INCLUDING THROUGH THE OFFICE OF
INDEPENDENT MEDICAL ASSISTANCE DIRECTOR, SHALL HAVE THE POWER
AND ITS DUTIES SHALL BE:
(1) WITH THE APPROVAL OF THE GOVERNOR, TO ACT AS THE SOLE
AGENCY OF THE STATE WHEN APPLYING FOR, RECEIVING AND USING
FEDERAL FUNDS FOR THE FINANCING IN WHOLE OR IN PART OF PROGRAMS
IN FIELDS IN WHICH THE DEPARTMENT HAS RESPONSIBILITY.
(2) WITH THE APPROVAL OF THE GOVERNOR, TO DEVELOP AND SUBMIT
STATE PLANS OR OTHER PROPOSALS TO THE FEDERAL [GOVERNMENT,]
GOVERNMENT, EXCEPT AS WHERE LIMITED UNDER PARAGRAPH (2.1), TO
PROMULGATE REGULATIONS, ESTABLISH AND ENFORCE STANDARDS AND TO
TAKE SUCH OTHER MEASURES AS MAY BE NECESSARY TO RENDER THE
COMMONWEALTH ELIGIBLE FOR AVAILABLE FEDERAL FUNDS OR OTHER
ASSISTANCE. NOTWITHSTANDING ANYTHING TO THE CONTRARY IN THE ACT
OF JULY 31, 1968 (P.L.769, NO.240), REFERRED TO AS THE
COMMONWEALTH DOCUMENTS LAW, THE DEPARTMENT MAY OMIT NOTICE OF
PROPOSED RULEMAKING AND PROMULGATE REGULATIONS AS FINAL WHEN A
DELAY OF THIRTY DAYS OR LESS IN THE FINAL ADOPTION OF
REGULATIONS WILL RESULT IN THE LOSS OF FEDERAL FUNDS OR WHEN A
DELAY OF THIRTY DAYS OR LESS IN ADOPTION WOULD REQUIRE THE
REPLACEMENT OF FEDERAL FUNDS WITH STATE FUNDS.
(2.1) TO DEVELOP AND SUBMIT STATE PLANS OR OTHER PROPOSALS
TO THE FEDERAL GOVERNMENT FOR MEDICAL ASSISTANCE THROUGH THE
INDEPENDENT OFFICE OF MEDICAL ASSISTANCE DIRECTOR, TO PROMULGATE
REGULATIONS, ESTABLISH AND ENFORCE STANDARDS AND TAKE OTHER
MEASURES AS MAY BE NECESSARY TO RENDER THE COMMONWEALTH ELIGIBLE
FOR AVAILABLE FEDERAL FUNDS OR OTHER ASSISTANCE. NOTWITHSTANDING
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ANY PROVISION TO THE CONTRARY IN THE ACT OF JULY 31, 1968
(P.L.769, NO.240), REFERRED TO AS THE COMMONWEALTH DOCUMENTS
LAW, THE DEPARTMENT MAY OMIT NOTICE OF PROPOSED RULEMAKING AND
PROMULGATE REGULATIONS AS FINAL WHEN A DELAY OF THIRTY DAYS OR
LESS IN THE FINAL ADOPTION OF REGULATIONS WILL RESULT IN THE
LOSS OF FEDERAL FUNDS OR WHEN A DELAY OF THIRTY DAYS OR LESS IN
ADOPTION WOULD REQUIRE THE REPLACEMENT OF FEDERAL FUNDS WITH
STATE FUNDS.
(3) TO MAKE SURVEYS AND INVENTORIES OF EXISTING FACILITIES
AND SERVICES AS REQUIRED IN CONNECTION WITH SUCH STATE PLANS,
AND TO ASSESS THE NEED FOR CONSTRUCTION, MODERNIZATION OR
ADDITIONAL SERVICES AND TO DETERMINE PRIORITIES WITH RESPECT
THERETO.
(4) TO CONDUCT INVESTIGATIONS OF ACTIVITIES RELATED TO
FRAUD, MISUSE OR THEFT OF PUBLIC ASSISTANCE MONEYS[, MEDICAL
ASSISTANCE MONEYS OR BENEFITS,] OR FEDERAL FOOD STAMPS,
COMMITTED BY ANY PERSON WHO IS OR HAS BEEN PARTICIPATING IN OR
ADMINISTERING PROGRAMS OF THE DEPARTMENT, OR BY PERSONS WHO AID
OR ABET OTHERS IN THE COMMISSION OF FRAUDULENT ACTS AFFECTING
WELFARE PROGRAMS.
(4.1) TO CONDUCT INVESTIGATIONS OF ACTIVITIES RELATED TO
FRAUD, MISUSE OR THEFT OF MEDICAL ASSISTANCE MONEYS OR BENEFIT
THROUGH THE OFFICE OF INDEPENDENT MEDICAL ASSISTANCE DIRECTOR BY
A PERSON WHO IS OR HAS BEEN PARTICIPATING IN OR ADMINISTERING
MEDICAL ASSISTANCE PROGRAMS OR BY A PERSON WHO AIDS OR ABETS
OTHERS IN THE COMMISSION OF FRAUDULENT ACTS AFFECTING MEDICAL
ASSISTANCE.
(5) TO COLLECT DATA ON ITS PROGRAMS AND SERVICES, INCLUDING
EFFORTS AIMED AT PREVENTATIVE HEALTH CARE, TO PROVIDE [THE
GENERAL ASSEMBLY WITH ADEQUATE INFORMATION] TO THE OFFICE OF
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INDEPENDENT MEDICAL ASSISTANCE DIRECTOR, WHO WILL COMPILE THE
DATA FOR USE BY THE GENERAL ASSEMBLY TO DETERMINE THE MOST COST-
EFFECTIVE ALLOCATION OF RESOURCES IN THE MEDICAL ASSISTANCE
PROGRAM.
(6) TO SUBMIT ON A [BIANNUAL] ANNUAL BASIS A REPORT PREPARED
BY THE OFFICE OF INDEPENDENT MEDICAL ASSISTANCE DIRECTOR TO THE
GENERAL ASSEMBLY REGARDING THE MEDICAL ASSISTANCE POPULATION,
WHICH SHALL INCLUDE AGGREGATE FIGURES, DELINEATED ON A MONTHLY
BASIS, FOR THE NUMBER OF INDIVIDUALS TO WHOM SERVICES WERE
PROVIDED, THE TYPE AND INCIDENCE OF SERVICES PROVIDED BY
PROCEDURE AND THE COST PER SERVICE AS WELL AS TOTAL EXPENDITURES
BY SERVICE.
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 MEDICAL
ASSISTANCE 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.), 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
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Independent Medicaid MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE 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
Office of Independent Medicaid MEDICAL ASSISTANCE 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
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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 MEDICAL ASSISTANCE
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 MEDICAL ASSISTANCE
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
thresholds established by the [department] Office of
Independent Medicaid MEDICAL ASSISTANCE Director .
(iii) Notwithstanding subparagraph (i), the [department]
Office of Independent Medicaid MEDICAL ASSISTANCE 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
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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.
(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
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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
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 MEDICAL
ASSISTANCE Director shall make enhanced capitation payments to
medical assistance managed care organizations if necessary
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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
MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE 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
assistance managed care organizations have received the enhanced
capitation payments from the [department] Office of Independent
Medicaid MEDICAL ASSISTANCE 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,
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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 MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE Director's payment
methods and standards specified in paragraph (1.1)(ii). If the
[department] Office of Independent Medicaid MEDICAL ASSISTANCE
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 MEDICAL ASSISTANCE 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
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
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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
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]
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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 MEDICAL
ASSISTANCE 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
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
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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
MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE Director .
(1.6) Notwithstanding any other provision of law or
departmental regulation to the contrary, the [department] Office
of Independent Medicaid MEDICAL ASSISTANCE Director shall make
separate fee-for-service APR/DRG payments for medically
necessary inpatient acute care general hospital services
provided for normal newborn care 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
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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 MEDICAL ASSISTANCE Director . This cost
in county homes shall be as specified by the regulations of the
[department] Officer of Independent Medicaid MEDICAL ASSISTANCE
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 MEDICAL ASSISTANCE 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
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
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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 MEDICAL ASSISTANCE
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
MEDICAL ASSISTANCE 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 MEDICAL
ASSISTANCE Director may recognize the costs incurred by county
nursing facilities to provide services to eligible persons as
medical 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
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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 MEDICAL ASSISTANCE
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 MEDICAL ASSISTANCE 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
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
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Commonwealth's approved Title XIX State Plan for nursing
facility services.
(ii) The [department] Office of Independent Medicaid MEDICAL
ASSISTANCE 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-
setting database, as specified in the department's regulations
in effect on July 1, 2007.
(C) The department shall propose regulations that phase out
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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 MEDICAL
ASSISTANCE 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.
(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
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Independent Medicaid MEDICAL ASSISTANCE Director shall make
quarterly medical assistance day-one incentive payments to
qualified nonpublic nursing facilities. The [department] Office
of Independent Medicaid MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE
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 MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE 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
product of the facility's licensed bed capacity, at the end of
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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 MEDICAL
ASSISTANCE 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
incentive payments shall equal eight million dollars
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($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 MEDICAL ASSISTANCE 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
divided by the product of the facility's licensed bed capacity,
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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
assistance day-one incentive payments shall equal eight million
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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
MEDICAL ASSISTANCE 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 and services under the medical assistance
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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
MEDICAL ASSISTANCE 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
MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE Director for post-
hospital home care, as specified by regulations of the
[department] Office of Independent Medicaid MEDICAL ASSISTANCE
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 MEDICAL ASSISTANCE Director for home health
care services if such services are furnished by a voluntary or
governmental health agency.
Section 4. Section 443.3 of the act, amended December 28,
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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 MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE
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
MEDICAL ASSISTANCE Director regulations, including regulations
adopted by the [department] Office of Independent Medicaid
MEDICAL ASSISTANCE Director to implement this paragraph. Pending
adoption of regulations implementing this paragraph, the
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conditions for payment of observation services shall be
specified in a medical assistance bulletin.
(2) Rates established by the [department] Office of
Independent Medicaid MEDICAL ASSISTANCE 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 MEDICAL
ASSISTANCE 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 MEDICAL
ASSISTANCE 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 MEDICAL
ASSISTANCE 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 MEDICAL
ASSISTANCE 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 MEDICAL ASSISTANCE 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,
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No.164), known as the "Commonwealth Attorneys Act."
(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 MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE
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 MEDICAL ASSISTANCE 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.
* * *
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(c) The [department] Office of Independent Medicaid MEDICAL
ASSISTANCE Director is authorized to grant exceptions to any
limits specified in the benefit packages adopted under this
section or when any of the following circumstances applies:
(1) The [department] Office of Independent Medicaid MEDICAL
ASSISTANCE 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 MEDICAL
ASSISTANCE 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 MEDICAL ASSISTANCE 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 MEDICAL ASSISTANCE 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.
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(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.
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:
"Affordable Care Act." The Patient Protection and Affordable
Care Act (Public Law 111-148, 124 Stat. 119).
"COMMONWEALTH AGENCY." A STATE AGENCY, DEPARTMENT, BOARD,
OFFICE, BUREAU, DIVISION, COMMITTEE OR COUNCIL.
"Director." The Director of the Office of Independent
Medicaid MEDICAL ASSISTANCE 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 MEDICAL
ASSISTANCE Director.
(A) ESTABLISHMENT.-- The Office of Independent Medicaid
MEDICAL ASSISTANCE Director is established within the department
for budgetary purposes.
(B) EMPLOYEES.--EMPLOYEES OF ANY COMMONWEALTH AGENCY WHO
OPERATE AND ADMINISTER MEDICAL ASSISTANCE PROGRAMS PRIOR TO THE
EFFECTIVE DATE OF THIS SECTION SHALL BE TRANSFERRED TO THE
OFFICE OF INDEPENDENT MEDICAL ASSISTANCE DIRECTOR AT THE
DISCRETION OF THE DIRECTOR. THE FUNDS THAT PAY FOR THE SALARIES
OF THE EMPLOYEES TRANSFERRED UNDER THIS SECTION SHALL BE PAID
OUT OF THE ENCUMBERED FUNDS OF THE AGENCY FROM WHICH THE
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EMPLOYEE WAS TRANSFERRED.
(C) FUNDING.-- ALL FUNDING FROM ANY FEDERAL OR STATE SOURCES
REGARDING THE OPERATION OF THE COMMONWEALTH'S MEDICAL ASSISTANCE
PROGRAMS SHALL BE TRANSFERRED INTO A RESTRICTED ACCOUNT IN THE
GENERAL FUND IN ACCORDANCE WITH THE FOLLOWING:
(1) MONEY FROM THE RESTRICTED ACCOUNT MAY BE TRANSFERRED
ONLY UPON THE APPROVAL OF THE DIRECTOR OR THE DIRECTOR'S
DESIGNEE, AS PRESCRIBED UNDER THIS ARTICLE.
(2) THE DIRECTOR SHALL COORDINATE PAYMENTS FROM THE
COMMONWEALTH'S MEDICAL ASSISTANCE PROGRAMS WITH THE STATE
TREASURER TO OPTIMIZE THE COMMONWEALTH'S CASH FLOW WITHIN THE
GENERAL FUND AND TOTAL OPERATING BUDGET.
Section 404-A. Director of the Office of Independent Medicaid
MEDICAL ASSISTANCE Director.
(a) Appointment.--The Governor shall appoint the Director of
the Office of Independent Medicaid Director 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 SIX years and shall
commence on July 1 after the date of confirmation. A DIRECTOR
MAY SERVE MORE THAN ONE TERM IF SELECTED BY THE SELECTION AND
ORGANIZATION COMMITTEE.
(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
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Committee of the Senate and the chair and minority chair of
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.
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(v) A clause providing that the nominee is submitted
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 UNTIL SUCH TIME
AS THE GENERAL ASSEMBLY HAS RECONVENED . An acting director
may not serve for more than three months without confirmation
by the Senate .
(3) IF NO DIRECTOR HAS BEEN APPROVED WITHIN 3 MONTHS OF
A VACANCY, A NEW DIRECTOR SHALL BE APPOINTED IN ACCORDANCE
WITH PARAGRAPH (1).
(E) REMOVAL.--THE GOVERNOR MAY REMOVE THE DIRECTOR ONLY IF
THE DIRECTOR HAS COMMITTED A BREACH OF PUBLIC TRUST OR VIOLATED
THE LAWS OF THIS COMMONWEALTH.
Section 405-A. Powers and duties of director.
The director shall have the following powers and duties:
(1) Administering Medicaid MEDICAL ASSISTANCE programs
in a manner in which the total expenditures, net of agency
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receipts, do not exceed the authorized budget for the
Medicaid MEDICAL ASSISTANCE programs.
(2) Employing clerical and professional staff for the
Office of Independent Medicaid MEDICAL ASSISTANCE Director,
including consultants, actuaries and legal counsel, for the
purpose of administering Medicaid MEDICAL ASSISTANCE
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.
(3) Notwithstanding any other provisions of law,
entering into and managing contracts for the administration
of Medicaid MEDICAL ASSISTANCE 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.
THE DEVELOPMENT OF MEDICAL HOMES.
(v) Uniformed coordination of services.
(vi) Cost containment provisions.
(vii) Maximizing the amount of Federal funds.
(VIII) RECOMMENDATIONS FOR IDENTIFYING COST SAVINGS
WITHIN MEDICAL ASSISTANCE PROGRAMS.
(4) Establishing and adjusting all components of
Medicaid MEDICAL ASSISTANCE programs within the appropriated
and allocated budget.
(5) Adopting rules and regulations relating to Medicaid
MEDICAL ASSISTANCE programs in accordance with Executive
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Order 1996-1.
(6) Developing mid-year budget correction plans and
strategies and taking mid-year budget corrective actions as
necessary to keep Medicaid MEDICAL ASSISTANCE programs within
budget.
(7) Approving or disapproving and overseeing all
expenditures to be allocated to Medicaid MEDICAL ASSISTANCE
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 AND
THE INDEPENDENT FISCAL OFFICE by January 1, 2018, and each
year thereafter, the following information about Medicaid
MEDICAL ASSISTANCE programs:
(i) A detailed four-year forecast of expected
changes to enrollment growth and enrollment demographics.
(ii) Changes that will be implemented by the
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 MEDICAL ASSISTANCE
Director and updating the website on at least a monthly basis
with the following information about the Medicaid M EDICAL
ASSISTANCE programs:
(i) Enrollment by Medicaid MEDICAL ASSISTANCE
program aid category by county.
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(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 M EDICAL ASSISTANCE programs.
(11) Making ANNUAL 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 WHO RESIDE WITHIN THIS COMMONWEALTH .
(12) Serving at the pleasure of the residents of this
Commonwealth in an independent manner.
(13) Developing and implementing policies to address
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.
(15) Immediately following the confirmation of the first
director and the hiring or transfer of employees as needed to
perform the duties of the Office of Independent Medical
Assistance, studying the effects of a potential full or
partial repeal of the Affordable Care Act and the elimination
of its Medicaid expansion on this Commonwealth as follows:
(i) Within 60 days of the confirmation of the first
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director, the Office of Independent Medical Assistance
shall issue a report, which shall include, but not be
limited to:
(A) An assessment of the current and potential
effects of health care coverage loss associated with
full or partial repeal of the Affordable Care Act on
the residents, public health and economy of this
Commonwealth, including what impact repeal would have
on individuals accessing drug treatment programs.
(B) An estimate of the possible financial costs
and other adverse effects to this Commonwealth, its
residents and health care providers associated with
full or partial repeal of the Affordable Care Act.
(C) An examination of measures that might
prevent or mitigate the effects of full or partial
repeal of the Affordable Care Act and health care
coverage losses on the residents, public health and
economy of this Commonwealth.
(D) Recommendations for laws and regulations
that may be warranted to minimize adverse impacts of
full or partial repeal of the Affordable Care Act,
and recommendations that assist residents in
obtaining and maintaining affordable health care
coverage moving forward.
(E) An analysis of pending alternative health
care policies under consideration by the Congress of
the United States and how the policies compare to the
Affordable Care Act.
(ii) A copy of the report shall be submitted to the
Governor, the General Assembly and the Congressional
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delegation from this Commonwealth.
(iii) The finished report shall be a public record
under the act of February 14, 2008 (P.L.6, No.3), known
as the Right-to-Know Law.
Section 406-A. Amendments to State plan for Medicaid MEDICAL
ASSISTANCE programs.
(A) AUTHORITY.--THE DIRECTOR SHALL HAVE THE SOLE AUTHORITY
TO MANAGE ALL M EDICAL ASSISTANCE PROGRAMS IN THE COMMONWEALTH,
INCLUDING, BUT NOT LIMITED TO, BEING THE SOLE AUTHORITY FOR
SUBMITTING AN AMENDMENT TO THE STATE'S PLAN UNDER TITLE XIX OF
THE SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. § 1396 ET SEQ.)
TO THE CENTERS FOR MEDICARE AND MEDICAID SERVICES OFFERED UNDER
ANY OF THE COMMONWEALTH'S MEDICAL ASSISTANCE PROGRAMS.
(a) (B) Amendments.--The director may take all necessary
action to amend the State plan for Medicaid M EDICAL ASSISTANCE
programs in order to keep Medicaid M EDICAL ASSISTANCE programs
within the certified budget, including State plan amendments,
waivers and waiver amendments.
(b) (C) Submission.--An amendment to the State plan for
Medicaid M EDICAL ASSISTANCE 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
M EDICAL ASSISTANCE programs.
(2) A law of this Commonwealth which changes Medicaid
M EDICAL ASSISTANCE programs and requires approval from the
Federal Government.
(3) A change in Federal law which requires an amendment
to the State plan for Medicaid M EDICAL ASSISTANCE programs.
(4) An order of a court of competent jurisdiction if the
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amendment to the State plan for Medicaid M EDICAL ASSISTANCE
programs is necessary to implement the order.
(5) In a manner as required to maintain Federal funding
for Medicaid M EDICAL ASSISTANCE programs.
(c) (D) Notice.--No less than 30 days before submitting an
amendment to the State plan for Medicaid MEDICAL ASSISTANCE
programs to the Federal Government, the director shall post the
amendment on the Office of Independent Medicaid MEDICAL
ASSISTANCE Director's publicly accessible Internet website and
notify the members of the General Assembly and the 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 MEDICAL ASSISTANCE
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
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director to ensure the residents of this Commonwealth have a
continuity of care.
SECTION 410-A. REGULATIONS.
THE OFFICE OF INDEPENDENT MEDICAL ASSISTANCE DIRECTOR SHALL
PROMULGATE REGULATIONS.
Section 410-A 411-A . Construction.
Nothing in this article shall MAY 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
immediately, whichever is later.
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