PRINTER'S NO. 2203
No. 1300 Session of 2001
INTRODUCED BY O'BRIEN, M. BAKER, BEBKO-JONES, BELARDI, BROWNE,
BUNT, BUTKOVITZ, CALTAGIRONE, CAPPELLI, CAWLEY, CLYMER, COY,
DAILEY, DeWEESE, FRANKEL, GEORGE, GODSHALL, HANNA, HERMAN,
JAMES, JOSEPHS, KENNEY, KIRKLAND, LAUGHLIN, MELIO, MUNDY,
PETRARCA, PRESTON, READSHAW, ROSS, SCHRODER, SHANER, SOLOBAY,
STABACK, SURRA, TANGRETTI, THOMAS, TIGUE, TRICH, WOJNAROSKI,
YOUNGBLOOD AND CIVERA, JUNE 13, 2001
REFERRED TO COMMITTEE ON AGING AND OLDER ADULT SERVICES,
JUNE 13, 2001
AN ACT
1 Providing for the expansion of publicly funded home-based and
2 community-based assisted living services; providing for
3 greater information to the public about long-term care
4 options; expanding access to Medicaid-funded services under
5 the Pennsylvania State plan and through the expansion of
6 home-based and community-based services waivers; establishing
7 a new State-funded program of assisted living services to
8 help consumers bridge to eligibility under Medicaid;
9 eliminating barriers and financial disincentives to receiving
10 home-based and community-based assisted living services;
11 conferring powers and duties on the Department of Public
12 Welfare and the Department of Aging; and making an
13 appropriation.
14 The General Assembly finds and declares as follows:
15 (1) Home-based and community-based assisted living
16 services are a rapidly growing long-term care alternative
17 across the nation.
18 (2) Home-based and community-based assisted living
19 services are widely accepted by the general public because
20 they allow people to age in place, maintain their
1 independence and exercise decision making and personal
2 choice.
3 (3) Consumers continue to say that if they should need
4 long-term care services the three things they want most are:
5 (i) to stay independent and live at home and in
6 their community as long as possible;
7 (ii) to be treated with respect and dignity; and
8 (iii) to have a choice of long-term care and
9 supportive services options.
10 (4) Medicare, the Medicaid State Plan and most private
11 insurance plans pay for very little home-based and community-
12 based assisted living services, and many Pennsylvanians
13 cannot afford to pay for these services themselves.
14 (5) It is often far less expensive to provide publicly
15 funded assisted living services in the home and community
16 than to provide housing and 24-hour services in a nursing
17 facility.
18 (6) Pennsylvania lags behind other states in the
19 imbalance in its public funding for nursing-facility care
20 versus home-based and community-based services.
21 (7) Pennsylvania's publicly funded programs for home-
22 based and community-based services have complicated
23 application forms, delays for assessment and approval, and
24 inadequate assisted living services for Pennsylvanians
25 needing long-term care services who wish to remain in their
26 home or community.
27 (8) Although Pennsylvanians wish to remain in their home
28 or community when they are in need of long-term care
29 services, they are generally unaware of what home-based and
30 community-based assisted living services are available or of
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1 the availability of public funding for those services.
2 (9) Publicly funded home-based and community-based
3 services should meet consumers' needs, assist family
4 caregivers, permit consumers to live independently in the
5 residential environment of their choice, promote integration
6 of consumers into the community, maximize consumer choice to
7 promote and support the consumer's changing needs, be
8 consumer oriented and meet professional standards of quality.
9 (10) It is in the best interest of all Pennsylvanians
10 that the Commonwealth establish a wider range of publicly
11 funded home-based and community-based assisted living
12 services, make information about these services widely
13 available, streamline and simplify the application and
14 assessment process, eliminate financial disincentives to
15 receiving publicly funded services in the community rather
16 than a nursing facility and make these services available in
17 residential settings with the availability of 24-hour
18 services, if the consumer lives alone and needs to move to
19 such a setting.
20 The General Assembly of the Commonwealth of Pennsylvania
21 hereby enacts as follows:
22 Section 1. Short title.
23 This act shall be known and may be cited as the Public
24 Funding for Assisted Living Services Program Act.
25 Section 2. Definitions.
26 The following words and phrases when used in this act shall
27 have the meanings given to them in this section unless the
28 context clearly indicates otherwise:
29 "Activities of daily living." Activities including eating,
30 bathing, dressing, toileting, transferring in and out of bed or
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1 in and out of a chair and personal hygiene.
2 "Aging in place." The process of providing increased or
3 adjusted services to a person to compensate for the physical or
4 mental decline that occurs with the aging process in order to
5 maximize individual dignity and independence and permit the
6 person to remain in a familiar, noninstitutional, residential
7 environment for as long as possible. Such services may be
8 provided through residence staff, a third party, volunteers,
9 friends or family.
10 "AIDS." Autoimmune deficiency syndrome.
11 "Applicant." An individual who applies for publicly funded
12 assisted living.
13 "Area agency on aging." The local agency designated by the
14 Department of Aging within each planning and service area to
15 administer the delivery of a comprehensive and coordinated plan
16 of social and other services and activities.
17 "Assisted living." Services as determined and self-directed
18 by a consumer or by a legal representative that permit and
19 assist the consumer to live in the consumer's home or community
20 and permit the consumer to be safely supported in a residence in
21 which the consumer's independence, dignity and ability to make
22 choices are maintained to the extent of the consumer's
23 capabilities.
24 "Assisted living residence." A residential setting that:
25 (1) offers, provides or coordinates a combination of
26 personal care services and activities, whether scheduled or
27 unscheduled, and 24-hour supervision and health-related
28 services for four or more consumers who are not related to
29 the operator;
30 (2) has a service program and physical environment
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1 designed to minimize the need for residents to move within or
2 from the setting to accommodate changing needs and
3 preferences;
4 (3) has an organized mission, service programs and a
5 physical environment designed to maximize residents' dignity,
6 autonomy, privacy and independence and to encourage family
7 and community involvement;
8 (4) provides that costs for housing and services may be
9 independent of one another and provides consumers with the
10 ability to choose their service provider and the services to
11 be provided;
12 (5) has a goal of fostering aging in place and promoting
13 consumer self-direction and active participation in decision
14 making while emphasizing an individual's privacy and dignity;
15 (6) does not include residential living units in
16 continuing care providers certified by the Insurance
17 Department; and
18 (7) does not include residential living units in
19 subsidized housing apartments, unless required to be licensed
20 under the United States Department of Housing and Urban
21 Development Assisted Living Conversion Program.
22 "Assisted living services." A combination of supportive
23 services, personal care services, personalized assistance
24 services, assistive technology and health-related services
25 designed to respond to the individual needs of those who need
26 assistance with activities of daily living and instrumental
27 activities of daily living.
28 "Cognitive support services." Services provided as part of a
29 coordinated care plan to individuals who have memory impairment
30 and other cognitive problems that significantly interfere with
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1 their ability to carry out activities of daily living without
2 assistance and who require that supervision, monitoring and
3 programming be available to them 24 hours a day, seven days a
4 week in order for them to reside safely in the setting of their
5 choice, including assessment, service planning, ongoing
6 monitoring, personal care services, health support services and
7 a full range of dementia-capable activity programming and crisis
8 management.
9 "Comprehensive assessment." A thorough review and analysis
10 of a consumer's functional status. The term includes a personal
11 history, assessment of physical and emotional health, ability to
12 carry out activities of daily living, informal supports,
13 environmental factors and cognitive functioning, including
14 immobility assessment.
15 "Consumer." A person who receives assisted living services
16 in an assisted living residence, a home or other location
17 approved by the Department of Public Welfare.
18 "Council on Aging" or "Pennsylvania Council of Aging." An
19 entity which advises the Governor and the Department of Aging on
20 the planning, coordination and delivery of services to older
21 people and serves as an advocate for the elderly in this
22 Commonwealth.
23 "Department." The Department of Public Welfare of the
24 Commonwealth.
25 "EPSDT" or "Early and periodic screening, diagnosis, and
26 treatment program." A program which is federally mandated and
27 medically necessary for medical assistance beneficiaries under
28 21 years of age.
29 "Fair share first-day medical assistance access formula."
30 The percentage determined by the Department of Public Welfare of
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1 those qualifying for publicly funded assisted living services
2 who were income eligible for medical assistance on the first day
3 they met the functional eligibility for publicly funded assisted
4 living services out of all those assessed as functionally
5 qualifying for assisted living services.
6 "HealthChoices." The Pennsylvania medical assistance
7 mandatory managed care program.
8 "Instrumental activities of daily living." The term
9 includes, but is not limited to, preparing meals, taking
10 medication, using the telephone, handling finances, banking and
11 shopping, light housekeeping, heavy housekeeping and getting to
12 appointments.
13 "Intra-Governmental Council on Long-Term Care." An entity
14 which examines long-term care issues in this Commonwealth
15 including the responsibilities and programs of the various
16 agencies of State government.
17 "Legal representative." A person duly authorized by law to
18 take certain action on behalf or a consumer, including, but not
19 limited to, legal counsel, a court-appointed guardian, an
20 attorney-in-fact appointed pursuant to a power of attorney, an
21 agent appointed under a health care proxy or a representative
22 payee. In cases where the consumer has a cognitive impairment,
23 this may include a responsible family member.
24 "Level-of-care screening." An assessment of a person's
25 functional abilities, general health status and family-friend
26 support system completed to determine the level of care and
27 services appropriate for the person.
28 "Medical Assistance Advisory Committee." An entity which
29 advises the Department of Public Welfare on issues of medical
30 assistance policy development and program administration.
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1 "OPTIONS." The State Lottery-funded program for providing
2 home and community-based services to certain individuals over 60
3 years of age.
4 "PACE." The Pharmaceutical Access Contract for the Elderly.
5 "PDA." The Department of Aging of the Commonwealth.
6 "Pennsylvania Assisted Living Services" or "PALS" Program."
7 The array of publicly funded home-based and community-based
8 assisted living services and other health and social services
9 benefits available to eligible consumers who have applied for
10 and been found to need these services.
11 "Personal Care Home Advisory Committee." An entity which
12 acts in an advisory manner to the Department of Public Welfare
13 on personal care issues in this Commonwealth.
14 "Personal care services." Assistance or supervision in
15 matters, such as dressing, bathing, diet, financial management,
16 evacuation of the resident in the event of an emergency and
17 medication prescribed for self-administration. The term shall
18 include prompting, cueing, monitoring and focusing on
19 maintaining functioning.
20 "Provider." An assisted living residence, assisted living
21 services provider, approved personal care home or approved
22 domiciliary care home.
23 "Publicly funded assisted living." The term includes the
24 Bridging Program, Medical Assistance, HealthChoices, OPTIONS and
25 waiver programs and other appropriate publicly funded services
26 that assist individuals to remain in their home or community.
27 "Qualified assessor." A person approved by the Department of
28 Public Welfare as qualified to conduct assessments of persons
29 needing long-term care services and develop service plans based
30 thereon. A qualified assessor may include an employee of an area
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1 agency on aging, an assisted living residence, an assisted
2 living services provider or an independent entity, but may not
3 include hospital discharge planners or other staff or employees
4 of an insured's health or long-term care insurance company.
5 "Qualified couple." A qualified couple for cost-of-living
6 increase is two qualified persons, living together, who are
7 considered a couple under the Supplemental Security Income
8 program, Title XVI of the Social Security Act (49 Stat. 620, 42
9 U.S.C. § 301 et seq.).
10 "Qualified person." A qualified person for cost-of-living
11 increase includes any person meeting the nonfinancial,
12 categorical eligibility requirements under Title XIX of the
13 Social Security Act (49 Stat. 620, 42 U.S.C. § 301 et seq.) as
14 aged, blind or disabled and receiving or applying for long-term
15 care services under a special income level.
16 "Resident." An individual who resides in and may receive
17 assisted living services from an assisted living residence or a
18 personal care home or domiciliary care home approved by the
19 Department of Public Welfare.
20 "Service plan." A detailed plan based on a comprehensive
21 assessment designed to meet the resident's individual physical,
22 mental and psychosocial needs, consistent with the resident's
23 preferences and capabilities.
24 "SSI." Supplemental security income.
25 "Stakeholders." The Medical Assistance Advisory Committee,
26 the Consumer and Long-Term Care Subcommittees of the Medical
27 Assistance Advisory Committee, the Intra-Governmental Council on
28 Long-Term Care, the Personal Care Home Advisory Committee, the
29 Statewide Independent Living Council and the Council on Aging.
30 "Statewide Independent Living Council." An entity in which
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1 oversees federally funded independent living services in
2 Pennsylvania and coordinates activities with other State
3 advisory bodies that address the needs of specific disability
4 populations and related issues under Federal and State laws.
5 Section 3. Expansion of availability of publicly funded
6 assisted living services.
7 (a) Department.--Within the next fiscal year following the
8 effective date of this act, the department shall:
9 (1) Immediately work with the stakeholders to identify
10 categories of persons qualifying for nursing facility care,
11 who do not presently fit in any of Pennsylvania's present
12 Medicaid home-based and community-based waiver programs, for
13 example, persons with autism, persons who suffered a stroke,
14 etc.
15 (2) Seek amendment of all present Medicaid home-based
16 and community-based services waivers, consistent with Federal
17 requirements, for the purposes of covering groups identified
18 in paragraph (1) and of adding or increasing needed services
19 not presently provided, to fill in the service gaps in
20 Pennsylvania's current Medicaid waivers and to maximize caps
21 on payment. Among other things, the department shall seek
22 amendment to add cognitive support services and assistive
23 technology to the PDA waiver, to expand coverage and
24 eligibility under the AIDS waiver, and to increase the 80% of
25 the cost of nursing home care financial cap on the PDA
26 waiver.
27 (3) Amend, if permitted by Federal law, the State plan
28 to include in medical assistance financial eligibility
29 determination the following:
30 (i) In determining the countable resources of
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1 qualified persons for purposes of medical assistance
2 eligibility, the department shall use a computation
3 method which exempts an amount of otherwise countable
4 resources which is equal to the difference between $2,000
5 and an amount calculated as follows: $2,000 increased by
6 each of the Social Security cost-of-living adjustments
7 sequentially from January 1, 1990, to the present.
8 (ii) For qualified couples, the department shall use
9 a computation method which exempts an amount of otherwise
10 countable resources which is equal to the difference
11 between $3,000 and the amount calculated as follows:
12 $3,000 increased by each of the Social Security cost-of-
13 living adjustments sequentially from January 1, 1990, to
14 the present.
15 (iii) The department shall promptly adjust upward
16 the exempted amounts each year as new Social Security
17 cost-of-living adjustments go into effect.
18 (4) Change and, where necessary, seek Federal approval
19 to liberalize eligibility requirements for nursing facility-
20 eligible persons receiving Medicaid-funded services in the
21 community to parallel the requirements for those receiving
22 care in a nursing facility to the extent they are more
23 favorable to applicants or consumers, or both. Where
24 permitted by Federal law, the department shall increase the
25 resource level, adjust the spousal impoverishment level and
26 revise spend-down allowances for those receiving services in
27 their home and community.
28 (b) Department of Aging and department.--Within nine months
29 the Department of Aging and the department shall:
30 (1) Establish a presumptive eligibility program for
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1 immediately putting assisted living services in place for
2 persons found eligible by the area agency on aging who appear
3 to be eligible for State-funded or Medicaid-funded programs,
4 where the individual is at risk of imminent placement in a
5 nursing facility. The department shall attempt to maximize
6 Federal matching funding, but, if necessary, may use State
7 funding exclusively.
8 (2) Establish rules and procedures for a program to
9 provide payment for a housing supplement to be used with
10 Medicaid-funded home-based and community-based services to
11 help keep the consumer at home, in approved domiciliary care
12 homes, in an assisted living residence or in an approved
13 personal care home where:
14 (i) the total State cost of the housing supplement
15 and home-based and community-based services is less than
16 the State cost for the consumer in a nursing facility;
17 (ii) a housing supplement is necessary to avoid
18 nursing facility placement unwanted by the consumer; and
19 (A) the person is certified for an available
20 waiver slot in the Medicaid-funded home-based and
21 community-based services waiver program; and
22 (B) adequate State funds have been appropriated
23 for the year for the payment of the supplement.
24 (3) Begin annual assessment of the availability of home-
25 based and community-based assisted living services in all
26 counties and assist counties to develop needed services, such
27 as adult day care, where they are presently unavailable.
28 (4) Establish a program which allows persons with
29 Medicaid-countable resources of up to $40,000 who are
30 presently income eligible for Medicaid-funded home-based and
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1 community-based assisted living services to equally share the
2 cost of those services with a State-funded program and
3 provide State support to bridge the transition to Medicaid-
4 funded services.
5 (5) Implement a quality assessment and improvement
6 program which includes consumer satisfaction surveys and
7 quality-of-life outcome measures to ensure that publicly
8 funded and home-based and community-based services meet
9 consumers' needs, permit consumers to live independently in
10 the residential environment of their choice, promote
11 integration of consumers into the community, maximize
12 consumer choice to promote and support the consumer's
13 changing needs, are consumer oriented and meet professional
14 standards of quality.
15 (6) Work with stakeholders to develop recommendations to
16 the General Assembly for public funding and cost sharing for
17 consumers needing assistance with activities of daily living
18 whose income is higher than the Medicaid or SSI State
19 supplement but less than the Medicaid home-based and
20 community-based waiver income level and who do not meet the
21 functional eligibility for Medicaid home-based and community-
22 based waiver services.
23 (c) Transfer to programs.--On a timely and ongoing basis,
24 the department shall identify persons aging out of the Early and
25 Periodic Screening, Diagnosis and Treatment (EPSDT) Program and
26 other publicly funded programs, who would be eligible for
27 publicly funded home-based and community-based assisted living
28 services and assist them to make a safe and uninterrupted
29 transfer to those programs so that they may continue to remain
30 in their communities.
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1 (d) Public report.--The Department of Aging and the
2 department shall provide annually a public report including the
3 following information:
4 (1) The types of home-based and community-based services
5 funded through public sources, by county, including
6 descriptions of services, units of services, an unduplicated
7 count of people served by the services and consumer
8 satisfaction information.
9 (2) The number of people who applied for home-based and
10 community-based services, the number of people on waiting
11 lists, the number of people denied home-based and community-
12 based services because of financial ineligibility, the
13 adequacy of access to providers funded under this act and
14 choice of quality providers for first-day medical assistance
15 beneficiaries qualifying for services under this act, an
16 analysis of the adequacy of reimbursement to providers for
17 publicly funded services under this act and the number of
18 people denied home-based and community-based services because
19 of functional ineligibility.
20 (3) The outcomes shall include the number, types and
21 results of complaints, consumer satisfaction information,
22 length of stay or service delivery, reasons for termination
23 of service and development of evaluation tools for
24 determining quality of life and care.
25 (e) Adequacy of access.--The department shall annually
26 determine, on a county-by-county basis, the adequacy of access
27 of first-day medical assistance beneficiaries who qualify for
28 services under this act to a reasonable choice of quality
29 providers funded for services under this act. In those counties
30 where first-day Medicaid beneficiaries do not have adequate
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1 access and choice of quality providers, the department shall,
2 after consultation with stakeholders, determine a fair share
3 first-day medical assistance access formula to be applied to
4 providers in that county who provide services under this act,
5 for the purpose of providing access for first-day medical
6 assistance beneficiaries. In such cases, the department shall
7 contract only with those providers who agree to serve a fair
8 share of first-day medical assistance consumers. However, a
9 provider shall not be penalized for not meeting the fair share
10 requirements if the provider can demonstrate that the provider
11 has not denied access or services to any first-day medical
12 assistance recipient meeting the provider's admission-acceptance
13 standards.
14 Section 4. Application, assessment and appeal process.
15 (a) Application form and application process.--Within six
16 months of the effective date of this act, the Department of
17 Aging and the department, working with the stakeholders, shall
18 design and utilize a single, simple, consumer-friendly,
19 attractive and readily available PALS application form for
20 publicly funded services and benefits available in Pennsylvania
21 for persons needing long-term care services, which will serve as
22 a one-stop application for these services. The application shall
23 be for all publicly funded assisted living services available in
24 this Commonwealth and shall be known as the "PALS Program
25 Application." The departments shall:
26 (1) To the extent possible, rely primarily on income and
27 asset verification that is independently available to the
28 Commonwealth, with little burden placed on the applicant.
29 (2) Insure swift and seamless application process for
30 all PALS programs to provide consistent income eligibility
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1 periods and use of self-declaration of income for PACE and
2 Medicaid so that Medicaid-eligible PACE applicants will
3 receive the greater package of services through Medicaid,
4 while helping the Commonwealth maximize Federal funding and
5 freeing up State lottery funds.
6 (3) Permit PALS application submission to either the
7 Department of Aging or the department and take other steps to
8 ensure the prompt and seamless processing of applications and
9 provision of services.
10 (4) Promptly assist and advise applicants and their
11 family members in gathering necessary nonindependently
12 available verification of income and assets and directly
13 contact sources of information if the consumer requests.
14 (5) Insure that the application is capable of swift
15 determination of completeness and eligibility so that, upon
16 submission, additional items necessary for processing the
17 completed application will be identified by the processor and
18 made known by the processor to the applicant.
19 (6) Ensure that eligibility determinations made in one
20 county are good for use in any county of this Commonwealth
21 during the period of eligibility.
22 (b) The Legislative Budget and Finance Committee of the
23 House of Representatives.--Within six months of the effective
24 date of this act, the Legislative Budget and Finance Committee
25 of the House of Representatives shall evaluate the efficiency,
26 responsiveness to consumers, consumer satisfaction with and the
27 effectiveness of the present staffing and application and
28 verification process for publicly funded home-based and
29 community-based assisted living services and make
30 recommendations for improvements.
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1 (c) Screening, assessment and eligibility determination.--
2 (1) The department shall establish procedures requiring
3 all persons seeking publicly funded long-term care services
4 in an assisted living residence or personal care home to
5 obtain a level-of-care screening and comprehensive assessment
6 from the area agency on aging program prior to admission to
7 the residence.
8 (2) The procedures shall permit an area agency on aging
9 level-of-care screening and comprehensive assessment to be
10 conducted by telephone based on representations made by the
11 provider and applicant, subject to retrospective face-to-face
12 evaluation of the applicant thereafter.
13 (3) All persons may obtain level-of-care screenings and
14 comprehensive assessments from the area agency on aging.
15 (4) All area agency on aging level-of-care screenings
16 and comprehensive assessments must be completed within five
17 business days of the request, except where an urgent
18 situation requires that they be completed within one business
19 day; and shall be valid for six months unless the resident's
20 or recipient's condition changes.
21 (5) All area agency on aging determinations of need for
22 publicly funded long-term care services shall be evaluated by
23 the county assistance offices for financial eligibility
24 within five business days, generally, or one day for
25 emergency cases, from date of receipt of completed Medicaid
26 application.
27 (6) The Department of Aging and the department, in
28 consultation with the stakeholders, shall establish the
29 negotiated risk standards to be used in determining the
30 consumer's eligibility for publicly funded assisted living
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1 services.
2 (d) Appeals.--The department shall promptly develop an
3 expedited fair hearing process for addressing challenges to
4 financial eligibility, level of care, service plan and SSI
5 supplement decisions where the denial has resulted in failure to
6 provide long-term care services. Hearing and decision must take
7 place within 30 days of filing of the request for fair hearing.
8 Section 5. Information on programs and services.
9 Within nine months of the effective date of this act, the
10 Department of Aging and the department shall:
11 (1) Develop an extensive multimedia public information
12 campaign to inform Pennsylvanians of the range of options
13 available and the availability of the PALS Program. The list
14 shall be updated and disseminated annually. The public
15 information campaign shall be reviewed and updated every two
16 years with reports to and an opportunity for input by the
17 stakeholders.
18 (2) Establish a toll-free PALS help line for consumers
19 needing home-based and community-based assisted living
20 services to advise consumers of programs in their area,
21 public funding availability and to assist with the
22 application process.
23 (3) Initiate a training program for hospital discharge
24 planners, area agency on aging personnel, nursing home staff,
25 department caseworkers, HealthChoices special needs personnel
26 and social service programs on the range of publicly funded
27 home-based and community-based assisted living services and
28 the new application process.
29 Section 6. Appropriation.
30 The sum of $1,000,000 is hereby appropriated from the General
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1 Fund for the fiscal year July 1, 2001, to June 30, 2002, for the
2 housing supplement provided for in section 3(b)(2). This shall
3 be a continuing appropriation and shall not lapse.
4 Section 7. Effective date.
5 This act shall take effect immediately.
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