PRINTER'S NO.  1806

  

THE GENERAL ASSEMBLY OF PENNSYLVANIA

  

HOUSE BILL

 

No.

1480

Session of

2011

  

  

INTRODUCED BY PEIFER, TURZAI, DERMODY, BAKER, PARKER, SCAVELLO, AUMENT, BENNINGHOFF, BISHOP, BROOKS, V. BROWN, CAUSER, CUTLER, DAY, FARRY, GINGRICH, KILLION, KIRKLAND, KNOWLES, MALONEY, MANN, MYERS, MASSER, MILLARD, MUSTIO, O'NEILL, PAYTON, PETRI, PICKETT, REED, SABATINA, STEPHENS, TAYLOR, TOEPEL, TOOHIL, WATERS, WILLIAMS, ADOLPH, GIBBONS, DeLUCA, SWANGER, SONNEY AND MILLER, MAY 9, 2011

  

  

REFERRED TO COMMITTEE ON HEALTH, MAY 9, 2011  

  

  

  

AN ACT

  

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Providing for the establishment and administration of a managed

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health care program for medical assistance recipients and for

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the powers and duties of the Department of Public Welfare.

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The General Assembly of the Commonwealth of Pennsylvania

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hereby enacts as follows:

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Section 1.  Short title.

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This act shall be known and may be cited as the HealthChoices

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Act.

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Section 2.  Legislative intent.

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It is the intent of the General Assembly to:

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(1)  Improve the accessibility, continuity and quality of

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health care services for participants in the Commonwealth's

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Medical Assistance Program, while responsibly controlling

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program costs.

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(2)  Establish a process for the establishment and

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maintenance of a program to manage the care of the physical

 


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health of participants in the medical assistance program.

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(3)  Establish rates for hospitals serving certain

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medical assistance recipients who participate in managed

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care.

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Section 3.  Definitions.

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The following words and phrases when used in this act shall

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have the meanings given to them in this section unless the

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context clearly indicates otherwise:

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"CMS."  The Centers for Medicare and Medicaid Services of the

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United States Department of Health and Human Services and such

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successor entities which may from time to time discharge the

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duties of CMS with respect to the medical assistance program.

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"Contractor."  A managed care organization that provides

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managed care services relating to physical care provided to

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recipients under one or more contracts with the department

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pursuant to the program. This term includes a managed care

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organization that seeks to enter into a contract with the

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department to provide services under HealthChoices.

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"Department."  The Department of Public Welfare of the

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Commonwealth.

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"HealthChoices" or "program."  The program of the

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Commonwealth that provides mandatory managed health care to

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recipients in specified areas of this Commonwealth through

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contracts with managed care organizations.

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"Hospital."  An entity licensed as a hospital under the act

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of June 13, 1967 (P.L.31, No.21), known as the Public Welfare

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Code, or the act of July 19, 1979 (P.L.130, No.48), known as the

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Health Care Facilities Act.

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"In-plan services."  Services included in the medical

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assistance program pursuant to the State plan.

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"Managed care organization."  A public or private

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organization that:

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(1)  is a federally qualified health maintenance

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organization;

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(2)  meets the State plan's definition of a health

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maintenance organization; or

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(3)  otherwise qualifies as a managed care plan as

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defined in Article XXI of the act of May 17, 1921 (P.L.682,

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No.284), known as The Insurance Company Law of 1921.

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"Medical assistance."  The Commonwealth program authorized by

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Title XIX of the Social Security Act (42 Stat. 620, 42 U.S.C. §

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1396 et seq.), known as Medicaid and authorized in this

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Commonwealth under the act of June 13, 1967 (P.L.31, No.21),

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known as the Public Welfare Code, and subject to regulations

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promulgated under such statutes. The term includes any successor

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program implemented by either the Federal Government or the

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Commonwealth, to the extent a contractor provides services

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contemplated in this act with respect to the program.

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"Recipient."  An individual eligible to receive health care

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or health-related services under the medical assistance program.

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"State plan."  The document required by section 1396a(a) of

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the Social Security Act (49 Stat. 620, 42 U.S.C. § 1396a(a)), as

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approved by CMS, that describes the nature, scope and operation

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of the medical assistance program and gives assurances that the

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Commonwealth will administer the program in compliance with

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Federal requirements. The term includes any waiver granted by

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CMS not otherwise included in the plan submitted by the

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Commonwealth for CMS approval.

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"Waiver."  A determination made by CMS under Subchapter XIX

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of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1396 et

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seq.), known as Medicaid, and regulations promulgated under that

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law, which allows the Commonwealth to make modifications in its

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operation of the medical assistance program.

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"Zone."  A geographic area that is designated as provided in

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this act and within which contractors provide services to

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recipients.

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Section 4.  HealthChoices.

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(a)  Administration.--

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(1)  The Commonwealth, acting by and through the

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department, shall implement and administer the provision of

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physical health services through HealthChoices in all areas

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of this Commonwealth as provided in this act.

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(2)  Nothing in this act shall be construed to affect the

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provision of behavioral health services to recipients by the

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department.

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(b)  Replacing other law as the means for providing

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assistance.--The program shall require the provision of all

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medical assistance-covered physical health benefits in the

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amount, duration and scope specified in the act of June 13, 1967

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(P.L.31, No.21), known as the Public Welfare Code, for

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recipients in the following categories:

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(1)  Supplemental security income.

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(2)  Temporary assistance for needy families.

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(3)  Healthy beginnings.

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(4)  General assistance.

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(5)  Successors to the categories listed in paragraphs

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(1), (2), (3) and (4).

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(c)  Recipients excluded.--A recipient who resides in a long-

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term care facility or who is admitted to a Commonwealth facility

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shall be excluded from participation in the program.

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(d)  Discretionary exclusion of recipients.--Notwithstanding

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the provisions of subsections (b) and (c), the department may

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exclude the following recipients from mandatory participation in

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the program:

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(1)  A recipient who is eligible for the Commonwealth's

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health insurance premium payment program.

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(2)  A recipient who is ventilator-dependent in an acute

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or rehabilitation hospital for more than 30 consecutive days.

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(3)  A recipient who is enrolled in the Department of

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Aging waiver.

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(4)  A recipient who is enrolled in the Michael Dallas

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Model waiver or other similar waiver.

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(5)  A dual eligible recipient with Medicare coverage.

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(6)  A recipient who is incarcerated in a penal facility,

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correctional institution or youth development center.

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(7)  A recipient who is enrolled in the Long-Term Care

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Capitated Assistance Program.

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(8)  A recipient who is admitted to a state ICF-MR

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facility.

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Section 5.  Program zones.

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The department shall administer HealthChoices for physical

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health care in the following areas of this Commonwealth:

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(1)  Southeast zone, which shall include Bucks, Chester,

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Delaware, Montgomery and Philadelphia Counties.

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(2)  Southwest zone, which shall include Allegheny,

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Armstrong, Beaver, Butler, Fayette, Greene, Indiana,

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Lawrence, Washington and Westmoreland Counties.

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(3)  Lehigh/Capital zone, which shall include Adams,

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Berks, Cumberland, Dauphin, Lancaster, Lebanon, Lehigh,

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Northampton, Perry and York Counties.

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(4)  Northeast zone, which shall include Carbon,

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Lackawanna, Luzerne, Monroe, Pike, Schuylkill, Susquehanna,

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Wayne and Wyoming Counties.

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(5)  Northwest zone, which shall include Cameron,

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Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson,

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McKean, Mercer, Venango and Warren Counties.

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(6)  Central zone, which shall include Bedford, Blair,

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Bradford, Cambria, Centre, Clinton, Columbia, Franklin,

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Fulton, Huntingdon, Juniata, Lycoming, Mifflin, Montour,

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Northumberland, Potter, Snyder, Somerset, Sullivan, Tioga and

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Union Counties.

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Section 6.  Program expansion.

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(a)  General rule.--The department shall take such actions as

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may be necessary or desirable to expand HealthChoices to areas

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of this Commonwealth where, prior to the effective date of this

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section, medical assistance recipients were not required to be

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enrolled in managed care and shall implement the expansion as

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follows:

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(1)  In the Northeast zone and Northwest zone, within 180

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days from the effective date of this section.

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(2)  In the Central zone, within 210 days from the

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effective date of this section.

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(b)  Procurement procedure.--In furtherance of the

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requirements of subsection (a), the department shall, without

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limitation:

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(1)  Issue one or more requests for proposals for the

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expansion of HealthChoices to the Northeast zone, Northwest

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zone and Central zone.

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(2)  Review and evaluate responses from managed care

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organizations to the requests for proposals issued under this

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section, in accordance with applicable Federal and State laws

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and regulations.

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(3)  Select contractors for each zone into which the

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program is to be expanded. The contractors selected for a

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zone shall serve all program recipients residing in the zone,

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subject only to the limitations imposed in section 4.

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(4)  Negotiate and execute contracts with selected

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contractors for each zone into which the program is to be

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expanded, which contracts shall be in conformance with the

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provisions of this act.

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(5)  Seek and make all efforts to obtain any necessary or

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desirable amendment to or approval of any waiver or amendment

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to the State plan from CMS or any other agency of the Federal

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Government to allow timely implementation of the expansion

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provided for in this section.

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(c)  Selection of contractors.-–The department shall select

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at least two contractors to provide managed care services for

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each zone into which the program is to be expanded, and the

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contractors shall have the responsibility to provide services

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for the benefit of all recipients residing in that zone, subject

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only to the limitations provided in section 4.

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Section 7.  Payments to hospitals.

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If a hospital and a contractor do not have a participation

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agreement in effect, the contractor shall pay, and the hospital

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shall accept the payment as payment in full, for services

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covered by the contractor and rendered to an enrollee of the

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contractor residing in the Northeast, Northwest or Central zone

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an amount equal to the rates payable for the services by the

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medical assistance fee for service program.

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Section 8.  Reports to General Assembly.

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Within 12 months following the effective date of this

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section, and annually thereafter, the department shall submit a

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report on the implementation and operation of HealthChoices to

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the President pro tempore of the Senate and the Speaker of the

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House of Representatives.

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Section 19.  Effective date.

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This act shall take effect immediately.

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