PRINTER'S NO. 2496
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1829
Session of
2017
INTRODUCED BY BERNSTINE, KAUFER, BAKER, DRISCOLL, LONGIETTI,
WARD, DAVIS, CHARLTON, ROTHMAN, MILLARD, SCHWEYER, COX,
WHEELAND, ZIMMERMAN, PHILLIPS-HILL, CORBIN, SCHLOSSBERG,
DeLUCA, HENNESSEY, COOK, KEEFER, RADER, CONKLIN AND DEAN,
SEPTEMBER 27, 2017
REFERRED TO COMMITTEE ON HEALTH, SEPTEMBER 27, 2017
AN ACT
Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
act to consolidate, editorially revise, and codify the public
welfare laws of the Commonwealth," in public assistance,
providing for medical assistance presumptive eligibility
program for home care and home health services.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of June 13, 1967 (P.L.31, No.21), known
as the Human Services Code, is amended by adding a section to
read:
Section 443.12. Medical Assistance Presumptive Eligibility
Program for Home Care and Home Health Services.--(a) The
department shall establish a presumptive eligibility program for
home care services and home health services to prevent the
unnecessary and costly institutionalization of individuals who
are eligible for medical assistance nursing facility services
and want to receive home care and assistance with daily living
in a less restrictive setting.
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(b) The program shall:
(1) be designed to provide home care services and home
health services only for individuals who are sixty years of age
or older and nursing facility clinically eligible;
(2) permit a qualified entity to submit an application for
medical assistance on behalf of individuals to the department;
(3) permit an individual who is applying for medical
assistance to declare income and assets on an application form
and attest to the accuracy of the income and assets provided on
the application form; and
(4) permit a qualified entity to determine the presumptive
eligibility of individuals to receive medical assistance.
(c) The following apply:
(1) If a qualified entity determines that an individual is
presumptively eligible to receive medical assistance under
subsection (b)(4), the individual may begin receiving home care
services and home health services from a medical assistance
provider immediately. As authorized under Federal law, the
department shall apply a final determination of medical
assistance eligibility beginning on the date that a qualified
entity determines that an individual is presumptively eligible
for medical assistance under subsection (b)(4).
(2) If a qualified entity determines that an individual is
presumptively eligible under subsection (b)(4), and the
individual is subsequently determined to be ineligible for home
care services and home health services by the department, the
qualified entity which made the determination under subsection
(b)(4) shall not be reimbursed by the Commonwealth for the cost
of home care services or home health services provided during
the period of presumed eligibility. If the individual provided
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fraudulent information under this section, the qualified entity
may seek reimbursement from the individual for the cost of home
care services and home health services provided during the
period of presumed eligibility.
(3) Once the department makes a final determination of
eligibility, the department shall authorize medical assistance
payments for home care services and home health services
provided during the period of presumed eligibility and as of the
date that the qualified entity established presumptive
eligibility under subsection (b)(4).
(4) Within sixty days of the submission of an application
under this section, the department shall verify the information
on the application and make a final determination of medical
assistance eligibility. The department may request additional
information from an applicant for the purpose of completing the
verification process under this paragraph.
(d) Upon request, the department shall provide information
to a qualified entity about Commonwealth policies and procedures
on how to determine whether an individual is presumptively
eligible for medical assistance under subsection (b)(4).
(e) The department shall issue a medical assistance bulletin
which contains the Commonwealth policies and procedures
necessary to implement this section.
(f) The department shall apply for any necessary Federal
waivers and maximize the use of Federal money for the program.
(g) The department shall issue any revisions to the State
medical assistance plan as required under Title XIX of the
Social Security Act (49 Stat. 620, 42 U.S.C. § 1396 et seq.)
before implementing the program.
(h) On or before January 1 of each year, the department
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shall issue a report to the General Assembly with the following
information about the program:
(1) The number of individuals who participated in the
program.
(2) The average cost for each individual in the program.
(3) The number of qualified entities in the program.
(4) The administration costs.
(5) The estimated savings.
(i) As used in this section, the following words and phrases
shall have the following meanings:
"Home care services." As defined in 28 Pa. Code § 611.5
(relating to definitions).
"Home health services." Part-time, intermittent skilled
nursing services and therapy services provided under 28 Pa. Code
Ch. 601 (relating to home health care agencies) at an
individual's place of residence.
"Nursing facility clinically eligible." An individual who:
(1) is certified by a physician to be nursing facility
clinically eligible;
(2) has been diagnosed with an illness, injury, disability
or medical condition by a physician which requires the
individual to receive health services in accordance with the
following:
(i) Skilled nursing and skilled rehabilitation services as
defined in 42 CFR 409.31 (relating to level of care
requirement).
(ii) 42 CFR 409.32 (relating to criteria for skilled
services and the need for skilled services).
(iii) 42 CFR 409.33 (relating to examples of skilled nursing
and rehabilitation services).
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(iv) 42 CFR 409.34 (relating to criteria for "daily basis").
(v) 42 CFR 409.35 (relating to criteria for "practical
matter").
(3) needs health services on a regular basis in the context
of a planned program of health care and management which was
only previously available through an institutional facility.
"Nursing facility services." As defined in 42 CFR 440.40
(relating to nursing facility services for individuals age 21 or
older (other than services in an institution for mental
disease), EPSDT, and family planning services and supplies) or
42 CFR 440.155 (relating to nursing facility services, other
than in institutions for mental diseases).
"Program." The presumptive eligibility program established
by the department under subsection (a).
"Qualified entity." A home care agency or home health agency
which elects to determine the presumptive eligibility of
individuals to receive medical assistance under subsection (b)
(4).
Section 2. This act shall take effect in 60 days.
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