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SENATE AMENDED
PRIOR PRINTER'S NO. 1527
PRINTER'S NO. 3371
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1420
Session of
2021
INTRODUCED BY THOMAS, FARRY, MIHALEK, SCHLOSSBERG, R. BROWN,
DRISCOLL, FREEMAN, HILL-EVANS, LABS, McNEILL, N. NELSON,
POLINCHOCK, SAMUELSON, SAPPEY, SCHROEDER, STEPHENS,
TOMLINSON, CIRESI, GUZMAN, WEBSTER, MIZGORSKI, T. DAVIS,
C. WILLIAMS, QUINN, KENYATTA, BERNSTINE, SAINATO AND BOYLE,
MAY 14, 2021
SENATOR BROWNE, APPROPRIATIONS, IN SENATE, RE-REPORTED AS
AMENDED, JULY 7, 2022
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 of Public Welfare, providing for
COVID-19 mental health public awareness campaign.; IN PUBLIC
ASSISTANCE, FURTHER PROVIDING FOR ELIGIBILITY AND FOR MEDICAL
ASSISTANCE PAYMENTS FOR INSTITUTIONAL CARE AND PROVIDING FOR
RESIDENT CARE AND RELATED COSTS AND FOR PHARMACY BENEFITS
MANAGER AUDIT AND OBLIGATIONS; IN THE AGED, FURTHER PROVIDING
FOR LIFE PROGRAM AND PROVIDING FOR AGENCY WITH CHOICE; IN
CHILDREN AND YOUTH, FURTHER PROVIDING FOR LIMITS ON
REIMBURSEMENTS TO COUNTIES; IN NURSING FACILITY ASSESSMENTS,
FURTHER PROVIDING FOR TIME PERIODS; IN MANAGED CARE
ORGANIZATION ASSESSMENTS, FURTHER PROVIDING FOR ASSESSMENT
AMOUNT; PROVIDING FOR INNOVATIVE HEALTH CARE DELIVERY MODELS;
ABROGATING REGULATIONS; AND MAKING A RELATED REPEAL.
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 217. COVID-19 Mental Health Public Awareness
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Campaign .-- The secretary shall establish a public awareness
campaign to provide information to the general public concerning
the programs and services available for first responders, health
care workers, other frontline workers and their families
experiencing mental health issues related to the COVID-19
pandemic, including, but not limited to, post-traumatic stress
disorder, anxiety, depression and substance use disorder.
(b) The secretary, in establishing the public awareness
campaign, shall develop outreach efforts and provide information
to the general public on:
(1) the link between mental health issues and the COVID-19
pandemic, including, but not limited to, post-traumatic stress
disorder, anxiety, depression and substance use disorder;
(2) resources for first responders, health care workers,
other frontline workers and their families experiencing mental
health issues related to the COVID-19 pandemic, including, but
not limited to, post-traumatic stress disorder, anxiety,
depression and substance use disorder, including the programs
provided by the department and other Federal, State and local
social services and mental health agencies during the COVID-19
pandemic;
(3) any telephone helpline established by the department for
first responders and health care workers experiencing mental
health issues due to their work during the COVID-19 pandemic,
including, but not limited to, post-traumatic stress disorder,
anxiety, depression and substance use disorder; and
(4) anxiety-reducing strategies and other methods to manage
stress, depression and other symptoms of post-traumatic stress
disorder during the COVID-19 pandemic.
(c) The following shall apply:
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(1) The public awareness campaign shall target the general
public and first responders, health care workers, other
frontline workers and their families through a variety of media,
including television, radio, print and on the department's
publicly accessible Internet website.
(2) The secretary shall provide for the development of
advertisements by signs, billboards, placards, posters and
displays, in English and Spanish, on the public awareness
campaign.
(d) As used in this section, the term "COVID-19 pandemic"
shall mean the novel coronavirus as identified in the
proclamation of disaster emergency issued by the Governor on
March 6, 2020, published at 50 Pa.B. 1644 (March 21, 2020), and
any renewal of the state of disaster emergency.
SECTION 2. SECTION 432(2)(VI) OF THE ACT IS AMENDED TO READ:
SECTION 432. ELIGIBILITY.--EXCEPT AS HEREINAFTER OTHERWISE
PROVIDED, AND SUBJECT TO THE RULES, REGULATIONS, AND STANDARDS
ESTABLISHED BY THE DEPARTMENT, BOTH AS TO ELIGIBILITY FOR
ASSISTANCE AND AS TO ITS NATURE AND EXTENT, NEEDY PERSONS OF THE
CLASSES DEFINED IN CLAUSES (1), (2), AND (3) SHALL BE ELIGIBLE
FOR ASSISTANCE:
* * *
(2) PERSONS WHO ARE ELIGIBLE FOR STATE SUPPLEMENTAL
ASSISTANCE.
* * *
(VI) THE AMOUNTS OF STATE SUPPLEMENTAL ASSISTANCE PAYMENTS
SHALL BE AS FOLLOWS:
(A) AFTER THE AMOUNTS OF ASSISTANCE PAYMENTS HAVE BEEN
DETERMINED BY THE DEPARTMENT WITH THE APPROVAL OF THE GOVERNOR
AND GENERAL ASSEMBLY, THE AMOUNTS OF ASSISTANCE PAYMENTS SHALL
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NOT BE INCREASED, EXCEPT UNDER CLAUSE (B), WITHOUT THE APPROVAL
OF THE GENERAL ASSEMBLY IN ACCORDANCE WITH THE PROCEDURE
ESTABLISHED BY THE ACT OF APRIL 7, 1955 (P.L.23, NO.8) KNOWN AS
THE "REORGANIZATION ACT OF 1955," AND A MESSAGE TO THE GENERAL
ASSEMBLY FROM THE GOVERNOR FOR THE PURPOSES OF EXECUTING SUCH
FUNCTION SHALL BE TRANSMITTED AS IN OTHER CASES UNDER THE
REORGANIZATION ACT.
(B) BEGINNING IN STATE FISCAL YEAR 2022-2023, THE MONTHLY
STATE SUPPLEMENTAL ASSISTANCE AMOUNTS FOR RESIDENTS OF A
DOMICILIARY CARE HOME, AS DEFINED IN SECTION 2202-A OF THE ACT
OF APRIL 9, 1929 (P.L.177, NO.175), KNOWN AS "THE ADMINISTRATIVE
CODE OF 1929," OR A PERSONAL CARE HOME AS DEFINED IN SECTION
1001 SHALL BE AS FOLLOWS:
INDIVIDUAL COUPLE
DOMICILIARY CARE HOME $634.30 $1,347.40
PERSONAL CARE HOME $639.30 $1,357.40
* * *
SECTION 3. SECTION 443.1(7)(IV) OF THE ACT IS AMENDED AND
THE PARAGRAPH IS AMENDED BY ADDING A SUBPARAGRAPH 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:
* * *
(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 REGULATIONS AND THE COMMONWEALTH'S APPROVED TITLE
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XIX STATE PLAN FOR NURSING FACILITY SERVICES IN EFFECT AFTER
JUNE 30, 2007. THE FOLLOWING SHALL APPLY:
* * *
(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 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,
[2022] 2026, 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.
(IV.1) NOTWITHSTANDING SUBPARAGRAPH (II) AND SUBJECT TO
FEDERAL APPROVAL AS MAY BE NECESSARY, THE FOLLOWING SHALL APPLY
TO NONPUBLIC AND COUNTY NURSING FACILITY PAYMENT RATES, TO THE
EXTENT FUNDS ARE APPROPRIATED FOR THE PURPOSE OF RATE INCREASES
FOR INCREASED DIRECT RESIDENT CARE REQUIREMENTS AND RESIDENT
CARE AND RELATED COSTS:
(A) BEGINNING JANUARY 1, 2023, THE DEPARTMENT SHALL MAKE
CAPITATION PAYMENTS TO MEDICAL ASSISTANCE COMMUNITY
HEALTHCHOICES MANAGED CARE ORGANIZATIONS THAT INCLUDE AMOUNTS
EXCLUSIVELY FOR THE PURPOSE OF MAKING PAYMENTS TO NONPUBLIC
NURSING FACILITIES AND COUNTY NURSING FACILITIES AS PROVIDED
UNDER CLAUSE (B)(I).
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(B) THE DEPARTMENT SHALL ADOPT A MINIMUM PAYMENT RATE FOR
PAYMENTS FOR SERVICES RENDERED TO MEDICAL ASSISTANCE RECIPIENTS
UNDER THE COMMUNITY HEALTHCHOICES PROGRAM, EFFECTIVE WITH DATES
OF SERVICE OF JANUARY 1, 2023, THROUGH DECEMBER 31, 2025, AS
FOLLOWS:
(I) COMMUNITY HEALTHCHOICES MANAGED CARE ORGANIZATIONS SHALL
APPLY NO LESS THAN THE MINIMUM PAYMENT RATE TO MAKE PAYMENTS TO
NONPUBLIC NURSING FACILITIES AND COUNTY NURSING FACILITIES FOR
SERVICES RENDERED TO MEDICAL ASSISTANCE RECIPIENTS UNDER THE
COMMUNITY HEALTHCHOICES PROGRAM.
(II) THE MINIMUM PAYMENT RATE SHALL BE GREATER THAN OR EQUAL
TO THE FOLLOWING AMOUNTS:
(A) FOR NONPUBLIC NURSING FACILITIES, THE NURSING FACILITY
CASE-MIX RATES CALCULATED IN ACCORDANCE WITH 55 PA. CODE CH.
1187 (RELATING TO NURSING FACILITY SERVICES) AND THE
COMMONWEALTH'S APPROVED TITLE XIX STATE PLAN IN EFFECT FOR THE
DATES OF SERVICE.
(B) FOR COUNTY NURSING FACILITIES, THE COUNTY NURSING
FACILITY RATES IN ACCORDANCE WITH 55 PA. CODE CH. 1189 (RELATING
TO COUNTY NURSING FACILITY SERVICES) AND THE COMMONWEALTH'S
APPROVED TITLE XIX STATE PLAN IN EFFECT FOR THE DATES OF
SERVICE.
* * *
SECTION 4. THE ACT IS AMENDED BY ADDING SECTIONS TO READ:
SECTION 443.13. RESIDENT CARE AND RELATED COSTS.--(A) THE
FOLLOWING APPLIES TO A COUNTY AND NONPUBLIC NURSING FACILITY
ENROLLED IN THE MEDICAL ASSISTANCE PROGRAM:
(1) THE COUNTY OR NONPUBLIC NURSING FACILITY SHALL
DEMONSTRATE ON ITS SUBMITTED MA-11 THAT SEVENTY PERCENT OF ITS
TOTAL COSTS, AS REPORTED BY THE FACILITY, ARE RESIDENT CARE
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COSTS OR OTHER RESIDENT-RELATED COSTS UNDER 55 PA. CODE §
1187.51(E)(1) AND (2) (RELATING TO SCOPE).
(2) EXCEPT AS PROVIDED UNDER PARAGRAPH (3), THE DEPARTMENT
SHALL USE THE FOLLOWING METHODOLOGY TO DETERMINE THE FACILITY'S
COMPLIANCE WITH PARAGRAPH (1):
(I) ADD THE FACILITY'S UNALLOCATED TOTAL NET OPERATING COSTS
REPORTED AS TOTAL EXPENSES ON THE FACILITY'S SCHEDULE C OF THE
MA-11, PLUS THE FOLLOWING CAPITAL COSTS REPORTED BY THE FACILITY
ON ITS SCHEDULE C, TO DETERMINE THE FACILITY'S TOTAL COSTS:
(A) REAL ESTATE TAXES.
(B) NURSING FACILITY ASSESSMENT/HAI ASSESSMENT.
(C) DEPRECIATION.
(D) INTEREST ON CAPITAL INDEBTEDNESS.
(E) RENT ON FACILITY.
(F) AMORTIZATION CAPITAL COSTS.
(II) ADD THE FACILITY'S UNALLOCATED TOTAL RESIDENT CARE
COSTS REPORTED AS TOTAL EXPENSES ON THE FACILITY'S SCHEDULE C
AND THE UNALLOCATED TOTAL OTHER RESIDENT RELATED COSTS REPORTED
AS TOTAL EXPENSES ON THE FACILITY'S SCHEDULE C TO DETERMINE THE
FACILITY'S TOTAL RESIDENT COST OF CARE.
(III) DIVIDE THE FACILITY'S TOTAL RESIDENT COST OF CARE
UNDER SUBPARAGRAPH (II) BY THE FACILITY'S TOTAL COSTS UNDER
SUBPARAGRAPH (I) TO DETERMINE THE PERCENTAGE OF TOTAL COSTS
RELATED TO RESIDENT CARE COSTS AND OTHER RESIDENT-RELATED COSTS.
(3) WHEN A COUNTY OR NONPUBLIC NURSING FACILITY IS
AFFILIATED WITH A CONTINUING CARE RETIREMENT COMMUNITY, THE
FOLLOWING SHALL APPLY:
(I) THE FACILITY SHALL SUBMIT A SUPPLEMENTAL COST REPORT
FORM APPORTIONING THE CAPITAL COSTS RELATED TO THE NURSING
FACILITY, IN A FORM AND MANNER AS PRESCRIBED BY THE DEPARTMENT.
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(II) THE DEPARTMENT SHALL USE THE FOLLOWING METHODOLOGY TO
DETERMINE THE FACILITY'S COMPLIANCE WITH PARAGRAPH (1):
(A) ADD THE FACILITY'S UNALLOCATED TOTAL NET OPERATING COSTS
REPORTED AS TOTAL EXPENSES ON THE FACILITY'S SCHEDULE C OF THE
MA-11, PLUS THE FOLLOWING CAPITAL COSTS, REPORTED BY THE
FACILITY ON ITS SUPPLEMENTAL COST REPORT FORM UNDER SUBPARAGRAPH
(I), TO DETERMINE THE FACILITY'S TOTAL COSTS:
(I) REAL ESTATE TAXES.
(II) NURSING FACILITY ASSESSMENT/HAI ASSESSMENT.
(III) DEPRECIATION.
(IV) INTEREST ON CAPITAL INDEBTEDNESS.
(V) RENT ON FACILITY.
(VI) AMORTIZATION CAPITAL COSTS.
(B) ADD THE FACILITY'S UNALLOCATED TOTAL RESIDENT CARE COSTS
REPORTED AS TOTAL EXPENSES ON THE FACILITY'S SCHEDULE C AND THE
UNALLOCATED TOTAL OTHER RESIDENT RELATED COSTS REPORTED AS TOTAL
EXPENSES ON THE FACILITY'S SCHEDULE C TO DETERMINE THE
FACILITY'S TOTAL RESIDENT COST OF CARE.
(C) DIVIDE THE FACILITY'S TOTAL RESIDENT COST OF CARE UNDER
CLAUSE (B) BY THE FACILITY'S TOTAL COSTS UNDER CLAUSE (A) TO
DETERMINE THE PERCENTAGE OF TOTAL COSTS RELATED TO RESIDENT CARE
AND OTHER RESIDENT-RELATED COSTS.
(B) (1) IF IN ANY TWELVE-MONTH COST-REPORTING PERIOD A
COUNTY OR NONPUBLIC NURSING FACILITY ENROLLED IN THE MEDICAL
ASSISTANCE PROGRAM FAILS TO MEET THE RESIDENT CARE PERCENTAGE
UNDER SUBSECTION (A)(1), THE DEPARTMENT MAY IMPOSE A PENALTY ON
THE FACILITY UP TO THE DIFFERENCE BETWEEN THE SEVENTY PERCENT OF
TOTAL COSTS REQUIREMENT UNDER PARAGRAPH (2) AND THE PERCENTAGE
SPENT BY THE FACILITY ON RESIDENT CARE COSTS OR OTHER RESIDENT-
RELATED COSTS, BUT NO MORE THAN FIVE PERCENT.
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(2) THE FORMULA FOR DETERMINING THE MAXIMUM PENALTY AMOUNT
IS AS FOLLOWS:
(I) DETERMINE THE PERCENTAGE DIFFERENCE FROM THE SEVENTY
PERCENT RESIDENT CARE REQUIREMENT BY SUBTRACTING THE PERCENTAGE
OF TOTAL COSTS RELATED TO RESIDENT CARE AND OTHER RESIDENT-
RELATED COSTS UNDER SUBSECTION (A)(2)(III) OR (3)(II)(C) FROM
SEVENTY PERCENT.
(II) DETERMINE THE PENALTY AMOUNT AS FOLLOWS:
(A) USE THE LESSER OF THE FOLLOWING:
(I) FIVE.
(II) THE DIFFERENCE UNDER SUBPARAGRAPH (I).
(B) MULTIPLY THE LOWEST NUMERAL UNDER CLAUSE (A) BY ONE
HUNDREDTH (.01).
(C) MULTIPLY THE PRODUCT UNDER CLAUSE (B) BY THE COUNTY OR
NONPUBLIC NURSING FACILITY'S FEE-FOR-SERVICE PER DIEM PAYMENT
RATE AS OF JUNE 30, 2022.
(D) MULTIPLY THE PRODUCT UNDER CLAUSE (C) BY THE TOTAL MA
RESIDENT DAYS OF CARE ON THE FACILITY'S MA-11.
(3) A PENALTY IMPOSED UNDER THIS SECTION SHALL BE
TRANSMITTED BY THE FACILITY TO THE DEPARTMENT FOR DEPOSIT IN THE
NURSING FACILITY QUALITY IMPROVEMENT FUND, ESTABLISHED UNDER
SUBSECTION (C).
(4) THE DEPARTMENT SHALL ENFORCE THE PENALTY PROVISIONS
UNDER THIS SUBSECTION AGAINST FULL TWELVE-MONTH COST REPORTS
WITH REPORTING PERIODS THAT BEGIN ON OR AFTER JANUARY 1, 2023,
AFTER MAKING THE FIRST PAYMENT OF THE INCREASED COUNTY AND
NONPUBLIC NURSING FACILITY RATES, UNDER BOTH THE FEE-FOR-SERVICE
PROGRAM AND THE COMMUNITY HEALTHCHOICES PROGRAM, BEGINNING
JANUARY 1, 2023. IF THE FIRST PAYMENT OF THE INCREASED COUNTY
AND NONPUBLIC NURSING FACILITY RATES, INCLUDING PAYMENTS UNDER
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BOTH THE FEE-FOR-SERVICE PROGRAM AND THE COMMUNITY HEALTHCHOICES
PROGRAM, IS AFTER JUNE 30, 2023, THE ENFORCEMENT OF THE PENALTY
PROVISIONS OF THIS SUBSECTION SHALL COMMENCE WITH THE FIRST FULL
TWELVE-MONTH COST REPORT AFTER PAYMENT OF THE INCREASED COUNTY
AND NONPUBLIC NURSING FACILITY RATES.
(5) PARAGRAPH (4) SHALL EXPIRE DECEMBER 31, 2025.
(C) (1) THE NURSING FACILITY QUALITY IMPROVEMENT FUND IS
ESTABLISHED AS A SEPARATE FUND IN THE STATE TREASURY AND SHALL
BE ADMINISTERED BY THE DEPARTMENT.
(2) ALL INTEREST EARNED FROM THE INVESTMENT OR DEPOSIT OF
MONEYS ACCUMULATED IN THE FUND SHALL BE DEPOSITED INTO THE FUND
FOR THE SAME USE.
(3) MONEYS IN THE FUND SHALL BE EXPENDED BY THE DEPARTMENT
FOR THE FOLLOWING PURPOSES:
(I) TO ADMINISTER AND ENFORCE THIS SECTION.
(II) TO PROVIDE FUNDING FOR NURSING FACILITY QUALITY
IMPROVEMENT.
(D) THE DEPARTMENT MAY PROMULGATE GUIDELINES, AS NECESSARY,
TO IMPLEMENT THIS SECTION. THE GUIDELINES SHALL BE TRANSMITTED
TO THE LEGISLATIVE REFERENCE BUREAU FOR PUBLICATION IN THE
PENNSYLVANIA BULLETIN. PRIOR TO PUBLICATION OF THE GUIDELINES,
THE DEPARTMENT SHALL CONSULT INTERESTED PARTIES. THE GUIDELINES
UNDER THIS SECTION SHALL NOT BE SUBJECT TO:
(1) SECTIONS 201, 202, 203, 204 AND 205 OF THE ACT OF JULY
31, 1968 (P.L.769, NO.240), REFERRED TO AS THE COMMONWEALTH
DOCUMENTS LAW.
(2) SECTIONS 204(B) AND 301(10) OF THE ACT OF OCTOBER 15,
1980 (P.L.950, NO.164), KNOWN AS THE "COMMONWEALTH ATTORNEYS
ACT."
(3) THE ACT OF JUNE 25, 1982 (P.L.633, NO.181), KNOWN AS THE
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"REGULATORY REVIEW ACT."
(E) AS USED IN THIS SECTION, THE FOLLOWING WORDS AND PHRASES
SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SUBSECTION UNLESS
THE CONTEXT CLEARLY INDICATES OTHERWISE:
"HAI" MEANS HOSPITAL ACQUIRED INFECTION.
"MA-11" MEANS THE MEDICAL ASSISTANCE FINANCIAL AND
STATISTICAL REPORT FOR NURSING FACILITIES AND SERVICES SUBMITTED
TO THE DEPARTMENT BY EITHER A COUNTY NURSING FACILITY OR A
NONPUBLIC NURSING FACILITY FOR A TWELVE-MONTH COST REPORT
PERIOD.
"SCHEDULE C" MEANS THE COMPUTATION AND ALLOCATION OF
ALLOWABLE COSTS SCHEDULE.
"TOTAL MA RESIDENT DAYS OF CARE" MEANS THE NURSING FACILITY
MA FEE-FOR-SERVICE DAYS OF CARE AND THE NURSING FACILITY MA
COMMUNITY HEALTHCHOICES DAYS OF CARE, AS REPORTED ON THE MA-11.
SECTION 449.2. PHARMACY BENEFITS MANAGER AUDIT AND
OBLIGATIONS.--(A) THE DEPARTMENT OF THE AUDITOR GENERAL MAY
CONDUCT AN AUDIT AND REVIEW OF A PHARMACY BENEFITS MANAGER THAT
PROVIDES PHARMACY BENEFITS MANAGEMENT TO A MEDICAL ASSISTANCE
MANAGED CARE ORGANIZATION UNDER CONTRACT WITH THE DEPARTMENT.
THE DEPARTMENT OF THE AUDITOR GENERAL MAY REVIEW ALL PREVIOUS
AUDITS COMPLETED BY THE DEPARTMENT AND SHALL HAVE ACCESS TO ALL
DOCUMENTS IT DEEMS NECESSARY TO COMPLETE THE REVIEW AND AUDIT.
(B) INFORMATION DISCLOSED OR PRODUCED BY A PHARMACY BENEFITS
MANAGER OR A MEDICAL ASSISTANCE MANAGED CARE ORGANIZATION FOR
THE USE OF THE DEPARTMENT OR THE DEPARTMENT OF THE AUDITOR
GENERAL UNDER THIS SECTION SHALL NOT BE SUBJECT TO THE ACT OF
FEBRUARY 14, 2008 (P.L.6, NO.3), KNOWN AS THE "RIGHT-TO-KNOW
LAW."
(C) AS USED IN THIS SECTION, THE FOLLOWING WORDS AND PHRASES
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SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SUBSECTION:
"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.
"PHARMACY BENEFITS MANAGEMENT" MEANS ANY OF THE FOLLOWING:
(1) PROCUREMENT OF PRESCRIPTION DRUGS AT A NEGOTIATED
CONTRACTED RATE FOR DISTRIBUTION WITHIN THIS COMMONWEALTH TO
COVERED INDIVIDUALS.
(2) ADMINISTRATION OR MANAGEMENT OF PRESCRIPTION DRUG
BENEFITS PROVIDED BY A COVERED ENTITY FOR THE BENEFIT OF COVERED
INDIVIDUALS.
(3) ADMINISTRATION OF PHARMACY BENEFITS, INCLUDING:
(I) OPERATING A MAIL-SERVICE PHARMACY.
(II) CLAIMS PROCESSING.
(III) MANAGING A RETAIL PHARMACY NETWORK MANAGEMENT.
(IV) PAYING CLAIMS TO PHARMACIES FOR PRESCRIPTION DRUGS
DISPENSED TO COVERED INDIVIDUALS BY A RETAIL, SPECIALTY OR MAIL-
ORDER PHARMACY.
(V) DEVELOPING AND MANAGING A CLINICAL FORMULARY,
UTILIZATION MANAGEMENT AND QUALITY ASSURANCE PROGRAMS.
(VI) REBATE CONTRACTING AND ADMINISTRATION.
(VII) MANAGING A PATIENT COMPLIANCE, THERAPEUTIC
INTERVENTION AND GENERIC SUBSTITUTION PROGRAM.
(VIII) OPERATING A DISEASE MANAGEMENT PROGRAM.
(IX) SETTING PHARMACY REIMBURSEMENT PRICING AND
METHODOLOGIES, INCLUDING MAXIMUM ALLOWABLE COST, AND DETERMINING
SINGLE OR MULTIPLE SOURCE DRUGS.
"PHARMACY BENEFITS MANAGER" MEANS A PERSON, BUSINESS OR OTHER
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ENTITY THAT PERFORMS PHARMACY BENEFITS MANAGEMENT. THE TERM
SHALL INCLUDE AN AFFILIATED OWNERSHIP OF A MEDICAL ASSISTANCE
MANAGED CARE ORGANIZATION THAT PERFORMS PHARMACY BENEFITS
MANAGEMENT.
SECTION 5. SECTION 602(A), (B) AND (C) OF THE ACT ARE
AMENDED TO READ:
SECTION 602. LIFE PROGRAM.--(A) INFORMATIONAL MATERIALS AND
DEPARTMENT CORRESPONDENCE USED BY THE DEPARTMENT AND THE
INDEPENDENT ENROLLMENT BROKER TO EDUCATE OR NOTIFY AN ELIGIBLE
INDIVIDUAL ABOUT LONG-TERM CARE SERVICES AND SUPPORTS, INCLUDING
AN INDIVIDUAL'S RIGHTS, RESPONSIBILITIES AND CHOICE OF MANAGED
CARE ORGANIZATION TO COVER LONG-TERM CARE SERVICES AND SUPPORTS,
SHALL INCLUDE THE FOLLOWING:
(1) A DESCRIPTION OF THE LIFE PROGRAM.
(2) A STATEMENT THAT AN ELIGIBLE INDIVIDUAL HAS THE OPTION
TO ENROLL IN THE LIFE PROGRAM OR A MANAGED CARE ORGANIZATION
UNDER THE COMMUNITY HEALTH CHOICES PROGRAM.
(3) CONTACT INFORMATION FOR LIFE PROVIDERS.
(B) THE DEPARTMENT SHALL CONTINUE TO PROVIDE TRAINING TO THE
INDEPENDENT ENROLLMENT BROKER ON THE LIFE PROGRAM THROUGH THE
INDEPENDENT ENROLLMENT BROKER LIFE MODULE TO BETTER EDUCATE THE
INDEPENDENT ENROLLMENT BROKER AND TO REQUIRE THAT THE LIFE
PROGRAM IS OFFERED EQUALLY TO ELIGIBLE INDIVIDUALS.
(C) AT THE END OF EACH QUARTER, THE DEPARTMENT SHALL ISSUE A
REPORT TO THE CHAIRPERSON AND MINORITY CHAIRPERSON OF THE HEALTH
AND HUMAN SERVICES COMMITTEE OF THE SENATE AND THE CHAIRPERSON
AND MINORITY CHAIRPERSON OF THE HUMAN SERVICES COMMITTEE OF THE
HOUSE OF REPRESENTATIVES THAT TRACKS BY COUNTY THE ENROLLMENT OF
ELIGIBLE INDIVIDUALS IN LONG-TERM CARE SERVICE PROGRAMS BY THE
INDEPENDENT ENROLLMENT BROKER, INCLUDING MANAGED CARE
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ORGANIZATIONS AND LIFE PROGRAMS. THE REPORT SHALL ALSO INCLUDE
DOCUMENTATION OF COMPLIANCE WITH SUBSECTIONS (A) AND (B).
* * *
SECTION 6. THE ACT IS AMENDED BY ADDING A SECTION TO READ:
SECTION 603. AGENCY WITH CHOICE.--THE DEPARTMENT SHALL NOT
ADMINISTER OR CONTRACT WITH A SINGLE STATEWIDE ENTITY TO
ADMINISTER THE AGENCY WITH CHOICE FINANCIAL MANAGEMENT SERVICES
MODEL OF SERVICE DELIVERY TO BENEFICIARIES OF PROGRAMS
ADMINISTERED BY THE OFFICE OF LONG-TERM LIVING FOR AT LEAST
TWELVE MONTHS FOLLOWING THE EFFECTIVE DATE OF THIS SECTION.
SECTION 7. SECTION 709.3 OF THE ACT IS AMENDED BY ADDING A
SUBSECTION TO READ:
SECTION 709.3. LIMITS ON REIMBURSEMENTS TO COUNTIES.--* * *
(F) MONEY APPROPRIATED FOR COMMUNITY-BASED FAMILY CENTERS
MAY NOT BE CONSIDERED AS PART OF THE BASE FOR CALCULATION OF A
COUNTY'S CHILD WELFARE NEEDS-BASED BUDGET FOR A FISCAL YEAR.
SECTION 8. SECTIONS 815-A AND 803-I(B) OF THE ACT ARE
AMENDED TO READ:
SECTION 815-A. TIME PERIODS.--THE ASSESSMENT AUTHORIZED IN
THIS ARTICLE SHALL BE IMPOSED JULY 1, 2003, THROUGH JUNE 30,
[2022] 2026.
SECTION 803-I. ASSESSMENT AMOUNT.
* * *
(B) FIXED FEE.--[BEGINNING JULY 1, 2016, AND ENDING JUNE 30,
2020] EXCEPT AS PROVIDED UNDER SUBSECTIONS (C) AND (D), THE
MANAGED CARE ORGANIZATION SHALL BE ASSESSED A FIXED FEE OF
[$13.48] $24.95 FOR EACH UNDUPLICATED MEMBER FOR EACH MONTH THE
MEMBER IS ENROLLED FOR ANY PERIOD OF TIME WITH THE MANAGED CARE
ORGANIZATION BEGINNING JULY 1, 2020, AND ENDING JUNE 30, 2025.
* * *
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SECTION 9. THE ACT IS AMENDED BY ADDING AN ARTICLE TO READ:
ARTICLE VIII-J
INNOVATIVE HEALTH CARE DELIVERY MODELS
SECTION 801-J. REQUIRED CRITERIA FOR OPERATION OF OED.
(A) REQUIREMENTS OF AN OED.--AN ELIGIBLE PROVIDER LOCATION
FOR MEDICAL ASSISTANCE REIMBURSEMENT THAT INTENDS TO OPERATE AN
OED SHALL MEET THE FOLLOWING CRITERIA:
(1) THE MAIN LICENSED HOSPITAL OF AN OED SHALL OFFER
GENERAL ACUTE CARE SERVICES.
(2) THE OED SHALL BE INCLUDED AS AN OUTPATIENT LOCATION
UNDER THE LICENSE OF THE HOSPITAL AND LOCATED WITHIN A
THIRTY-FIVE-MILE RADIUS OF THE MAIN LICENSED HOSPITAL.
(3) AT THE TIME THE OED BEGINS OPERATING, THE OED SHALL
HAVE A CATCHMENT AREA THAT IS NO LESS THAN THIRTY-FIVE MILES
OF TRAVEL DISTANCE ESTABLISHED BY ROADWAYS TO A MAIN LICENSED
HOSPITAL OR A CAMPUS THAT OFFERS EMERGENCY SERVICES AND IS
NOT UNDER COMMON LEGAL OWNERSHIP WITH THE OED OR ANOTHER OED
THAT IS NOT UNDER COMMON LEGAL OWNERSHIP.
(4) THE HOSPITAL SHALL CONTINUE TO MEET THE STATUTORY
DEFINITION OF A "HOSPITAL" AS DEFINED IN SECTION 802.1 OF THE
ACT OF JULY 19, 1979 (P.L.130, NO.48), KNOWN AS THE "HEALTH
CARE FACILITIES ACT."
(5) THE HOSPITAL, INCLUDING THE OED, SHALL MAINTAIN FULL
OR SUBSTANTIAL COMPLIANCE WITH THE PROVISIONS OF 28 PA. CODE
PT. IV SUBPT. B (RELATING TO GENERAL AND SPECIAL HOSPITALS).
(B) DEFINITIONS.--AS USED IN THIS SECTION, THE FOLLOWING
WORDS AND PHRASES SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS
SUBSECTION UNLESS THE CONTEXT CLEARLY INDICATES OTHERWISE:
"CAMPUS" MEANS A CLINICAL FACILITY THAT OFFERS INPATIENT
SERVICES AND IS INCLUDED UNDER THE LICENSE OF THE MAIN LICENSED
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HOSPITAL BUT NOT LOCATED ON THE GROUNDS OF THE MAIN LICENSED
HOSPITAL.
"CATCHMENT AREA" MEANS THE AREA SURROUNDING AN OED.
"HOSPITAL" MEANS THE MAIN LICENSED HOSPITAL, ITS CAMPUSES AND
OUTPATIENT LOCATIONS, UNDER COMMON LEGAL OWNERSHIP.
"MAIN LICENSED HOSPITAL OF THE OED" MEANS THE LOCATION WHERE
A HOSPITAL LICENSE IS HELD.
"OUTPATIENT EMERGENCY DEPARTMENT" OR "OED" MEANS AN
OUTPATIENT LOCATION OF A HOSPITAL UNDER COMMON LEGAL OWNERSHIP
THAT OFFERS EMERGENCY SERVICES AND IS NOT LOCATED ON THE GROUNDS
OF THE MAIN LICENSED HOSPITAL.
"OUTPATIENT LOCATION" MEANS A LOCATION OFFERING ONLY
OUTPATIENT SERVICES THAT ARE INCLUDED UNDER THE LICENSE OF A
MAIN LICENSED HOSPITAL BUT NOT LOCATED ON THE GROUNDS OF THE
MAIN LICENSED HOSPITAL.
SECTION 10. REGULATIONS ARE ABROGATED AS FOLLOWS:
(1) THE FOLLOWING PROVISIONS OF 55 PA. CODE ARE
ABROGATED:
(I) SECTION 1153.14(1) (RELATING TO NONCOVERED
SERVICES).
(II) SECTION 1223.14(2) (RELATING TO NONCOVERED
SERVICES).
(III) SECTION 5230.55(C) (RELATING TO SUPERVISION)
TO THE EXTENT THAT IT REQUIRES A FACE-TO-FACE MEETING.
(IV) SECTION 1121.53(C) (RELATING TO LIMITATIONS ON
PAYMENT) TO THE EXTENT THAT PAYMENT FOR PRESCRIPTIONS IS
LIMITED TO A 34-DAY SUPPLY OR 100 UNITS.
(V) TO THE EXTENT PERMITTED UNDER FEDERAL LAW:
(A) SECTION 1123.2 (RELATING TO DEFINITIONS) TO
THE EXTENT THAT THE DEFINITION OF "SHOE INSERTS"
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LIMITS THE PRESCRIPTIONS FOR AN ORTHOTIC DEVICE TO A
PRESCRIPTION FROM A PHYSICIAN.
(B) SECTION 1249.52(A)(1) (RELATING TO PAYMENT
CONDITIONS FOR VARIOUS SERVICES) AND SECTION
1249.53(A)(1) (RELATING TO PAYMENT CONDITIONS FOR
SKILLED NURSING CARE) TO THE EXTENT THAT HOME HEALTH
SERVICES ARE ONLY COVERED AND REIMBURSABLE UNDER THE
MEDICAL ASSISTANCE PROGRAM IF A PHYSICIAN ORDERS THE
SERVICES AND ESTABLISHES THE PLAN OF TREATMENT.
(C) SECTION 1249.54(A)(3) (RELATING TO PAYMENT
CONDITIONS FOR HOME HEALTH AIDE SERVICES) TO THE
EXTENT THAT A HOME HEALTH AIDE SERVICE IS ONLY
COVERED AND REIMBURSABLE UNDER THE MEDICAL ASSISTANCE
PROGRAM IF A PHYSICIAN ESTABLISHES THE WRITTEN PLAN
OF TREATMENT AND, IF SKILLED CARE IS NOT REQUIRED,
CERTIFIES THAT THE PERSONAL CARE SERVICES ARE
MEDICALLY NECESSARY.
(D) SECTION 1249.55(A) (RELATING TO PAYMENT
CONDITIONS FOR MEDICAL SUPPLIES) TO THE EXTENT
SUPPLIES MAY ONLY BE REIMBURSED IF PRESCRIBED BY A
PHYSICIAN.
(2) THE FOLLOWING PROVISIONS OF 55 PA. CODE, RELATING TO
PHYSICIAN OR CERTIFIED REGISTERED NURSE PRACTITIONER
NOTIFICATION REQUIREMENTS, ARE ABROGATED TO THE EXTENT THEY
APPLY TO INDIVIDUALS WITH SYMPTOMS OF COVID-19:
(I) SECTION 3270.137 (RELATING TO CHILDREN WITH
SYMPTOMS OF DISEASE).
(II) SECTION 3270.153 (RELATING TO FACILITY PERSONS
WITH SYMPTOMS OF DISEASE).
(III) SECTION 3280.137 (RELATING TO CHILDREN WITH
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SYMPTOMS OF DISEASE).
(IV) SECTION 3280.153 (RELATING TO FACILITY PERSONS
WITH SYMPTOMS OF DISEASE).
(V) SECTION 3290.137 (RELATING TO CHILDREN WITH
SYMPTOMS OF DISEASE).
(VI) SECTION 3290.153 (RELATING TO FACILITY PERSONS
WITH SYMPTOMS OF DISEASE).
SECTION 11. REPEALS ARE AS FOLLOWS:
(1) THE GENERAL ASSEMBLY DECLARES THAT THE REPEAL UNDER
PARAGRAPH (2) IS NECESSARY TO EFFECTUATE THE AMENDMENT OF
SECTION 803-I(B) OF THE ACT.
(2) SECTION 1601-O OF THE ACT OF APRIL 9, 1929 (P.L.343,
NO.176), KNOWN AS THE FISCAL CODE, IS REPEALED.
SECTION 12. THE AMENDMENT OF SECTION 803-I(B) OF THE ACT IS
A CONTINUATION OF SECTION 1601-O OF THE ACT OF APRIL 9, 1929
(P.L.343, NO.176), KNOWN AS THE FISCAL CODE. EXCEPT AS OTHERWISE
PROVIDED IN THE AMENDMENT OF SECTION 803-I(B) OF THE ACT, ALL
ACTIVITIES INITIATED UNDER SECTION 1601-O OF THE FISCAL CODE
SHALL CONTINUE AND REMAIN IN FULL FORCE AND EFFECT AND MAY BE
COMPLETED UNDER THE AMENDMENT OF SECTION 803-I(B) OF THE ACT.
ORDERS, REGULATIONS, RULES AND DECISIONS WHICH WERE MADE UNDER
SECTION 1601-O OF THE FISCAL CODE AND WHICH ARE IN EFFECT ON THE
EFFECTIVE DATE OF THIS SECTION SHALL REMAIN IN FULL FORCE AND
EFFECT UNTIL REVOKED, VACATED OR MODIFIED UNDER THE AMENDMENT OF
SECTION 803-I(B) OF THE ACT. CONTRACTS, OBLIGATIONS AND
COLLECTIVE BARGAINING AGREEMENTS ENTERED INTO UNDER SECTION
1601-O OF THE FISCAL CODE ARE NOT AFFECTED NOR IMPAIRED BY THE
REPEAL OF SECTION 1601-O OF THE FISCAL CODE.
SECTION 13. THE AMENDMENT OF SECTIONS 443.1(7)(IV) AND 815-A
OF THE ACT SHALL APPLY RETROACTIVE TO JUNE 29, 2022.
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Section 2 14. This act shall take effect immediately.
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