PRINTER'S NO. 1161
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1105
Session of
2023
INTRODUCED BY SCIALABBA, KUTZ, ROWE AND GROVE, MAY 5, 2023
REFERRED TO COMMITTEE ON HUMAN SERVICES, MAY 5, 2023
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 prohibition on medical assistance managed care
payment for provider-preventable conditions.
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 449.3. Prohibition on Medical Assistance Managed
Care Payment for Provider-Preventable Conditions.--(a) A
medical assistance managed care organization may not pay for
provider-preventable conditions.
(b) As used in this section, the following words and phrases
shall have the meanings given to them in this subsection:
"Medical assistance managed care organization" means a
Medicaid managed care organization as defined under 42 U.S.C. ยง
1396b(m)(1)(A) (relating to payment to states) that is a party
to a Medicaid managed care agreement with the department to
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provide physical or behavioral health services on a capitated
basis.
"Provider-preventable conditions" shall:
(1) Include the term as defined in 42 CFR 447.26 (relating
to prohibition on payment for provider-preventable conditions).
(2) Mean any conditions occurring in a health care setting
that meet the following criteria:
(i) is identified in the State plan in line with the fee-
for-service model;
(ii) has been found by the Commonwealth, based upon a review
of medical literature by qualified professionals, to be
reasonably preventable through the application of procedures
supported by evidence-based guidelines;
(iii) has a negative consequence for the patient;
(iv) is auditable; and
(v) includes, at a minimum, any of the following:
(A) a wrong surgical or other invasive procedure performed
on a patient;
(B) a surgical or other invasive procedure performed on the
wrong body part; or
(C) a surgical or other invasive procedure performed on the
wrong patient.
Section 2. This act shall take effect in 60 days.
20230HB1105PN1161 - 2 -
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