Regular Session 2019-2020 House Bill 2876 P.N. 4405

PRINTER'S NO. 4405

THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

No.

2876

Session of

2020

INTRODUCED BY GROVE, SEPTEMBER 23, 2020

REFERRED TO COMMITTEE ON HEALTH, SEPTEMBER 23, 2020

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 Human Services, further providing

for State participation in cooperative Federal programs; in

public assistance, further providing for income for the

community spouse, for medical assistance payments for

institutional care, for medical assistance payments for home

health care, for other medical assistance payments and for

medical assistance benefit packages and coverage, copayments,

premiums and rates; providing for the Office of Independent

Medical Assistance Director; and making an editorial change.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1. Article II heading and sections 201 and 441.7(a)

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

Services Code, are amended to read:

ARTICLE II

GENERAL POWERS AND DUTIES

OF THE DEPARTMENT OF [PUBLIC WELFARE] HUMAN SERVICES

Section 201. State Participation in Cooperative Federal

Programs.--The department, including through the Office of

Independent Medical Assistance Director, shall have the power

and its duties shall be:

(1) With the approval of the Governor, to act as the sole

agency of the State when applying for, receiving and using

Federal funds for the financing in whole or in part of programs

in fields in which the department has responsibility.

(2) With the approval of the Governor, to develop and submit

State plans or other proposals to the Federal [government,]

Government, except as where limited under paragraph (2.1), to

promulgate regulations, establish and enforce standards and to

take such other measures as may be necessary to render the

Commonwealth eligible for available Federal funds or other

assistance. Notwithstanding anything to the contrary in the act

of July 31, 1968 (P.L.769, No.240), referred to as the

Commonwealth Documents Law, the department may omit notice of

proposed rulemaking and promulgate regulations as final when a

delay of thirty days or less in the final adoption of

regulations will result in the loss of Federal funds or when a

delay of thirty days or less in adoption would require the

replacement of Federal funds with State funds.

(2.1) To develop and submit State plans or other proposals

to the Federal Government for medical assistance through the

Independent Office of Medical Assistance Director, to promulgate

regulations, establish and enforce standards and take other

measures as may be necessary to render the Commonwealth eligible

for available Federal funds or other assistance. Notwithstanding

any provision to the contrary in the act of July 31, 1968

(P.L.769, No.240), referred to as the Commonwealth Documents

Law, the department may omit notice of proposed rulemaking and

promulgate regulations as final when a delay of thirty days or

less in the final adoption of regulations will result in the

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loss of Federal funds or when a delay of thirty days or less in

adoption would require the replacement of Federal funds with

State funds.

(3) To make surveys and inventories of existing facilities

and services as required in connection with such State plans,

and to assess the need for construction, modernization or

additional services and to determine priorities with respect

thereto.

(4) To conduct investigations of activities related to

fraud, misuse or theft of public assistance moneys[, medical

assistance moneys or benefits,] or Federal food stamps,

committed by any person who is or has been participating in or

administering programs of the department, or by persons who aid

or abet others in the commission of fraudulent acts affecting

welfare programs.

(4.1) To conduct investigations of activities related to

fraud, misuse or theft of medical assistance moneys or benefit

through the Office of Independent Medical Assistance Director by

a person who is or has been participating in or administering

medical assistance programs or by a person who aids or abets

others in the commission of fraudulent acts affecting medical

assistance.

(5) To collect data on its programs and services, including

efforts aimed at preventative health care, to provide [the

General Assembly with adequate information] to the Office of

Independent Medical Assistance Director, who will compile the

data for use by the General Assembly to determine the most cost-

effective allocation of resources in the medical assistance

program.

(6) To submit on [a biannual] an annual basis a report

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prepared by the Office of Independent Medical Assistance

Director to the General Assembly regarding the medical

assistance population, which shall include aggregate figures,

delineated on a monthly basis, for the number of individuals to

whom services were provided, the type and incidence of services

provided by procedure and the cost per service as well as total

expenditures by service.

Section 441.7. Income for the Community Spouse.--(a) When a

community spouse has income below the monthly maintenance needs

allowance as determined under the [department's] regulations

[and] adopted by the Office of Independent Medical Assistance

Director for the Commonwealth approved State plan under Title

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

et seq.), the institutionalized spouse may transfer additional

resources to the community spouse only in accordance with this

section.

* * *

Section 2. Sections 443.1, 443.2, 443.3 and 454(a) and (c)

of the act are amended 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:

(1) Payments as determined by the [department] Office of

Independent Medical Assistance Director for inpatient hospital

care consistent with Title XIX of the Social Security Act (49

Stat. 620, 42 U.S.C. § 1396 et seq.). To be eligible for such

payments, a hospital must be qualified to participate under

Title XIX of the Social Security Act and have entered into a

written agreement with the [department] Office of Independent

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Medical Assistance Director regarding matters designated by the

secretary as necessary to efficient administration, such as

hospital utilization, maintenance of proper cost accounting

records and access to patients' records. Such efficient

administration shall require the [department] Office of

Independent Medical Assistance Director to permit participating

hospitals to utilize the same fiscal intermediary for this Title

XIX program as such hospitals use for the Title XVIII program.

(1.1) Subject to section 813-G, for inpatient hospital

services provided during a fiscal year in which an assessment is

imposed under Article VIII-G, payments under the medical

assistance fee-for-service program shall be determined in

accordance with the [department's] regulations adopted by the

Office of Independent Medical Assistance Director , except as

follows:

(i) If the Commonwealth's approved Title XIX State Plan for

inpatient hospital services in effect for the period of July 1,

2010, through June 30, 2018, specifies a methodology for

calculating payments that is different from the department's

regulations or authorizes additional payments not specified in

the department's regulations, such as inpatient disproportionate

share payments and direct medical education payments, the

department shall follow the methodology or make the additional

payments as specified in the approved Title XIX State Plan.

(ii) Subject to Federal approval of an amendment to the

Commonwealth's approved Title XIX State Plan, in making medical

assistance fee-for-service payments to acute care hospitals for

inpatient services provided on or after July 1, 2010, the

[department] Office of Independent Medical Assistance Director

shall use payment methods and standards that provide for all of

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the following:

(A) Use of the All Patient Refined-Diagnosis Related Group

(APR/DRG) system for the classification of inpatient stays into

DRGs.

(B) Calculation of base DRG rates, based upon a Statewide

average cost, which are adjusted to account for a hospital's

regional labor costs, teaching status, capital and medical

assistance patient levels and such other factors as the

[department] Office of Independent Medical Assistance Director

determines may significantly impact the costs that a hospital

incurs in delivering inpatient services and which may be

adjusted based on the assessment revenue collected under Article

VIII-G.

costs of the inpatient stays either exceed or are below cost

thresholds established by the [department] Office of

Independent Medical Assistance Director .

(iii) Notwithstanding subparagraph (i), the [department]

Office of Independent Medical Assistance Director may make

additional changes to its payment methods and standards for

inpatient hospital services consistent with Title XIX of the

Social Security Act, including changes to supplemental payments

currently authorized in the State plan based on the availability

of Federal and State funds.

(1.2) Subject to section 813-G, for inpatient acute care

hospital services provided under the physical health medical

assistance managed care program during State fiscal year 2010-

2011, the following shall apply:

(i) For inpatient hospital services provided under a

participation agreement between an inpatient acute care hospital

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and a medical assistance managed care organization in effect as

of June 30, 2010, the medical assistance managed care

organization shall pay, and the hospital shall accept as payment

in full, amounts determined in accordance with the payment terms

and rate methodology specified in the agreement and in effect as

of June 30, 2010, during the term of that participation

agreement. If a participation agreement in effect as of June 30,

2010, uses the [department] fee for service DRG rate methodology

in determining payment amounts, the medical assistance managed

care organization shall pay, and the hospital shall accept as

payment in full, amounts determined in accordance with the fee

for service payment methodology in effect as of June 30, 2010,

including, without limitation, continuation of the same grouper,

outlier methodology, base rates and relative weights, during the

term of that participation agreement.

(ii) Nothing in subparagraph (i) shall prohibit payment

rates for inpatient acute care hospital services provided under

a participation agreement to change from the rates in effect as

of June 30, 2010, if the change in payment rates is authorized

by the terms of the participation agreement between the

inpatient acute care hospital and the medical assistance managed

care organization. For purposes of this act, any contract

provision that provides that payment rates and changes to

payment rates shall be calculated based upon the department's

fee for service DRG payment methodology shall be interpreted to

mean the [department's] fee for service medical assistance DRG

methodology in place on June 30, 2010.

(iii) If a participation agreement between a hospital and a

medical assistance managed care organization terminates during a

fiscal year in which an assessment is imposed under Article

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VIII-G prior to the expiration of the term of the participation

agreement, payment for services, other than emergency services,

covered by the medical assistance managed care organization and

rendered by the hospital shall be made at the rate in effect as

of the termination date, as adjusted in accordance with

subparagraphs (i) and (ii), during the period in which the

participation agreement would have been in effect had the

agreement not terminated. The hospital shall receive the

supplemental payment in accordance with subparagraph (v).

(iv) If a hospital and a medical assistance managed care

organization do not have a participation agreement in effect as

of June 30, 2010, the medical assistance managed care

organization shall pay, and the hospital shall accept as payment

in full, for services, other than emergency services, covered by

the medical assistance managed care organization and rendered

during a fiscal year in which an assessment is imposed under

Article VIII-G, an amount equal to the rates payable for the

services by the medical assistance fee for service program as of

June 30, 2010. The hospital shall receive the supplemental

payment in accordance with subparagraph (v).

(v) The [department] Office of Independent Medical

Assistance Director shall make enhanced capitation payments to

medical assistance managed care organizations if necessary

exclusively for the purpose of making supplemental payments to

hospitals in order to promote continued access to quality care

for medical assistance recipients. Medical assistance managed

care organizations shall use the enhanced capitation payments

received pursuant to this section solely for the purpose of

making supplemental payments to hospitals and shall provide

documentation to the [department] Office of Independent Medical

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Assistance Director certifying that all funds received in this

manner are used in accordance with this section. The

supplemental payments to hospitals made pursuant to this

subsection are in lieu of increased or additional payments for

inpatient acute care services from medical assistance managed

care organizations resulting from the [department's] Office of

Independent Medical Assistance Director's implementation of

payments under paragraph (1.1)(ii). Medical assistance managed

care organizations shall in no event be obligated under this

section to make supplemental or other additional payments to

hospitals that exceed the enhanced capitation payments made to

the medical assistance managed care organization under this

section. Medical assistance managed care organizations shall not

be required to advance the supplemental payments to hospitals

authorized by this subsection and shall only make the

supplemental payments to hospitals once medical assistance

managed care organizations have received the enhanced capitation

payments from the [department] Office of Independent Medical

Assistance Director .

(vi) Nothing in this subsection shall prohibit an inpatient

acute care hospital and a medical assistance managed care

organization from executing a new participation agreement or

amending an existing participation agreement on or after July 1,

2010, in which they agree to payment terms that would result in

payments that are different than the payments determined in

accordance with subparagraphs (i), (ii), (iii) and (iv).

(1.3) Subject to section 813-G, the [department] Office of

Independent Medical Assistance Director may adjust its

capitation payments to medical assistance managed care

organizations under the physical health medical assistance

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managed care program during State fiscal year 2011-2012 to

provide additional funds for inpatient hospital services to

mitigate the impact, if any, to the managed care organizations

that may result from the changes to the [department's] Office of

Independent Medical Assistance Director's payment methods and

standards specified in paragraph (1.1)(ii). If the [department]

Office of Independent Medical Assistance Director adjusts a

medical assistance managed care organization's capitation

payments pursuant to this paragraph, the following shall apply:

(i) The medical assistance managed care organization shall

provide documentation to the [department] Office of Independent

Medical Assistance Director identifying how the additional funds

received pursuant to this subsection were used by the medical

assistance managed care organization.

(ii) If the medical assistance managed care organization

uses all of the additional funds received pursuant to this

subsection to make additional payments to hospitals, the

following shall apply:

(A) For inpatient hospital services provided under a

participation agreement between an inpatient acute care hospital

and the medical assistance managed care organization in effect

as of June 30, 2010, the medical assistance managed care

organization shall pay, and the hospital shall accept as payment

in full, amounts determined in accordance with the payment terms

and rate methodology specified in the agreement and in effect as

of June 30, 2010, during the term of that participation

agreement. If a participation agreement in effect as of June 30,

2010, uses the [department] fee-for-service DRG rate methodology

in determining payment amounts, the medical assistance managed

care organization shall pay, and the hospital shall accept as

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payment in full, amounts determined in accordance with the fee-

for-service payment methodology in effect as of June 30, 2010,

including, without limitation, continuation of the same grouper,

outlier methodology, base rates and relative weights during the

term of that participation agreement.

(B) Nothing in clause (A) shall prohibit payment rates for

inpatient acute care hospital services provided under a

participation agreement to change from the rates in effect as of

June 30, 2010, if the change in payment rates is authorized by

the terms of the participation agreement between the inpatient

acute care hospital and the medical assistance managed care

organization. For purposes of this act, any contract provision

that provides that payment rates and changes to payment rates

shall be calculated based upon the [department's] fee-for-

service DRG payment methodology shall be interpreted to mean the

department's fee-for-service medical assistance DRG methodology

in place on June 30, 2010.

enrolled in a medical assistance managed care organization that

occurs in State fiscal year 2011-2012, the medical assistance

managed care organization shall pay, and the hospital shall

accept as payment in full, the amount that the [department's]

fee-for-service program would have paid for the discharge if the

recipient were enrolled in the [department's] fee-for-service

program and the discharge occurred on June 30, 2010.

(D) Nothing in this subparagraph shall prohibit an inpatient

acute care hospital and a medical assistance managed care

organization from executing a new participation agreement or

amending an existing participation agreement on or after July 1,

2010, in which they agree to payment terms that would result in

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payments that are different from the payments determined in

accordance with clauses (A), (B) and (C).

(1.4) Subject to section 813-G, for inpatient hospital

services provided under the physical health medical assistance

managed care program during State fiscal years 2012-2013, 2013-

2014, 2014-2015, 2015-2016, 2016-2017 and 2017-2018, the

following shall apply:

(A) The [department] Office of Independent Medical

Assistance Director may adjust its capitation payments to

medical assistance managed care organizations to provide

additional funds for inpatient and outpatient hospital services.

(B) For an out-of-network inpatient discharge of a recipient

enrolled in a medical assistance managed care organization that

occurs in State fiscal year 2012-2013, 2013-2014, 2014-2015,

2015-2016, 2016-2017 and 2017-2018, the medical assistance

managed care organization shall pay, and the hospital shall

accept as payment in full, the amount that the [department's]

fee-for-service program would have paid for the discharge if the

recipient was enrolled in the [department's] fee-for-service

program.

acute care hospital and a medical assistance managed care

organization from executing a new participation agreement or

amending an existing participation agreement on or after July 1,

2013.

(1.5) As used in paragraphs (1.2), (1.3) and (1.4), the

following terms shall have the following meanings:

(i) "Emergency services" means emergency services as defined

in section 1932(b) of the Social Security Act (49 Stat. 620, 42

U.S.C. § 1396u-2(b)(2)(B)). The term shall not include

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poststabilization care services as defined in 42 CFR 438.114(a)

(1) (relating to emergency and poststabilization services).

(ii) "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] Office of Independent Medical

Assistance Director , other than a behavioral health managed care

organization that is a party to a medical assistance managed

care contract with the [department] Office of Independent

Medical Assistance Director .

(1.6) Notwithstanding any other provision of law or

departmental regulation to the contrary, the [department] Office

of Independent Medical Assistance Director shall make separate

fee-for-service APR/DRG payments for medically necessary

inpatient acute care general hospital services provided for

normal newborn care and for mothers' obstetrical delivery.

(2) The cost of skilled nursing and intermediate nursing

care in State-owned geriatric centers, institutions for the

mentally retarded, institutions for the mentally ill, and the

cost of skilled and intermediate nursing care provided prior to

June 30, 2004, in county homes which meet the State and Federal

requirements for participation under Title XIX of the Social

Security Act and which are approved by the [department] Office

of Independent Medical Assistance Director . This cost in county

homes shall be as specified by the regulations of the

[department] Office of Independent Medical Assistance Director

adopted under Title XIX of the Social Security Act and certified

to the department by the Auditor General; elsewhere the cost

shall be determined by the [department] Office of Independent

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Medical Assistance Director ;

(3) Rates on a cost-related basis established by the

department for skilled nursing home or intermediate care in a

non-public nursing home, when furnished by a nursing home

licensed or approved by the department and qualified to

participate under Title XIX of the Social Security Act and

provided prior to June 30, 2004;

(4) Payments as determined by the department for inpatient

psychiatric care consistent with Title XIX of the Social

Security Act. To be eligible for such payments, a hospital must

be qualified to participate under Title XIX of the Social

Security Act and have entered into a written agreement with the

department regarding matters designated by the secretary as

necessary to efficient administration, such as hospital

utilization, maintenance of proper cost accounting records and

access to patients' records. Care in a private mental hospital

provided under the fee for service delivery system shall be

limited to thirty days in any fiscal year for recipients aged

twenty-one years or older who are eligible for medical

assistance under Title XIX of the Social Security Act and for

recipients aged twenty-one years or older who are eligible for

general assistance-related medical assistance. Exceptions to the

thirty-day limit may be granted under section 443.3. Only

persons aged twenty-one years or under and aged sixty-five years

or older shall be eligible for care in a public mental hospital.

This cost shall be as specified by regulations of the

[department] Office of Independent Medical Assistance Director

adopted under Title XIX of the Social Security Act and certified

to the department by the Auditor General for county and non-

public institutions;

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(5) After June 30, 2004, and before June 30, 2007, payments

to county and nonpublic nursing facilities enrolled in the

medical assistance program as providers of nursing facility

services shall be calculated and made as specified in the

[department's] regulations in effect on July 1, 2003, except

that if the Commonwealth's approved Title XIX State Plan for

nursing facility services in effect for the period of July 1,

2004, through June 30, 2007, specifies a methodology for

calculating county and nonpublic nursing facility payment rates

that is different than the department's regulations in effect on

July 1, 2003, the [department] Office of Independent Medical

Assistance Director shall follow the methodology in the

Federally approved Title XIX State plan.

(6) For public nursing home care provided on or after July

1, 2005, the [department] Office of Independent Medical

Assistance Director may recognize the costs incurred by county

nursing facilities to provide services to eligible persons as

medical assistance program expenditures to the extent the costs

qualify for Federal matching funds and so long as the costs are

allowable as determined by the department and reported and

certified by the county nursing facilities in a form and manner

specified by the department. Expenditures reported and certified

by county nursing facilities shall be subject to periodic review

and verification by the department or the Auditor General.

Notwithstanding this paragraph, county nursing facilities shall

be paid based upon rates determined in accordance with

paragraphs (5) and (7).

(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

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accordance with the methodologies for establishing payment rates

for county and nonpublic nursing facilities specified in the

[department's] Office of Independent Medical Assistance

Director's regulations and the Commonwealth's approved Title XIX

State Plan for nursing facility services in effect after June

30, 2007. The following shall apply:

(i) For the fiscal year 2007-2008, the [department] Office

of Independent Medical Assistance Director shall apply a revenue

adjustment neutrality factor and make adjustments to county and

nonpublic nursing facility payment rates for medical assistance

nursing facility services. The revenue adjustment factor shall

limit the estimated aggregate increase in the Statewide day-

weighted average payment rate over the three-year period

commencing July 1, 2005, and ending June 30, 2008, from the

Statewide day-weighted average payment rate for medical

assistance nursing facility services in fiscal year 2004-2005 to

6.912% plus any percentage rate of increase permitted by the

amount of funds appropriated for nursing facility services in

the General Appropriation Act of 2007. Application of the

revenue adjustment neutrality factor shall be subject to Federal

approval of any amendments as may be necessary to the

Commonwealth's approved Title XIX State Plan for nursing

facility services.

(ii) The [department] Office of Independent Medical

Assistance Director may make additional changes to its

methodologies for establishing payment rates for county and

nonpublic nursing facilities enrolled in the medical assistance

program consistent with Title XIX of the Social Security Act,

except that if during a fiscal year an assessment is implemented

under Article VIII-A, the department shall not make a change

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under this subparagraph unless it adopts regulations as provided

under section 814-A.

(iii) Subject to Federal approval of such amendments as may

be necessary to the Commonwealth's approved Title XIX State

Plan, the department shall do all of the following:

(A) For each fiscal year between July 1, 2008, and June 30,

2011, the department shall apply a revenue adjustment neutrality

factor to county and nonpublic nursing facility payment rates.

For each such fiscal year, the revenue adjustment neutrality

factor shall limit the estimated aggregate increase in the

Statewide day-weighted average payment rate so that the

aggregate percentage rate of increase for the period that begins

on July 1, 2005, and ends on the last day of the fiscal year is

limited to the amount permitted by the funds appropriated by the

General Appropriations Act for those fiscal years.

(B) In calculating rates for nonpublic nursing facilities

for fiscal year 2008-2009, the department shall continue to

include costs incurred by county nursing facilities in the rate-

setting database, as specified in the department's regulations

in effect on July 1, 2007.

the use of county nursing facility costs as an input in the

process of setting payment rates of nonpublic nursing

facilities. The final regulations shall be effective July 1,

2009, and shall phase out the use of these costs in rate-setting

over a period of three rate years, beginning fiscal year 2009-

2010 and ending on June 30, 2012.

(D) The department shall propose regulations that establish

minimum occupancy requirements as a condition for bed-hold

payments. The final regulations shall be effective July 1, 2009,

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and shall phase in these requirements over a period of two rate

years, beginning fiscal year 2009-2010.

(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] Office of Independent Medical Assistance

Director 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, 2019, 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.

(v) Subject to Federal approval of such amendments as may be

necessary to the Commonwealth's approved Title XIX State Plan,

for fiscal year 2013-2014, the [department] Office of

Independent Medical Assistance Director shall make quarterly

medical assistance day-one incentive payments to qualified

nonpublic nursing facilities. The [department] Office of

Independent Medical Assistance Director shall determine the

nonpublic nursing facilities that qualify for the quarterly

medical assistance day-one incentive payments and calculate the

payments using the total Pennsylvania medical assistance (PA MA)

days and total resident days as reported by nonpublic nursing

facilities under Article VIII-A. The [department's] Office of

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Independent Medical Assistance Director's determination and

calculations under this subparagraph shall be based on the

nursing facility assessment quarterly resident day reporting

forms available on October 31, January 31, April 30 and July 31.

The [department] Office of Independent Medical Assistance

Director shall not retroactively revise a medical assistance

day-one incentive payment amount based on a nursing facility's

late submission or revision of its report after these dates. The

[department] Office of Independent Medical Assistance Director,

however, may recoup payments based on an audit of a nursing

facility's report. The following shall apply:

(A) A nonpublic nursing facility shall meet all of the

following criteria to qualify for a medical assistance day-one

incentive payment:

(I) The nursing facility shall have an overall occupancy

rate of at least 85% during the resident day quarter. For

purposes of determining a nursing facility's overall occupancy

rate, a nursing facility's total resident days, as reported by

the facility under Article VIII-A, shall be divided by the

product of the facility's licensed bed capacity, at the end of

the quarter, multiplied by the number of calendar days in the

quarter.

(II) The nursing facility shall have a medical assistance

occupancy rate of at least 65% during the resident day quarter.

For purposes of determining a nursing facility's medical

assistance occupancy rate, the nursing facility's total PA MA

days shall be divided by the nursing facility's total resident

days, as reported by the facility under Article VIII-A.

(III) The nursing facility shall be a nonpublic nursing

facility for a full resident day quarter prior to the applicable

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quarterly reporting due dates of October 31, January 31, April

30 and July 31.

(B) The [department] Office of Independent Medical

Assistance Director shall calculate a qualified nonpublic

nursing facility's medical assistance day-one incentive

quarterly payment as follows:

(I) The total funds appropriated for payments under this

subparagraph shall be divided by four.

(II) To establish the quarterly per diem rate, the amount

under subclause (I) shall be divided by the total PA MA days, as

reported by all qualifying nonpublic nursing facilities under

Article VIII-A.

(III) To determine a qualifying nonpublic nursing facility's

quarterly medical assistance day-one incentive payment, the

quarterly per diem rate shall be multiplied by a nonpublic

nursing facility's total PA MA days, as reported by the facility

under Article VIII-A.

the nonpublic nursing facility medical assistance day-one

incentive payments shall equal eight million dollars

($8,000,000).

(vi) Subject to Federal approval of such amendments as may

be necessary to the Commonwealth's approved Title XIX State

Plan, for fiscal years 2015-2016, 2016-2017 and 2018-2019, the

[department] Office of Independent Medical Assistance Director

shall make up to four medical assistance day-one incentive

payments to qualified nonpublic nursing facilities. The

department shall determine the nonpublic nursing facilities that

qualify for the medical assistance day-one incentive payments

and calculate the payments using the total Pennsylvania medical

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assistance (PA MA) days and total resident days as reported by

nonpublic nursing facilities under Article VIII-A. The

department's determination and calculations under this

subparagraph shall be based on the nursing facility assessment

quarterly resident day reporting forms, as determined by the

department. The department shall not retroactively revise a

medical assistance day-one incentive payment amount based on a

nursing facility's late submission or revision of the

department's report after the dates designated by the

department. The department, however, may recoup payments based

on an audit of a nursing facility's report. The following shall

apply:

(A) A nonpublic nursing facility shall meet all of the

following criteria to qualify for a medical assistance day-one

incentive payment:

(I) The nursing facility shall have an overall occupancy

rate of at least eighty-five percent during the resident day

quarter. For purposes of determining a nursing facility's

overall occupancy rate, a nursing facility's total resident

days, as reported by the facility under Article VIII-A, shall be

divided by the product of the facility's licensed bed capacity,

at the end of the quarter, multiplied by the number of calendar

days in the quarter.

(II) The nursing facility shall have a medical assistance

occupancy rate of at least sixty-five percent during the

resident day quarter. For purposes of determining a nursing

facility's medical assistance occupancy rate, the nursing

facility's total PA MA days shall be divided by the nursing

facility's total resident days, as reported by the facility

under Article VIII-A.

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(III) The nursing facility shall be a nonpublic nursing

facility for a full resident day quarter prior to the applicable

quarterly reporting due dates, as determined by the department.

(B) The department shall calculate a qualified nonpublic

nursing facility's medical assistance day-one incentive payment

as follows:

(I) The total funds appropriated for payments under this

subparagraph shall be divided by the number of payments, as

determined by the department.

(II) To establish the per diem rate for a payment, the

amount under subclause (I) shall be divided by the total PA MA

days, as reported by all qualifying nonpublic nursing facilities

under Article VIII-A for that payment.

(III) To determine a qualifying nonpublic nursing facility's

medical assistance day-one incentive payment, the per diem rate

calculated for the payment shall be multiplied by a nonpublic

nursing facility's total PA MA days, as reported by the facility

under Article VIII-A for the payment.

State funds available for the nonpublic nursing facility medical

assistance day-one incentive payments shall equal eight million

dollars ($8,000,000).

(8) As a condition of participation in the medical

assistance program, before any county or nonpublic nursing

facility increases the number of medical assistance certified

beds in its facility or in the medical assistance program,

whether as a result of an increase in beds in an existing

facility or the enrollment of a new provider, the facility must

seek and obtain advance written approval of the increase in

certified beds from the department. The following shall apply:

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(i) Before July 1, 2009, the department shall propose

regulations that would establish the process and criteria to be

used to review and respond to requests for increases in medical

assistance certified beds, including whether an increase in the

number of certified beds is necessary to assure that long-term

living care and services under the medical assistance program

will be provided in a manner consistent with applicable Federal

and State law, including Title XIX of the Social Security Act.

(ii) Pending adoption of regulations, a nursing facility's

request for advance written approval for an increase in medical

assistance certified beds shall be submitted and reviewed in

accordance with the process and guidelines contained in the

statement of policy published in 28 Pa.B. 138.

(iii) The [department] Office of Independent Medical

Assistance Director may publish amendments to the statement of

policy if the department determines that changes to the process

and guidelines for reviewing and responding to requests for

approval of increases in medical assistance certified beds will

facilitate access to medically necessary nursing facility

services or are required to assure that long-term living care

and services under the medical assistance program will be

provided in a manner consistent with applicable Federal and

State law, including Title XIX of the Social Security Act. The

[department] Office of Independent Medical Assistance Director

shall publish the proposed amendments in the Pennsylvania

Bulletin and solicit public comments for thirty days. After

consideration of the comments it receives, the [department]

Office of Independent Medical Assistance Director may proceed to

adopt the amendments by publishing an amended statement of

policy in the Pennsylvania Bulletin which shall include its

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responses to the public comments that it received concerning the

proposed amendments.

Section 443.2. Medical Assistance Payments for Home Health

Care.--The following medical assistance payments shall be made

in behalf of eligible persons whose care in the home has been

prescribed by a physician, chiropractor or podiatrist:

(1) Rates established by the [department] Office of

Independent Medical Assistance Director for post-hospital home

care, as specified by regulations of the [department] Office of

Independent Medical Assistance Director adopted under Title XIX

of the Federal Social Security Act for not more than one hundred

eighty days following a period of hospitalization, if such care

is related to the reason the person was hospitalized and if

given by a hospital as comprehensive, hospital type care in a

patient's home;

(2) Rates established by the [department] Office of

Independent Medical Assistance Director for home health care

services if such services are furnished by a voluntary or

governmental health agency.

Section 443.3. Other Medical Assistance Payments.--(a)

Payments on behalf of eligible persons shall be made for other

services, as follows:

(1) Rates established by the [department] Office of

Independent Medical Assistance Director for outpatient services

as specified by regulations of the department adopted under

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

1396 et seq.) consisting of preventive, diagnostic, therapeutic,

rehabilitative or palliative services; furnished by or under the

direction of a physician, chiropractor or podiatrist, by a

hospital or outpatient clinic which qualifies to participate

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under Title XIX of the Social Security Act, to a patient to whom

such hospital or outpatient clinic does not furnish room, board

and professional services on a continuous, twenty-four hour a

day basis.

(1.1) Rates established by the [department] Office of

Independent Medical Assistance Director for observation services

provided by or furnished under the direction of a physician and

furnished by a hospital. Payment for observation services shall

be made in an amount specified by the [department] Office of

Independent Medical Assistance Director by notice in the

Pennsylvania Bulletin and shall be effective for dates of

service on or after July 1, 2016. Payment for observation

services shall be subject to conditions specified in the

[department's] Office of Independent Medical Assistance Director

regulations, including regulations adopted by the [department]

Office of Independent Medical Assistance Director to implement

this paragraph. Pending adoption of regulations implementing

this paragraph, the conditions for payment of observation

services shall be specified in a medical assistance bulletin.

(2) Rates established by the [department] Office of

Independent Medical Assistance Director for (i) other laboratory

and X-ray services prescribed by a physician, chiropractor or

podiatrist and furnished by a facility other than a hospital

which is qualified to participate under Title XIX of the Social

Security Act, (ii) physician's services consisting of

professional care by a physician, chiropractor or podiatrist in

his office, the patient's home, a hospital, a nursing facility

or elsewhere, (iii) the first three pints of whole blood, (iv)

remedial eye care, as provided in Article VIII consisting of

medical or surgical care and aids and services and other vision

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care provided by a physician skilled in diseases of the eye or

by an optometrist which are not otherwise available under this

Article, (v) special medical services for school children, as

provided in the Public School Code of 1949, consisting of

medical, dental, vision care provided by a physician skilled in

diseases of the eye or by an optometrist or surgical care and

aids and services which are not otherwise available under this

article.

(3) Notwithstanding any other provision of law, for

recipients aged twenty-one years or older receiving services

under the fee for service delivery system who are eligible for

medical assistance under Title XIX of the Social Security Act

and for recipients aged twenty-one years or older receiving

services under the fee-for-service delivery system who are

eligible for general assistance-related categories of medical

assistance, the following medically necessary services:

(i) Psychiatric outpatient clinic services not to exceed

five hours or ten one-half-hour sessions per thirty consecutive

day period.

(ii) Psychiatric partial hospitalization not to exceed five

hundred forty hours per fiscal year.

(b) The [department] Office of Independent Medical

Assistance Director may grant exceptions to the limits specified

in this section, section 443.1(4) or the department's

regulations when any of the following circumstances applies:

(1) The [department] Office of Independent Medical

Assistance Director determines that the recipient has a serious

chronic systemic illness or other serious health condition and

denial of the exception will jeopardize the life of or result in

the rapid, serious deterioration of the health of the recipient.

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(2) The [department] Office of Independent Medical

Assistance Director determines that granting a specific

exception to a limit is a cost-effective alternative for the

medical assistance program.

(3) The [department] Office of Independent Medical

Assistance Director determines that granting an exception to a

limit is necessary in order to comply with Federal law.

Medical Assistance Director shall promulgate regulations

pursuant to section 204(1)(iv) of the act of July 31, 1968

(P.L.769, No.240), referred to as the Commonwealth Documents

Law, to implement this section. Notwithstanding any other

provision of law, the promulgation of regulations under this

subsection shall, until December 31, 2005, be exempt from all of

the following:

(1) Section 205 of the Commonwealth Documents Law.

(2) Section 204(b) 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

"Regulatory Review Act."

Section 454. Medical Assistance Benefit Packages; Coverage,

Copayments, Premiums and Rates.--(a) Notwithstanding any other

provision of law to the contrary, the [department] Office of

Independent Medical Assistance Director shall promulgate

regulations as provided in subsection (b) to establish provider

payment rates; the benefit packages and any copayments for

adults eligible for medical assistance under Title XIX of the

Social Security Act (49 Stat 620, 42 U.S.C. § 1396 et seq.) and

adults eligible for medical assistance in general assistance-

related categories; and the premium or copayment requirements

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for disabled children whose family income is above two hundred

percent of the Federal poverty income limit. Subject to such

Federal approval as may be necessary, the regulations shall

authorize and describe the available benefit packages and any

copayments and premiums, except that the [department] Office of

Independent Medical Assistance Director shall set forth the

copayment and premium schedule for disabled children whose

family income is above two hundred percent of the Federal

poverty income limit by publishing a notice in the Pennsylvania

Bulletin. The [department] Office of Independent Medical

Assistance Director may adjust such copayments and premiums for

disabled children by notice published in the Pennsylvania

Bulletin. The regulations shall also specify the effective date

for provider payment rates.

* * *

Assistance Director is authorized to grant exceptions to any

limits specified in the benefit packages adopted under this

section or when any of the following circumstances applies:

(1) The [department] Office of Independent Medical

Assistance Director determines the recipient has a serious

chronic systemic illness or other serious health condition and

denial of the exception will jeopardize the life of or result in

the rapid, serious deterioration of the health of the recipient.

(2) The [department] Office of Independent Medical

Assistance Director determines that granting a specific

exception to a limit is a cost-effective alternative for the

medical assistance program.

(3) The department determines that granting an exception to

a limit is necessary in order to comply with Federal law.

20200HB2876PN4405 - 28 -

* * *

Section 3. The act is amended by adding an article to read:

ARTICLE IV-A

OFFICE OF INDEPENDENT MEDICAL ASSISTANCE DIRECTOR

Section 401-A. Declaration of purpose.

The General Assembly finds and declares that the intent of

this article is to ensure that the Commonwealth's current

medical assistance programs provide all of the following:

(1) Budget stability and predictability through defined

outcomes, performance and accountability.

(2) A balance of quality, patient satisfaction,

financial measures and self-sufficiency.

(3) The most efficient and cost-effective services,

administrative systems and structures.

(4) A sustainable and uniform delivery system across the

Commonwealth's departments and agencies.

(5) Services are offered to assist recipients attain

independence or self-care.

Section 402-A. Definitions.

The following words and phrases when used in this article

shall have the meanings given to them in this section unless the

context clearly indicates otherwise:

"Commonwealth agency." A State agency, department, board,

office, bureau, division, committee or council.

"Director." The Director of the Office of Independent

Medical Assistance Director.

Section 403-A. Office of Independent Medical Assistance

Director.

(a) Establishment.-- The Office of Independent Medical

Assistance Director is established within the department for

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budgetary purposes.

(b) Employees.--Employees of any Commonwealth agency who

operate and administer medical assistance programs prior to the

effective date of this section shall be transferred to the

Office of Independent Medical Assistance Director at the

discretion of the director. The funds that pay for the salaries

of the employees transferred under this section shall be paid

out of the encumbered funds of the agency from which the

employee was transferred.

regarding the operation of the Commonwealth's medical assistance

programs shall be transferred into a restricted account in the

General Fund in accordance with the following:

(1) Money from the restricted account may be transferred

only upon the approval of the director or the director's

designee, as prescribed under this article.

(2) The director shall coordinate payments from the

Commonwealth's medical assistance programs with the State

Treasurer to optimize the Commonwealth's cash flow within the

General Fund and total operating budget.

Section 404-A. Director of the Office of Independent Medical

Assistance Director.

(a) Appointment.--The Governor shall appoint the director

from the list submitted by the Selection and Organization

Committee under subsection (c) for a term of six years and

subject to confirmation by the Senate. The initial term of

office for the director shall commence upon confirmation by the

Senate and shall expire June 30, 2022. After June 30, 2022, the

term of office for the director shall be six years and shall

commence on July 1 after the date of confirmation. A director

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may serve more than one term if selected by the Selection and

Organization Committee.

(b) Committee.--The Selection and Organization Committee is

established for the purpose of comprising a list of potential

nominees for director. The committee shall consist of the

following:

(1) The chair and minority chair of the Appropriations

Committee of the Senate and the chair and minority chair of

the Appropriations Committee of the House of Representatives.

(2) The Majority Leader and the Minority Leader of the

Senate and the Majority Leader and the Minority Leader of the

House of Representatives.

(3) The President pro tempore of the Senate and the

Speaker of the House of Representatives.

(5) The chair and minority chair of the Health and Human

Services Committee of the Senate.

(6) The chair and minority chair of the Health Committee

of the House of Representatives.

(1) The Selection and Organization Committee shall

submit no more than three potential nominees to the Governor

within 30 days of a vacancy.

(2) The Governor shall submit a nominee from the list

submitted under paragraph (1) for director to the Senate for

confirmation no later than May 1 of the year when the term of

office expires.

(3) If the Governor fails to submit a nominee under

paragraph (2) by May 1 of the year when the term of office

expires, the President pro tempore of the Senate and the

Speaker of the House of Representatives shall jointly submit

20200HB2876PN4405 - 31 -

a nominee to the Senate on or before May 15 of the same year

by resolution. The resolution shall include all of the

following:

(i) The name of the nominee.

(ii) The effective date of the appointment.

(iii) The date of expiration of the term of office.

(iv) The residence of the nominee.

(v) A clause providing that the nominee is submitted

upon joint recommendation of the President pro tempore of

the Senate and the Speaker of the House of

Representatives.

(4) If a nominee for director is not confirmed within 30

days of submission to the Senate, a new nominee for director

shall be submitted to the Senate.

(d) Vacancy.--The following shall apply if the position of

director is vacant:

(1) If the vacancy occurs before the director's term of

office expires, the Governor shall submit a nominee from the

list submitted by the Selection and Organization Committee

under subsection (c) for director to the Senate no later than

60 days after the vacancy occurs.

(2) If the vacancy occurs when the General Assembly is

not in session, the Governor shall appoint an acting director

until such time as the General Assembly has reconvened . An

acting director may not serve for more than three months.

(3) If no director has been approved within 3 months of

a vacancy, a new director shall be appointed in accordance

with paragraph (1).

(e) Removal.--The Governor may remove the director only if

the director has committed a breach of public trust or violated

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the laws of this Commonwealth.

Section 405-A. Powers and duties of director.

The director shall have the following powers and duties:

(1) Administering medical assistance programs in a

manner in which the total expenditures, net of agency

receipts, do not exceed the authorized budget for the medical

assistance programs.

(2) Employing clerical and professional staff for the

Office of Independent Medical Assistance Director, including

consultants, actuaries and legal counsel, for the purpose of

administering medical assistance programs. The director may

offer employment contracts for specified terms and set

compensation for the employees, which may include

performance-based bonuses based on meeting budget or other

targets.

(3) Notwithstanding any other provisions of law,

entering into and managing contracts for the administration

of medical assistance programs, which shall include all of

the following:

(i) Expected outcomes to improve the health and

well-being of residents of this Commonwealth.

(ii) Value-based purchasing.

(iii) The use of evidence-based programs.

(iv) The development of medical homes.

(v) Uniform coordination of services.

(vi) Cost containment provisions.

(vii) Maximizing the amount of Federal funds.

(viii) Recommendations for identifying cost savings

within medical assistance programs.

(4) Establishing and adjusting all components of

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medical assistance programs within the appropriated and

allocated budget.

(5) Adopting rules and regulations relating to medical

assistance programs in accordance with Executive Order 1996-

(6) Developing mid-year budget correction plans and

strategies and taking mid-year budget corrective actions as

necessary to keep medical assistance programs within budget.

(7) Approving or disapproving and overseeing all

expenditures to be allocated to medical assistance programs.

(8) Developing and providing to the Office of the

Budget, the Appropriations Committee of the Senate , the

Appropriations Committee of the House of Representatives and

the Independent Fiscal Office by January 1, 2018, and each

year thereafter, the following information about medical

assistance programs:

(i) A detailed four-year forecast of expected

changes to enrollment growth and enrollment demographics.

(ii) Changes that will be implemented by the

department in order to stay within the existing budget

based on the next fiscal year's forecasted enrollment

growth and enrollment demographics.

(iii) The cost to maintain the current level of

services based on the next fiscal year's forecasted

enrollment growth and enrollment demographics.

(9) Creating a publicly accessible Internet website for

the Office of Independent Medical Assistance Director and

updating the website on at least a monthly basis with the

following information about the m edical assistance programs:

(i) Enrollment by medical assistance program aid

20200HB2876PN4405 - 34 -

category by county.

(ii) Per member, per month spending by category of

service.

(iii) Spending and receipts by fund, including a

detailed variance analysis.

(iv) A comparison of the figures specified under

subparagraphs (i), (ii) and (iii) to the amounts

forecasted and budgeted for the corresponding time

period.

(10) Developing performance measures and outcomes for

programs under the director's jurisdiction and programs which

are billed against m edical assistance programs.

(11) Making annual recommendations to the Governor and

the General Assembly to streamline programs to provide better

services for residents of this Commonwealth at a lower cost

to taxpayers who reside within this Commonwealth .

(12) Serving at the pleasure of the residents of this

Commonwealth in an independent manner.

(13) Developing and implementing policies to address

excessive utilization of health care services.

(14) Ensuring that services are coordinated throughout

Commonwealth agencies, including physical health, behavioral

health, long-term services and supports and third-party

insurances.

Section 406-A. Amendments to State plan for medical assistance

programs.

(a) Authority.--The director shall have the sole authority

to manage all m edical assistance programs in the Commonwealth,

including, but not limited to, being the sole authority for

submitting an amendment to the State's plan under Title XIX of

20200HB2876PN4405 - 35 -

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

to the Centers for Medicare and Medicaid services offered under

any of the Commonwealth's medical assistance programs.

(b) Amendments.--The director may take all necessary action

to amend the State plan for m edical assistance programs in order

to keep m edical assistance programs within the certified budget,

including State plan amendments, waivers and waiver amendments.

assistance programs shall be submitted by the director in

accordance with the following:

(1) A law of this Commonwealth mandating that the

director submit an amendment to the State plan for m edical

assistance programs.

(2) A law of this Commonwealth which changes m edical

assistance programs and requires approval from the Federal

Government.

(3) A change in Federal law which requires an amendment

to the State plan for m edical assistance programs.

(4) An order of a court of competent jurisdiction if the

amendment to the State plan for m edical assistance programs

is necessary to implement the order.

(5) In a manner as required to maintain Federal funding

for m edical assistance programs.

(d) Notice.--No less than 30 days before submitting an

amendment to the State plan for medical assistance programs to

the Federal Government, the director shall post the amendment on

the Office of Independent Medical Assistance Director's publicly

accessible Internet website and notify the members of the

General Assembly and the Independent Fiscal Office that the

amendment has been posted. The notice requirement under this

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subsection shall not apply to a draft or proposed amendment

submitted to the Federal Government for comments and not for

approval.

Section 407-A. Use of funds.

The Office of Independent Medical Assistance Director shall

use encumbered funds appropriated to the department to implement

this article.

Section 408-A. Legislative oversight powers.

The Appropriations Committee of the Senate and the

Appropriations Committee of House of Representatives, while in

discharge of official duties, shall have access to any document

and may compel the attendance of an employee or secure any

evidence.

Section 409-A. Duties of Commonwealth agencies.

The following shall apply:

(1) A Commonwealth agency shall not interfere with the

duties of the director or withhold information requested by

the director.

(2) A Commonwealth agency shall coordinate with the

director to ensure the residents of this Commonwealth have a

continuity of care.

Section 410-A. Regulations.

The Office of Independent Medical Assistance Director shall

promulgate regulations.

Section 411-A . Construction.

Nothing in this article may be construed to limit the budget

authority of the Office of the Budget under Article VI of the

act of April 9, 1929 (P.L.177, No.175), known as The

Administrative Code of 1929.

Section 4. All acts and parts of acts are repealed insofar

20200HB2876PN4405 - 37 -

as they are inconsistent with this act.

Section 5. This act shall take effect July 1, 2019, or

immediately, whichever is later.

20200HB2876PN4405 - 38 -