PRINTER'S NO. 299

THE GENERAL ASSEMBLY OF PENNSYLVANIA

SENATE BILL

No.

322

Session of

2019

INTRODUCED BY MARTIN, SCARNATI, MENSCH, AUMENT, STEFANO AND

ALLOWAY, FEBRUARY 22, 2019

REFERRED TO HEALTH AND HUMAN SERVICES, FEBRUARY 22, 2019

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 411.1. Total Population Medicaid Decision System

Health Initiative .--(a) The department shall issue a request

for proposals for a total population Medicaid Decision System

pilot program in one Medicaid managed care region of this

Commonwealth that incorporates electronic evidence-based

and a control group. The purpose of the health initiative is to

increase the use of appropriate primary and preventive care by

medical assistance recipients while decreasing unnecessary

utilization of services, including specialty care and hospital

emergency department services, in addition to providing the

department with timely operational and strategic reporting. The

following apply:

(1) All medical assistance recipients in the selected

Medicaid managed care region who are randomized into the active

pilot group will have access to the health initiative.

(2) The department shall define the Medicaid Decision System

access provided through a single telephone access point and a

private portal specific to each medical assistance recipient.

(ii) Support existing State resources available to medical

assistance recipients in the selected Medicaid managed care

region by providing health management services as needed.

(iii) Coordinate efforts with existing and future providers,

contractors, services and agencies.

(iv) Utilize technology to provide an advanced electronic

information and evidence-based medical system to guide and

support medical assistance recipients and physicians in the

validation information to the department annually or at more

frequent predetermined intervals via transmitted reports and an

administrative web portal for department-approved personnel.

(3) The department shall enter into a contract with one

offeror within ninety days of the effective date of this section

and require that the annual savings to the Commonwealth

resulting from the use of the health initiative exceed the cost

of the health initiative. The secretary shall forward notice to

the Legislative Reference Bureau for publication in the

Pennsylvania Bulletin of the date the contract is awarded to the

offeror.

To measure the effectiveness of the health initiative, the

offeror is required to report on and process one hundred percent

of the claims in both the active pilot group and the control

group. The data analytic system must include:

(i) Ad hoc reporting that identifies the health care costs

and utilization of services for the active pilot group.

(ii) Ad hoc reporting that compares total costs and service

utilization between the active pilot group and the control

group.

(iii) Ad hoc reporting that compares total costs and service

(6) The department shall require all medical,

pharmaceutical, dental, transportation and PCS claims and

encounter data be made available to the offeror for all medical

assistance recipients no less than once a month. Claim and

encounter data include all elements and concepts included in

ANSI ASC X12 837 v5010 standards. The department shall require

that the offeror operate and maintain processes to support the

collection, extraction, translation, loading and maintenance of

required information, data and reports.

(7) The offeror shall define Commonwealth-approved data

validation rules for each data source to identify errors and to

be maintained in compliance with the Health Insurance

Portability and Accountability Act of 1996 (Public Law 104-191,

110 Stat. 1936) or the Health Information Technology for

Economic and Clinical Health Act (Public Law 111-5, 123 Stat.

226-279 and 467-496), including protecting the storage of,

access to and dissemination of protected health information.

(9) Offeror bears all financial risk for executing the

health initiative. No administrative or service fee may be paid

to the offeror during the initial six months of the health

initiative.

department shall retroactively pay the offeror a data management

service fee of one dollar ($1) per member per month for the

execution of all data processing, collection, validation and

analysis, and shall continue the health initiative for an

additional six months and pay the offeror an amount equal to one

half the customary per member per month fee, in addition to the

one dollar ($1) data management fee for the subsequent six

months if the savings exceed the cost of service. The customary

per member per month fee is not to exceed five dollars ($5) per

member per month.

(b) The department and offeror shall issue a report at the

(1) Analytic and utilization information.

(2) Cost savings realized by the Commonwealth for the active

pilot group as compared to the control group and against the

base years for the active pilot group.

(3) Recommendations by the department regarding expansion of

the health initiative should the financial performance warrant

expansion.

(c) At the conclusion of the contract, the department may

expand the health initiative if the following conditions are

met:

(2) Actuarial analysis certifies that the expansion will

reduce or not increase net program spending.

(3) The department determines that the expansion will not

deny or limit coverage or benefits to medical assistance

recipients.

(d) As used in this section, the term "health initiative"

means the total population Medicaid Decision System pilot

program.