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A00049
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
51
Session of
2019
INTRODUCED BY BERNSTINE, RYAN, McNEILL, SCHLOSSBERG, LONGIETTI,
MENTZER, PICKETT, HILL-EVANS, WARREN, RAPP, MIZGORSKI,
DeLISSIO, DeLUCA AND SOLOMON, JANUARY 28, 2019
REFERRED TO COMMITTEE ON HEALTH, JANUARY 28, 2019
AN ACT
Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
act to consolidate, editorially revise, and codify the public
welfare laws of the Commonwealth," in public assistance,
providing for medical assistance deemed eligibility program
for home care, home health and older adult daily living
center services.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of June 13, 1967 (P.L.31, No.21), known
as the Human Services Code, is amended by adding a section to
read:
Section 443.13 . Medical Assistance Deemed Eligibility
Program for Home Care , Home Health and Older Adult Daily Living
Center Services .--(a) The department shall establish a deemed
eligibility program for home care services , home health services
and older adult daily living center services to prevent the
unnecessary and costly institutionalization of individuals who
are eligible for medical assistance nursing facility services
and want to receive home care and assistance with daily living
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in a less restrictive setting.
(b) The program shall:
(1) be designed to provide home care services , home health
services and older adult daily living center services only for
individuals who are sixty-five years of age or older and nursing
facility clinically eligible;
(2) permit a qualified entity to submit an application for
medical assistance on behalf of individuals to the department;
(3) permit an individual who is applying for medical
assistance to declare income and assets on an application form
and attest to the accuracy of the income and assets provided on
the application form; and
(4) permit a qualified entity to determine the deemed
eligibility of individuals to receive medical assistance.
(c) The following apply:
(1) If a qualified entity determines that an individual is
deemed eligible to receive medical assistance under subsection
(b)(4), the individual may begin receiving home care services ,
home health services and older adult daily living center
services from a medical assistance provider as soon as a
preliminary service plan is developed . As authorized under
Federal law, the department shall apply a final determination of
medical assistance eligibility beginning on the date that a
qualified entity determines that an individual is deemed
eligible for medical assistance under subsection (b)(4).
(2) If a qualified entity determines that an individual is
deemed eligible under subsection (b)(4), and the individual is
subsequently determined to be ineligible for home care services ,
home health services and older adult daily living center
services by the department, the medical assistance provider
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which provided home care services , home health services and
older adult daily living center services under clause (1) shall
not be reimbursed by the Commonwealth for the cost of the home
care services , home health services and older adult daily living
center services provided during the period of deemed
eligibility. If the individual provided fraudulent information
under this section, the medical assistance provider may seek
reimbursement from the individual for the cost of home care
services , home health services and older adult daily living
center services provided during the period of deemed
eligibility.
(3) Once the department makes a final determination of
eligibility, the department shall authorize medical assistance
payments for the first sixty days of home care services , home
health services and older adult daily living center services
provided during the period of deemed eligibility following the
date that the qualified entity established the preliminary
service plan.
(4) The department shall verify the information on the
application and make a final determination of medical assistance
eligibility. The department may request additional information
from an applicant for the purpose of completing the verification
process under this clause .
(d) Upon request, the department shall provide information
to a qualified entity about Commonwealth policies and procedures
on how to determine whether an individual may be deemed eligible
for medical assistance under subsection (b)(4).
(e) The department shall issue a medical assistance bulletin
which contains the Commonwealth policies and procedures
necessary to implement this section. The publication of the
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medical assistance bulletin under this subsection shall not
delay the implementation of this section.
(f) Within seventy-five days of the effective date of this
subsection, the department shall apply for any necessary Federal
waiver or State plan amendment. Fifteen days prior to applying
for any necessary Federal waiver or State plan amendment, the
department shall submit the proposed application to the Health
and Human Services Committee of the Senate, the Health Committee
of the House of Representatives and the Human Services Committee
of the House of Representatives. The department shall maximize
the use of Federal money for the program.
(g) Within seventy-five days of the effective date of this
subsection, the department shall issue any revisions to the
State medical assistance plan as required under Title XIX of the
Social Security Act (49 Stat. 620, 42 U.S.C. § 1396 et seq.).
Fifteen days prior to issuing any revisions, the department
shall submit the proposed revisions to the Health and Human
Services Committee of the Senate, the Health Committee of the
House of Representatives and the Human Services Committee of the
House of Representatives.
(h) On or before January 1 of each year, the department
shall issue a report to the General Assembly with the following
information about the program:
(1) The number of individuals who participated in the
program.
(2) The average cost for each individual in the program.
(3) The number of qualified entities in the program.
(4) The administrative costs.
(5) The estimated savings.
(i) The Legislative Budget and Finance Committee shall
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conduct a study of the fiscal impact and effectiveness of the
deemed eligibility program. The committee shall submit a final
report with its findings and recommendations to the Secretary of
the Senate and the Chief Clerk of the House of Representatives
by October 31, 2024.
(j) This section shall expire October 31, 2025.
(k) As used in this section, the following words and phrases
shall have the following meanings:
"Home care services." As defined in 28 Pa. Code § 611.5
(relating to definitions).
"Home health services." Part-time, intermittent skilled
nursing services and therapy services provided under 28 Pa. Code
Ch. 601 (relating to home health care agencies) at an
individual's place of residence.
"Nursing facility clinically eligible." An individual who:
(1) is certified by a physician to be nursing facility
clinically eligible;
(2) has been diagnosed with an illness, injury, disability
or medical condition by a physician which requires the
individual to receive health services in accordance with the
following:
(i) Skilled nursing and skilled rehabilitation services as
defined in 42 CFR 409.31 (relating to level of care
requirement).
(ii) 42 CFR 409.32 (relating to criteria for skilled
services and the need for skilled services).
(iii) 42 CFR 409.33 (relating to examples of skilled nursing
and rehabilitation services).
(iv) 42 CFR 409.34 (relating to criteria for "daily basis").
(v) 42 CFR 409.35 (relating to criteria for "practical
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matter").
(3) needs health services on a regular basis in the context
of a planned program of health care and management which was
only previously available through an institutional facility.
"Nursing facility services." As defined in 42 CFR 440.40
(relating to nursing facility services for individuals age 21 or
older (other than services in an institution for mental
disease), EPSDT, and family planning services and supplies) or
42 CFR 440.155 (relating to nursing facility services, other
than in institutions for mental diseases).
"Older adult daily living center services." Services
provided to assist an individual with activities of daily living
and essential activities of daily living at an older adult daily
living center as defined under 6 Pa. Code § 11.3 (relating to
definitions). Services provided or arranged to assist in meeting
the needs, including personal car e, social, nutritional , health
and educational needs, of clients through a program of social,
educational, therapeutic, rehabilitative, habilitative and
developmental activities. The term does not include services
provided for persons whose needs can only be met in a long-term
care facility on an inpatient basis receiving professionally
supervised nursing care and related medical care and other
health services .
"Program." The deemed eligibility program established by the
department under subsection (a).
"Qualified entity." A home care agency , home health agency,
older adult daily living center or an organization authorized by
the department which elects to determine the deemed eligibility
of individuals to receive medical assistance under subsection
(b)(4).
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Section 2. The Secretary of Human Services shall transmit to
the Legislative Reference Bureau, for publication in the
Pennsylvania Bulletin, notice of approval of any necessary
Federal waiver or State plan amendment under section 443.13 of
the act.
Section 3. This act shall take effect as follows:
(1) Except as set forth in paragraph (2), the addition
of section 443.13 of the act shall take effect 30 days
following publication of the notice under section 2.
(2) The addition of section 443.13(f) of the act shall
take effect immediately.
(3) The remainder of this act shall take effect
immediately.
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