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Comment on DPW Act 22 Regulatory Notices
February 17, 2012

The Department of Public Welfare (DPW) issued notices in the February 18 Pennsylvania Bulletin (PAB) available today on the PAB web site under Act 22 expedited rulemaking authority. These notices have a 15-day comment period. Instructions for submission of comments are found in each notice. DPW will consider comments received during this time period as they develop final-omitted regulations that will be issued and implemented without opportunity for further comment. DPW will submit a Medicaid State Plan Amendment request to the Centers for Medicare and Medicaid Services (CMS) to facilitate these changes. Questions regarding this Alert may be addressed to Betty Simmonds (betty@paproviders.org).

ODP HCBS Regulations
The Office of Developmental Programs (ODP) will promulgate home and community-based services (HCBS) regulations and submit waiver amendments needed for provider qualifications, provider payment methodologies, and rates for providers in the Medical Assistance (MA) Consolidated, Person/Family Directed Support, and Adult Autism HCBS waivers, providers of targeted services management, and base-funded providers offering services in a waiver service location. Providers will be required under 55 Pa. Code § 51.11 to complete the provider enrollment application, sign both an MA provider agreement and a HCBS provider agreement, and submit supporting provider qualification documentation. Providers must also comply with applicable waivers and amendments found at http://www.dpw.state.pa.us/dpworganization/officeofdevelopmentalprograms/index.htm.  Requalification will occur every two years under §51.13. If required documentation is not submitted, the provider will no longer qualify to provide the service. Providers must provide annual staff training as required in individual support plans (ISP), including training for direct care workers hired by a participant (§51.23). Under §51.25 providers must develop, implement, and update a quality management plan for performance improvement. Providers must have a back-up plan for service provision as required in the ISP.

Subchapter C will stipulate the payment methodology for reimbursable services. Payment will be made under one of the following reimbursement methods: cost-based, MA fee schedule, or payment as a vendor. Cost-based rate methodology is based on approved cost report data submitted by providers and approved in a desk review process as described in 41 PAB 6175 (November 12, 2011) for the period July 1 - November 14, 2011, and 41 PAB 6173 (November 12, 2011) for the period November 15, 2011 - June 30, 2012. The MA fee schedule method and rates are the same as those found in 41 PAB 6168 (November 12, 2011) for the period July 1 - November 14, 2011, and 41 PAB 6163 (November 12, 2011) for the period November 15, 2011 - June 30, 2012. A limited number of vendor goods and services are reimbursed at actual cost. The regulation will require publication of a list of vendor goods and services in the PAB. Billing, audit, and cost report requirements will also be addressed in Subchapter C. Providers will be required to comply with the Single Audit Act or to retain books, records, and documents for audit and inspection for at least five years from the provider’s fiscal year end date.
ODP will also establish sanctions for noncompliance in §§51.151-152. Sanctions include disallowance of all or a portion of payment, suspension of payment pending compliance, and recoupment of payment for services that a provider cannot verify as provided in the required amount, duration, and frequency. The complete notice is available on the PAB web site.

Copayments
DPW intends to change 55 Pa. Code §1101.63(b) that establishes copayment for covered MA services. Final-omitted regulations are to be implemented April 1. Changes affect MA-eligible individuals by eliminating provisions that require reimbursement of individuals eligible for General Assistance (GA) for copayments paid in excess of $180 in a six-month period and all other categories of MA recipients for copayments paid in excess of $90 in a six-month period. DPW will adjust the MA sliding scale copayment amounts to incorporate the current medical care component of the Consumer Price Index for All Urban Consumers (CPI-U) and will continue to update the amounts based on future CPI-U changes through notices published in the PAB. The sliding scale copayment amounts for GA will be updated to reflect copayment amounts that are twice that of MA as is current practice. Copayment of $2 for a one-way trip and $4 for a round trip will be required for non-emergency medical paratransit transportation services for individual who are eligible for MA or GA. The complete notice is available at http://www.pabulletin.com/secure/data/vol42/42-7/299.html. The governor’s proposed budget eliminates General Assistance.  

Pharmaceutical Services Payment Methodology
DPW intends to amend 55 Pa. Code §§1121.55 and 1121.56 to establish the dispensing fee paid to pharmacies at $2 for prescriptions for compensable, non-compounded legend and non-legend drugs, and $3 for compensable compounded prescriptions, and $0.50 for compensable legend and non-legend drugs for individuals with a primary third party resource to cover the pharmacy's cost to transmit the claim to the MA program for secondary payment. The estimated acquisition cost for brand name and generic drugs will be revised. DPW will also make technical changes to amend the list of noncompensable services and items to clarify payment for pharmaceutical services that have been in effect but have not yet been codified in regulation. DPW plans an April 1 effective date for these changes that may be reviewed at http://www.pabulletin.com/secure/data/vol42/42-7/300.html.

OLTL HCBS Provider Qualifications and Rates
DPW intends to promulgate HCBS regulations and submit waiver amendments needed for provider qualifications, payment methodology and rates for providers in MA Aging, Attendant Care, COMM CARE, Independence and OBRA HCBS waivers, and the Act 150 program. Regulation will create two payment methods for HCBS programs. The first method will establish a fee schedule rate that will be published as a notice in the PAB. The second method is for vendor goods and services that will be paid at actual cost. The list of vendor goods and services will be published as a notice in the PAB.

Providers will be required to submit an MA application, an MA provider agreement and addendum, verify fiscal solvency, create and follow various policies and procedures, and comply with waiver requirements. Critical incident reporting and investigation and risk management policies and procedures will be required. Provider monitoring will occur every two years. A quality management plan will be required. Service coordination will be conflict free. Regulations will establish audit requirements and sanctions for noncompliance with state and federal requirements. The complete notice is available at http://www.pabulletin.com/secure/data/vol42/42-7/302.html.

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