An Act amending the act of June 13, 1967 (P.L.31, No.21), known as the Human Services Code, in public assistance, providing for pending medical assistance applications.

PRINTER'S NO. 3449
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 2543
Session of
2026
INTRODUCED BY VENKAT, PROBST, McNEILL, HILL-EVANS, MERSKI,
PARKER, SANCHEZ, CIRESI, CEPEDA-FREYTIZ AND KUZMA,
MAY 27, 2026
REFERRED TO COMMITTEE ON AGING AND OLDER ADULT SERVICES,
MAY 27, 2026
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 pending medical assistance applications.
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. Pending Medical Assistance Applications.--(a)
The department shall develop and implement a standardized
process to be adhered to by all county assistance offices when a
medical assistance application for long-term care services is
received. The process must include the following requirements:
(1) Prior to rendering a decision on a medical assistance
application, the caseworker assigned to the application shall:
(i) Review and take into account all submitted documentation
related to the individual's eligibility for long-term care
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medical assistance.
(ii) Use all resources and tools available, including the
Asset Verification System, to obtain documentation necessary to
make an informed decision on the application.
(iii) If, after considering and reviewing all submitted
documentation and other accessible information available,
additional documentation is needed, no later than ten days from
the date of the application, send a pending letter to the
provider electronically, advising the provider of the following:
(A) a list of any specific outstanding documentation needed
to render an informed decision on the application;
(B) direct contact information for the caseworker assigned
to the application; and
(C) a time frame to submit the outstanding documentation
requested.
(iv) Communicate weekly with the provider, using a
standardized electronic communication template developed by the
department to provide status of the application and specify any
outstanding documentation needed to process the application.
(2) When a medical assistance application for long-term care
services is denied, the caseworker assigned to the application
shall:
(i) Honor the provider's request for a reconsideration of
the denial and, within ten days of receipt of related documents,
review and take appropriate action on the application. If, as a
result of the review of the information, the application can be
approved, approve the application and issue a notice of
eligibility to the provider within seven calendar days. If the
application cannot be approved, send an electronic notice
stating the reason for the denial and any additional information
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or documentation that is needed.
(ii) Review and act on any newly submitted documentation
subsequent to a request for a fair hearing within ten days of
receipt of the documentation. If, as a result of the review of
the new documentation, the application can be approved, approve
the application and issue a notice of eligibility to the
provider within seven calendar days.
(3) Regardless of the status of the medical assistance
application for long-term care services, including pending,
denied, appealed or under stipulation, the caseworker assigned
to the application shall review and act on all submitted
documentation within ten days of receipt. If, after review of
the documentation, the application can be approved, issue an
eligibility notice to the provider within seven calendar days.
(4) No later than ninety days following the end of each
calendar year, the department shall issue a public report, for
the prior calendar year, to the chair of the Health and Human
Services Committee of the Senate and the chair of the Human
Services Committee of the House of Representatives that includes
the following information from county assistance offices:
(i) The total number of medical assistance applications for
long-term care services submitted.
(ii) The total number of medical assistance applications for
long-term care services approved on initial determination.
(iii) The total number of medical assistance applications
for long-term care services denied on initial determination and
approved through the appeal process.
(iv) The total number of medical assistance applications for
long-term care services approved for uncompensated care
payments.
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(v) The total number of medical assistance applications for
long-term care services approved for uncompensated care payments
but denied on final determination.
(5) The report under paragraph (4) shall be made publicly
available on the department's publicly accessible Internet
website.
(b) If a resident has an application of eligibility for
medical assistance long-term care services in a nursing facility
pending with the department, the department shall include:
(1) the resident in the nursing facility's census as a
medical assistant resident; and
(2) the resident's case-mix index picture date data in the
rate determination for the relevant rate quarter during the time
the application is pending.
(c) If a medical assistance application for an individual
residing at a long-term care provider has been pending at the
department for at least sixty days for one of the following
reasons, the provider may request an uncompensated care payment
from the department:
(1) the determination of an initial or renewal application
of medical assistance has not been made; or
(2) the initial medical assistance application was denied,
and an appeal was submitted and received by the department to
amend the application.
(d) The department shall make payment to the provider for
the uncompensated care as though the application were approved,
beginning on the date of request for uncompensated care payment.
Payment under this subsection shall not be made for the dates of
service prior to the provider's request but shall continue
thereafter until the department makes a final determination on
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the application.
(e) If the determination for benefits is denied, the
department shall have the right of recovery, offset or
recoupment with respect to payments made for dates of service
beginning with initial application through sixty days following
the request of the provider to receive an uncompensated care
payment. The department may not recover, offset or recoup
payments received for dates of service for the period sixty days
after the date of the provider's request for uncompensated care
payments. In the event the application is approved, the
department may offset payments due for the dates of service
between the date of the provider's request and the final
determination by amounts already paid.
(f) A provider providing uncompensated care to a medical
assistance applicant that submitted an application on behalf of
the applicant shall be provided the status of the application
from the county assistance office on a weekly basis until the
application has final resolution.
(g) A provider providing uncompensated care to a medical
assistance applicant that did not submit the application on
behalf of the applicant may inquire of the secretary or designee
as to the status of the individual's application, and the
secretary or designee shall respond within five business days as
follows:
(1) If the provider has not obtained a signed release, the
secretary or designee shall provide the following information
only in writing:
(i) whether or not the application has been approved;
(ii) the identity of any authorized representative; and
(iii) if the application has not yet been decided whether or
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not the application is a complete application.
(2) If the provider has obtained a signed release, the
secretary or designee shall, in addition to the information
listed under paragraph (1), provide any other information
requested by the provider, to the extent that the release
permits disclosure of the information.
(h) As used in this section, the following words and phrases
shall have the meanings given to them in this subsection unless
the context clearly indicates otherwise:
"Long-term care provider" or "provider" means as follows:
(1) One of the following:
(i) A long-term care nursing facility that is:
(A) licensed by the Department of Health;
(B) enrolled in the Medical Assistance Program as a provider
of nursing facility services; and
(C) owned by an individual, partnership, association or
corporation and operated on a profit or nonprofit basis.
(ii) A county nursing facility as defined under 55 Pa. Code
§ 1187.2 (relating to definitions).
(iii) A managed care program that provides all-inclusive
care for elderly individuals in this Commonwealth as established
in accordance with 42 CFR Pt. 460 (relating to programs of all-
inclusive care for the elderly (PACE)).
(2) The term does not include an intermediate care facility
for persons with an intellectual disability, Federal-owned or
State-owned long-term care nursing facility or veterans' home.
"Long-term care services" means services provided by a long-
term care provider.
Section 2. This act shall take effect in 60 days.
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