An Act establishing the Medicaid Care Transition Program; and imposing duties on the Department of Human Services.

PRINTER'S NO. 21
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No. 58
Session of
2025
INTRODUCED BY FARRY AND FONTANA, JANUARY 22, 2025
REFERRED TO INSTITUTIONAL SUSTAINABILITY AND INNOVATION,
JANUARY 22, 2025
AN ACT
Establishing the Medicaid Care Transition Program; and imposing
duties on the Department of Human Services.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the Medicaid Care
Transition Program Act.
Section 2. Legislative findings.
The General Assembly finds and declares as follows:
(1) Hospital emergency departments are one of the main
entry points to obtaining critical health care services when
patients are in crisis.
(2) While emergency departments effectively assess and
triage patients in need of behavioral health care or other
long-term care services, hospitals often face long delays in
dispositioning patients to appropriate inpatient and
outpatient treatment settings, causing patients to wait in
the emergency department for extended periods of time.
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(3) Delayed disposition of patients impacts both
patients and delivery system outcomes, increasing
psychological stress on patients and their families, delaying
treatment that could mitigate the need for inpatient stays,
consuming scarce emergency department resources, worsening
emergency department crowding and delaying treatment for
other patients.
Section 3. Purpose.
The purpose of the Medicaid Care Transition Program is to
establish clear steps and responsibility for escalating cases,
where placement of individuals enrolled in Medicaid has not been
achieved in a reasonable period of time, to senior clinical
leadership within responsible entities and senior officials with
the department.
Section 4. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Department." The Department of Human Services of the
Commonwealth.
"Hospital." The following:
(1) A "hospital" as defined in 28 Pa. Code § 101.4
(relating to definitions) located inside or outside of this
Commonwealth.
(2) A behavioral health crisis center.
"Patient." An individual, enrolled in the Medicaid program,
being served in a hospital emergency department, inpatient unit
or crisis response center who has been identified as requiring
postacute treatment.
"Responsible entity." A county Medicaid managed care plan or
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other organization contractually or statutorily required to
ensure access to medically necessary postacute care for Medicaid
enrollees.
Section 5. Medicaid Care Transition Program.
(a) Establishment.--The Medicaid Care Transition Program is
established within the department for the purposes under this
section.
(b) Escalation policy.--Within 180 days of the effective
date of this subsection, the department shall establish policies
and procedures that require responsible entities to establish
care transition units responsible for working directly with
hospitals to identify appropriate postacute placements for
individuals awaiting transfer. The policies and procedures shall
require the responsible entity to, at a minimum:
(1) Ensure that hospitals have appropriate contact
information for the care transition units of responsible
entities.
(2) Establish a formal request for assistance mechanism
that triggers a process to facilitate the admission of the
patient to an appropriate setting.
(3) Require the responsible entity to mitigate any
authorization issues that are presenting barriers to a
successful placement.
(4) Require the responsible entity, if a placement in an
in-network provider is not anticipated to be available within
24 hours from the request for assistance, to seek placement
in appropriate out-of-network facilities, taking into account
services required by the individual, geography and other
relevant factors.
(5) Remain actively engaged and seek to obtain admission
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of the individual until a placement has been secured.
(6) Once a responsible entity has exhausted its network
and appropriate out-of-network options, or after another 48
hours has elapsed from a request for assistance, notify the
department of the failure to find the necessary placement.
(c) Department responsibilities.--The department shall,
after being notified of the failure to find medically
appropriate placement under subsection (b)(6):
(1) Establish an internal team to work with the
responsible entity to determine next steps to address
barriers to a postacute placement in a timely matter.
(2) If a barrier is clinically based, convene
conversations with clinical leaders of the responsible entity
to understand and resolve these barriers.
(3) If a barrier to admission requires other State
agencies to resolve the issue, convene a conference call with
the appropriate State agency representatives, providers,
responsible entities and other payors as well as others
needed to resolve the issues.
(4) If a barrier concerns payment, facilitate a
discussion with the responsible entity to address network
adequacy and payment issues with the responsible entity and
consult with the Insurance Department, as may be appropriate,
to address network adequacy issues.
(5) Collect data about the interventions under this
subsection and review the data as part of relevant licensing
surveys.
(6) Require corrective action plans from responsible
entities, as appropriate.
Section 6. Report.
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(a) Preparation and submittal.--No later than one year after
the effective date of this subsection, and on an annual basis
thereafter, the department shall prepare and submit a report in
accordance with subsection (b) to:
(1) The chairperson and minority chairperson of the
Health and Human Services Committee of the Senate.
(2) The chairperson and minority chairperson of the
Health Committee of the House of Representatives.
(3) The chairperson and minority chairperson of the
Human Services Committee of the House of Representatives.
(b) Contents.--Each report under this section must include
the following:
(1) A general summary describing the establishment of
the escalation policy and the department's compliance with
the requirements of this act.
(2) The number of instances that responsible entities
have notified the department of the responsible entities'
inability to find a necessary placement under section 5(b)
(6), sorted by the name of the responsible entity and region
of this Commonwealth, among other relevant factors.
(3) A summary of the department's activities under
section 5(c) to work internally to find appropriate
placements for individuals requiring postacute placements.
(4) Information on the diagnosis and length of the
hospital stay for de-identified individuals, prior to
discharge, referred to the department under this act.
(5) Information on corrective action taken by the
department to address delays in finding postacute placements
for individuals awaiting transfer.
Section 7. Effective date.
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This act shall take effect in 60 days.
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