SB 58 — 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
 1   Establishing the Medicaid Care Transition Program; and imposing
 2      duties on the Department of Human Services.
 3      The General Assembly of the Commonwealth of Pennsylvania
 4   hereby enacts as follows:
 5   Section 1.   Short title.
 6      This act shall be known and may be cited as the Medicaid Care
 7   Transition Program Act.
 8   Section 2.   Legislative findings.
 9      The General Assembly finds and declares as follows:
10          (1)   Hospital emergency departments are one of the main
11      entry points to obtaining critical health care services when
12      patients are in crisis.
13          (2)   While emergency departments effectively assess and
14      triage patients in need of behavioral health care or other
15      long-term care services, hospitals often face long delays in
16      dispositioning patients to appropriate inpatient and
17      outpatient treatment settings, causing patients to wait in
18      the emergency department for extended periods of time.
 1          (3)   Delayed disposition of patients impacts both
 2      patients and delivery system outcomes, increasing
 3      psychological stress on patients and their families, delaying
 4      treatment that could mitigate the need for inpatient stays,
 5      consuming scarce emergency department resources, worsening
 6      emergency department crowding and delaying treatment for
 7      other patients.
 8   Section 3.   Purpose.
 9      The purpose of the Medicaid Care Transition Program is to
10   establish clear steps and responsibility for escalating cases,
11   where placement of individuals enrolled in Medicaid has not been
12   achieved in a reasonable period of time, to senior clinical
13   leadership within responsible entities and senior officials with
14   the department.
15   Section 4.   Definitions.
16      The following words and phrases when used in this act shall
17   have the meanings given to them in this section unless the
18   context clearly indicates otherwise:
19      "Department."    The Department of Human Services of the
20   Commonwealth.
21      "Hospital."    The following:
22          (1)   A "hospital" as defined in 28 Pa. Code § 101.4
23      (relating to definitions) located inside or outside of this
24      Commonwealth.
25          (2)   A behavioral health crisis center.
26      "Patient."     An individual, enrolled in the Medicaid program,
27   being served in a hospital emergency department, inpatient unit
28   or crisis response center who has been identified as requiring
29   postacute treatment.
30      "Responsible entity."    A county Medicaid managed care plan or

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 1   other organization contractually or statutorily required to
 2   ensure access to medically necessary postacute care for Medicaid
 3   enrollees.
 4   Section 5.     Medicaid Care Transition Program.
 5      (a)     Establishment.--The Medicaid Care Transition Program is
 6   established within the department for the purposes under this
 7   section.
 8      (b)     Escalation policy.--Within 180 days of the effective
 9   date of this subsection, the department shall establish policies
10   and procedures that require responsible entities to establish
11   care transition units responsible for working directly with
12   hospitals to identify appropriate postacute placements for
13   individuals awaiting transfer. The policies and procedures shall
14   require the responsible entity to, at a minimum:
15            (1)   Ensure that hospitals have appropriate contact
16      information for the care transition units of responsible
17      entities.
18            (2)   Establish a formal request for assistance mechanism
19      that triggers a process to facilitate the admission of the
20      patient to an appropriate setting.
21            (3)   Require the responsible entity to mitigate any
22      authorization issues that are presenting barriers to a
23      successful placement.
24            (4)   Require the responsible entity, if a placement in an
25      in-network provider is not anticipated to be available within
26      24 hours from the request for assistance, to seek placement
27      in appropriate out-of-network facilities, taking into account
28      services required by the individual, geography and other
29      relevant factors.
30            (5)   Remain actively engaged and seek to obtain admission

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 1      of the individual until a placement has been secured.
 2            (6)   Once a responsible entity has exhausted its network
 3      and appropriate out-of-network options, or after another 48
 4      hours has elapsed from a request for assistance, notify the
 5      department of the failure to find the necessary placement.
 6      (c)   Department responsibilities.--The department shall,
 7   after being notified of the failure to find medically
 8   appropriate placement under subsection (b)(6):
 9            (1)   Establish an internal team to work with the
10      responsible entity to determine next steps to address
11      barriers to a postacute placement in a timely matter.
12            (2)   If a barrier is clinically based, convene
13      conversations with clinical leaders of the responsible entity
14      to understand and resolve these barriers.
15            (3)   If a barrier to admission requires other State
16      agencies to resolve the issue, convene a conference call with
17      the appropriate State agency representatives, providers,
18      responsible entities and other payors as well as others
19      needed to resolve the issues.
20            (4)   If a barrier concerns payment, facilitate a
21      discussion with the responsible entity to address network
22      adequacy and payment issues with the responsible entity and
23      consult with the Insurance Department, as may be appropriate,
24      to address network adequacy issues.
25            (5)   Collect data about the interventions under this
26      subsection and review the data as part of relevant licensing
27      surveys.
28            (6)   Require corrective action plans from responsible
29      entities, as appropriate.
30   Section 6.     Report.

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 1      (a)   Preparation and submittal.--No later than one year after
 2   the effective date of this subsection, and on an annual basis
 3   thereafter, the department shall prepare and submit a report in
 4   accordance with subsection (b) to:
 5            (1)   The chairperson and minority chairperson of the
 6      Health and Human Services Committee of the Senate.
 7            (2)   The chairperson and minority chairperson of the
 8      Health Committee of the House of Representatives.
 9            (3)   The chairperson and minority chairperson of the
10      Human Services Committee of the House of Representatives.
11      (b)   Contents.--Each report under this section must include
12   the following:
13            (1)   A general summary describing the establishment of
14      the escalation policy and the department's compliance with
15      the requirements of this act.
16            (2)   The number of instances that responsible entities
17      have notified the department of the responsible entities'
18      inability to find a necessary placement under section 5(b)
19      (6), sorted by the name of the responsible entity and region
20      of this Commonwealth, among other relevant factors.
21            (3)   A summary of the department's activities under
22      section 5(c) to work internally to find appropriate
23      placements for individuals requiring postacute placements.
24            (4)   Information on the diagnosis and length of the
25      hospital stay for de-identified individuals, prior to
26      discharge, referred to the department under this act.
27            (5)   Information on corrective action taken by the
28      department to address delays in finding postacute placements
29      for individuals awaiting transfer.
30   Section 7.     Effective date.

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1     This act shall take effect in 60 days.




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