NOTICES
Office of Developmental Programs Community Based Services; Provider Qualification and Rates
[42 Pa.B. 1006]
[Saturday, February 18, 2012]The purpose of this notice is to provide advance public notice of the Department of Public Welfare's (Department) intent to promulgate home and community-based services (HCBS) regulations and submit waiver amendments, as necessary, regarding provider qualifications and provider payment methodologies and rates. These regulations will apply to HCBS providers rendering services for the Medical Assistance (MA) Consolidated, Person/Family Directed Support and Adult Autism home and community-based service waivers, providers of targeted services management and base-funded providers offering services in a waiver service location.
Background
On July 1, 2011, the General Assembly enacted the act of June 30, 2011 (P. L. 89, No. 22) (Act 22), which amended the Public Welfare Code (code) (62 P. S. §§ 101—1503). Act 22 added several provisions to the code, including section 403.1 (62 P. S. § 403.1). Section 403.1(a)(4) and (6), (c) and (d) of the code authorizes the Department to promulgate final-omitted regulations under section 204(1)(iv) of the Commonwealth Documents Law (CDL)1 to establish or revise provider payment rates or fee schedules, reimbursement models or payment methodologies for particular services and to establish provider qualifications. In addition, to ensure that the Department's expenditures for State Fiscal Year (FY) 2011-2012 do not exceed the aggregate amount appropriated by the General Assembly, section 403.1 of the code expressly exempts the regulations from the Regulatory Review Act (71 P. S. §§ 745.1—745.12), section 205 of the CDL (45 P. S. § 1205) and section 204(b) of the Commonwealth Attorneys Act (71 P. S. § 732-204(b)).
The Office of Developmental Program's HCBS programs have grown 141% in the past 11 years and the cost of these programs has increased from $752 million in FY 2000 to $1.81 billion in FY 2011. To strengthen program integrity and to improve cost efficiencies of these programs, the Department will be promulgating regulations.
The following is a summary of the major provisions of this rulemaking:
§ 51.11 (relating to prerequisites for provider participation).
The regulation will require providers to meet prerequisites prior to enrollment to verify providers are qualified to provide services. A provider will be required to complete the provider enrollment application, sign an MA provider agreement and HCBS provider agreement and submit supporting qualification documentation. Providers will also be required to comply with the approved applicable waivers, including approved waiver amendments, as provided at http://www.dpw.state.pa.us/dpworganization/officeofdevelopmentalprograms/index.htm.
§ 51.13. (relating to ongoing responsibilities of providers).
The regulation will establish the process to act on a provider's failure to continue to remain qualified by submitting qualification documentation. A provider will be required to be requalified on a 2-year cycle. If a provider fails to submit the qualification documentation, the provider will no longer be qualified to provide that service.
§ 51.23. (relating to provider training).
The regulation will require annual staff training as required in a participant's individual support plan (ISP), including direct care workers hired by a participant.
§ 51.25. (relating to quality management).
The regulation will require providers to create, implement and update a quality management plan, which describes how the provider will measure, remediate and improve its performance.
§ 51.31. (relating to back-up plans).
The regulation will require providers to have a back-up plan to eliminate deviations in service frequency and duration so all approved and authorized services are implemented as established in a participant's ISP.
Chapter 51, Subchapter C (relating to payment for services).
The regulation will identify the payment methodologies for which services will be reimbursed. The methodologies for setting payment rates will be made under one of the following methods: cost-based reimbursement; MA Program fee schedule reimbursement; or reimbursement as vendor goods and services.
The cost based rate methodology is based on approved cost report data submitted by providers and approved in a desk review process. This is the same methodology as provided at 41 Pa.B. 6175 (November 12, 2011) for the time period July 1, 2011, through November 14, 2011, and 41 Pa.B. 6173 (November 12, 2011) for the time period July 1, 2011, through November 14, 2011.
The MA Program fee schedule reimbursement payment methodology includes a review of the service definitions under the waiver and a determination of allowable cost components which reflect costs that are reasonable, necessary, and related to the delivery of the service. This is the same methodology and rates as provided at 41 Pa.B. 6168 (November 12, 2011) for the time period July 1, 2011, through November 14, 2011, and 41 Pa.B. 6163 (November 12, 2011) for the time period November 15, 2011, through June 30, 2012.
For a limited number of goods and services provided through the HCBS program, referred to as vendor goods and services, these goods and services are reimbursed for the actual cost of the service. The regulation will provide that the Department will publish the list of vendor goods and services as a public notice in the Pennsylvania Bulletin.
In addition, this subchapter will specify provider billing, audit and cost report requirements. Providers that are governed by the Single Audit Act (31 U.S.C.A. §§ 7501—7507) are required to comply with Single Audit Act. Other providers will be required to retain books, records and documents for audit and inspection for at least 5 years from the provider's State fiscal year end.
§§ 51.151 and 51.152. (relating to termination of provider agreement; and sanctions).
The regulation will provide for sanctions or termination of a provider if a provider fails to comply with the requirements of the regulation. These sanctions include disallowing all or a portion of a payment, suspending a current or future payment pending compliance, and recouping payments for services a provider cannot verify as being provided in the required amount, duration and frequency.
Fiscal Impact
The Department anticipates savings of approximately $8.028 million in State funds for FY 2011-2012.
Public Comment
Copies of this notice may be obtained at the local Mental Health/Mental Retardation (MH/MR) County Program, Administrative Entity (AE) or regional Office of Developmental Programs in the corresponding regions:
• Western region: Piatt Place, Room 4900, 301 5th Avenue, Pittsburgh, PA 15222, (412) 565-5144
• Northeast region: Room 315, Scranton State Office Building, 100 Lackawanna Avenue, Scranton, PA 18503, (570) 963-4749
• Southeast region: 801 Market Street, Suite 5071, Philadelphia, PA 19107, (215) 560-2242 or (215) 560-2245
• Central region: Room 430, Willow Oak Building, P. O. Box 2675, DGS Annex Complex, Harrisburg, PA 17105, (717) 772-6507
Contact information for the local MH/MR County Program or AE may be accessed through a link on the internet at https://www.hcsis.state.pa.us/hcsis-ssd/pgm/asp/PRCNT.ASP, or contact the previously referenced regional Office of Developmental Programs (ODP).
Interested persons are invited to submit written comments regarding HCBS provider qualifications and the provider payment rates and methodology to the Department within 15 days from the date of publication of this notice by sending an e-mail to ODP's rate-setting mailbox at ra-ratesetting@pa.gov, use subject header ''PN Community based services; provider qualifications and rates'' or send postal mail to the Department of Public Welfare, Office of Developmental Programs, Division of Provider Assistance and Rate Setting, 4th Floor, Health and Welfare Building, Forster and Commonwealth Avenues, Harrisburg, PA 17120.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
GARY D. ALEXANDER,
SecretaryFiscal Note: 14-NOT-745. No fiscal impact; (8) recommends adoption. The Department anticipates that these changes will result in savings of $8.028 million in State funds in 2011-12.
[Pa.B. Doc. No. 12-304. Filed for public inspection February 17, 2012, 9:00 a.m.] _______
1 The act of July 31, 1968 (P. L. 769, No. 240) (45 P. S. § 1204(1)(iv). Section 204(1)(iv) of the CDL authorizes an agency to omit or modify notice of proposed rulemaking when a regulation relates to Commonwealth grants or benefits. The Medical Assistance Waiver Program is a Commonwealth grant program through which eligible recipients receive coverage of certain benefits.
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