HB 440 — 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 prohibition on medical assistance managed care payment for provider-preventable conditions.

PRINTER'S NO.    409

                     THE GENERAL ASSEMBLY OF PENNSYLVANIA



                         HOUSE BILL
                         No. 440
                                               Session of
                                                 2025

     INTRODUCED BY SCIALABBA, GROVE AND ROWE, JANUARY 31, 2025

     REFERRED TO COMMITTEE ON HUMAN SERVICES, JANUARY 31, 2025


                                    AN ACT
 1   Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
 2      act to consolidate, editorially revise, and codify the public
 3      welfare laws of the Commonwealth," in public assistance,
 4      providing for prohibition on medical assistance managed care
 5      payment for provider-preventable conditions.
 6      The General Assembly of the Commonwealth of Pennsylvania
 7   hereby enacts as follows:
 8      Section 1.    The act of June 13, 1967 (P.L.31, No.21), known
 9   as the Human Services Code, is amended by adding a section to
10   read:
11      Section 449.3.    Prohibition on Medical Assistance Managed
12   Care Payment for Provider-Preventable Conditions.--(a)    A
13   medical assistance managed care organization may not pay for
14   provider-preventable conditions.
15      (b)   As used in this section, the following words and phrases
16   shall have the meanings given to them in this subsection:
17      "Medical assistance managed care organization" means a
18   Medicaid managed care organization as defined under 42 U.S.C. §
19   1396b(m)(1)(A) (relating to payment to states) that is a party
20   to a Medicaid managed care agreement with the department to
 1   provide physical or behavioral health services on a capitated
 2   basis.
 3      "Provider-preventable conditions" shall:
 4      (1)    Include the term as defined in 42 CFR 447.26 (relating
 5   to prohibition on payment for provider-preventable conditions).
 6      (2)    Mean any conditions occurring in a health care setting
 7   that meet the following criteria:
 8      (i)    is identified in the State plan in line with the fee-
 9   for-service program;
10      (ii)    has been found by the Commonwealth, based upon a review
11   of medical literature by qualified professionals, to be
12   reasonably preventable through the application of procedures
13   supported by evidence-based guidelines;
14      (iii)   has a negative consequence for the patient;
15      (iv)    is auditable; and
16      (v)    includes, at a minimum, any of the following:
17      (A)    a wrong surgical or other invasive procedure performed
18   on a patient;
19      (B)    a surgical or other invasive procedure performed on the
20   wrong body part; or
21      (C)    a surgical or other invasive procedure performed on the
22   wrong patient.
23      Section 2.    This act shall take effect in 60 days.




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