Pennsylvania Act 2024-115 — HUMAN SERVICES CODE - MEDICAL ASSISTANCE COVERAGE FOR DOULA SERVICES, THIRD PARTY LIABILITY AND DATA MATCHING

Act text

Session of 2024

No. 2024-115

HB 1608

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 medical assistance coverage for doula services; and, in fraud and abuse control, further providing for third party liability and for data matching.

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 443.15. Medical Assistance Coverage for Doula Services.--(a) Subject to Federal approval, doula services are compensable under the medical assistance program for eligible and enrolled medical assistance recipients during pregnancy, labor and delivery and up to one year postpartum.

(b) The department shall establish a Doula Advisory Board to advise the secretary regarding the following:

(1) Doula best practices.

(2) Doula participation in the medical assistance program.

(3) Racial and geographic disparities in the provision of maternal health services.

(4) Best practices to promote uniform access to care.

(c) The Doula Advisory Board shall include the following:

(1) The secretary.

(2) A representative from the Department of State.

(3) A representative from the Office of Medical Assistance Programs within the department.

(4) A representative from the Bureau of Family Health within the Department of Health.

(5) A representative from the Office of Health Equity within the Department of Health.

(6) A representative from a nationally recognized doula organization.

(7) A doula practicing in this Commonwealth.

(8) A member of the Maternal Mortality Review Committee established under the act of May 9, 2018 (P.L.118, No.24), known as the Maternal Mortality Review Act.

(9) A physician, licensed as a Doctor of Medicine or Doctor of Osteopathic Medicine under the laws of this Commonwealth, who practices in the field of obstetrics and gynecology and is a member of the Pennsylvania Medical Society.

(10) As deemed appropriate by the department, any other residents of this Commonwealth who represent the diverse demographics of Pennsylvania.

(d) The department shall seek a State plan amendment or Federal waiver from the Centers for Medicare and Medicaid Services, if needed, for provision of doula services under the medical assistance program.

(e) As used in this section, the term "doula" shall mean a professional trained to provide physical, emotional and informational support to a mother before, during and after childbirth.

Section 2. Section 1409(a)(2) of the act is amended to read:

Section 1409. Third Party Liability.--(a) * * *

(2) If such a person receives health care furnished or paid for by a publicly funded health care program, the insurer of his private health care coverage shall reimburse the publicly funded health care program, the cost incurred in rendering such care to the extent of the benefits provided under the terms of the policy for the services rendered , except as otherwise provided under section 1413(b.1) .

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Section 3. Section 1413 heading and (e.1) of the act are amended and the section is amended by adding a subsection to read:

Section 1413. Data Matching and Claims for Reimbursement .--* * *

(b.1) The following apply:

(1) All entities providing health insurance or health care coverage that require prior authorization for an item or service furnished to an individual who is also a medical assistance recipient shall accept the authorization from the medical assistance program that the item or service is covered under the medical assistance program for the recipient as if the authorization was the entity's prior authorization for the item or service.

(2) This subsection does not apply to the original Medicare fee-for-service program under Parts A and B of Title XVIII of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1395 et seq.), a Medicare Advantage plan offered by a Medicare Advantage organization under Part C of Title XVIII of the Social Security Act, a reasonable cost reimbursement contract under 42 U.S.C. § 1395mm (relating to payments to health maintenance organizations and competitive medical plans), a health care prepayment plan under 42 U.S.C. § 1395l (relating to payment of benefits) or a prescription drug plan offered by a prescription drug plan sponsor under Part D of Title XVIII of the Social Security Act.

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(e.1) It is a condition of doing business in this Commonwealth that every entity subject to this section comply with the provisions of this section and agree not to deny a claim submitted by the department on the basis of a plan or contract provision that is inconsistent with subsection (b.1) or (c).

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Section 4. If a necessary State plan amendment or Federal waiver under section 443.15 of the act is approved by the Centers for Medicare and Medicaid Services, the Secretary of Human Services shall transmit notice of the approval to the Legislative Reference Bureau for publication in the next available issue of the Pennsylvania Bulletin.

Section 5. This act shall take effect as follows:

(1) Except as provided under paragraph (2), the addition of section 443.15 of the act shall take effect 30 days following publication of the notice under section 4 of this act.

(2) The addition of section 443.15(b) and (c) of the act shall take effect immediately.

(3) The remainder of this act shall take effect immediately.

APPROVED--The 29th day of October, A.D. 2024.

JOSH SHAPIRO