The bill introduces several changes aimed at improving the regulation of assisted living residences, healthcare billing processes, and Medicaid services. Below are the main provisions:
1. Exemption for Assisted Living Residences:
An assisted living residence with fewer than 19 beds, that has not undergone new construction or renovations, and that complies with the state standards for assisted living residences is exempted from complying with the facility guidelines adopted by the State Board of Health.
2. Medicaid Provider Rate Updates:
Beginning January 1, 2026, for claims that need to be reprocessed as a result of updated provider rates, a managed care organization (MCO) must issue payment to a contracted provider within one year after the provider rate is updated.
3. Managed Care Entities (MCEs):
The State Department of Health Care Policy and Financing (state department) must require MCEs to submit, on an annual basis, information on the amount they are paid and their medical loss ratio (MLR). This data must then be published on the state department’s website annually.
4. Physician and Practitioner Signature Requirements:
The bill prohibits the state department from imposing signature requirements on a physician or practitioner certifying a Medicaid member's plan of care that involves physical therapy or occupational therapy. This provision helps streamline the process for certification.
5. Home- and Community-Based Services (HCBS):
The bill ensures that Medicaid members receiving home- and community-based services will not lose access to these services as long as the member's disability and need for services have not changed in the preceding three years. This provision provides continuity of care for those dependent on these services.
6. Updating Billing Manual:
The State Department of Health Care Policy and Financing must follow the Centers for Medicare and Medicaid Services (CMS) standards when updating rules and establish a process for annual updates to the general billing manual, ensuring that it includes all necessary CPT codes.
The bill aims to reduce administrative burdens on smaller assisted living facilities, improve transparency in Medicaid managed care payments, and ensure continuity of care for members receiving home- and community-based services. It also streamlines the billing process by aligning with federal guidelines and improving the efficiency of provider rate updates.
Summary
The bill exempts an assisted living residence with fewer than 19
beds that has not undergone new construction or renovations and that complies with the standards for assisted living residences from complying with facility guidelines adopted by the state board of health.
The bill requires the department of health care policy and
financing (state department) to follow the standards set by the federal centers for medicare and medicaid when updating rules.
The state department must establish a process for reviewing and updating the general billing manual on an annual basis and ensure that the general billing manual includes all necessary CPT codes.
Beginning January 1, 2026, for claims that must be reprocessed as
a result of updating the provider rates, the bill requires a managed care organization to issue payment to a contracted provider within one year after the provider rate is updated.
The bill requires the state department to include in each new
contract with, or renewal of a contract with, a managed care entity (MCE) a provision requiring the MCE to submit to the state department, on an annual basis, the amount the MCE is paid and the MCE's medical loss ratio. The state department is required to publish this information on the state department's website on an annual basis.
The bill prohibits the state department from imposing signature
requirements on a physician or practitioner certifying a medicaid member's (member) plan of care that involves physical therapy or occupational therapy.
The bill prevents a member receiving home- and community-based
services from losing the services the member currently receives if the member's disability and need for services have not changed in the preceding 3 years.
