On Friday, August 30, 2024, Pennsylvania's Office of Development Programs (ODP) published final fee schedule rates for services provided under Pennsylvania's Medicaid waiver programs to individuals with intellectual disabilities and/or autism. Most of the rates become effective immediately with a retroactive date to July 1, 2024, while a smaller subset of the rates will take effect on October 1, 2024. The rates will be officially published in the Pennsylvania Bulletin on Saturday, August 31, 2024. The Pennsylvania Bulletin notice is available online here.
Based on the August 31, 2024 publication date, any ID/A service providers who wish to appeal the rates must have their appeals received by the Bureau of Hearings and Appeals (BHA) within the Department of Human Services no later than September 30, 2024.
Vorys will be joining the panelists in a complimentary webinar presented by Pennsylvania Advocates and Resources for Autism and Intellectual Disabilities (PAR) on the rate appeals process on September 10, 2024, from 3:00-4:30pm. PAR members can register for the webinar at www.par.net.
Vorys is proud to represent numerous ID/A providers in rate appeals pending before BHA and is accepting new clients who wish to appeal the newly published rates. Providers interested in discussing how Vorys can represent their organization at no financial risk to the provider should contact one of the listed Vorys lawyers as soon as possible, to ensure compliance with the September 30 deadline.
Background
Services to the ID/A community are funded through a mixture of federal dollars and state-budget dollars through Pennsylvania's approved Medicaid waiver(s) with the Centers for Medicaid Services (CMS). As there is no significant private payor or third-party payor system for these services in Pennsylvania, ODP (as the state agency that oversees the waiver programs for ID/A services) acts effectively as the single payor for the industry.
Services funded through Consolidated, Community Living, and Person/Family Directed Support (P/FDS) Waivers and the Adult Autism Waiver are paid based on published fee schedule rates, which are typically updated roughly every three years. ODP most recently updated the fee schedule rates paid for certain services (Community Participation Services, Transportation Rates, Group Equine Therapy, and Group Music Therapy) in November 2023. Prior to that, the last wholesale fee schedule rate update became effective on January 1, 2022.
Pennsylvania law (Title 55, Chapter 41 of the Pa. Code) provides every ID/A provider the legal right to appeal any ODP agency action impacting that provider, including the setting of fee schedule rates. Recent decisions by Pennsylvania's appellate courts have upheld that the provider's right to appeal rates to BHA is a mandatory administrative remedy, making BHA rate appeals the provider's sole avenue to challenge any aspect of the rate setting process. While the issuance of new fee schedule rates triggers a 30-day window for every Pennsylvania ID/A provider to file an appeal, few providers (estimated at less than 10%) do so, historically.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.