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SB 1371

An Act amending the act of June 13, 1967 (P.L.31, No.21), known as the Human Services Code, in public assistance, further providing for enrollment limitation.

2025-2026 Regular Session Introduced by Dawn Keefer

Requires a minimum 12-month enrollment in a managed care plan, with limited, documented opportunities to switch and strong good-cause protections.

Referred to Health & Human Services
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WeVote Research Nonpartisan
Bill Summary · SB 1371

Summary of SB 1371 (Session 2025-2026) – Pennsylvania Human Services Code (Enrollment Limitation)

Purpose and intent

  • Proposes to amend the Human Services Code to establish and regulate enrollment limitations and transfer rules for recipients enrolled in managed care plans under public assistance programs.
  • Aims to set minimum enrollment duration, clarify when changes of managed care plans are allowed, and require procedures for denials or approvals of plan changes, with consideration of federal authority and waivers.

Key provisions and changes

  • Section 458, Enrollment Limitation:
    • (a) Requirement to remain enrolled: Once an eligible person enrolls in a managed care plan and retains eligibility, they must stay enrolled for at least 12 months unless a waiver is granted by the department.
    • (b) Allowed changes without cause:
    • (1) Within 90 days after initial enrollment or after the department's enrollment notice (whichever is later).
    • (2) During an annual enrollment period, provided the department gives at least 60 days’ advance notice.
    • (3) For good cause, at any time.
    • (c) Good cause criteria (disenrollment bases):
    • (1) Moving out of service area.
    • (2) Plan’s refusal to cover a sought service due to moral or religious objections.
    • (3) Need for related services to be performed concurrently; if not all are available within the network and separate service delivery would pose unnecessary risk.
    • (4) For enrollees using managed long-term services and supports, disruption due to a provider status change from in-network to out-of-network affecting residence or employment.
    • (5) Other reasons including poor quality of care, lack of access to covered services, or lack of access to appropriately experienced providers.
    • (d) Documentation for good cause: Applications must be supported with adequate documentation; generic preferences, self-attestation without specifics, or unsupported dissatisfaction cannot justify a plan change.
    • (e) Poor quality of care standard: A change request based on poor quality must be supported by objective information (health, safety, access, continuity of care, medically necessary services). The department may rely on complaints, quality reports, external reviews, and other reliable sources. General dissatisfaction or unsupported assertions are insufficient.
    • (f) No broad waiver: Nothing in this section authorizes a blanket waiver allowing plan changes at any time without cause unless required by federal law or statute.
    • (g) Appeals and notice: The department must establish procedures for notice, review, and appeal of denied plan-change requests.
    • (h) Federal authority and implementation: The secretary must seek federal amendments or waivers (including 1915(b) waivers and related approvals) to implement enrollment limitations, annual plan selection periods, and a good-cause transfer process aligned with 42 CFR 438.56. Implementation is contingent on federal approval as required.

Who is affected

  • Eligible individuals enrolled in Pennsylvania public assistance managed care plans.
  • Managed care plans and the Pennsylvania Department of Human Services (or relevant department) responsible for enrollment, waivers, and administration of plan changes.
  • Providers, particularly those involved in long-term services and supports, as changes may affect provider networks and continuity of care.

Procedural and timeline aspects

  • Effective date: 60 days after enactment.
  • Enrollment discipline:
    • Minimum 12-month enrollment unless a waiver is granted.
    • Potential for plan change within specified windows (initial 90-day period, annual enrollment with 60-day notice, or for good cause anytime).
  • Good-cause determinations require supporting documentation.
  • Appeals process to be established by the department.
  • Federal waivers and amendments: Department must pursue federal approvals necessary to implement these changes (including enrollment limitations and a defined annual plan selection period) and condition implementation on obtaining those approvals.

Potential impact and considerations

  • Strengthens continuity requirements by ensuring a 12-month minimum enrollment in a managed care plan.
  • Introduces defined, limited opportunities to switch plans without cause, potentially reducing disruption but offering protections through good-cause criteria.
  • Emphasizes evidence-based approval for plan changes, aiming to prevent arbitrary transfers.
  • Requires administrative processes for notice, review, and federal compatibility, which may affect timelines and implementation complexity.

If you’d like, I can provide a quick comparison to current Pennsylvania law on enrollment and any anticipated federal waiver considerations based on 42 CFR 438.56.

Compiled from official sources — confirm details with the bill’s official record.

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