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SB 466

An Act amending Title 35 (Health and Safety) of the Pennsylvania Consolidated Statutes, in Commonwealth services, further providing for powers and duties and for curriculum, training and education certification management system; in grants to fire companies and emergency medical services companies, further providing for award of grants to fire companies and for award of grants to emergency medical services companies and providing for expiration of authority; and making a repeal.

2025-2026 Regular Session Introduced by Michele Brooks and 10 co-sponsors

The bill aims to preserve continuity of care for Medicaid beneficiaries in BH‑IDD Tailored Plans by enabling opt‑out to Medicaid Direct for non-contracted providers or opt‑in to cr

Act No. 25 of 2025
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WeVote Research Nonpartisan
Bill Summary · SB 466

Summary — SB 466: Ensure Continuity of Care in Tailored Plans

Status: Passed 1st reading (NC) — Effective when enacted
Introduced: February 19, 2025 (text provided); key deadlines: July 1, 2025 and August 1, 2025

Purpose / Intent

To preserve continuity of care for Medicaid beneficiaries enrolled in Behavioral Health / Intellectual & Developmental Disabilities (BH‑IDD) Tailored Plans (LME/MCOs) and to promote competition and innovation among those Tailored Plans. The bill directs the NC Department of Health and Human Services (DHHS), Division of Health Benefits, to seek federal approval of necessary Medicaid waiver amendments and to report back to the legislature with recommendations.

Key provisions

  • Waiver amendment submission (deadline: July 1, 2025)
    • DHHS must submit to CMS any amendment to the State’s 1115 Medicaid Transformation waiver necessary to implement the bill’s two options for beneficiaries:
    • Continuity-of-care opt‑out to Medicaid Direct (fee‑for‑service) for physical health services when a beneficiary’s existing provider(s) are not contracted with their LME/MCO Tailored Plan — if remaining in Medicaid Direct is needed as a reasonable accommodation to preserve continuity of care.
    • Geographic opt‑in across regions — beneficiaries may opt into a BH‑IDD Tailored Plan that operates outside their region when service arrays, provider networks, or available services differ across plans.
  • Legislative report (deadline: August 1, 2025)
    • DHHS must report to the Joint Legislative Oversight Committee on Medicaid with:
    • Recommendations to promote competition among LME/MCO Tailored Plans to foster innovation and better care;
    • Copies of all State Plan amendments or documents submitted to CMS per Section 1;
    • Any legislative changes necessary to implement Section 1 and other report recommendations.
  • Effective date
    • The act becomes effective upon enactment.

Who is affected

  • Primary: Medicaid beneficiaries enrolled in BH‑IDD Tailored Plans (and their families/caregivers), especially those whose physical‑health providers are outside plan networks or who require specialized services not available in their home region.
  • Providers: Community physical‑health and behavioral‑health providers (may see changes in contracting and billing pathways).
  • Payers/Plans: Local Management Entities / Managed Care Organizations (LME/MCOs) operating Tailored Plans — potential for altered enrollment patterns and cross‑regional competition.
  • State & federal: DHHS (administration/operational changes) and CMS (must approve waiver or SPA changes).

Practical and procedural implications

  • Federal approval required: Implementation depends on CMS acceptance of the State’s 1115 waiver (or other federal authorizations), which can take time and negotiation.
  • Administrative changes: Systems, provider contracting, care coordination, and billing processes must be adapted to allow cross‑program continuity (fee‑for‑service vs. managed care) and cross‑region plan enrollment.
  • Potential impacts:
    • Improved continuity of care for individuals with complex BH‑IDD needs and those in rural or underserved areas.
    • Possible shifts in enrollment and provider network dynamics that could affect plan finances, provider negotiations, and access patterns.
    • Legislative follow‑up: the mandated report may recommend statutory or budgetary adjustments to operationalize the changes.

If you’d like, I can draft a short explainer for beneficiaries or an implementation checklist for DHHS outlining operational steps the agency would need to take after CMS approval.

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

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