2015 -- H 5515

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LC000992

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2015

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A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL ASSISTANCE

     

     Introduced By: Representatives Slater, Serpa, Diaz, Hull, and Bennett

     Date Introduced: February 12, 2015

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

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     SECTION 1. Section 40-8.9-9 of the General Laws in Chapter 40-8.9 entitled "Medical

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Assistance - Long-Term Care Service and Finance Reform" is hereby amended to read as

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follows:

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     40-8.9-9. Long-term care re-balancing system reform goal. -- (a) Notwithstanding any

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other provision of state law, the department of human services is authorized and directed to apply

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for and obtain any necessary waiver(s), waiver amendment(s) and/or state plan amendments from

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the secretary of the United States department of health and human services, and to promulgate

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rules necessary to adopt an affirmative plan of program design and implementation that addresses

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the goal of allocating a minimum of fifty percent (50%) of Medicaid long-term care funding for

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persons aged sixty-five (65) and over and adults with disabilities, in addition to services for

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persons with developmental disabilities and mental disabilities, to home and community-based

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care on or before December 31, 2013; provided, further, the executive office of health and human

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services shall report annually as part of its budget submission, the percentage distribution

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between institutional care and home and community-based care by population and shall report

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current and projected waiting lists for long-term care and home and community-based care

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services. The department is further authorized and directed to prioritize investments in home and

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community-based care and to maintain the integrity and financial viability of all current long-

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term care services while pursuing this goal.

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      (b) The reformed long-term care system re-balancing goal is person-centered and

 

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encourages individual self-determination, family involvement, interagency collaboration, and

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individual choice through the provision of highly specialized and individually tailored home-

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based services. Additionally, individuals with severe behavioral, physical, or developmental

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disabilities must have the opportunity to live safe and healthful lives through access to a wide

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range of supportive services in an array of community-based settings, regardless of the

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complexity of their medical condition, the severity of their disability, or the challenges of their

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behavior. Delivery of services and supports in less costly and less restrictive community settings,

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will enable children, adolescents and adults to be able to curtail, delay or avoid lengthy stays in

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long-term care institutions, such as behavioral health residential treatment facilities, long-term

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care hospitals, intermediate care facilities and/or skilled nursing facilities.

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      (c) Pursuant to federal authority procured under § 42-7.2-16 of the general laws, the

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department of human services is directed and authorized to adopt a tiered set of criteria to be used

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to determine eligibility for services. Such criteria shall be developed in collaboration with the

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state's health and human services departments and, to the extent feasible, any consumer group,

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advisory board, or other entity designated for such purposes, and shall encompass eligibility

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determinations for long-term care services in nursing facilities, hospitals, and intermediate care

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facilities for the mentally retarded as well as home and community-based alternatives, and shall

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provide a common standard of income eligibility for both institutional and home and community-

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based care. The department is, subject to prior approval of the general assembly, authorized to

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adopt criteria for admission to a nursing facility, hospital, or intermediate care facility for the

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mentally retarded that are more stringent than those employed for access to home and

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community-based services. The department is also authorized to promulgate rules that define the

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frequency of re-assessments for services provided for under this section. Legislatively approved

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levels of care may be applied in accordance with the following:

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      (1) The department shall apply pre-waiver level of care criteria for any Medicaid

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recipient eligible for a nursing facility, hospital, or intermediate care facility for the mentally

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retarded as of June 30, 2009, unless the recipient transitions to home and community based

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services because he or she: (a) Improves to a level where he/she would no longer meet the pre-

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waiver level of care criteria; or (b) The individual chooses home and community based services

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over the nursing facility, hospital, or intermediate care facility for the mentally retarded. For the

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purposes of this section, a failed community placement, as defined in regulations promulgated by

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the department, shall be considered a condition of clinical eligibility for the highest level of care.

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The department shall confer with the long-term care ombudsperson with respect to the

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determination of a failed placement under the ombudsperson's jurisdiction. Should any Medicaid

 

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recipient eligible for a nursing facility, hospital, or intermediate care facility for the mentally

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retarded as of June 30, 2009 receive a determination of a failed community placement, the

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recipient shall have access to the highest level of care; furthermore, a recipient who has

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experienced a failed community placement shall be transitioned back into his or her former

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nursing home, hospital, or intermediate care facility for the mentally retarded whenever possible.

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Additionally, residents shall only be moved from a nursing home, hospital, or intermediate care

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facility for the mentally retarded in a manner consistent with applicable state and federal laws.

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      (2) Any Medicaid recipient eligible for the highest level of care who voluntarily leaves a

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nursing home, hospital, or intermediate care facility for the mentally retarded shall not be subject

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to any wait list for home and community based services.

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      (3) No nursing home, hospital, or intermediate care facility for the mentally retarded

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shall be denied payment for services rendered to a Medicaid recipient on the grounds that the

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recipient does not meet level of care criteria unless and until the department of human services

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has: (i) performed an individual assessment of the recipient at issue and provided written notice to

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the nursing home, hospital, or intermediate care facility for the mentally retarded that the

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recipient does not meet level of care criteria; and (ii) the recipient has either appealed that level of

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care determination and been unsuccessful, or any appeal period available to the recipient

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regarding that level of care determination has expired.

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      (d) The department of human services is further authorized and directed to consolidate

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all home and community-based services currently provided pursuant to § 1915(c) of title XIX of

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the United States Code into a single system of home and community-based services that include

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options for consumer direction and shared living. The resulting single home and community-

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based services system shall replace and supersede all § 1915(c) programs when fully

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implemented. Notwithstanding the foregoing, the resulting single program home and community-

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based services system shall include the continued funding of assisted living services at any

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assisted living facility financed by the Rhode Island housing and mortgage finance corporation

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prior to January 1, 2006, and shall be in accordance with chapter 66.8 of title 42 of the general

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laws as long as assisted living services are a covered Medicaid benefit.

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      (e) The department of human services is authorized to promulgate rules that permit

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certain optional services including, but not limited to, homemaker services, home modifications,

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respite, and physical therapy evaluations to be offered subject to availability of state-appropriated

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funding for these purposes.

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      (f) To promote the expansion of home and community-based service capacity, the

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department of human services is and executive office of health and human services is authorized

 

LC000992 - Page 3 of 6

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and directed to pursue rate reform for homemaker, personal care (home health aide) and adult day

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care services, as follows:

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      (1) A prospective base adjustment effective, not later than July 1, 2008, across all

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departments and programs, of ten percent (10%) of the existing standard or average rate,

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contingent upon a demonstrated increase in the state-funded or Medicaid caseload by June 30,

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2009;

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      (2) Development, not later than September 30, 2008, of certification standards

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supporting and defining targeted rate increments to encourage service specialization and

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scheduling accommodations including, but not limited to, medication and pain management,

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wound management, certified Alzheimer's Syndrome treatment and support programs, and shift

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differentials for night and week-end services; and

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      (3) Development and submission to the governor and the general assembly, not later than

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December 31, 2008, of a proposed rate-setting methodology for home and community-based

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services to assure coverage of the base cost of service delivery as well as reasonable coverage of

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changes in cost caused by wage inflation.

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     (2) A prospective base adjustment effective not later than October 1, 2015 across all

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departments and programs of ten percent (10%) of the existing base rate.

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     (3) Development of rate enhancements for complex adult day participants to reflect

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participant acuity, dementia care, and other criteria as determined by the department of human

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services and executive office of health and human services, to be implemented on January 1,

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2016.

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     (4) Annual adjustments to the provider reimbursement rates by a percentage amount

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equal to the change in a recognized national long-term care inflation index to begin on October 1,

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2016.

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     (g) The department, in collaboration with the executive office of human services, shall

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implement a long-term care options counseling program to provide individuals or their

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representatives, or both, with long-term care consultations that shall include, at a minimum,

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information about: long-term care options, sources and methods of both public and private

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payment for long-term care services and an assessment of an individual's functional capabilities

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and opportunities for maximizing independence. Each individual admitted to or seeking

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admission to a long-term care facility regardless of the payment source shall be informed by the

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facility of the availability of the long-term care options counseling program and shall be provided

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with long-term care options consultation if they so request. Each individual who applies for

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Medicaid long-term care services shall be provided with a long-term care consultation.

 

LC000992 - Page 4 of 6

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      (h) The department of human services is also authorized, subject to availability of

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appropriation of funding, to pay for certain expenses necessary to transition residents back to the

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community; provided, however, payments shall not exceed an annual or per person amount.

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      (i) To assure the continued financial viability of nursing facilities, the department of

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human services is authorized and directed to develop a proposal for revisions to § 40-8-19 that

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reflect the changes in cost and resident acuity that result from implementation of this re-balancing

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goal. Said proposal shall be submitted to the governor and the general assembly on or before

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January 1, 2010.

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      (j) To ensure persons with long-term care needs who remain living at home have

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adequate resources to deal with housing maintenance and unanticipated housing related costs, the

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department of human services is authorized to develop higher resource eligibility limits for

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persons on home and community waiver services who are living in their own homes or rental

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units.

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     SECTION 2. This act shall take effect upon passage.

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LC000992

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL ASSISTANCE

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     This act would provide for annual adjustments to the provider reimbursement rates and

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development of rate enhancements for complex adult day participants.

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     This act would take effect upon passage.

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LC000992

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