2021 -- H 5112

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LC000083

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2021

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A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL ASSISTANCE - LONG-TERM CARE

SERVICES AND FINANCE REFORMS

     Introduced By: Representative David A. Bennett

     Date Introduced: January 25, 2021

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

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

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

     40-8.9-9. Long-term-care rebalancing system reform goal.

     (a) Notwithstanding any other provision of state law, the executive office of health and

human services is authorized and directed to apply for, and obtain, any necessary waiver(s), waiver

amendment(s), and/or state-plan amendments from the secretary of the United States Department

of Health and Human Services, and to promulgate rules necessary to adopt an affirmative plan of

program design and implementation that addresses the goal of allocating a minimum of fifty percent

(50%) of Medicaid long-term-care funding for persons aged sixty-five (65) and over and adults

with disabilities, in addition to services for persons with developmental disabilities, to home- and

community-based care; provided, further, the executive office shall report annually as part of its

budget submission, the percentage distribution between institutional care and home- and

community-based care by population and shall report current and projected waiting lists for long-

term-care and home- and community-based care services. The executive office is further

authorized and directed to prioritize investments in home- and community-based care and to

maintain the integrity and financial viability of all current long-term-care services while pursuing

this goal.

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

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

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

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

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

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

medical condition, the severity of their disability, or the challenges of their behavior. Delivery of

services and supports in less costly and less restrictive community settings, will enable children,

adolescents, and adults to be able to curtail, delay, or avoid lengthy stays in long-term care

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

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

     (c) Pursuant to federal authority procured under § 42-7.2-16, the executive office of health

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

eligibility for services. Such criteria shall be developed in collaboration with the state's health and

human services departments and, to the extent feasible, any consumer group, advisory board, or

other entity designated for such purposes, and shall encompass eligibility determinations for long-

term-care services in nursing facilities, hospitals, and intermediate-care facilities for persons with

intellectual disabilities, as well as home- and community-based alternatives, and shall provide a

common standard of income eligibility for both institutional and home- and community-based care.

The executive office is authorized to adopt clinical and/or functional criteria for admission to a

nursing facility, hospital, or intermediate-care facility for persons with intellectual disabilities that

are more stringent than those employed for access to home- and community-based services. The

executive office is also authorized to promulgate rules that define the frequency of re-assessments

for services provided for under this section. Levels of care may be applied in accordance with the

following:

     (1) The executive office shall continue to apply the level of care criteria in effect on June

30, 2015, for any recipient determined eligible for and receiving Medicaid-funded, long-term

services in supports in a nursing facility, hospital, or intermediate-care facility for persons with

intellectual disabilities on or before that date, unless:

     (i) The recipient transitions to home- and community-based services because he or she

would no longer meet the level of care criteria in effect on June 30, 2015; or

     (ii) The recipient chooses home- and community-based services over the nursing facility,

hospital, or intermediate-care facility for persons with intellectual disabilities. For the purposes of

this section, a failed community placement, as defined in regulations promulgated by the executive

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

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executive office shall confer with the long-term-care ombudsperson with respect to the

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

recipient eligible for a nursing facility, hospital, or intermediate-care facility for persons with

intellectual disabilities as of June 30, 2015, receive a determination of a failed community

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

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

nursing home, hospital, or intermediate-care facility for persons with intellectual disabilities

whenever possible. Additionally, residents shall only be moved from a nursing home, hospital, or

intermediate-care facility for persons with intellectual disabilities in a manner consistent with

applicable state and federal laws.

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

nursing home, hospital, or intermediate-care facility for persons with intellectual disabilities shall

not be subject to any wait list for home- and community-based services.

     (3) No nursing home, hospital, or intermediate-care facility for persons with intellectual

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

that the recipient does not meet level of care criteria unless and until the executive office has:

     (i) Performed an individual assessment of the recipient at issue and provided written notice

to the nursing home, hospital, or intermediate-care facility for persons with intellectual disabilities

that the recipient does not meet level of care criteria; and

     (ii) The recipient has either appealed that level of care determination and been

unsuccessful, or any appeal period available to the recipient regarding that level of care

determination has expired.

     (d) The executive office is further authorized to consolidate all home- and community-

based services currently provided pursuant to 42 U.S.C. § 1396n into a single system of home- and

community-based services that include options for consumer direction and shared living. The

resulting single home- and community-based services system shall replace and supersede all 42

U.S.C. § 1396n programs when fully implemented. Notwithstanding the foregoing, the resulting

single program home- and community-based services system shall include the continued funding

of assisted-living services at any assisted-living facility financed by the Rhode Island housing and

mortgage finance corporation prior to January 1, 2006, and shall be in accordance with chapter 66.8

of title 42 as long as assisted-living services are a covered Medicaid benefit.

     (e) The executive office is authorized to promulgate rules that permit certain optional

services including, but not limited to, homemaker services, home modifications, respite, and

physical therapy evaluations to be offered to persons at risk for Medicaid-funded, long-term care

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subject to availability of state-appropriated funding for these purposes.

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

executive office is authorized to pursue payment methodology reforms that increase access to

homemaker, personal care (home health aide), assisted living, adult supportive-care homes, and

adult day services, as follows:

     (1) Development of revised or new Medicaid certification standards that increase access to

service specialization and scheduling accommodations by using payment strategies designed to

achieve specific quality and health outcomes.

     (2) Development of Medicaid certification standards for state-authorized providers of

adult-day services, excluding such providers of services authorized under § 40.1-24-1(3), assisted

living, and adult supportive care (as defined under chapter 17.24 of title 23) that establish for each,

an acuity-based, tiered service and payment methodology tied to: licensure authority; level of

beneficiary needs; the scope of services and supports provided; and specific quality and outcome

measures.

     The standards for adult-day services for persons eligible for Medicaid-funded, long-term

services may differ from those who do not meet the clinical/functional criteria set forth in § 40-

8.10-3.

     (3) As the state's Medicaid program seeks to assist more beneficiaries requiring long-term

services and supports in home- and community-based settings, the demand for home care workers

has increased, and wages for these workers has not kept pace with neighboring states, leading to

high turnover and vacancy rates in the state's home-care industry, the executive office shall institute

a one-time increase in the base-payment rates for home-care service providers to promote increased

access to and an adequate supply of highly trained home health care professionals, in amount to be

determined by the appropriations process, for the purpose of raising wages for personal care

attendants and home health aides to be implemented by such providers.

     (4) A prospective base adjustment, effective not later than July 1, 2018, of ten percent

(10%) of the current base rate for home care providers, home nursing care providers, and hospice

providers contracted with the executive office of health and human services and its subordinate

agencies to deliver Medicaid fee-for-service personal care attendant services.

     (5) A prospective base adjustment, effective not later than July 1, 2018, of twenty percent

(20%) of the current base rate for home care providers, home nursing care providers, and hospice

providers contracted with the executive office of health and human services and its subordinate

agencies to deliver Medicaid fee-for-service skilled nursing and therapeutic services and hospice

care.

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     (6) Effective upon passage of this section, hospice provider reimbursement, exclusively for

room and board expenses for individuals residing in a skilled nursing facility, shall revert to the

rate methodology in effect on June 30, 2018, and these room and board expenses shall be exempted

from any and all annual rate increases to hospice providers as provided for in this section.

     (7) The rate for hospice providers delivering hospice care in a skilled nursing facility shall

not exceed ninety-five percent (95%) of the rate paid for non-hospice care in a skilled nursing

facility.

     (7)(8) The first of July in each year, beginning on July 1, 2019, the executive office of

health and human services will initiate an annual inflation increase to the base rate for home care

providers, home nursing care providers, and hospice providers contracted with the executive office

and its subordinate agencies to deliver Medicaid fee-for-service personal care attendant services,

skilled nursing and therapeutic services and hospice care. The base rate increase shall be a

percentage amount equal to the New England Consumer Price Index card as determined by the

United States Department of Labor for medical care and for compliance with all federal and state

laws, regulations, and rules, and all national accreditation program requirements.

     (g) The executive office shall implement a long-term-care options counseling program to

provide individuals, or their representatives, or both, with long-term-care consultations that shall

include, at a minimum, information about: long-term-care options, sources, and methods of both

public and private payment for long-term-care services and an assessment of an individual's

functional capabilities and opportunities for maximizing independence. Each individual admitted

to, or seeking admission to, a long-term-care facility, regardless of the payment source, shall be

informed by the facility of the availability of the long-term-care options counseling program and

shall be provided with long-term-care options consultation if they so request. Each individual who

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

     (h) The executive office is also authorized, subject to availability of appropriation of

funding, and federal, Medicaid-matching funds, to pay for certain services and supports necessary

to transition or divert beneficiaries from institutional or restrictive settings and optimize their health

and safety when receiving care in a home or the community. The secretary is authorized to obtain

any state plan or waiver authorities required to maximize the federal funds available to support

expanded access to such home- and community-transition and stabilization services; provided,

however, payments shall not exceed an annual or per-person amount.

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

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

is authorized to develop higher resource eligibility limits for persons or obtain any state plan or

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waiver authorities necessary to change the financial eligibility criteria for long-term services and

supports to enable beneficiaries receiving home and community waiver services to have the

resources to continue living in their own homes or rental units or other home-based settings.

     (j) The executive office shall implement, no later than January 1, 2016, the following home-

and community-based service and payment reforms:

     (1) Community-based, supportive-living program established in § 40-8.13-12 or an

alternative, successor, or substitute program, or delivery option designated for these purposes by

the secretary of the executive office of health and human services;

     (2) Adult day services level of need criteria and acuity-based, tiered-payment

methodology; and

     (3) Payment reforms that encourage home- and community-based providers to provide the

specialized services and accommodations beneficiaries need to avoid or delay institutional care.

     (k) The secretary is authorized to seek any Medicaid section 1115 waiver or state-plan

amendments and take any administrative actions necessary to ensure timely adoption of any new

or amended rules, regulations, policies, or procedures and any system enhancements or changes,

for which appropriations have been authorized, that are necessary to facilitate implementation of

the requirements of this section by the dates established. The secretary shall reserve the discretion

to exercise the authority established under §§ 42-7.2-5(6)(v) and 42-7.2-6.1, in consultation with

the governor, to meet the legislative directives established herein.

     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL ASSISTANCE - LONG-TERM CARE

SERVICES AND FINANCE REFORMS

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     This act would require that the rate for hospice providers, delivering hospice care in a

skilled nursing facility, not exceed ninety-five percent (95%) of the rate paid for non-hospice care

in a skilled nursing facility.

     This act would take effect upon passage.

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