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art.012/7/012/6/012/5/012/4/012/3/012/2/012/1

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     ARTICLE 12 AS AMENDED

RELATING TO MEDICAL ASSISTANCE

     SECTION 1. Sections 12-1.6-1 and 12-1.6-2 of the General Laws in Chapter 12-1.6 entitled

"National Criminal Records Check System" are hereby amended to read as follows:

     12-1.6-1. Automated fingerprint identification system database.

     The department of attorney general may establish and maintain an automated fingerprint

identification system database that would allow the department to store and maintain all fingerprints

submitted in accordance with the national criminal records check system. The automated

fingerprint identification system database would provide for an automatic notification if, and when,

a subsequent criminal arrest fingerprint card is submitted to the system that matches a set of

fingerprints previously submitted in accordance with a national criminal records check. If the

aforementioned arrest results in a conviction, the department shall immediately notify those

individuals and entities with which that individual is associated and who are required to be notified

of disqualifying information concerning national criminal records checks as provided in chapters

17, 17.4, 17.7.1 of title 23 or § 23-1-52 and 42-7.2 of title 42 or §§ 42-7.2-18.2 and 42-7.2-18.4.

The information in the database established under this section is confidential and not subject to

disclosure under chapter 38-2.

     12-1.6-2. Long-term healthcare workers Long-term healthcare workers -- High-risk

Medicaid providers and personal care attendants.

     The department of attorney general shall maintain an electronic, web-based system to assist

facilities, licensed under chapters 17, 17.4, 17.7.1 of title 23 or § 23-1-52, and the executive office

of health and human services under §§ 42-7.2-18.1 and 42-7.2-18.3, required to check relevant

registries and conduct national criminal records checks of routine contact patient employees.,

personal care attendants and high-risk providers. The department of attorney general shall provide

for an automated notice, as authorized in § 12-1.6-1, to those facilities or to the executive office of

health and human services if a routine-contact patient employee, personal care attendant or high-

risk provider is subsequently convicted of a disqualifying offense, as described in the relevant

licensing statute or in §§ 42-7.2-18.2 and 42-7.2-18.4. The department of attorney general may

charge a facility a one-time, set-up fee of up to one hundred dollars ($100) for access to the

electronic web-based system under this section.

     SECTION 2. Sections 40-8-13.4 and 40-8-19 of the General Laws in Chapter 40-8 entitled

"Medical Assistance" are hereby amended to read as follows:

     40-8-13.4. Rate methodology for payment for in-state and out-of-state hospital

services.

     (a) The executive office of health and human services ("executive office") shall implement

a new methodology for payment for in-state and out-of-state hospital services in order to ensure

access to, and the provision of, high-quality and cost-effective hospital care to its eligible recipients.

     (b) In order to improve efficiency and cost-effectiveness, the executive office shall:

     (1)(i) With respect to inpatient services for persons in fee-for-service Medicaid, which is

non-managed care, implement a new payment methodology for inpatient services utilizing the

Diagnosis Related Groups (DRG) method of payment, which is, a patient-classification method

that provides a means of relating payment to the hospitals to the type of patients cared for by the

hospitals. It is understood that a payment method based on DRG may include cost outlier payments

and other specific exceptions. The executive office will review the DRG-payment method and the

DRG base price annually, making adjustments as appropriate in consideration of such elements as

trends in hospital input costs; patterns in hospital coding; beneficiary access to care; and the Centers

for Medicare and Medicaid Services national CMS Prospective Payment System (IPPS) Hospital

Input Price index. For the twelve-month (12) period beginning July 1, 2015, the DRG base rate for

Medicaid fee-for-service inpatient hospital services shall not exceed ninety-seven and one-half

percent (97.5%) of the payment rates in effect as of July 1, 2014. Beginning July 1, 2019, the DRG

base rate for Medicaid fee-for-service inpatient hospital services shall be 107.2% of the payment

rates in effect as of July 1, 2018. Increases in the Medicaid fee-for-service DRG hospital payments

for the twelve-month (12) period beginning July 1, 2020, shall be based on the payment rates in

effect as of July 1 of the preceding fiscal year, and shall be the Centers for Medicare and Medicaid

Services national Prospective Payment System (IPPS) Hospital Input Price Index. Beginning July

1, 2022, the DRG base rate for Medicaid fee-for-service inpatient hospital services shall be one

hundred five percent (105%) of the payment rates in effect as of July 1, 2021. Increases in the

Medicaid fee-for-service DRG hospital payments for each annual twelve-month (12) period

beginning July 1, 2023, shall be based on the payment rates in effect as of July 1 of the preceding

fiscal year, and shall be the Centers for Medicare and Medicaid Services national Prospective

Payment System (IPPS) Hospital Input Price Index.

     (ii) With respect to inpatient services, (A) It is required as of January 1, 2011, until

December 31, 2011, that the Medicaid managed care payment rates between each hospital and

health plan shall not exceed ninety and one-tenth percent (90.1%) of the rate in effect as of June

30, 2010. Increases in inpatient hospital payments for each annual twelve-month (12) period

beginning January 1, 2012, may not exceed the Centers for Medicare and Medicaid Services

national CMS Prospective Payment System (IPPS) Hospital Input Price index for the applicable

period; (B) Provided, however, for the twenty-four-month (24) period beginning July 1, 2013, the

Medicaid managed care payment rates between each hospital and health plan shall not exceed the

payment rates in effect as of January 1, 2013, and for the twelve-month (12) period beginning July

1, 2015, the Medicaid managed care payment inpatient rates between each hospital and health plan

shall not exceed ninety-seven and one-half percent (97.5%) of the payment rates in effect as of

January 1, 2013; (C) Increases in inpatient hospital payments for each annual twelve-month (12)

period beginning July 1, 2017, shall be the Centers for Medicare and Medicaid Services national

CMS Prospective Payment System (IPPS) Hospital Input Price Index, less Productivity

Adjustment, for the applicable period and shall be paid to each hospital retroactively to July 1; (D)

Beginning July 1, 2019, the Medicaid managed care payment inpatient rates between each hospital

and health plan shall be 107.2% of the payment rates in effect as of January 1, 2019, and shall be

paid to each hospital retroactively to July 1; (E) Increases in inpatient hospital payments for each

annual twelve-month (12) period beginning July 1, 2020, shall be based on the payment rates in

effect as of January 1 of the preceding fiscal year, and shall be the Centers for Medicare and

Medicaid Services national CMS Prospective Payment System (IPPS) Hospital Input Price Index,

less Productivity Adjustment, for the applicable period and shall be paid to each hospital

retroactively to July 1; the executive office will develop an audit methodology and process to assure

that savings associated with the payment reductions will accrue directly to the Rhode Island

Medicaid program through reduced managed care plan payments and shall not be retained by the

managed care plans; (F) Beginning July 1, 2022, the Medicaid managed care payment inpatient

rates between each hospital and health plan shall be one hundred five percent (105%) of the

payment rates in effect as of January 1, 2022, and shall be paid to each hospital retroactively to July

1 within ninety days of passage; (G) Increases in inpatient hospital payments for each annual

twelve-month (12) period beginning July 1, 2023, shall be based on the payment rates in effect as

of January 1 of the preceding fiscal year, and shall be the Centers for Medicare and Medicaid

Services national CMS Prospective Payment System (IPPS) Hospital Input Price Index, less

Productivity Adjustment, for the applicable period and shall be paid to each hospital retroactively

to July 1 within ninety days of passage; (F)(H) All hospitals licensed in Rhode Island shall accept

such payment rates as payment in full; and (G)(I) For all such hospitals, compliance with the

provisions of this section shall be a condition of participation in the Rhode Island Medicaid

program.

     (2) With respect to outpatient services and notwithstanding any provisions of the law to the

contrary, for persons enrolled in fee-for-service Medicaid, the executive office will reimburse

hospitals for outpatient services using a rate methodology determined by the executive office and

in accordance with federal regulations. Fee-for-service outpatient rates shall align with Medicare

payments for similar services. Notwithstanding the above, there shall be no increase in the

Medicaid fee-for-service outpatient rates effective on July 1, 2013, July 1, 2014, or July 1, 2015.

For the twelve-month (12) period beginning July 1, 2015, Medicaid fee-for-service outpatient rates

shall not exceed ninety-seven and one-half percent (97.5%) of the rates in effect as of July 1, 2014.

Increases in the outpatient hospital payments for the twelve-month (12) period beginning July 1,

2016, may not exceed the CMS national Outpatient Prospective Payment System (OPPS) Hospital

Input Price Index. Beginning July 1, 2019, the Medicaid fee-for-service outpatient rates shall be

107.2% of the payment rates in effect as of July 1, 2018. Increases in the outpatient hospital

payments for the twelve-month (12) period beginning July 1, 2020, shall be based on the payment

rates in effect as of July 1 of the preceding fiscal year, and shall be the CMS national Outpatient

Prospective Payment System (OPPS) Hospital Input Price Index. Beginning July 1, 2022, the

Medicaid fee-for-service outpatient rates shall be one hundred five percent (105%) of the payment

rates in effect as of July 1. 2021. Increases in the outpatient hospital payments for each annual

twelve-month (12) period beginning July 1, 2023, shall be based on the payment rates in effect as

of July 1 of the preceding fiscal year, and shall be the CMS national Outpatient Prospective

Payment System (OPPS) Hospital Input Price Index. With respect to the outpatient rate, (i) It is

required as of January 1, 2011, until December 31, 2011, that the Medicaid managed care payment

rates between each hospital and health plan shall not exceed one hundred percent (100%) of the

rate in effect as of June 30, 2010; (ii) Increases in hospital outpatient payments for each annual

twelve-month (12) period beginning January 1, 2012, until July 1, 2017, may not exceed the Centers

for Medicare and Medicaid Services national CMS Outpatient Prospective Payment System OPPS

hospital price index for the applicable period; (iii) Provided, however, for the twenty-four-month

(24) period beginning July 1, 2013, the Medicaid managed care outpatient payment rates between

each hospital and health plan shall not exceed the payment rates in effect as of January 1, 2013,

and for the twelve-month (12) period beginning July 1, 2015, the Medicaid managed care outpatient

payment rates between each hospital and health plan shall not exceed ninety-seven and one-half

percent (97.5%) of the payment rates in effect as of January 1, 2013; (iv) Increases in outpatient

hospital payments for each annual twelve-month (12) period beginning July 1, 2017, shall be the

Centers for Medicare and Medicaid Services national CMS OPPS Hospital Input Price Index, less

Productivity Adjustment, for the applicable period and shall be paid to each hospital retroactively

to July 1; (v) Beginning July 1, 2019, the Medicaid managed care outpatient payment rates between

each hospital and health plan shall be one hundred seven and two-tenths percent (107.2%) of the

payment rates in effect as of January 1, 2019 and shall be paid to each hospital retroactively to July

1; (vi) Increases in outpatient hospital payments for each annual twelve-month (12) period

beginning July 1, 2020, shall be based on the payment rates in effect as of January 1 of the preceding

fiscal year, and shall be the Centers for Medicare and Medicaid Services national CMS OPPS

Hospital Input Price Index, less Productivity Adjustment, for the applicable period and shall be

paid to each hospital retroactively to July 1; (vii) Beginning July 1. 2022. the Medicaid managed

care outpatient payment rates between each hospital and health plan shall be one hundred five

percent (105%) of the payment rates in effect as of January 1, 2022 and shall be paid to each hospital

retroactively to July 1 within ninety days of passage; (viii) Increases in outpatient hospital payments

for each annual twelve-month (12) period beginning July 1, 2020. shall be based on the payment

rates in effect as of January 1 of the preceding fiscal year, and shall be the Centers for Medicare

and Medicaid Services national CMS OPPS Hospital Input Price Index, less Productivity

Adjustment, for the applicable period and shall be paid to each hospital retroactively to July 1.

     (3) "Hospital," as used in this section, shall mean the actual facilities and buildings in

existence in Rhode Island, licensed pursuant to § 23-17-1 et seq. on June 30, 2010, and thereafter

any premises included on that license, regardless of changes in licensure status pursuant to chapter

17.14 of title 23 (hospital conversions) and § 23-17-6(b) (change in effective control), that provides

short-term, acute inpatient and/or outpatient care to persons who require definitive diagnosis and

treatment for injury, illness, disabilities, or pregnancy. Notwithstanding the preceding language,

the Medicaid managed care payment rates for a court-approved purchaser that acquires a hospital

through receivership, special mastership or other similar state insolvency proceedings (which court-

approved purchaser is issued a hospital license after January 1, 2013), shall be based upon the new

rates between the court-approved purchaser and the health plan, and such rates shall be effective as

of the date that the court-approved purchaser and the health plan execute the initial agreement

containing the new rates. The rate-setting methodology for inpatient-hospital payments and

outpatient-hospital payments set forth in subsections (b)(1)(ii)(C) and (b)(2), respectively, shall

thereafter apply to increases for each annual twelve-month (12) period as of July 1 following the

completion of the first full year of the court-approved purchaser's initial Medicaid managed care

contract.

     (c) It is intended that payment utilizing the DRG method shall reward hospitals for

providing the most efficient care, and provide the executive office the opportunity to conduct value-

based purchasing of inpatient care.

     (d) The secretary of the executive office is hereby authorized to promulgate such rules and

regulations consistent with this chapter, and to establish fiscal procedures he or she deems

necessary, for the proper implementation and administration of this chapter in order to provide

payment to hospitals using the DRG-payment methodology. Furthermore, amendment of the Rhode

Island state plan for Medicaid, pursuant to Title XIX of the federal Social Security Act, 42 U.S.C.

§ 1396 et seq., is hereby authorized to provide for payment to hospitals for services provided to

eligible recipients in accordance with this chapter.

     (e) The executive office shall comply with all public notice requirements necessary to

implement these rate changes.

     (f) As a condition of participation in the DRG methodology for payment of hospital

services, every hospital shall submit year-end settlement reports to the executive office within one

year from the close of a hospital's fiscal year. Should a participating hospital fail to timely submit

a year-end settlement report as required by this section, the executive office shall withhold

financial-cycle payments due by any state agency with respect to this hospital by not more than ten

percent (10%) until the report is submitted. For hospital fiscal year 2010 and all subsequent fiscal

years, hospitals will not be required to submit year-end settlement reports on payments for

outpatient services. For hospital fiscal year 2011 and all subsequent fiscal years, hospitals will not

be required to submit year-end settlement reports on claims for hospital inpatient services. Further,

for hospital fiscal year 2010, hospital inpatient claims subject to settlement shall include only those

claims received between October 1, 2009, and June 30, 2010.

     (g) The provisions of this section shall be effective upon implementation of the new

payment methodology set forth in this section and § 40-8-13.3, which shall in any event be no later

than March 30, 2010, at which time the provisions of §§ 40-8-13.2, 27-19-14, 27-19-15, and 27-

19-16 shall be repealed in their entirety.

     40-8-19. Rates of payment to nursing facilities.

     (a) Rate reform.

     (1) The rates to be paid by the state to nursing facilities licensed pursuant to chapter 17 of

title 23, and certified to participate in Title XIX of the Social Security Act for services rendered to

Medicaid-eligible residents, shall be reasonable and adequate to meet the costs that must be

incurred by efficiently and economically operated facilities in accordance with 42 U.S.C. §

1396a(a)(13). The executive office of health and human services ("executive office") shall

promulgate or modify the principles of reimbursement for nursing facilities in effect as of July 1,

2011, to be consistent with the provisions of this section and Title XIX, 42 U.S.C. § 1396 et seq.,

of the Social Security Act.

     (2) The executive office shall review the current methodology for providing Medicaid

payments to nursing facilities, including other long-term-care services providers, and is authorized

to modify the principles of reimbursement to replace the current cost-based methodology rates with

rates based on a price-based methodology to be paid to all facilities with recognition of the acuity

of patients and the relative Medicaid occupancy, and to include the following elements to be

developed by the executive office:

     (i) A direct-care rate adjusted for resident acuity;

     (ii) An indirect-care rate comprised of a base per diem for all facilities;

     (iii) A rearray of costs for all facilities every three (3) years beginning October, 2015, that

may or may not result in automatic per diem revisions Revise rates as necessary based on increases

in direct and indirect costs beginning October 2024 utilizing data from the most recent finalized

year of facility cost report. The per diem rate components deferred in subsections (a)(2)(i) and

(a)(2)(ii) of this section shall be adjusted accordingly to reflect changes in direct and indirect care

costs since the previous rate review;

     (iv) Application of a fair-rental value system;

     (v) Application of a pass-through system; and

     (vi) Adjustment of rates by the change in a recognized national nursing home inflation

index to be applied on October 1 of each year, beginning October 1, 2012. This adjustment will not

occur on October 1, 2013, October 1, 2014, or October 1, 2015, but will occur on April 1, 2015.

The adjustment of rates will also not occur on October 1, 2017, October 1, 2018, and October 1,

2019., and October 2022. Effective July 1, 2018, rates paid to nursing facilities from the rates

approved by the Centers for Medicare and Medicaid Services and in effect on October 1, 2017,

both fee-for-service and managed care, will be increased by one and one-half percent (1.5%) and

further increased by one percent (1%) on October 1, 2018, and further increased by one percent

(1%) on October 1, 2019. Effective October 1, 2022, rates paid to nursing facilities from the rates

approved by the Centers for Medicare and Medicaid Services and in effect on October 1, 2021,

both fee-for-service and managed care, will be increased by three percent (3%). In addition to the

annual nursing home inflation index adjustment, there shall be a base rate staffing adjustment of

one-half percent (0.5%) on October 1, 2021, one percent (1.0%) on October 1, 2022, and one and

one-half percent (1.5%) on October 1, 2023. The inflation index shall be applied without regard for

the transition factors in subsections (b)(1) and (b)(2). For purposes of October 1, 2016, adjustment

only, any rate increase that results from application of the inflation index to subsections (a)(2)(i)

and (a)(2)(ii) shall be dedicated to increase compensation for direct-care workers in the following

manner: Not less than 85% of this aggregate amount shall be expended to fund an increase in wages,

benefits, or related employer costs of direct-care staff of nursing homes. For purposes of this

section, direct-care staff shall include registered nurses (RNs), licensed practical nurses (LPNs),

certified nursing assistants (CNAs), certified medical technicians, housekeeping staff, laundry staff,

dietary staff, or other similar employees providing direct-care services; provided, however, that this

definition of direct-care staff shall not include: (i) RNs and LPNs who are classified as "exempt

employees" under the federal Fair Labor Standards Act (29 U.S.C. § 201 et seq.); or (ii) CNAs,

certified medical technicians, RNs, or LPNs who are contracted, or subcontracted, through a third-

party vendor or staffing agency. By July 31, 2017, nursing facilities shall submit to the secretary,

or designee, a certification that they have complied with the provisions of this subsection (a)(2)(vi)

with respect to the inflation index applied on October 1, 2016. Any facility that does not comply

with terms of such certification shall be subjected to a clawback, paid by the nursing facility to the

state, in the amount of increased reimbursement subject to this provision that was not expended in

compliance with that certification.

     (3) Commencing on October 1, 2021, eighty percent (80%) of any rate increase that results

from application of the inflation index to subsections (a)(2)(i) and (a)(2)(ii) of this section shall be

dedicated to increase compensation for all eligible direct-care workers in the following manner on

October 1, of each year.

     (i) For purposes of this subsection, compensation increases shall include base salary or

hourly wage increases, benefits, other compensation, and associated payroll tax increases for

eligible direct-care workers. This application of the inflation index shall apply for Medicaid

reimbursement in nursing facilities for both managed care and fee-for-service. For purposes of this

subsection, direct-care staff shall include registered nurses (RNs), licensed practical nurses (LPNs),

certified nursing assistants (CNAs), certified medication technicians, licensed physical therapists,

licensed occupational therapists, licensed speech-language pathologists, mental health workers

who are also certified nurse assistants, physical therapist assistants, housekeeping staff, laundry

staff, dietary staff or other similar employees providing direct-care services; provided, however

that this definition of direct-care staff shall not include:

     (A) RNs and LPNs who are classified as "exempt employees" under the federal Fair Labor

Standards Act (29 U.S.C. § 201 et seq.); or

     (B) CNAs, certified medication technicians, RNs or LPNs who are contracted or

subcontracted through a third-party vendor or staffing agency.

     (4) (i) By July 31, 2021, and July 31 of each year thereafter, nursing facilities shall submit

to the secretary or designee a certification that they have complied with the provisions of subsection

(a)(3) of this section with respect to the inflation index applied on October 1. The executive office

of health and human services (EOHHS) shall create the certification form nursing facilities must

complete with information on how each individual eligible employee's compensation increased,

including information regarding hourly wages prior to the increase and after the compensation

increase, hours paid after the compensation increase, and associated increased payroll taxes. A

collective bargaining agreement can be used in lieu of the certification form for represented

employees. All data reported on the compliance form is subject to review and audit by EOHHS.

The audits may include field or desk audits, and facilities may be required to provide additional

supporting documents including, but not limited to, payroll records.

     (ii) Any facility that does not comply with the terms of certification shall be subjected to a

clawback and twenty-five percent (25%) penalty of the unspent or impermissibly spent funds, paid

by the nursing facility to the state, in the amount of increased reimbursement subject to this

provision that was not expended in compliance with that certification.

     (iii) In any calendar year where no inflationary index is applied, eighty percent (80%) of

the base rate staffing adjustment in that calendar year pursuant to subsection (a)(2)(vi) of this

section shall be dedicated to increase compensation for all eligible direct-care workers in the

manner referenced in subsections (a)(3)(i), (a)(3)(i)(A), and (a)(3)(i)(B) of this section.

     (b) Transition to full implementation of rate reform. For no less than four (4) years after

the initial application of the price-based methodology described in subsection (a)(2) to payment

rates, the executive office of health and human services shall implement a transition plan to

moderate the impact of the rate reform on individual nursing facilities. The transition shall include

the following components:

     (1) No nursing facility shall receive reimbursement for direct-care costs that is less than

the rate of reimbursement for direct-care costs received under the methodology in effect at the time

of passage of this act; for the year beginning October 1, 2017, the reimbursement for direct-care

costs under this provision will be phased out in twenty-five-percent (25%) increments each year

until October 1, 2021, when the reimbursement will no longer be in effect; and

     (2) No facility shall lose or gain more than five dollars ($5.00) in its total, per diem rate the

first year of the transition. An adjustment to the per diem loss or gain may be phased out by twenty-

five percent (25%) each year; except, however, for the years beginning October 1, 2015, there shall

be no adjustment to the per diem gain or loss, but the phase out shall resume thereafter; and

     (3) The transition plan and/or period may be modified upon full implementation of facility

per diem rate increases for quality of care-related measures. Said modifications shall be submitted

in a report to the general assembly at least six (6) months prior to implementation.

     (4) Notwithstanding any law to the contrary, for the twelve-month (12) period beginning

July 1, 2015, Medicaid payment rates for nursing facilities established pursuant to this section shall

not exceed ninety-eight percent (98%) of the rates in effect on April 1, 2015. Consistent with the

other provisions of this chapter, nothing in this provision shall require the executive office to restore

the rates to those in effect on April 1, 2015, at the end of this twelve-month (12) period.

     SECTION 3. Sections 40-8.3-2 and 40-8.3-3 of the General Laws in Chapter 40-8.3 entitled

"Uncompensated Care" are hereby amended to read as follows:

     40-8.3-2. Definitions.

     As used in this chapter:

     (1) "Base year" means, for the purpose of calculating a disproportionate share payment for

any fiscal year ending after September 30, 2020 2021, the period from October 1, 2018 2019,

through September 30, 2019 2020, and for any fiscal year ending after September 30, 2021 2022,

the period from October 1, 2019, through September 30, 2020.

     (2) "Medicaid inpatient utilization rate for a hospital" means a fraction (expressed as a

percentage), the numerator of which is the hospital's number of inpatient days during the base year

attributable to patients who were eligible for medical assistance during the base year and the

denominator of which is the total number of the hospital's inpatient days in the base year.

     (3) "Participating hospital" means any nongovernment and nonpsychiatric hospital that:

     (i) Was licensed as a hospital in accordance with chapter 17 of title 23 during the base year

and shall mean the actual facilities and buildings in existence in Rhode Island, licensed pursuant to

§ 23-17-1 et seq. on June 30, 2010, and thereafter any premises included on that license, regardless

of changes in licensure status pursuant to chapter 17.14 of title 23 (hospital conversions) and § 23-

17-6(b) (change in effective control), that provides short-term, acute inpatient and/or outpatient

care to persons who require definitive diagnosis and treatment for injury, illness, disabilities, or

pregnancy. Notwithstanding the preceding language, the negotiated Medicaid managed care

payment rates for a court-approved purchaser that acquires a hospital through receivership, special

mastership, or other similar state insolvency proceedings (which court-approved purchaser is issued

a hospital license after January 1, 2013), shall be based upon the newly negotiated rates between

the court-approved purchaser and the health plan, and the rates shall be effective as of the date that

the court-approved purchaser and the health plan execute the initial agreement containing the newly

negotiated rate. The rate-setting methodology for inpatient hospital payments and outpatient

hospital payments set forth in §§ 40-8-13.4(b)(1)(ii)(C) and 40-8-13.4(b)(2), respectively, shall

thereafter apply to negotiated increases for each annual twelve-month (12) period as of July 1

following the completion of the first full year of the court-approved purchaser's initial Medicaid

managed care contract;

     (ii) Achieved a medical assistance inpatient utilization rate of at least one percent (1%)

during the base year; and

     (iii) Continues to be licensed as a hospital in accordance with chapter 17 of title 23 during

the payment year.

     (4) "Uncompensated-care costs" means, as to any hospital, the sum of: (i) The cost incurred

by the hospital during the base year for inpatient or outpatient services attributable to charity care

(free care and bad debts) for which the patient has no health insurance or other third-party coverage

less payments, if any, received directly from such patients; and (ii) The cost incurred by the hospital

during the base year for inpatient or outpatient services attributable to Medicaid beneficiaries less

any Medicaid reimbursement received therefor; multiplied by the uncompensated-care index.

     (5) "Uncompensated-care index" means the annual percentage increase for hospitals

established pursuant to § 27-19-14 [repealed] for each year after the base year, up to and including

the payment year; provided, however, that the uncompensated-care index for the payment year

ending September 30, 2007, shall be deemed to be five and thirty-eight hundredths percent (5.38%),

and that the uncompensated-care index for the payment year ending September 30, 2008, shall be

deemed to be five and forty-seven hundredths percent (5.47%), and that the uncompensated-care

index for the payment year ending September 30, 2009, shall be deemed to be five and thirty-eight

hundredths percent (5.38%), and that the uncompensated-care index for the payment years ending

September 30, 2010, September 30, 2011, September 30, 2012, September 30, 2013, September

30, 2014, September 30, 2015, September 30, 2016, September 30, 2017, September 30, 2018,

September 30, 2019, September 30, 2020, September 30, 2021, and September 30, 2022, and

September 30, 2023 shall be deemed to be five and thirty hundredths percent (5.30%).

     40-8.3-3. Implementation.

     (a) For federal fiscal year 2020, commencing on October 1, 2019, and ending September

30, 2020, the executive office of health and human services shall submit to the Secretary of the

United States Department of Health and Human Services a state plan amendment to the Rhode

Island Medicaid DSH Plan to provide:

     (1) That the DSH Plan to all participating hospitals, not to exceed an aggregate limit of

$142.4 million, shall be allocated by the executive office of health and human services to the Pool

D component of the DSH Plan; and

     (2) That the Pool D allotment shall be distributed among the participating hospitals in direct

proportion to the individual participating hospital's uncompensated-care costs for the base year,

inflated by the uncompensated-care index to the total uncompensated-care costs for the base year

inflated by the uncompensated-care index for all participating hospitals. The disproportionate share

payments shall be made on or before July 13, 2020, and are expressly conditioned upon approval

on or before July 6, 2020, by the Secretary of the United States Department of Health and Human

Services, or his or her authorized representative, of all Medicaid state plan amendments necessary

to secure for the state the benefit of federal financial participation in federal fiscal year 2020 for

the disproportionate share payments.

     (b) (a) For federal fiscal year 2021, commencing on October 1, 2020, and ending

September 30, 2021, the executive office of health and human services shall submit to the Secretary

of the United States Department of Health and Human Services a state plan amendment to the

Rhode Island Medicaid DSH Plan to provide:

     (1) That the DSH Plan to all participating hospitals, not to exceed an aggregate limit of

$142.5 million, shall be allocated by the executive office of health and human services to the Pool

D component of the DSH Plan; and

     (2) That the Pool D allotment shall be distributed among the participating hospitals in direct

proportion to the individual participating hospital's uncompensated-care costs for the base year,

inflated by the uncompensated-care index to the total uncompensated-care costs for the base year

inflated by the uncompensated-care index for all participating hospitals. The disproportionate share

payments shall be made on or before July 12, 2021, and are expressly conditioned upon approval

on or before July 5, 2021, by the Secretary of the United States department of health and human

services, or his or her authorized representative, of all Medicaid state plan amendments necessary

to secure for the state the benefit of federal financial participation in federal fiscal year 2021 for

the disproportionate share payments.

     (c)(b) For federal fiscal year 2022, commencing on October 1, 2021, and ending September

30, 2022, the executive office of health and human services shall submit to the Secretary of the

United States Department of Health and Human Services a state plan amendment to the Rhode

Island Medicaid DSH Plan to provide:

     (1) That the DSH Plan to all participating hospitals, not to exceed an aggregate limit of

$143.8 $145.1 million, shall be allocated by the executive office of health and human services to

the Pool D component of the DSH Plan; and

     (2) That the Pool D allotment shall be distributed among the participating hospitals in direct

proportion to the individual participating hospital's uncompensated-care costs for the base year,

inflated by the uncompensated-care index to the total uncompensated-care costs for the base year

inflated by the uncompensated-care index for all participating hospitals. The disproportionate share

payments shall be made on or before July 12, 2022 June 30, 2022, and are expressly conditioned

upon approval on or before July 5, 2022, by the Secretary of the United States Department of Health

and Human Services, or his or her authorized representative, of all Medicaid state plan amendments

necessary to secure for the state the benefit of federal financial participation in federal fiscal year

2022 for the disproportionate share payments.

     (c) For federal fiscal year 2023, commencing on October 1, 2022, and ending September

30, 2023, the executive office of health and human services shall submit to the Secretary of the

United States Department of Health and Human Services a state plan amendment to the Rhode

Island Medicaid DSH Plan to provide:

     (1) That the DSH Plan to all participating hospitals, not to exceed an aggregate limit of

$145.1 million, shall be allocated by the executive office of health and human services to the Pool

D component of the DSH Plan; and

     (2) That the Pool D allotment shall be distributed among the participating hospitals in direct

proportion to the individual participating hospital's uncompensated-care costs for the base year,

inflated by the uncompensated-care index to the total uncompensated-care costs for the base year

inflated by the uncompensated-care index for all participating hospitals. The disproportionate share

payments shall be made on or before June 15, 2023, and are expressly conditioned upon approval

on or before June 23, 2023, by the Secretary of the United States Department of Health and Human

Services, or his or her authorized representative, of all Medicaid state plan amendments necessary

to secure for the state the benefit of federal financial participation in federal fiscal year 2023 for

the disproportionate share payments.

     (d) No provision is made pursuant to this chapter for disproportionate-share hospital

payments to participating hospitals for uncompensated-care costs related to graduate medical

education programs.

     (e) The executive office of health and human services is directed, on at least a monthly

basis, to collect patient-level uninsured information, including, but not limited to, demographics,

services rendered, and reason for uninsured status from all hospitals licensed in Rhode Island.

     (f) [Deleted by P.L. 2019, ch. 88, art. 13, § 6.]

     SECTION 4. Chapter 40.1-8.5 of the General Laws entitled "Community Mental Health

Services" is hereby amended by adding thereto the following section:

     40.1-8.5-8. Certified community behavioral health clinics.

     (a) The executive office of health and human services is authorized and directed to submit

to the Secretary of the United States Department of Health and Human Services a state plan

amendment for the purposes of establishing Certified Community Behavioral Health Clinics in

accordance with Section 223 of the federal Protecting Access to Medicare Act of 2014.

     (b) The executive office of health and human services shall amend its Title XIX state plan

pursuant to Title XIX [42 U.S.C. § 1396 et seq.] and Title XXI [42 U.S.C § 1397 et seq.] of the

Social Security Act as necessary to cover all required services for persons with mental health and

substance use disorders at a certified community behavioral health clinic through a daily or monthly

bundled payment methodology that is specific to each organization’s anticipated costs and inclusive

of all required services within Section 223 of the federal Protecting Access to Medicare Act of

2014. Such certified community behavioral health clinics shall adhere to the federal model,

including payment structures and rates.

     (c) A certified community behavioral health clinic means any licensed behavioral health

organization that meets the federal certification criteria of Section 223 of the Protecting Access to

Medicare Act of 2014. The department of behavioral healthcare, developmental disabilities and

hospitals shall define additional criteria to certify the clinics including, but not limited to the

provision of, these services:

     (1) Outpatient mental health and substance use services;

      (2) Twenty-four (24) hour mobile crisis response and hotline services;

      (3) Screening, assessment, and diagnosis, including risk assessments;

      (4) Person-centered treatment planning;

      (5) Primary care screening and monitoring of key indicators of health risks;

      (6) Targeted case management;

      (7) Psychiatric rehabilitation services;

      (8) Peer support and family supports;

      (9) Medication-assisted treatment;

      (10) Assertive community treatment; and

      (11) Community-based mental health care for military service members and veterans.

      (d) Subject to the approval from the United States Department of Health and Human

Services’ Centers for Medicare and Medicaid Services, the certified community behavioral health

clinic model pursuant to this chapter, shall be established by July 1, 2023, and include any enhanced

Medicaid match for required services or populations served.

     (e) By August 1, 2022, the executive office of health and human services will issue the

appropriate Purchasing process and vehicle for organizations who want to participate in the

Certified Community Behavioral Health Clinic model program.

     (f) By December 1, 2022, the organizations will submit a detailed cost report developed by

the department of behavioral healthcare, developmental disabilities and hospitals with approval

from the executive office of health and human services, that includes the cost for the organization

to provide the required services.

     (g) By January 15, 2023, the department of behavioral healthcare, developmental

disabilities and hospitals, in coordination with the executive office of health and human services,

will prepare an analysis of proposals, determine how many behavioral health clinics can be certified

in FY 2024 and the costs for each one. Funding for the Certified Behavioral Health Clinics will be

included in the FY 2024 budget recommended by the Governor.

     (h) The executive office of health and human services shall apply for the federal Certified

Community Behavioral Health Clinics Demonstration Program if another round of funding

becomes available.

     SECTION 5. Section 42-7.2-18 of Chapter 42-7.2 the General Laws entitled "Office of

Health and Human Services" is hereby amended by adding thereto the following sections:

     42-7.2-18.1. Professional responsibility -- Criminal records check for high- risk

providers.

     (a) As a condition of enrollment and/or continued participation as a Medicaid provider,

applicants to become and/or remain a provider shall be required to undergo criminal records checks

including a national criminal records check supported by fingerprints by the level of screening

based on risk of fraud, waste or abuse as determined by the executive office of health and human

services for that category of Medicaid provider.

     (b) Establishment of Risk Categories – The executive office of health and human services

in consultation with the department of attorney general, shall establish through regulation, risk

categories for Medicaid providers and provider categories who pose an increased financial risk of

fraud, waste or abuse to the Medicaid/CHIP program, in accordance with § 42 CFR §§ 455.434 and

455.450.

     (c) High risk categories, as determined by the executive office health and human services

may include:

     (1) Newly enrolled home health agencies that have not been medicare certified;

     (2) Newly enrolled durable medical equipment providers;

     (3) New or revalidating providers that have been categorized by the executive office of

health and human services as high risk;

     (4) New or revalidating providers with payment suspension histories;

     (5) New or revalidating providers with office of inspector general exclusion histories;

     (6) New or revalidating providers with qualified overpayment histories; and,

     (7) New or revalidating providers applying for enrollment post debarment or moratorium

(Federal or State-based)

     (d) Upon the state Medicaid agency determination that a provider or an applicant to become

a provider, or a person with a five percent (5%) or more direct or indirect ownership interest in the

provider, meets the executive office of health and human services’ criteria for criminal records

checks as a "high" risk to the Medicaid program, the executive office of health and human services

shall require that each such provider or applicant to become a provider undergo a national criminal

records check supported by fingerprints.

     (e) The executive office of health and human services shall require such a "high risk"

Medicaid provider or applicant to become a provider, or any person with a five percent (5%) or

more direct or indirect ownership interest in the provider, to submit to a national criminal records

check supported by fingerprints within thirty (30) days upon request from the Centers for Medicare

and Medicaid Services or the executive office of health and human services.

     (f) The Medicaid providers requiring the national criminal records check shall apply to the

department of attorney general, bureau of criminal identification (BCI) to be fingerprinted. The

fingerprints will subsequently be transmitted to the federal bureau of investigation for a national

criminal records check. The results of the national criminal records check shall be made available

to the applicant undergoing a record check and submitting fingerprints.

     (g) Upon the discovery of any disqualifying information, as defined in § 42-7.2-18.2 and

as in accordance with the regulations promulgated by the executive office of health and human

services, the bureau of criminal identification of the department of the attorney general will inform

the applicant, in writing, of the nature of the disqualifying information; and, without disclosing the

nature of the disqualifying information, will notify the executive office of health and human

services, in writing, that disqualifying information has been discovered.

     (h) In those situations, in which no disqualifying information has been found, the bureau

of criminal identification of the department of the attorney general shall inform the applicant and

the executive office of health and human services, in writing, of this fact.

     (i) The applicant shall be responsible for the cost of conducting the national criminal

records check through the bureau of criminal identification of the department of attorney general.

     42-7.2-18.2. Professional responsibility -- Criminal records check disqualifying

information for high-risk providers.

     (a) Information produced by a national criminal records check pertaining to conviction, for

the following crimes will result in a letter to the executive office of health and human services ,

disqualifying the applicant from being a medicaid provider: murder, voluntary manslaughter,

involuntary manslaughter, first degree sexual assault, second degree sexual assault, third degree

sexual assault, assault on persons sixty (60) years of age or older, assault with intent to commit

specified felonies (murder, robbery, rape, burglary, or the abominable and detestable crime against

nature) felony assault, patient abuse, neglect or mistreatment of patients, burglary, first degree

arson, robbery, felony drug offenses, felony larceny, or felony banking law violations, felony

obtaining money under false pretenses, felony embezzlement, abuse, neglect and/or exploitation of

adults with severe impairments, exploitation of elders, or a crime under section 1128 (a) of the

Social Security Act (42 U.S.C. 1320a-7(a)). An applicant against whom disqualifying information

has been found, for purposes of appeal, may provide a copy of the national criminal records check

to the executive office of health and human services, who shall make a judgment regarding the

approval of or the continued status of that person as a provider.

     (b) For purposes of this section, "conviction" means, in addition to judgments of conviction

entered by a court subsequent to a finding of guilty or a plea of guilty, those instances where the

defendant has entered a plea of nolo contendere and has received a sentence of probation and those

instances where a defendant has entered into a deferred sentence agreement with the attorney

general.

     42-7.2-18.3. Professional responsibility -- Criminal records check for personal care

aides.

     (a) Any person seeking employment to provide care to elderly or individuals with

disabilities who is, or may be required to be, licensed, registered, trained or certified with the office

of medicaid if that employment involves routine contact with elderly or individuals with disabilities

without the presence of other employees, shall undergo a national criminal records check supported

by fingerprints. The applicant will report to the office of attorney general, bureau of criminal

identification to submit their fingerprints. The fingerprints will subsequently be submitted to the

federal bureau of investigation (FBI) by the bureau of criminal identification of the office of

attorney general. The national criminal records check shall be initiated prior to, or within one week

of, employment.

     (b) The director of the office of medicaid may, by rule, identify those positions requiring

criminal records checks. The identified employee, through the executive office of health and human

services, shall apply to the bureau of criminal identification of the department of attorney general

for a national criminal records check. Upon the discovery of any disqualifying information, as

defined in § 42-7.2-18.4 and in accordance with the rule promulgated by the secretary of the

executive office of health and human services, the bureau of criminal identification of the

department of the attorney general will inform the applicant, in writing, of the nature of the

disqualifying information; and, without disclosing the nature of the disqualifying information, will

notify the executive office of health and human services executive office of health and human

services in writing, that disqualifying information has been discovered.

     (c) An applicant against whom disqualifying information has been found, for purposes of

appeal, may provide a copy of the national criminal history check to the executive office of health

and human services, who shall make a judgment regarding the approval of the applicant.

     (d) In those situations, in which no disqualifying information has been found, the bureau

of criminal identification of the department of the attorney general shall inform the applicant and

the executive office health and human services, in writing, of this fact.

     (e) The executive office of health and human services shall maintain on file evidence that

criminal records checks have been initiated on all applicants subsequent to July 1, 2022.

     (f) The applicant shall be responsible for the cost of conducting the national criminal

records check through the bureau of criminal identification of the department of the attorney

general.

     42-7.2-18.4. Professional responsibility -- Criminal records check disqualifying

information for personal care aides.

     (a) Information produced by a national criminal records check pertaining to conviction, for

the following crimes will result in a letter to the applicant and the executive office of health and

human services, disqualifying the applicant: murder, voluntary manslaughter, involuntary

manslaughter, first degree sexual assault, second degree sexual assault, third degree sexual assault,

assault on persons sixty (60) years of age or older, assault with intent to commit specified felonies

(murder, robbery, rape, burglary, or the abominable and detestable crime against nature) felony

assault, patient abuse, neglect or mistreatment of patients, burglary, first degree arson, robbery,

felony drug offenses, felony larceny, or felony banking law violations, felony obtaining money

under false pretenses, felony embezzlement, abuse, neglect and/or exploitation of adults with severe

impairments, exploitation of elders, or a crime under section 1128(a) of the Social Security Act (42

U.S.C. 1320a-7(a)).

     (b) For purposes of this section, "conviction" means, in addition to judgments of conviction

entered by a court subsequent to a finding of guilty or a plea of guilty, those instances where the

defendant has entered a plea of nolo contendere and has received a sentence of probation and those

instances where a defendant has entered into a deferred sentence agreement with the attorney

general.

     SECTION 6. Sections 42-12.3-3, 42-12.3-4 and 42-12.3-15 of the General Laws in Chapter

42-12.3 "Health Care for Children and Pregnant Women" are hereby amended to read as follows:

     42-12.3-3. Medical assistance expansion for pregnant women/RIte Start.

     (a) The director of the department of human services secretary of the executive office of

health and human services is authorized to amend its Title XIX state plan pursuant to Title XIX of

the Social Security Act to provide Medicaid coverage and to amend its Title XXI state plan pursuant

to Title XXI of the Social Security Act to provide medical assistance coverage through expanded

family income disregards for pregnant women whose family income levels are between one

hundred eighty-five percent (185%) and two hundred fifty percent (250%) of the federal poverty

level. The department is further authorized to promulgate any regulations necessary and in accord

with Title XIX [42 U.S.C. § 1396 et seq.] and Title XXI [ 42 U.S.C. § 1397aa et seq.] of the Social

Security Act necessary in order to implement said state plan amendment. The services provided

shall be in accord with Title XIX [ 42 U.S.C. § 1396 et seq.] and Title XXI [ 42 U.S.C. § 1397aa

et seq.] of the Social Security Act.

     (b) The director of the department of human services secretary of health and human

services is authorized and directed to establish a payor of last resort program to cover prenatal,

delivery and postpartum care. The program shall cover the cost of maternity care for any woman

who lacks health insurance coverage for maternity care and who is not eligible for medical

assistance under Title XIX [42 U.S.C. § 1396 et seq.] and Title XXI [ 42 U.S.C. § 1397aa et seq.]

of the Social Security Act including, but not limited to, a noncitizen pregnant woman lawfully

admitted for permanent residence on or after August 22, 1996, without regard to the availability of

federal financial participation, provided such pregnant woman satisfies all other eligibility

requirements. The director secretary shall promulgate regulations to implement this program. Such

regulations shall include specific eligibility criteria; the scope of services to be covered; procedures

for administration and service delivery; referrals for non-covered services; outreach; and public

education. Excluded services under this subsection will include, but not be limited to, induced

abortion except in cases of rape or incest or to save the life of the pregnant individual.

     (c) The department of human services secretary of health and human services may enter

into cooperative agreements with the department of health and/or other state agencies to provide

services to individuals eligible for services under subsections (a) and (b) above.

     (d) The following services shall be provided through the program:

     (1) Ante-partum and postpartum care;

     (2) Delivery;

     (3) Cesarean section;

     (4) Newborn hospital care;

     (5) Inpatient transportation from one hospital to another when authorized by a medical

provider; and

     (6) Prescription medications and laboratory tests.

     (e) The department of human services secretary of health and human services shall provide

enhanced services, as appropriate, to pregnant women as defined in subsections (a) and (b), as well

as to other pregnant women eligible for medical assistance. These services shall include: care

coordination, nutrition and social service counseling, high risk obstetrical care, childbirth and

parenting preparation programs, smoking cessation programs, outpatient counseling for drug-

alcohol use, interpreter services, mental health services, and home visitation. The provision of

enhanced services is subject to available appropriations. In the event that appropriations are not

adequate for the provision of these services, the department executive office has the authority to

limit the amount, scope and duration of these enhanced services.

     (f) The department of human services executive office of health and human services shall

provide for extended family planning services for up to twenty-four (24) months postpartum. These

services shall be available to women who have been determined eligible for RIte Start or for

medical assistance under Title XIX [42 U.S.C. § 1396 et seq.] or Title XXI [ 42 U.S.C. § 1397aa

et seq.] of the Social Security Act.

     (g) Effective October 1, 2022, individuals eligible for RIte Start pursuant to this section or

for medical assistance under Title XIX or Title XXI of the Social Security Act while pregnant

(including during a period of retroactive eligibility), are eligible for full Medicaid benefits through

the last day of the month in which their twelve (12) month postpartum period ends. This benefit

will be provided to eligible Rhode Island residents without regard to the availability of federal

financial participation. The executive office of health and human services is directed to ensure that

federal financial participation is used to the maximum extent allowable to provide coverage

pursuant to this section, and that state-only funds will be used only if federal financial participation

is not available.

     42-12.3-4. "RIte track" program.

     (a) There is hereby established a payor of last resort program for comprehensive health

care for children until they reach nineteen (19) years of age, to be known as "RIte track." The

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

to amend its Title XIX state plan pursuant to Title XIX [42 U.S.C. § 1396 et seq.] and Title XXI [

42 U.S.C. § 1397aa et seq.] of the Social Security Act as necessary to provide for expanded

Medicaid coverage through expanded family income disregards for children, until they reach

nineteen (19) years of age, whose family income levels are up to two hundred fifty percent (250%)

of the federal poverty level. Provided, however, that healthcare coverage provided under this

section shall also be provided without regard to the availability of federal financial participation in

accordance to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., to a noncitizen child

who is a resident of Rhode Island lawfully residing in the United States, and who is otherwise

eligible for such assistance. The department is further authorized to promulgate any regulations

necessary, and in accord with Title XIX [42 U.S.C. § 1396 et seq.] and Title XXI [ 42 U.S.C. §

1397aa et seq.] of the Social Security Act as necessary in order to implement the state plan

amendment. For those children who lack health insurance, and whose family incomes are in excess

of two hundred fifty percent (250%) of the federal poverty level, the department of human services

shall promulgate necessary regulations to implement the program. The department of human

services is further directed to ascertain and promulgate the scope of services that will be available

to those children whose family income exceeds the maximum family income specified in the

approved Title XIX [42 U.S.C. § 1396 et seq.] and Title XXI [ 42 U.S.C. § 1397aa et seq.] state

plan amendment.

     (b) The executive office of health and human services is directed to ensure that federal

financial participation is used to the maximum extent allowable to provide coverage pursuant to

this section, and that state-only funds will be used only if federal financial participation is not

available.

     42-12.3-15. Expansion of RIte track program.

     (a) The Department of Human Services executive office of health and human services is

hereby authorized and directed to submit to the United States Department of Health and Human

Services an amendment to the "RIte Care" waiver project number 11-W-0004/1-01 to provide for

expanded Medicaid coverage for children until they reach eight (8) years of age, whose family

income levels are to two hundred fifty percent (250%) of the federal poverty level. Expansion of

the RIte track program from the age of six (6) until they reach eighteen (18) years of age in

accordance with this chapter shall be subject to the approval of the amended waiver by the United

States Department of Health and Human Services. Healthcare coverage under this section shall also

be provided to a noncitizen child lawfully residing in the United States who is a resident of Rhode

Island, and who is otherwise eligible for such assistance under Title XIX [42 U.S.C. § 1396 et seq.]

or Title XXI [ 42 U.S.C. § 1397aa et seq.]

     (b) The executive office of health and human services is directed to ensure that federal

financial participation is used to the maximum extent allowable to provide coverage pursuant to

this section, and that state-only funds will be used only if federal financial participation is not

available.

     SECTION 7. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The

Rhode Island Health Care Reform Act of 2004 - Health Insurance Oversight" is hereby amended

to read as follows:

     42-14.5-3. Powers and duties.

     The health insurance commissioner shall have the following powers and duties:

     (a) To conduct quarterly public meetings throughout the state, separate and distinct from

rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers

licensed to provide health insurance in the state; the effects of such rates, services, and operations

on consumers, medical care providers, patients, and the market environment in which the insurers

operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less

than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island

Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney

general, and the chambers of commerce. Public notice shall be posted on the department's website

and given in the newspaper of general circulation, and to any entity in writing requesting notice.

     (b) To make recommendations to the governor and the house of representatives and senate

finance committees regarding healthcare insurance and the regulations, rates, services,

administrative expenses, reserve requirements, and operations of insurers providing health

insurance in the state, and to prepare or comment on, upon the request of the governor or

chairpersons of the house or senate finance committees, draft legislation to improve the regulation

of health insurance. In making the recommendations, the commissioner shall recognize that it is

the intent of the legislature that the maximum disclosure be provided regarding the reasonableness

of individual administrative expenditures as well as total administrative costs. The commissioner

shall make recommendations on the levels of reserves, including consideration of: targeted reserve

levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess

reserves.

     (c) To establish a consumer/business/labor/medical advisory council to obtain information

and present concerns of consumers, business, and medical providers affected by health insurance

decisions. The council shall develop proposals to allow the market for small business health

insurance to be affordable and fairer. The council shall be involved in the planning and conduct of

the quarterly public meetings in accordance with subsection (a). The advisory council shall develop

measures to inform small businesses of an insurance complaint process to ensure that small

businesses that experience rate increases in a given year may request and receive a formal review

by the department. The advisory council shall assess views of the health provider community

relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the

insurers' role in promoting efficient and high-quality health care. The advisory council shall issue

an annual report of findings and recommendations to the governor and the general assembly and

present its findings at hearings before the house and senate finance committees. The advisory

council is to be diverse in interests and shall include representatives of community consumer

organizations; small businesses, other than those involved in the sale of insurance products; and

hospital, medical, and other health provider organizations. Such representatives shall be nominated

by their respective organizations. The advisory council shall be co-chaired by the health insurance

commissioner and a community consumer organization or small business member to be elected by

the full advisory council.

     (d) To establish and provide guidance and assistance to a subcommittee ("the professional-

provider-health-plan work group") of the advisory council created pursuant to subsection (c),

composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall

include in its annual report and presentation before the house and senate finance committees the

following information:

     (1) A method whereby health plans shall disclose to contracted providers the fee schedules

used to provide payment to those providers for services rendered to covered patients;

     (2) A standardized provider application and credentials verification process, for the

purpose of verifying professional qualifications of participating healthcare providers;

     (3) The uniform health plan claim form utilized by participating providers;

     (4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit

hospital or medical-service corporations, as defined by chapters 19 and 20 of title 27, to make

facility-specific data and other medical service-specific data available in reasonably consistent

formats to patients regarding quality and costs. This information would help consumers make

informed choices regarding the facilities and clinicians or physician practices at which to seek care.

Among the items considered would be the unique health services and other public goods provided

by facilities and clinicians or physician practices in establishing the most appropriate cost

comparisons;

     (5) All activities related to contractual disclosure to participating providers of the

mechanisms for resolving health plan/provider disputes;

     (6) The uniform process being utilized for confirming, in real time, patient insurance

enrollment status, benefits coverage, including co-pays and deductibles;

     (7) Information related to temporary credentialing of providers seeking to participate in the

plan's network and the impact of the activity on health plan accreditation;

     (8) The feasibility of regular contract renegotiations between plans and the providers in

their networks; and

     (9) Efforts conducted related to reviewing impact of silent PPOs on physician practices.

     (e) To enforce the provisions of Title 27 and Title 42 as set forth in § 42-14-5(d).

     (f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The

fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17.

     (g) To analyze the impact of changing the rating guidelines and/or merging the individual

health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health

insurance market, as defined in chapter 50 of title 27, in accordance with the following:

     (1) The analysis shall forecast the likely rate increases required to effect the changes

recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer

health insurance market over the next five (5) years, based on the current rating structure and

current products.

     (2) The analysis shall include examining the impact of merging the individual and small-

employer markets on premiums charged to individuals and small-employer groups.

     (3) The analysis shall include examining the impact on rates in each of the individual and

small-employer health insurance markets and the number of insureds in the context of possible

changes to the rating guidelines used for small-employer groups, including: community rating

principles; expanding small-employer rate bonds beyond the current range; increasing the employer

group size in the small-group market; and/or adding rating factors for broker and/or tobacco use.

     (4) The analysis shall include examining the adequacy of current statutory and regulatory

oversight of the rating process and factors employed by the participants in the proposed, new

merged market.

     (5) The analysis shall include assessment of possible reinsurance mechanisms and/or

federal high-risk pool structures and funding to support the health insurance market in Rhode Island

by reducing the risk of adverse selection and the incremental insurance premiums charged for this

risk, and/or by making health insurance affordable for a selected at-risk population.

     (6) The health insurance commissioner shall work with an insurance market merger task

force to assist with the analysis. The task force shall be chaired by the health insurance

commissioner and shall include, but not be limited to, representatives of the general assembly, the

business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in

the individual market in Rhode Island, health insurance brokers, and members of the general public.

     (7) For the purposes of conducting this analysis, the commissioner may contract with an

outside organization with expertise in fiscal analysis of the private insurance market. In conducting

its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said

data shall be subject to state and federal laws and regulations governing confidentiality of health

care and proprietary information.

     (8) The task force shall meet as necessary and include its findings in the annual report, and

the commissioner shall include the information in the annual presentation before the house and

senate finance committees.

     (h) To establish and convene a workgroup representing healthcare providers and health

insurers for the purpose of coordinating the development of processes, guidelines, and standards to

streamline healthcare administration that are to be adopted by payors and providers of healthcare

services operating in the state. This workgroup shall include representatives with expertise who

would contribute to the streamlining of healthcare administration and who are selected from

hospitals, physician practices, community behavioral health organizations, each health insurer, and

other affected entities. The workgroup shall also include at least one designee each from the Rhode

Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the

Rhode Island Health Center Association, and the Hospital Association of Rhode Island. The

workgroup shall consider and make recommendations for:

     (1) Establishing a consistent standard for electronic eligibility and coverage verification.

Such standard shall:

     (i) Include standards for eligibility inquiry and response and, wherever possible, be

consistent with the standards adopted by nationally recognized organizations, such as the Centers

for Medicare and Medicaid Services;

     (ii) Enable providers and payors to exchange eligibility requests and responses on a system-

to-system basis or using a payor-supported web browser;

     (iii) Provide reasonably detailed information on a consumer's eligibility for healthcare

coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing

requirements for specific services at the specific time of the inquiry; current deductible amounts;

accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and

other information required for the provider to collect the patient's portion of the bill;

     (iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility

and benefits information;

     (v) Recommend a standard or common process to protect all providers from the costs of

services to patients who are ineligible for insurance coverage in circumstances where a payor

provides eligibility verification based on best information available to the payor at the date of the

request of eligibility.

     (2) Developing implementation guidelines and promoting adoption of the guidelines for:

     (i) The use of the National Correct Coding Initiative code-edit policy by payors and

providers in the state;

     (ii) Publishing any variations from codes and mutually exclusive codes by payors in a

manner that makes for simple retrieval and implementation by providers;

     (iii) Use of Health Insurance Portability and Accountability Act standard group codes,

reason codes, and remark codes by payors in electronic remittances sent to providers;

     (iv) The processing of corrections to claims by providers and payors.

     (v) A standard payor-denial review process for providers when they request a

reconsideration of a denial of a claim that results from differences in clinical edits where no single,

common-standards body or process exists and multiple conflicting sources are in use by payors and

providers.

     (vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual

payor's ability to employ, and not disclose to providers, temporary code edits for the purpose of

detecting and deterring fraudulent billing activities. The guidelines shall require that each payor

disclose to the provider its adjudication decision on a claim that was denied or adjusted based on

the application of such edits and that the provider have access to the payor's review and appeal

process to challenge the payor's adjudication decision.

     (vii) Nothing in this subsection shall be construed to modify the rights or obligations of

payors or providers with respect to procedures relating to the investigation, reporting, appeal, or

prosecution under applicable law of potentially fraudulent billing activities.

     (3) Developing and promoting widespread adoption by payors and providers of guidelines

to:

     (i) Ensure payors do not automatically deny claims for services when extenuating

circumstances make it impossible for the provider to obtain a preauthorization before services are

performed or notify a payor within an appropriate standardized timeline of a patient's admission;

     (ii) Require payors to use common and consistent processes and time frames when

responding to provider requests for medical management approvals. Whenever possible, such time

frames shall be consistent with those established by leading national organizations and be based

upon the acuity of the patient's need for care or treatment. For the purposes of this section, medical

management includes prior authorization of services, preauthorization of services, precertification

of services, post-service review, medical-necessity review, and benefits advisory;

     (iii) Develop, maintain, and promote widespread adoption of a single, common website

where providers can obtain payors' preauthorization, benefits advisory, and preadmission

requirements;

     (iv) Establish guidelines for payors to develop and maintain a website that providers can

use to request a preauthorization, including a prospective clinical necessity review; receive an

authorization number; and transmit an admission notification.

     (4) To provide a report to the house and senate, on or before January 1, 2017, with

recommendations for establishing guidelines and regulations for systems that give patients

electronic access to their claims information, particularly to information regarding their obligations

to pay for received medical services, pursuant to 45 C.F.R. 164.524.

     (i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually

thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate

committee on health and human services, and the house committee on corporations, with: (1)

Information on the availability in the commercial market of coverage for anti-cancer medication

options; (2) For the state employee's health benefit plan, the costs of various cancer-treatment

options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member

utilization and cost-sharing expense.

     (j) To monitor the adequacy of each health plan's compliance with the provisions of the

federal Mental Health Parity Act, including a review of related claims processing and

reimbursement procedures. Findings, recommendations, and assessments shall be made available

to the public.

     (k) To monitor the transition from fee-for-service and toward global and other alternative

payment methodologies for the payment for healthcare services. Alternative payment

methodologies should be assessed for their likelihood to promote access to affordable health

insurance, health outcomes, and performance.

     (l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital

payment variation, including findings and recommendations, subject to available resources.

     (m) Notwithstanding any provision of the general or public laws or regulation to the

contrary, provide a report with findings and recommendations to the president of the senate and the

speaker of the house, on or before April 1, 2014, including, but not limited to, the following

information:

     (1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1,

27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-

18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health

insurance for fully insured employers, subject to available resources;

     (2) Current provider and insurer mandates that are unnecessary and/or duplicative due to

the existing standards of care and/or delivery of services in the healthcare system;

     (3) A state-by-state comparison of health insurance mandates and the extent to which

Rhode Island mandates exceed other states benefits; and

     (4) Recommendations for amendments to existing mandated benefits based on the findings

in (m)(1), (m)(2), and (m)(3) above.

     (n) On or before July 1, 2014, the office of the health insurance commissioner, in

collaboration with the director of health and lieutenant governor's office, shall submit a report to

the general assembly and the governor to inform the design of accountable care organizations

(ACOs) in Rhode Island as unique structures for comprehensive health-care delivery and value-

based payment arrangements, that shall include, but not be limited to:

     (1) Utilization review;

     (2) Contracting; and

     (3) Licensing and regulation.

     (o) On or before February 3, 2015, the office of the health insurance commissioner shall

submit a report to the general assembly and the governor that describes, analyzes, and proposes

recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard

to patients with mental health and substance use disorders.

     (p) To work to ensure the health insurance coverage of behavioral health care under the

same terms and conditions as other health care, and to integrate behavioral health parity

requirements into the office of the health insurance commissioner insurance oversight and health

care transformation efforts.

     (q) To work with other state agencies to seek delivery system improvements that enhance

access to a continuum of mental health and substance use disorder treatment in the state; and

integrate that treatment with primary and other medical care to the fullest extent possible.

     (r) To direct insurers toward policies and practices that address the behavioral health needs

of the public and greater integration of physical and behavioral healthcare delivery.

     (s) The office of the health insurance commissioner shall conduct an analysis of the impact

of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and

submit a report of its findings to the general assembly on or before June 1, 2023.

     (t) To undertake the analyses, reports, and studies contained in this section:

     (1) The office shall hire the necessary staff and prepare a request for proposal for a qualified

and competent firm or firms to undertake the following analyses, reports, and studies;

     (i) The firm shall undertake a comprehensive review of all social and human service

programs having a contract with or licensed by the state or any subdivision of the department of

children, youth and families (DCYF), the department of behavioral healthcare, developmental

disabilities, and hospitals (BHDDH), the department of human services (DHS), the department of

health (DOH), and Medicaid for the purposes of:

     (A) Establishing a baseline of the eligibility factors for receiving services;

     (B) Establishing a baseline of the service offering through each agency for those

determined eligible;

     (C) Establishing a baseline understanding of reimbursement rates for all social and human

service programs including rates currently being paid, the date of the last increase, and a proposed

model which the state may use to conduct future studies and analyses;

     (D) Ensuring accurate and adequate reimbursement to social and human service providers

that facilitate the availability of high-quality services to individuals receiving home and

community-based long-term services and supports provided by social and human service providers;

     (E) Ensuring the general assembly is provided accurate financial projections on social and

human service program costs, demand for services, and workforce needs to ensure access to entitled

beneficiaries and services;

     (F) Establishing a baseline and determining the relationship between state government and

the provider network including functions, responsibilities and duties;

     (G) Determining a set of measures and accountability standards to be used by EOHHS and

the general assembly to measure the outcomes of the provision of services including budgetary

reporting requirements, transparency portals and other methods; and

     (H) Reporting the findings of human services analyses and reports to the speaker of the

house, senate president, chairs of the house and senate finance committees, chairs of the house and

senate health and human services committees and the governor.

     (2) The analyses, reports, and studies required pursuant to this section shall be

accomplished and published as follows and shall provide:

     (i) An assessment and detailed reporting on all social and human service program rates to

be completed by January 1, 2023, including rates currently being paid and the date of the last

increase;

     (ii) An assessment and detailed reporting on eligibility standards and processes of all

mandatory and discretionary social and human service programs to be completed by January 1,

2023;

     (iii) An assessment and detailed reporting on utilization trends from the period of January

1, 2017 through December 31, 2021 for social and human service programs to be completed by

January 1, 2023;

     (iv) An assessment and detailed reporting on the structure of the state government as it

relates to the provision of services by social and human service providers including eligibility and

functions of the provider network to be completed by January 1, 2023;

     (v) An assessment and detailed reporting on accountability standards for services for social

and human service programs to be completed by January 1, 2023;

     (vi) An assessment and detailed reporting by April 1, 2023 on all professional licensed and

unlicensed personnel requirements for established rates for social and human service programs

pursuant to a contract or established fee schedule;

     (vii) An assessment and reporting on access to social and human service programs, to

include any wait lists and length of time on wait lists, in each service category by April 1, 2023;

     (viii) An assessment and reporting of national and regional Medicaid rates in comparison

to Rhode Island social and human service provider rates by April 1, 2023; and

     (ix) An assessment and reporting on usual and customary rates paid by private insurers and

private pay for similar social and human service providers, both nationally and regionally, by April

1, 2023;

     (x) Completion of the development of an assessment and review process that includes the

following components: eligibility, scope of services, relationship of social and human service

provider and the state, national and regional rate comparisons and accountability standards that

result in recommended rate adjustments, and this process shall be completed by September 1, 2023

and conducted biennially hereafter. The biennial rate setting shall be consistent with payment

requirements established in §1902(a)(30)(A) of the Social Security Act and all federal, and state

law, regulations and quality and safety standards. The results and findings of this process shall be

transparent, and public meetings shall be conducted to allow providers, recipients and other

interested parties an opportunity to ask questions and provide comment beginning in September

2023 and biennially thereafter. (3) In fulfillment of the responsibilities defined in section (t), the

office of the health insurance commissioner shall consult with the Executive Office of Health and

Human Services.

     (u) Annually, each department (namely EOHHS, DCYF, DOH, DHS, and BHDDH) shall

include the corresponding components of the assessment and review (i.e. eligibility, scope of

services, relationship of social and human service provider and the state, national and regional rate

comparisons and accountability standards including any changes or substantive issues between

biennial reviews) including the recommended rates from the most recent assessment and review

with their annual budget submission to the office of management and budget and provide a detailed

explanation and impact statement if any rate variances exist between submitted recommended

budget and the corresponding recommended rate from the most recent assessment and review

process starting October 1, 2023, and biennially thereafter.

     (v) The general assembly shall appropriate adequate funding as it deems necessary to

undertake the analyses, reports, and studies contained in this section relating to the powers and

duties of the office of the health insurance commissioner.

     SECTION 8. Chapter 42-14.5 of the General Laws entitled "The Rhode Island Health Care

Reform Act of 2004 - Health Insurance Oversight" is hereby amended by adding thereto the

following sections:

     42-14.5-2.1. Definitions.

     As used in this chapter:

     (1) "Accountability standards" means measures including service processes, client and

population outcomes, practice standard compliance and fiscal integrity of social and human service

providers on the individual contractual level and service type for all state contacts of the state or

any subdivision or agency to include, but not limited to, the department of children, youth and

families (DCYF), the department of behavioral healthcare, developmental disabilities and hospitals

(BHDDH), the department of human services (DHS), the department of health (DOH), and

Medicaid. This may include mandatory reporting, consolidated, standardized reporting, audits

regardless of organizational tax status and accountability dashboards of aforementioned state

departments or subdivisions that are regularly shared with public.

     (2) "Executive Office of Health and Human Services (EOHHS)" means the department that

serves as "principal agency of the executive branch of state government" (RIGL § 42-7.2-2)

responsible for managing the departments and offices of: health (RIDOH); human services (DHS);

healthy aging (OHA); veterans services (VETS); children, youth and families (DCYF); and

behavioral healthcare, developmental disabilities and hospitals (BHDDH). EOHHS is also

designated at the single state agency with authority to administer the Medicaid program in Rhode

Island.

     (3) "Rate review" means the process of reviewing and reporting of specific trending factors

that influence the cost of service that informs rate setting.

     (4) "Rate setting" means the process of establishing rates for social and human service

programs that are based on a thorough rate review process.

     (5) "Social and human service program" means a social, mental health, developmental

disability, child welfare, juvenile justice, prevention services, habilitative, rehabilitative, substance

use disorder treatment, residential care, adult or adolescent day services, vocational, employment

and training, or aging service program or accommodations purchased by the state.

     (6) "Social and human service provider" means a provider of social and human service

programs pursuant to a contract with the state or any subdivision or agency to include, but not be

limited to, the department of children, youth and families (DCYF), the department of behavioral

healthcare, developmental disabilities and hospitals (BHDDH), the department of human services

(DHS), the department of health (DOH), and Medicaid.

     (7) "State government and the provider network" refers to the contractual relationship

between a state agency or subdivision of state agency and private companies the state contracts

with to provide the network of mandated and discretionary social and human services.

     42-14.5-5. Severability.

     If any provision of this chapter or the application thereof to any person or circumstance is

held invalid, such invalidity shall not affect other provisions or applications of the chapter, which

can be given effect without the invalid provision or application, and to this end the provisions of

this chapter are declared to be severable.

     SECTION 9. Section 42-66.3-4 of the General Laws in Chapter 42-66.3 entitled "Home

and Community Care Services to the Elderly" is hereby amended to read as follows:

     42-66.3-4. Persons eligible.

     (a) To be eligible for this program the client must be determined, through a functional

assessment, to be in need of assistance with activities of daily living or and/or must meet a required

level of care as defined in rules and regulations promulgated by the department;

     (b) Medicaid eligible individuals age sixty-five (65) or older of the state who meet the

financial guidelines of the Rhode Island medical assistance program, as defined in rules and

regulations promulgated by the department, shall be provided the services without charge; or

     (c) Persons eligible for assistance under the provisions of this section, subject to the annual

appropriations deemed necessary by the general assembly to carry out the provisions of this chapter,

include: (1) any homebound unmarried resident or homebound married resident of the state living

separate and apart, who is ineligible for Medicaid, at least sixty-five (65) years of age or, if under

sixty-five (65) years of age, has a diagnosis of Alzheimer's disease or a related dementia, confirmed

by a licensed physician, ineligible for Medicaid, and whose income does not exceed the income

eligibility limits as defined by rules and regulations promulgated by the department two hundred

fifty percent (250%) of the federal poverty level; and (2) any married resident of the state who is

ineligible for Medicaid, at least sixty-five (65) years of age, ineligible for Medicaid, or, if under

sixty-five (65) years of age, has a diagnosis of Alzheimer's disease or a related dementia confirmed

by a licensed physician and whose income when combined with any income of that person's spouse

does not exceed two hundred fifty percent (250%) of the federal poverty level the income eligibility

limits as defined in rules and regulations promulgated by the department. Persons who meet the

eligibility requirement of this subsection shall be eligible for the co-payment portion as set forth in

§ 42-66.3-5.

     SECTION 10. Rhode Island Medicaid Reform Act of 2008 Resolution.

     WHEREAS, the General Assembly enacted Chapter 12.4 of Title 42 entitled "The Rhode

Island Medicaid Reform Act of 2008"; and

     WHEREAS, a legislative enactment is required pursuant to Rhode Island General Laws

42-12.4-1, et seq.; and

     WHEREAS, Rhode Island General Laws section 42-7.2-5(3)(i) provides that the Secretary

of the Executive Office of Health and Human Services ("Executive Office") is responsible for the

review and coordination of any Medicaid section 1115 demonstration waiver requests and renewals

as well as any initiatives and proposals requiring amendments to the Medicaid state plan or category

II or III changes as described in the demonstration, "with potential to affect the scope, amount, or

duration of publicly-funded health care services, provider payments or reimbursements, or access

to or the availability of benefits and services provided by Rhode Island general and public laws";

and

     WHEREAS, in pursuit of a more cost-effective consumer choice system of care that is

fiscally sound and sustainable, the Secretary requests legislative approval of the following

proposals to amend the demonstration; and

     WHEREAS, implementation of adjustments may require amendments to the Rhode

Island’s Medicaid state plan and/or section 1115 waiver under the terms and conditions of the

demonstration. Further, adoption of new or amended rules, regulations and procedures may also be

required:

     (a) Section 1115 Demonstration Waiver – Extension Request. The Executive Office

proposes to seek approval from the federal centers for Medicare and Medicaid services ("CMS")

to extend the Medicaid section 1115 demonstration waiver as authorized in Rhode Island General

Laws § 42-12.4. In the Medicaid section 1115 demonstration waiver extension request due to CMS

by December 31, 2022, in addition to maintaining existing Medicaid section 1115 demonstration

waiver authorities, the Executive Office proposes to seek additional federal authorities including

but not limited to promoting choice and community integration.

     (b) Meals on Wheels. The Executive Office proposes an increase to existing fee-for-service

and managed care rates to account for growing utilization and rising food and delivery costs.

Additionally, the Executive Office of Health and Human Services will offer new Medicaid

reimbursement for therapeutic and cultural meals that are specifically tailored to improve health

through nutrition, provide post discharge support, and bolster complex care management for those

with chronic health conditions. To ensure the continued adequacy of rates, effective July 1, 2022,

and annually thereafter, the Executive Office proposes an annual rate increase based on the CPI-U

for New England: Food at Home, March release (containing the February data).

     (c) American Rescue Plan Act. The Executive Office proposes to seek approval from CMS

for any necessary amendments to the Rhode Island State Plan or the 1115 Demonstration Waiver

to implement the spending plan approved by CMS under section 9817 of the American Rescue Plan

Act of 2021.

     (d) HealthSource RI automatic enrollment: The Executive Office shall work with

HealthSource RI to establish a program for automatically enrolling qualified individuals who lose

Medicaid coverage at the end of the COVID-19 Public Health Emergency into Qualified Health

Plans ("QHP"). HealthSource RI may use funds available through the American Rescue Plan Act

to pay the first two (2) month’s premium for individuals who qualify for this program.

HealthSource RI may promulgate regulations establishing the scope and parameters of this

program.

     (e) Increase Nursing Facility Rates. The Executive Office proposes to increase rates, both

fee-for-service and managed care, paid to nursing facilities by three percent (3.0%) on October 1,

2022, in lieu of the adjustment of rates by the change in a recognized national home inflation index

as defined in § 40-8-19 (2)(vi) and in addition to the one percent (1.0%) increase required for the

minimum wage pass through as defined in § 40-8-19 (2)(vi).

     (f) Extend Post-Partum Medicaid Coverage. The Executive Office proposes extending the

continuous coverage of full benefit medical assistance from sixty (60) days to twelve (12) months

postpartum to women who are (1) not eligible for Medicaid under another Medicaid eligibility

category, or (2) do not have qualified immigrant status for Medicaid whose births are financed by

Medicaid through coverage of the child and currently only receive state-only extended family

planning benefits postpartum.

     (g) Extending Medical Coverage to Children Previously Ineligible. The executive office of

health and human services will maximize federal financial participation if and when available,

though state-only funds will be used if federal financial participation is not available.

     (h) Federal Financing Opportunities. The Executive Office proposes to review Medicaid

requirements and opportunities under the U.S. Patient Protection and Affordable Care Act of 2010

(PPACA) and various other recently enacted federal laws and pursue any changes in the Rhode

Island Medicaid program that promote service quality, access and cost-effectiveness that may

warrant a Medicaid state plan amendment or amendment under the terms and conditions of Rhode

Island’s section 1115 waiver, its successor, or any extension thereof. Any such actions by the

Executive Office shall not have an adverse impact on beneficiaries or cause there to be an increase

in expenditures beyond the amount appropriated for state fiscal year 2023.

     (i) Increase Adult Dental Rates. To ensure better access to dental care for adults, the

Executive Office proposes to increase rates in both fee-for-service and managed care.

     (j) Increase Pediatric Provider Rates. To ensure better access to pediatric providers, the

Executive Office proposes to increase rates in both fee-for-service and managed care to be equal to

Medicare primary care rates.

     (k) Increase Early Intervention Rates. To ensure better access to Early Intervention

Services, the Executive Office proposes to increase rates in both fee-for-service and managed care

by forty-five percent (45%).

     (l) Increase Hospital Rates. The Executive Office proposes to increase inpatient and

outpatient rates, both fee-for-service and managed care, paid to hospitals by five percent (5%) on

July 1, 2022, in lieu of the adjustment of rates by the change in the recognized inflation index as

defined in § 40-8-13.4(1)(i). The Executive Office proposes amendments, as needed, to the

inpatient and outpatient supplemental payment methodology to incorporate the five percent (5%)

rate increase into the upper payment limit demonstration modeling.

     (m) Nursing Facility Rate Setting. The Executive Office proposes to seek approval from

the federal Centers for Medicare and Medicaid Services ("CMS") for amendments to the Rhode

Island State Plan to eliminate references to the rate review process and audit requirements for

nursing facilities.

     (n) Public Health Emergency Unwinding. The Executive Office proposes to seek approval

from the federal Centers for Medicare and Medicaid Services ("CMS") for section 1115

demonstration waivers and State Plan Amendments as necessary to: (1) continue some of the

temporary federal authorities granted during the Public Health Emergency ("PHE") for a period not

to extend 14 months beyond the termination of the PHE; and (2) ensure minimum adverse impact

on beneficiaries and state operations at the end of the PHE, including temporary authorities where

applicable, provided that such temporary authorities shall not extend beyond 14 months following

the termination of the PHE.

     (o) Labor and Delivery Rates. The Executive Office proposes to increase rates paid for

labor and delivery services by 20 percent.

     (o) Managed Care Payment for Antepartum, Delivery, and Postpartum Care. The

Executive Office proposes to increase the payment it makes to the managed care plans by twenty

percent (20%) to reimburse hospitals that provide antepartum, delivery, postpartum, newborn care,

and to pay for other authorized services.

     (p) Increase Rates for Home Based Services. To ensure better access to home care services

for children, the elderly and disabled adults, the Executive Office proposes to increase

reimbursement rates in both fee-for-service and managed care to a minimum of $15 an hour for

direct care workers.

     (q) Certified Behavioral Healthcare Clinics. The Executive Office proposes to seek

approval from the federal Centers for Medicare and Medicaid Service for any necessary

amendments to the Rhode Island State Plan or 1115 Demonstration Waiver to implement the

Certified Behavioral Health Clinics federal model.

     Now, therefore, be it:

     (r) Palliative Care. The Executive Office of Health and Human Services proposes to seek

approval from the federal Centers for Medicare and Medicaid Services for an amendment to the

Rhode Island State Plan that ensures palliative care coverage to those age nineteen (19) to under

twenty-six (26) who are either covered by an individual or family health insurance plan but have

aged out of the option to receive services through the Katie Beckett coverage category. The services

offered shall be determined by the Executive Office and may include, but are not limited to,

consultations for pain and symptom management, case management and assessment, social

services, counseling, volunteer support services, and respite services.

     (s) Biomarker Testing. The Executive Office of Health and Human Services proposes to

seek approval from the federal Centers for Medicare and Medicaid Services for an amendment to

the Rhode Island State Plan to provide coverage for biomarker testing that must be covered for the

purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a Medicaid

beneficiary's disease or condition when the test is supported by medical and scientific evidence.

     RESOLVED, that the General Assembly hereby approves the proposals stated above in the

recitals; and be it further;

     RESOLVED, that the Secretary of the Executive Office of Health and Human Services is

authorized to pursue and implement any waiver amendments, state plan amendments, and/or

changes to the applicable department’s rules, regulations and procedures approved herein and as

authorized by 42-12.4; and be it further;

     RESOLVED, that this Joint Resolution shall take effect upon passage.

     SECTION 11. Sections 1 through 6 and 9 of this Article shall take effect as of July 1, 2022.

Sections 7, 8 and 10 shall take effect upon passage.