2022 -- H 7489

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LC004421

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2022

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A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL AND CLINICAL SERVICES PROGRAMS

RATE REVIEW AND RATE SETTING PROCESS ACT OF 2022

     

     Introduced By: Representatives Casimiro, Noret, Solomon, McEntee, Kislak,
Chippendale, Kazarian, Felix, Henries, and McGaw

     Date Introduced: February 16, 2022

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

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     SECTION 1. Title 40 of the General Laws entitled "HUMAN SERVICES" is hereby

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amended by adding thereto the following chapter:

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CHAPTER 23

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MEDICAL AND CLINICAL SERVICES PROGRAMS RATE REVIEW AND RATE

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SETTING ACT OF 2022

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     40-23-1. Definitions.

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     As used in this chapter:

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     (1) "Medical and clinical service program" means medical care, financial assistance for:

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medical care, health insurance, prescription drug assistance, medical equipment, medical supplies,

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disease screening or other medical assistance program or services purchased by the state, excluding

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any program, service, or accommodation that is reimbursable exclusively by a federal grant.

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     (2) "Medical and clinical service provider" means a provider of medical and clinical service

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programs pursuant to a contract with the state or any division or agency including, but not limited

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to, the department of children, youth and families (DCYF), the department of behavioral healthcare,

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developmental disabilities, and hospitals (BHDDH), department of human services (DHS),

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department of health (DOH) and Medicaid.

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     (3) "Rate review" means the process of reviewing and reporting of specific trending factors

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that influence the cost of service that informs rate setting.

 

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     (4) "Rate setting" means the process of establishing rates for medical and clinical service

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programs that are based on a thorough rate review process.

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     40-23-2. Medical and clinical service program rate review and rate reform.

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     The executive office of health and human services (EOHHS) shall conduct a

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comprehensive rate review of all medical and clinical service programs pursuant to having a

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contract with or licensed by the state or any subdivision DCYF, BHDDH, DHS, DOH, Medicaid

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for the purposes of:

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     (1) Establishing a baseline understanding of reimbursement rates for all medical and

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clinical service programs;

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     (2) Ensuring accurate and adequate reimbursement to medical and clinical service

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providers that facilitate the availability of high-quality services to individuals receiving home and

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community-based long-term services and supports provided by medical and clinical service

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providers; and

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     (3) Ensuring the general assembly is informed and provided accurate financial projections

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on medical and clinical service program costs, demand for services, and workforce needs to ensure

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access to entitled beneficiaries and services.

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     40-23-3. Assessment and detailed reporting of current rates -- Collaboration of

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departments and advisory committee.

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     (a) EOHHS shall work in collaboration with DCYF, BHDDH, DHS, DOH, Medicaid, and

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the advisory committee established in § 40-23-4 to assess current rates for medical and clinical

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service programs. This assessment shall include, but not be limited to, the following information

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and report development:

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     (1) Assessment and detailed reporting on all medical and clinical service program rates to

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be completed by October 1, 2022;

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     (2) Assessment and detailed reporting on eligible medical and clinical service programs to

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be completed by October 1, 2022;

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     (3) Assessment and detailed reporting on utilization trends from the period of January 1,

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2017 through December 31, 2021 for medical and clinical service programs to be completed by

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October 31, 2022;

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     (4) Assessment and detailed reporting on all rate methodology and rationale for established

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rates as of January 1, 2023, for medical and clinical service programs;

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     (5) Assessment and detailed reporting on medical and clinical service provider reported

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cost of established rates for services and contracts by January l, 2023 for medical and clinical

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service programs as of December 31, 2021;

 

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     (6) Assessment and detailed reporting by January 1, 2023 on all professional licensed and

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unlicensed personnel requirements for established rates for medical and clinical service programs

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pursuant to a contract or established fee schedule;

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     (7) Assessment and reporting on access to medical and clinical service programs, to include

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any wait lists and length of time on wait lists, or any delays in care, or denials due to limited

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resources, that can be tracked and quantified in each service category by January 1, 2023.

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     (8) Assessment and reporting that includes comparable rates paid regionally for similar

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medical and clinical service providers by January 1, 2023;

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     (9) Assessment and reporting of national Medicaid rates in comparison to Rhode Island

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medical and clinical service provider rates by January 1, 2023; and

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     (10) Assessment and reporting on usual and customary rates paid by private insurers and

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private pay for similar medical and clinical service providers by January 1, 2023.

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     (b) Detailed reports of this assessment shall be submitted to the advisory committee, the

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speaker of the house, president of the senate, governor, senate finance committee, house finance

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committee, house fiscal advisor, senate fiscal advisor, and director of the office of management and

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budget on or before March 1, 2023, and biennially thereafter.

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     40-23-4. Advisory committee.

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     (a) There is hereby established the medical and clinical services provider rate review and

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rate setting advisory committee, referred to in this section as the ("advisory committee"). The

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purpose of this advisory committee is to provide expert review and recommendations for the

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process of rate setting and ongoing review of rate setting. The advisory committee shall:

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     (1) Review documents, reports, assumptions, and fiscal data for biennial rate review

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assessment within thirty (30) days of receipt as they relate to petitions or proposals received from

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EOHHS as detailed in subsection (a)(4) of this section;

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     (2) Define and establish consistent policy and methods for standardized service rate

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development, for the purposes of conducting a biennial "rate setting" in coordination with EOHHS

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by July 1, 2023, to ensure payments are consistent with efficiency, economy, and quality of care in

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order to enlist enough medical and clinical service providers to ensure that care and services are

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available for beneficiaries and/or eligible persons. The biennial rate setting shall be consistent with

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payment requirements established in § 1902(a)(30) of the Social Security Act, 42 U.S.C. 1396 a,

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and all federal, and state law, regulations and quality and safety standards. The rate setting process

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shall include, but is not that limited to, industry standard methodology(ies); industry standard cost-

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based assumptions, access to service benchmarks, relevant regional and national economic

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inflationary index, regional labor market indicators and benchmarks, Centers for Medicaid and

 

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Medicare Services (CMS) market-based indicators for relevant services, state mandated regulations

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and requirements of medical and clinical service providers, triggers for adjustments according to

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projected trends, for the purposes of pricing of medical and clinical service program rates. Proposed

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rates shall be published by January 1, 2024 and effective no later than July 1, 2024;

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     (3) With EOHHS, conduct public meetings to allow providers, recipients, and other

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interested parties an opportunity to comment on the report required by the provisions of this section;

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     (4) Review petitions or proposals for provider rates to be reviewed or adjusted that are

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received by the advisory committee from EOHHS; and

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     (5) Prepare written recommendations to the governor, the speaker of the house, and

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president of the senate as to all changes to the process of reviewing provider rates, including

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measures to increase access to the process such as by providing for electronic comments by

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providers and the public.

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     (b) The advisory committee may, by a majority vote, recommend to EOHHS to include

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any rate that the EOHHS has selected to exclude or remove any rate selected for inclusion from the

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schedule pursuant to this section. The advisory committee may recommend that EOHHS determine

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whether any provider rates not scheduled for review during the next calendar year should be

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recommended for review during that calendar year. The advisory committee shall provide other

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assistance to the EOHHS and DHS agencies as requested.

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     (c) On or before November 1, 2022, and each November 1 thereafter, EOHHS shall submit

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a written report to the speaker of the house, the president of the senate, the governor, and the

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advisory committee containing its determinations on all the provider rates reviewed pursuant to this

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section and all of the data relied upon by EOHHS in making its determinations for rate setting.

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EOHHS shall prepare proposed projections of costs associated with biennial rate setting for medical

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and clinical service programs.

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     (d) The advisory committee shall consist of the following twenty-four (24) members:

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     (1) The following members shall be appointed by the senate president:

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     (i) Two (2) members of the senate;

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     (ii) A representative of the Hospital Association of Rhode Island;

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     (iii) A representative of the Psychological Association;

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     (iv) A representative of the Chiropractic Society of Rhode Island;

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     (v) A representative of the specialized community-based health care;

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     (vi) A representative of the Leading Age RI;

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     (vii) A representative of the Substance Use and Mental Health Leadership Council of RI;

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     (viii) A representative of pediatric primary care physicians who see patients;

 

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     (ix) A representative of the Rhode Island Health Care Association;

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     (x) A representative of providers of home-based hospice/palliative care; and

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     (xi) A representative of facility-based physicians, who see patients, including

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anesthesiologists, emergency room physicians, neonatologists, pathologists and radiologists;

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     (2) The following members shall be appointed by the speaker of the house:

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     (i) Two (2) members of the house of representatives, one from each political party;

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     (ii) A representative of a provider of emergency medical transportation;

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     (iii) A representative of the providers of durable medical equipment;

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     (iv) A representative of primary care physicians who see patients;

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     (v) A representative of dentists who see patients;

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     (vi) A representative of providers of alternative care facilities;

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     (vii) A representative of obstetricians who see patients;

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     (viii) A representative of pharmacists providing services to recipients;

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     (ix) A representative of physical or occupational therapists providing services to patients;

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     (x) A representative of advance practices nurses; and

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     (xi) A representative of ambulatory surgical centers.

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     (e) The appointing authorities shall make their initial appointments to the advisory

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committee no later than August 1, 2022. In making appointments to the advisory committee, to the

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greatest extent possible, the appointing authorities shall consider the diversity of Rhode Island.

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     (f) Each member of the advisory committee shall serve at the pleasure of the official who

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appointed the member. Each member of the advisory committee shall serve a four (4) year term

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and may be reappointed for no more than one additional term. Members who have served two (2)

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consecutive terms may be reappointed no sooner than one year after the end of the second term.

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     (g) The members of the advisory committee shall serve without compensation and without

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reimbursement for expenses.

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     (h) At the first meeting of the advisory committee, to be held on or before September 1,

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2022, the members shall elect a chair, vice-chair and secretary from among the members.

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     (i) The advisory committee shall meet at least once every quarter. The chair may call such

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additional meetings as may be necessary for the advisory committee to perform its duties.

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     (j) The advisory committee shall develop bylaws and procedures to govern its operations.

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     (k) The department of administration, in collaboration with EOHHS, shall assist the

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advisory committee in its work by providing resources, staff support, and any information that may

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be necessary to facilitate the purposes of this chapter.

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     40-24-5. Funding.

 

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     The general assembly shall annually appropriate any sums it may deem necessary to enable

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the advisory committee to carry out its assigned purposes.

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     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL AND CLINICAL SERVICES PROGRAMS

RATE REVIEW AND RATE SETTING PROCESS ACT OF 2022

***

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     This act would require the executive office of health and human services (EOHHS) with

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the assistance of a twenty-four (24) person advisory committee to provide expert review and

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recommendations for the process for rate setting and ongoing review of rate setting for all medical

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and clinical service programs contracted by, or with or licensed by the state or any department of

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the state as well as Medicaid.

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     This act would take effect upon passage.

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