2022 -- H 8119

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LC005714

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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 HEALTH AND SAFETY -- COMPREHENSIVE HEALTH INSURANCE

PROGRAM

     

     Introduced By: Representatives Morales, Henries, Felix, Giraldo, McGaw, Potter, J
Lombardi, Batista, Ranglin-Vassell, and Tanzi

     Date Introduced: April 08, 2022

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

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     SECTION 1. Title 23 of the General Laws entitled "HEALTH AND SAFETY" is hereby

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amended by adding thereto the following chapter:

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CHAPTER 97

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THE RHODE ISLAND COMPREHENSIVE HEALTH INSURANCE PROGRAM

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     23-97-1. Legislative findings.

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     (1) Health care is a human right, not a commodity available only to those who can afford

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it;

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     (2) Although the federal Affordable Care Act (ACA) allowed states to offer more people

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taxpayer subsidized private health insurance, the ACA has not provided universal, comprehensive,

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affordable coverage for all Rhode Islanders:

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     (i) In 2019, about four and three-tenths percent (4.3%) of Rhode Islanders had no health

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insurance, causing about forty-three (43) (1 per 1,000 uninsured) unnecessary deaths each year;

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     (ii) An estimated forty-five percent (45%) of Rhode Islanders are under-insured (e.g., not

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seeking health care because of high deductibles and co-pays);

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     (3) COVID-19 exacerbated and highlighted problems with the status quo health insurance

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system including:

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     (i) Coverage is too easily lost when health insurance is tied to jobs - between February and

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May, 2020, about twenty-one thousand (21,000) more Rhode Islanders lost their jobs and their

 

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health insurance;

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     (ii) Systemic racism is reinforced - Black and Hispanic/Latinx Rhode Islanders, more likely

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to be uninsured or underinsured, have suffered the highest rates of COVID-19 mortality and

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morbidity;

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     (iii) The fear of out-of-pocket costs for uninsured and underinsured puts everyone at risk

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because they avoid testing and treatment;

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     (4) In 2016, sixty million (60,000,000) people separated from their job at some point during

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the year (i.e., about forty-two percent (42%) of the American workforce) and although this act may

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cause some job loss, on balance, single payer would increase employment in Rhode Island by nearly

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three percent (3%);

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     (5) The existing US health insurance system has failed to control the cost of health care

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and to provide universal access to health care in a system which is widely accepted to waste thirty

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percent (30%) of its revenues on activities that do not improve the health of Americans;

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     (6) Every industrialized nation in the world, except the United States, offers universal

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health care to its citizens and enjoys better health outcomes for less than two thirds (2/3) to one-

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half (1/2) the cost;

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     (7) Health care is rationed under our current multi-payer system, despite the fact that Rhode

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Island patients, businesses and taxpayers already pay enough to have comprehensive and universal

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health insurance under a single-payer system;

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     (8) About one-third (1/3) of every "health care" dollar spent in the U.S. is wasted on

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unnecessary administrative costs and excessive pharmaceutical company profits due to laws

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preventing Medicare from negotiating prices and private health insurance companies lacking

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adequate market share to effectively negotiate prices;

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     (9) Private health insurance companies are incentivized to let the cost of health care rise

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because higher costs require health insurance companies to charge higher health insurance

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premiums, increasing companies' revenue and stock price;

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     (10) The health care marketplace is not an efficient market and because it represents only

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eighteen percent (18%) of the US domestic market, significantly restricts economic growth and

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thus the financial well-being of every American, including every Rhode Islander;

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     (11) Rhode Islanders cannot afford to keep the current multi-payer health insurance system:

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     (i) Between 1991 and 2014, health care spending in Rhode Island per person rose by over

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two hundred fifty percent (250%) rising much faster than income and greatly reducing disposable

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income;

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     (ii) It is estimated that by 2025, the cost of health insurance for an average family of four

 

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(4) will equal about one-half (1/2) of their annual income;

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     (iii) In the U.S., about two-thirds (2/3) of personal bankruptcies are medical cost-related

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and of these, about three-fourths (3/4) had health insurance at the onset of their medical problems.

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In no other industrialized country do people worry about going bankrupt over medical costs;

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     (12) Rhode Island private businesses bear most of the costs of employee health insurance

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coverage and spend significant time and money choosing from a confusing array of increasingly

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expensive plans which do not provide comprehensive coverage;

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     (13) Rhode Island employees and retirees lose significant wages and pensions as they are

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forced to pay higher amounts of health insurance and health care costs;

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     (14) Rhode Island's hospitals are under increasing financial distress i.e., closing, sold to

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out-of-state entities, attempting mergers largely due to health insurance reimbursement problems

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that other nations do not face and are fixed by a single-payer system;

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     (15) The state and its municipalities face enormous other post-employment benefits

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(OPEB) unfunded liabilities due mostly to health insurance costs;

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     (16) An improved Medicare-for-all style single-payer program would, based on the

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performance of existing Medicare, eliminate fifty percent (50%) of the administrative waste in the

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current system of private insurance before other savings achieved through meaningful negotiation

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of prices and other savings are considered;

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     (17) The high costs of medical care could be lowered significantly if the state could

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negotiate on behalf of all its residents for bulk purchasing, as well as gain access to usage and price

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information currently kept confidential by private health insurers as "proprietary information;"

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     (18) Single payer health care would establish a true "free market" system where doctors

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compete for patients rather than health insurance companies dictating which patients are able to see

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which doctors and setting reimbursement rates;

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     (19) Health care providers would spend significantly less time with administrative work

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caused by multiple health insurance company requirements and barriers to care delivery and would

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spend significantly less for overhead costs because of streamlined billing;

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     (20) Rhode Island must act because there are currently no effective state or federal laws

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that can provide universal coverage and adequately control rising premiums, co-pays, deductibles

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and medical costs, or prevent private insurance companies from continuing to limit available

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providers and coverage;

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     (21) In 1962, Canada's successful single-payer program began in the province of

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Saskatchewan (with approximately the same population as Rhode Island) and became a national

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program within ten (10) years; and

 

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     (22) The proposed Rhode Island single payer program was studied by Professor Gerald

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Friedman at UMass Amherst in 2015 and he concluded that:

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     "Single-payer in Rhode Island will finance medical care with substantial savings compared

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with the existing multi-payer system of public and private insurers and would improve access to

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health care by extending coverage to the four percent (4%) of Rhode Island residents still without

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insurance under the Affordable Care Act and expanding coverage for the growing number with

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inadequate health care coverage. Single-payer would improve the economic health of Rhode Island

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by: increasing real disposable income for most residents; reducing the burden of health care on

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businesses and promoting increased employment; and shifting the costs of health care away from

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working and middle-class residents."

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     23-97-2. Legislative purpose.

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     It is the intent of the general assembly that this chapter establish a universal,

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comprehensive, affordable single-payer health care insurance program that will help control health

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care costs which shall be referred to as, "the Rhode Island comprehensive health insurance

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program" (RICHIP). The program will be paid for by consolidating government and private

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payments to multiple insurance carriers into a more economical and efficient improved Medicare-

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for-all style single-payer program and substituting lower progressive taxes for higher health

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insurance premiums, co-pays, deductibles and costs in excess of caps. This program will save

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Rhode Islanders from the current overly expensive, inefficient and unsustainable multi-payer health

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insurance system that unnecessarily prevents access to medically necessary health care. The

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program will be established after the standard of care funded by Medicaid has been raised to a

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Medicare standard.

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     23-97-3. Definitions.

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     As used in this chapter:

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     (1) "Affordable Care Act" or "ACA" means the Federal Patient Protection and Affordable

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Care Act (Pub. L. 111-148), as amended by the Federal Health Care and Education Reconciliation

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Act of 2010 (Pub. L. 111-152), and any amendments to, or regulations or guidance issued under,

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those acts.

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     (2) "Carrier" means either a private health insurer authorized to sell health insurance in

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Rhode Island or a health care service plan, i.e., any person who undertakes to arrange for the

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provision of health care services to subscribers or enrollees, or to pay for or to reimburse any part

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of the cost for those services, in return for a prepaid or periodic charge paid by or on behalf of the

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subscribers or enrollees, or any person, whether located within or outside of this state, who solicits

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or contracts with a subscriber or enrollee in this state to pay for or reimburse any part of the cost

 

LC005714 - Page 4 of 92

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of, or who undertakes to arrange or arranges for, the provision of health care services that are to be

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provided, wholly or in part, in a foreign country in return for a prepaid or periodic charge paid by

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or on behalf of the subscriber or enrollee.

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     (3) "Dependent" has the same definition as set forth in federal tax law (26 U.S.C. § 152).

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     (4) "Emergency and urgently needed services" has the same definition as set forth in the

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federal Medicare law (42 CFR 422.113).

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     (5) "Federally matched public health program" means the state's Medicaid program under

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Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.) and the state's Children's Health

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Insurance Program (CHIP) under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa et

10

seq.).

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     (6) "For-profit provider" means any health care professional or health care institution that

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provides payments, profits or dividends to investors or owners who do not directly provide health

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care.

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     (7) "Medicaid" or "medical assistance" means a program that is one of the following:

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     (i) The state's Medicaid program under Title XIX of the Social Security Act (42 U.S.C.

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Sec. 1396 et seq.); or

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     (ii) The state's Children's Health Insurance Program under Title XXI of the Social Security

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Act (42 U.S.C. Sec. 1397aa et seq.).

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     (8) "Medically necessary" means medical, surgical or other services or goods (including

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prescription drugs) required for the prevention, diagnosis, cure, or treatment of a health-related

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condition including any such services that are necessary to prevent a detrimental change in either

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medical or mental health status. Medically necessary services shall be provided in a cost-effective

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and appropriate setting and shall not be provided solely for the convenience of the patient or service

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provider. "Medically necessary" does not include services or goods that are primarily for cosmetic

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purposes; and does not include services or goods that are experimental, unless approved pursuant

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to § 23-97-6(b).

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     (9) "Medicare" means Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.)

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and the programs thereunder.

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     (10) "Qualified health care provider" means any individual who meets requirements set

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forth in § 23-97-7(a)(1).

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     (11) "Qualified Rhode Island resident" means any individual who is a "resident" as defined

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by §§ 44-30-5(a)(1) and (a)(2) or a dependent of that resident.

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     (12) "Rhode Island comprehensive health insurance program" or ("RICHIP") means the

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affordable, comprehensive and effective health insurance program as set forth in this chapter.

 

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     (13) "RICHIP participant" means a qualified Rhode Island resident who is enrolled in

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RICHIP (and not disenrolled or disqualified) at the time they seek health care.

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     23-97-4. Rhode Island health insurance program.

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     (a) Organization. This chapter creates the Rhode Island comprehensive health insurance

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program (RICHIP), as an independent state government agency.

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     (b) Director. A director shall be appointed by the governor, with the advice and consent of

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the senate, to lead RICHIP and serve a term of four (4) years, subject to oversight by an executive

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board. The director shall be compensated in accordance with the job title and job classification

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established by the division of human resources and approved by the general assembly. The duties

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of the director shall include:

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     (1) Employ staff and authorize reasonable expenditures, as necessary, from the RICHIP

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trust fund, to pay program expenses and to administer the program, including creation and oversight

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of RICHIP budgets;

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     (2) Oversee management of the RICHIP trust fund set forth in § 23-97-12(a) to ensure the

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operational well-being and fiscal solvency of the program, including ensuring that all available

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funds from all appropriate sources are collected and placed into the trust fund;

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     (3) Take any actions necessary and proper to implement the provisions of this chapter;

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     (4) Implement standardized claims and reporting procedures;

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     (5) Provide for timely payments to participating providers through a structure that is well

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organized and that eliminates unnecessary administrative costs, i.e., coordinate with the state

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comptroller to facilitate billing from and payments to providers using the state's computerized

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financial system, the Rhode Island financial and accounting network system (RIFANS);

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     (6) Coordinate with federal health care programs, including Medicare and Medicaid, to

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obtain necessary waivers and streamline federal funding and reimbursement;

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     (7) Monitor billing and reimbursements to detect inappropriate behavior by providers and

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patients and create prohibitions and penalties regarding bad faith or criminal RICHIP participation,

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and procedures by which they will be enforced;

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     (8) Support the development of an integrated health care database for health care planning

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and quality assurance and ensure the legally required confidentiality of all health records it

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contains;

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     (9) Determine eligibility for RICHIP and establish procedures for enrollment,

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disenrollment and disqualification from RICHIP, as well as procedures for handling complaints

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and appeals from affected individuals, as set forth in § 29-97-5;

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     (10) Create RICHIP expenditure, status, and assessment reports, including, but not limited

 

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to, annual reports with the following:

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     (i) Performance of the program;

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     (ii) Fiscal condition of the program;

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     (iii) Recommendations for statutory changes;

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     (iv) Receipt of payments from the federal government;

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     (v) Whether current year goals and priorities were met; and

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     (vi) Future goals and priorities;

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     (11) Review RICHIP collections and disbursements on at least a quarterly basis and

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recommend adjustments needed to achieve budgetary targets and permit adequate access to care;

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     (12) Develop procedures for accommodating:

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     (i) Employer retiree health benefits for people who have been members of RICHIP but go

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to live as retirees out of the state;

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     (ii) Employer retiree health benefits for people who earned or accrued those benefits while

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residing in the state prior to the implementation of RICHIP and live as retirees out of the state; and

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     (iii) RICHIP coverage of health care services currently covered under the workers'

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compensation system, including whether and how to continue funding for those services under that

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system and whether and how to incorporate an element of experience rating; and

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     (13) No later than two (2) years after the effective date of this chapter, develop a proposal,

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consistent with the principles of this chapter, for provision and funding by the program of long-

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term care coverage.

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     (c) Board. There shall be a RICHIP board composed of nine (9) members serving terms of

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four (4) years. Members shall be appointed by the governor with advice and consent of the senate.

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Members of the board shall have no pecuniary interest in any health insurance company or any

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business subject to regulation of the board and cannot have previously worked for a health

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insurance company. The duties of the board shall include:

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     (1) Annually establish a RICHIP benefits package for participants, including a formulary

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and a list of other medically necessary goods, as well as a procedure for handling complaints and

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appeals relating to the benefits package, pursuant to § 23-97-6.

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     (2) Establish RICHIP provider reimbursement and a procedure for handling provider

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complaints and appeals as set forth in § 23-97-9;

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     (3) Review budget proposals from providers pursuant to § 23-97-11(b); and

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     (4) The board shall be subject to chapter 46 of title 42 ("open meetings").

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     23-97-5. Coverage.

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     (a) All qualified Rhode Island residents may participate in RICHIP. The director shall

 

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establish procedures to determine eligibility, enrollment, disenrollment and disqualification,

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including criteria and procedures by which RICHIP can:

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     (1) Identify, automatically enroll, and provide a RICHIP card to qualified Rhode Island

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residents;

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     (2) Process applications from individuals seeking to obtain RICHIP coverage for

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dependents after the implementation date;

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     (3) Ensure eligible residents are knowledgeable and aware of their rights to health care;

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     (4) Determine whether an individual should be disenrolled (e.g., for leaving the state);

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     (5) Determine whether an individual should be disqualified (e.g., for fraudulent receipt of

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benefits or reimbursements);

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     (6) Determine appropriate actions that should be taken with respect to individuals who are

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disenrolled or disqualified (including civil and criminal penalties); and

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     (7) Permit individuals to request review and appeal decisions to disenroll or disqualify

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them.

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     (b) Medicare and Medicaid eligible coverage under RICHIP shall be as follows:

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     (1) If all necessary federal waivers are obtained, qualified Rhode Island residents eligible

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for federal Medicare ("Medicare eligible residents") shall continue to pay required fees to the

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federal government. RICHIP shall establish procedures to ensure that Medicare eligible residents

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shall have such amounts deducted from what they owe to RICHIP under § 23-97-12(h). RICHIP

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shall become the equivalent of qualifying coverage under Medicare part D and Medicare advantage

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programs, and as such shall be the vendor for coverage to RICHIP participants. RICHIP shall

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provide Medicare eligible residents benefits equal to those available to all other RICHIP

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participants and equal to or greater than those available through the federal Medicare program. To

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streamline the process, RICHIP shall seek to receive federal reimbursements for services and goods

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to Medicare eligible residents and administer all Medicare funds.

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     (2) If all necessary federal waivers are obtained, RICHIP shall become the state's sole

27

Medicaid provider. RICHIP shall create procedures to enroll all qualified Rhode Island residents

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eligible for Medicaid ("Medicaid eligible residents") in the federal Medicaid program to ensure a

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maximum amount of federal Medicaid funds go to the RICHIP trust fund. RICHIP shall provide

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benefits to Medicaid eligible residents equal to those available to all other RICHIP participants.

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     (3) If all necessary federal waivers are not granted from the Medicaid or Medicare

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programs operated under Title XVIII or XIX of the Social Security Act, the Medicaid or Medicare

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program for which a waiver is not granted shall act as the primary insurer for those eligible for such

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coverage, and RICHIP shall serve as the secondary or supplemental plan of health insurance

 

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coverage. Until such time as a waiver is granted, the plan shall not pay for services for persons

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otherwise eligible for the same health care benefits under the Medicaid or Medicare program. The

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director shall establish procedures for determining amounts owed by Medicare and Medicaid

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eligible residents for supplemental RICHIP coverage and the extent of such coverage.

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     (4) The director may require Rhode Island residents to provide information necessary to

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determine whether the resident is eligible for a federally matched public health program or for

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Medicare, or any program or benefit under Medicare.

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     (5) As a condition of eligibility or continued eligibility for health care services under

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RICHIP, a qualified Rhode Island resident who is eligible for benefits under Medicare shall enroll

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in Medicare, including Parts A, B, and D.

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     (c) Veterans. RICHIP shall serve as the secondary or supplemental plan of health insurance

12

coverage for military veterans. The director shall establish procedures for determining amounts

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owed by military veterans who are qualified residents for such supplemental RICHIP coverage and

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the extent of such coverage.

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     (d) This chapter does not create any employment benefit, nor require, prohibit, or limit the

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providing of any employment benefit.

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     (e) This chapter does not affect or limit collective action or collective bargaining on the

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part of a health care provider with their employer or any other lawful collective action or collective

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bargaining.

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     23-97-6. Benefits.

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     (a) This chapter shall provide insurance coverage for services and goods (including

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prescription drugs) deemed medically necessary by a qualified health care provider and that is

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currently covered under:

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     (1) Services and goods currently covered by the federal Medicare program (Social Security

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Act title XVIII) parts A, B and D;

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     (2) Services and goods covered by Medicaid as of January 1, 2023;

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     (3) Services and goods currently covered by the state's Children's Health Insurance

28

Program;

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     (4) Essential health benefits mandated by the Affordable Care Act; and

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     (5) Services and goods within the following categories:

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     (i) Primary and preventive care;

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     (ii) Approved dietary and nutritional therapies;

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     (iii) Inpatient care;

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     (iv) Outpatient care;

 

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     (v) Emergency and urgently needed care;

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     (vi) Prescription drugs and medical devices;

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     (vii) Laboratory and diagnostic services;

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     (viii) Palliative care;

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     (ix) Mental health services;

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     (x) Oral health, including dental services, periodontics, oral surgery, and endodontics;

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     (xi) Substance abuse treatment services;

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     (xii) Physical therapy and chiropractic services;

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     (xiii) Vision care and vision correction;

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     (xiv) Hearing services, including coverage of hearing aids;

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     (xv) Podiatric care;

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     (xvi) Comprehensive family planning, reproductive, maternity, and newborn care;

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     (xvii) Short-term rehabilitative services and devices;

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     (xviii) Durable medical equipment;

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     (xix) Gender affirming health care; and

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     (xx) Diagnostic and routine medical testing.

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     (b) Additional coverage. The director shall create a procedure that may permit additional

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medically necessary goods and services beyond that provided by federal laws cited herein and

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within the areas set forth in § 23-97-5, if the coverage is for services and goods deemed medically

20

necessary based on credible scientific evidence published in peer-reviewed medical literature

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generally recognized by the relevant medical community, physician specialty society

22

recommendations, and the views of physicians practicing in relevant clinical areas and any other

23

relevant factors. The director shall create procedures for handling complaints and appeals

24

concerning the benefits package.

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     (c) Restrictions shall not apply. In order for RICHIP participants to be able to receive

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medically necessary goods and services, this chapter shall override any state law that restricts the

27

provision or use of state funds for any medically necessary goods or services, including those

28

related to family planning and reproductive health care.

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     (d) Medically necessary goods:

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     (1) Prescription drug formulary:

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     (i) In general. The director shall establish a prescription drug formulary system, to be

32

approved by the board, and encourage best-practices in prescribing and discourage the use of

33

ineffective, dangerous, or excessively costly medications when better alternatives are available.

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     (ii) Promotion of generics. The formulary under this subsection shall promote the use of

 

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generic medications to the greatest extent possible.

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     (iii) Formulary updates and petition rights. The formulary under this subsection shall be

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updated frequently and the director shall create a procedure for patients and providers to make

4

requests and appeal denials to add new pharmaceuticals or to remove ineffective or dangerous

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medications from the formulary.

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     (iv) Use of off-formulary medications. The director shall promulgate rules regarding the

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use of off-formulary medications which allow for patient access but do not compromise the

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formulary.

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     (v) Approved devices and equipment. The director shall present a list of medically

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necessary devices and equipment that shall be covered by RICHIP, subject to final approval by the

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board.

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     (vi) Bulk purchasing. The director shall seek and implement ways to obtain goods at the

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lowest possible cost, including bulk purchasing agreements.

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     23-97-7. Providers.

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     (a) Rhode Island providers.

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     (1) Licensing. Participating providers shall meet state licensing requirements in order to

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participate in RICHIP. No provider whose license is under suspension or has been revoked shall

18

participate in the program.

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     (2) Participation. All providers may participate in RICHIP by providing items on the

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RICHIP benefits list for which they are licensed. Providers may elect either to participate fully, or

21

not at all, in the program.

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     (3) For-profit providers. For-profit providers may continue to offer services and goods in

23

Rhode Island, but are prohibited from charging patients more than RICHIP reimbursement rates

24

for covered services and goods and shall notify qualified Rhode Island residents when the services

25

and goods they offer will not be reimbursed fully under RICHIP.

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     (b) Out-of-state providers. Except for emergency and urgently needed service, as set forth

27

in § 23-97-7(d), RICHIP shall not pay for health care services obtained outside of Rhode Island

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unless the following requirements are met:

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     (1) The out-of-state provider agrees to accept the RICHIP rate for out-of-state providers;

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and

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     (2) The services are medically necessary care.

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     (c) Out-of-state provider reimbursement. The program shall pay out-of-state health care

33

providers at a rate equal to the average rate paid by commercial insurers or Medicare for the services

34

rendered, whichever is higher.

 

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     (d) Out-of-state residents.

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     (1) In general. Rhode Island providers who provide any services to individuals who are not

3

RICHIP participants shall not be reimbursed by RICHIP and shall seek reimbursement from those

4

individuals or other sources.

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     (2) Emergency care exception. Nothing in this chapter shall prevent any individual from

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receiving or any provider from providing emergency health care services and goods in Rhode

7

Island. The director shall adopt rules to provide reimbursement; however, the rules shall reasonably

8

limit reimbursement to protect the fiscal integrity of RICHIP. The director shall implement

9

procedures to secure reimbursement from any appropriate third-party funding source or from the

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individual to whom the emergency services were rendered.

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     23-97-8. Cross border employees.

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     (a) State residents employed out-of-state. If an individual is employed out-of-state by an

13

employer that is subject to Rhode Island state law, the employer and employee shall be required to

14

pay the payroll taxes as to that employee as if the employment were in the state. If an individual is

15

employed out-of-state by an employer that is not subject to Rhode Island state law, the employee

16

health coverage provided by the out-of-state employer to a resident working out-of-state shall serve

17

as the employee's primary plan of health coverage, and RICHIP shall serve as the employee's

18

secondary plan of health coverage. The director shall establish procedures for determining amounts

19

owed by residents employed out-of-state for such supplemental secondary RICHIP coverage and

20

the extent of such coverage.

21

     (b) Out-of-state residents employed in the state. The payroll tax set forth in § 23-97-12(i)

22

shall apply to any out-of-state resident who is employed or self-employed in the state. However,

23

such out-of-state residents shall be able to take a credit for amounts they spend on health benefits

24

for themselves that would otherwise be covered by RICHIP if the individual were a RICHIP

25

participant. The out-of-state resident's employer shall be able to take a credit against such payroll

26

taxes regardless of the form of the health benefit (e.g., health insurance, a self-insured plan, direct

27

services, or reimbursement for services), to ensure that the revenue proposal does not relate to

28

employment benefits in violation of the Federal Employee Retirement Income Security Act

29

("ERISA") law. For non-employment-based spending by individuals, the credit shall be available

30

for and limited to spending for health coverage (not out-of-pocket health spending). The credit shall

31

be available without regard to how little is spent or how sparse the benefit. The credit may only be

32

taken against the payroll taxes set forth in § 23-97-12(i). Any excess amount may not be applied to

33

other tax liability. For employment-based health benefits, the credit shall be distributed between

34

the employer and employee in the same proportion as the spending by each for the benefit. The

 

LC005714 - Page 12 of 92

1

employer and employee may each apply their respective portion of the credit to their respective

2

portion of the payroll taxes set forth in § 23-97-12(i). If any provision of this clause or any

3

application of it shall be ruled to violate ERISA, the provision or the application of it shall be null

4

and void and the ruling shall not affect any other provision or application of this section or this

5

chapter.

6

     23-97-9. Provider reimbursement.

7

     (a) Rates for services and goods. RICHIP reimbursement rates to providers shall be

8

determined by the RICHIP board. These rates shall be equal to or greater than the federal Medicare

9

rates available to Rhode Island qualified residents that are in effect at the time services and goods

10

are provided. For outpatient behavioral health services, the minimum rate shall equal one hundred

11

fifty percent (150%) of federal Medicare rates. If the director determines that there are no such

12

federal Medicare reimbursement rates, the director shall set the minimum rate. The director shall

13

review the rates at least annually, recommend changes to the board, and establish procedures by

14

which complaints about reimbursement rates may be reviewed by the board.

15

     (b) Billing and payments. Providers shall submit billing for services to RICHIP participants

16

in the form of electronic invoices entered into RIFANS, the state's computerized financial system.

17

The director shall coordinate the manner of processing and payment with the office of accounts and

18

control and the RIFANS support team within the division of information technology. Payments

19

shall be made by check or electronic funds transfer in accordance with terms and procedures

20

coordinated by the director and the office of accounts and control and consistent with the fiduciary

21

management of the RICHIP trust fund.

22

     (c) Provider restrictions. In-state providers who accept any payment from RICHIP shall

23

not bill any patient for any covered benefit. In-state providers cannot use any of their operating

24

budgets for expansion, profit, excessive executive income, including bonuses, marketing, or major

25

capital purchases or leases.

26

     23-97-10. Private insurance companies.

27

     (a) Non-duplication. It is unlawful for a private health insurer to sell health insurance

28

coverage to qualified Rhode Island residents that duplicates the benefits provided under this

29

chapter. Nothing in this chapter shall be construed as prohibiting the sale of health insurance

30

coverage for any additional benefits not covered by this chapter, including additional benefits that

31

an employer may provide to employees or their dependents, or to former employees or their

32

dependents (e.g., multiemployer plans can continue to provide wrap-around coverage for any

33

benefits not provided by RICHIP).

34

     (b) Displaced employees. Re-education and job placement of persons employed in Rhode

 

LC005714 - Page 13 of 92

1

Island-located enterprises who have lost their jobs as a result of this chapter shall be managed by

2

the Rhode Island department of labor and training or an appropriate federal retraining program. The

3

director may provide funds from RICHIP or funds otherwise appropriated for this purpose for

4

retraining and assisting job transition for individuals employed or previously employed in the fields

5

of health insurance, health care service plans, and other third-party payments for health care or

6

those individuals providing services to health care providers to deal with third-party payers for

7

health care, whose jobs may be or have been ended as a result of the implementation of the program,

8

consistent with applicable laws.

9

     23-97-11. Budgeting.

10

     (a) Operating budget. Annually, the director shall create an operating budget for the

11

program that includes the costs for all benefits set forth in § 23-97-5 and the costs for RICHIP

12

administration. The director shall determine appropriate reimbursement rates for benefits pursuant

13

to § 23-97-9(a). The operating budget shall be approved by the executive board prior to submission

14

to the governor and general assembly.

15

     (b) Capital expenditures. The director shall work with representatives from state entities

16

involved with provider capital expenditures (e.g., the Rhode Island department of administration

17

office of capital projects, the Rhode Island health and educational building corporation, etc.), and

18

providers to help ensure that capital expenditures proposed by providers, including amounts to be

19

spent on construction and renovation of health facilities and major equipment purchases, will

20

address health care needs of RICHIP participants. To the extent that providers are seeking to use

21

RICHIP funds for capital expenditures, the director shall have the authority to approve or deny such

22

expenditures.

23

     (c) Prohibition against co-mingling operations and capital improvement funds. It is

24

prohibited to use funds under this chapter that are earmarked:

25

     (1) For operations for capital expenditures; or

26

     (2) For capital expenditures for operations.

27

     23-97-12. Financing.

28

     (a) RICHIP trust fund. There shall be established a RICHIP trust fund into which funds

29

collected pursuant to this chapter are deposited and from which funds are distributed. All money

30

collected and received shall be used exclusively to finance RICHIP. The governor or general

31

assembly may provide funds to the RICHIP trust fund, but may not remove or borrow funds from

32

the RICHIP trust fund.

33

     (b) Revenue proposal. After approval of the RICHIP executive board, the director shall

34

submit to the governor and the general assembly a revenue plan and, if required, legislation

 

LC005714 - Page 14 of 92

1

(referred to collectively in this section as the "revenue proposal") to provide the revenue necessary

2

to finance RICHIP. The initial revenue proposal shall be submitted once waiver negotiations have

3

proceeded to a level deemed sufficient by the director and annually, thereafter. The basic structure

4

of the initial revenue proposal will be based on a consideration of:

5

     (1) Anticipated savings from a single payer program;

6

     (2) Government funds available for health care;

7

     (3) Private funds available for health care; and

8

     (4) Replacing current regressive health insurance payments made to multiple health

9

insurance carriers with progressive contributions to a single payer (RICHIP) in order to make health

10

care insurance affordable and remove unnecessary barriers to health care access.

11

     Subsequent proposals shall adjust the RICHIP contributions, based on projections from the

12

total RICHIP costs in the previous year, and shall include a five (5) year plan for adjusting RICHIP

13

contributions to best meet the goals set forth in this section and § 23-97-2.

14

     (c) Anticipated savings. It is anticipated that RICHIP will lower health care costs by:

15

     (1) Eliminating payments to private health insurance carriers;

16

     (2) Reducing paperwork and administrative expenses for both providers and payers created

17

by the marketing, sales, eligibility checks, network contract management, issues associated

18

multiple benefit packages, and other administrative waste associated with the current multi-payer

19

private health insurance system;

20

     (3) Allowing the planning and delivery of a public health strategy for the entire population

21

of Rhode Island;

22

     (4) Improving access to preventive health care; and

23

     (5) Negotiating on behalf of the state for bulk purchasing of medical supplies and

24

pharmaceuticals.

25

     (d) Federal funds. The executive office of health and human services, in collaboration with

26

the director, the board and the Medicaid office, shall seek and obtain waivers and other approvals

27

relating to Medicaid, the Children's Health Insurance Program, Medicare, federal tax exemptions

28

for health care, the ACA, and any other relevant federal programs in order that:

29

     (1) Federal funds and other subsidies for health care that would otherwise be paid to the

30

state and its residents and health care providers, would be paid by the federal government to the

31

state and deposited into the RICHIP trust fund;

32

     (2) Programs would be waived and such funding from federal programs in Rhode Island

33

would be replaced or merged into RICHIP in order that it can operate as a single payer program;

34

     (3) Maximum federal funding for health care is sought even if any necessary waivers or

 

LC005714 - Page 15 of 92

1

approvals are not obtained and multiple sources of funding with RICHIP trust fund monies are

2

pooled, in order that RICHIP can act as much as possible like a single payer program to maximize

3

benefits to Rhode Islanders; and

4

     (4) Federal financial participation in the programs that are incorporated into RICHIP are

5

not jeopardized.

6

     (e) State funds. State funds that would otherwise be appropriated to any governmental

7

agency, office, program, instrumentality, or institution for services and benefits covered under

8

RICHIP shall be directed into the RICHIP trust fund. Payments to the fund pursuant to this section

9

shall be in an amount equal to the money appropriated for those purposes in the fiscal year

10

beginning immediately preceding the effective date of this chapter.

11

     (f) Private funds. Private grants (e.g., from nonprofit corporations) and other funds

12

specifically ear-marked for health care (e.g., from litigation against tobacco companies, opioid

13

manufacturers, etc.), shall also be put into the RICHIP trust fund.

14

     (g) Assignments from RICHIP participants. Receipt of health care services under the plan

15

shall be deemed an assignment by the RICHIP participant of any right to payment for services from

16

a policy of insurance, a health benefit plan or other source. The other source of health care benefits

17

shall pay to the fund all amounts it is obligated to pay to, or on behalf of, the RICHIP participant

18

for covered health care services. The director may commence any action necessary to recover the

19

amounts due.

20

     (h) Replacing current health insurance payments with progressive contributions. Instead of

21

making health insurance payments to multiple carriers (i.e., for premiums, co-pays deductibles, and

22

costs in excess of caps) for limited coverage, individuals and entities subject to Rhode Island

23

taxation pursuant to § 44-30-1 shall pay progressive contributions to the RICHIP trust fund

24

(referred to collectively in this section as the "RICHIP contributions") for comprehensive coverage.

25

These RICHIP contributions shall be set and adjusted over time to an appropriate level to:

26

     (1) Cover the actual cost of the program;

27

     (2) Ensure that higher brackets of income subject to specified taxes shall be assessed at a

28

higher marginal rate than lower brackets; and

29

     (3) Protect the economic welfare of small businesses, low-income earners and working

30

families through tax credits or exemptions.

31

     (i) Contributions based on earned income. The amounts currently paid by employers and

32

employees for health insurance shall initially be replaced by a ten percent (10%) payroll tax, based

33

on the projected average payroll of employees over three (3) previous calendar years. The employer

34

shall pay eighty percent (80%) and the employee shall pay twenty percent (20%) of this payroll

 

LC005714 - Page 16 of 92

1

tax, except that an employer may agree to pay all or part of the employee's share. Self- employed

2

individuals shall initially pay one-hundred percent (100%) of the payroll tax. The ten percent (10%)

3

initial rate will be adjusted by the director in order that higher brackets of income subject to these

4

taxes shall be assessed at a higher marginal rate than lower brackets and in order that small

5

businesses and lower income earners receive a credit or exemption.

6

     (j) Contributions based on unearned income. There shall be a progressive contribution

7

based on unearned income, i.e., capital gains, dividends, interest, profits, and rents. Initially, the

8

unearned income RICHIP contributions shall be equal to ten percent (10%) of such unearned

9

income. The ten percent (10%) initial rate may be adjusted by the director to allow for a graduated

10

progressive exemption or credit for individuals with lower unearned income levels.

11

     23-97-13. Implementation.

12

     (a) State laws and regulations.

13

     (1) In general. The director shall work with the executive board and receive such assistance

14

as may be necessary from other state agencies and entities to examine state laws and regulations

15

and to make recommendations necessary to conform such laws and regulations to properly

16

implement the RICHIP program. The director shall report recommendations to the governor and

17

the general assembly.

18

     (2) Anti-trust laws. The intent of this chapter is to exempt activities provided for under this

19

chapter from state antitrust laws and to provide immunity from federal antitrust laws through the

20

state action doctrine.

21

     (b) The director shall complete an implementation plan to provide health care coverage for

22

qualified residents in accordance with this chapter within twelve (12) months of its effective date.

23

     (c) The executive office of health and human services, in collaboration with the director,

24

the board, and the Medicaid director, will have the initial responsibility of negotiating the waivers.

25

     (d) Severability. If any provision or application of this chapter shall be held to be invalid,

26

or to violate or be inconsistent with any applicable federal law or regulation, that shall not affect

27

other provisions or applications of this chapter which can be given effect without that provision or

28

application; and to that end, the provisions and applications of this chapter are severable.

29

     SECTION 2. Chapter 22-11 of the General Laws entitled "Joint Committee on Legislative

30

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

31

     22-11-4.1. Employees needed to maximize federal Medicaid funding.

32

     The joint committee on legislative services shall fund five (5) new FTEs for the senate

33

fiscal office and five (5) new FTEs for the house fiscal office exclusively devoted to finding ways

34

to maximize federal Medicaid funding, including compiling proposals for expanding eligibility to

 

LC005714 - Page 17 of 92

1

maximize the eligibility allowed by Centers for Medicare & Medicaid Services (CMS).

2

     SECTION 3. Section 27-34.3-7 of the General Laws in Chapter 27-34.3 entitled "Licensing

3

of Healthcare Facilities" is hereby amended to read as follows:

4

     23-17-38.1. Hospitals -- Licensing fee.

5

     (a) There is imposed a hospital licensing fee at the rate of six percent (6%) upon the net

6

patient-services revenue of every hospital for the hospital's first fiscal year ending on or after

7

January 1, 2018, except that the license fee for all hospitals located in Washington County, Rhode

8

Island shall be discounted by thirty-seven percent (37%). The discount for Washington County

9

hospitals is subject to approval by the Secretary of the U.S. Department of Health and Human

10

Services of a state plan amendment submitted by the executive office of health and human services

11

for the purpose of pursuing a waiver of the uniformity requirement for the hospital license fee. This

12

licensing fee shall be administered and collected by the tax administrator, division of taxation

13

within the department of revenue, and all the administration, collection, and other provisions of

14

Chapter 51 of title 44 shall apply. Every hospital shall pay the licensing fee to the tax administrator

15

on or before July 13, 2020, and payments shall be made by electronic transfer of monies to the

16

general treasurer and deposited to the general fund. Every hospital shall, on or before June 15,

17

2020, make a return to the tax administrator containing the correct computation of net patient-

18

services revenue for the hospital fiscal year ending September 30, 2018, and the licensing fee due

19

upon that amount. All returns shall be signed by the hospital's authorized representative, subject to

20

the pains and penalties of perjury.

21

     (b) There is also imposed a hospital licensing fee for state fiscal year 2021 against each

22

hospital in the state. The hospital licensing fee is equal to five percent (5.0%) of the net patient-

23

services revenue of every hospital for the hospital's first fiscal year ending on or after January 1,

24

2019, except that the license fee for all hospitals located in Washington County, Rhode Island shall

25

be discounted by thirty-seven percent (37%). The discount for Washington County hospitals is

26

subject to approval by the Secretary of the U.S. Department of Health and Human Services of a

27

state plan amendment submitted by the executive office of health and human services for the

28

purpose of pursuing a waiver of the uniformity requirement for the hospital license fee. This

29

licensing fee shall be administered and collected by the tax administrator, division of taxation

30

within the department of revenue, and all the administration, collection, and other provisions of

31

Chapter 51 of title 44 shall apply. Every hospital shall pay the licensing fee to the tax administrator

32

on or before July 13, 2021, and payments shall be made by electronic transfer of monies to the

33

general treasurer and deposited to the general fund. Every hospital shall, on or before June 15,

34

2020, make a return to the tax administrator containing the correct computation of net patient-

 

LC005714 - Page 18 of 92

1

services revenue for the hospital fiscal year ending September 30, 2019, and the licensing fee due

2

upon that amount. All returns shall be signed by the hospital's authorized representative, subject to

3

the pains and penalties of perjury.

4

     (c) There is also imposed a hospital licensing fee for state fiscal year 2022 against each

5

hospital in the state. The hospital licensing fee is equal to five and seven hundred twenty-five

6

thousandths percent (5.725%) of the net patient-services revenue of every hospital for the hospital's

7

first fiscal year ending on or after January 1, 2020, except that the license fee for all hospitals

8

located in Washington County, Rhode Island shall be discounted by thirty-seven percent (37%).

9

The discount for Washington County hospitals is subject to approval by the Secretary of the U.S.

10

Department of Health and Human Services of a state plan amendment submitted by the executive

11

office of health and human services for the purpose of pursuing a waiver of the uniformity

12

requirement for the hospital license fee. This licensing fee shall be administered and collected by

13

the tax administrator, division of taxation within the department of revenue, and all the

14

administration, collection, and other provisions of Chapter 51 of title 44 shall apply. Every hospital

15

shall pay the licensing fee to the tax administrator on or before July 13, 2022, and payments shall

16

be made by electronic transfer of monies to the general treasurer and deposited to the general fund.

17

Every hospital shall, on or before June 15, 2022, make a return to the tax administrator containing

18

the correct computation of net patient-services revenue for the hospital fiscal year ending

19

September 30, 2020, and the licensing fee due upon that amount. All returns shall be signed by the

20

hospital's authorized representative, subject to the pains and penalties of perjury.

21

     (d) There is also imposed a hospital licensing fee for state fiscal year 2023 against each

22

hospital in the state. The hospital licensing fee is equal to six percent (6%) of the net patient-services

23

revenue of every hospital for the hospital's first fiscal year ending on or after January 1, 2021. This

24

licensing fee shall be administered and collected by the tax administrator, division of taxation

25

within the department of revenue, and all the administration, collection, and other provisions of

26

chapter 51 of title 44 shall apply. Every hospital shall pay the licensing fee to the tax administrator

27

on or before July 13, 2023, and payments shall be made by electronic transfer of monies to the

28

general treasurer and deposited to the general fund. Every hospital shall, on or before June 15,

29

2023, make a return to the tax administrator containing the correct computation of net patient-

30

services revenue for the hospital fiscal year ending September 30, 2021, and the licensing fee due

31

upon that amount. All returns shall be signed by the hospital's authorized representative, subject to

32

the pains and penalties of perjury.

33

     (d)(e) For purposes of this section the following words and phrases have the following

34

meanings:

 

LC005714 - Page 19 of 92

1

     (1) "Hospital" means the actual facilities and buildings in existence in Rhode Island,

2

licensed pursuant to § 23-17-1 et seq. on June 30, 2010, and thereafter any premises included on

3

that license, regardless of changes in licensure status pursuant to chapter 17.14 of title 23 (hospital

4

conversions) and § 23-17-6(b) (change in effective control), that provides short-term acute inpatient

5

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

6

disabilities, or pregnancy. Notwithstanding the preceding language, the negotiated Medicaid

7

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

8

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

9

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

10

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

11

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

12

agreement containing the newly negotiated rate. The rate-setting methodology for inpatient hospital

13

payments and outpatient hospital payments set forth in §§ 40-8-13.4(b) and 40-8-13.4(b)(2),

14

respectively, shall thereafter apply to negotiated increases for each annual twelve-month (12)

15

period as of July 1 following the completion of the first full year of the court-approved purchaser's

16

initial Medicaid managed care contract.

17

     (2) "Gross patient-services revenue" means the gross revenue related to patient care

18

services.

19

     (3) "Net patient-services revenue" means the charges related to patient care services less

20

(i) Charges attributable to charity care; (ii) Bad debt expenses; and (iii) Contractual allowances.

21

     (e)(f) The tax administrator shall make and promulgate any rules, regulations, and

22

procedures not inconsistent with state law and fiscal procedures that he or she deems necessary for

23

the proper administration of this section and to carry out the provisions, policy, and purposes of

24

this section.

25

     (f)(g) The licensing fee imposed by subsection (b) shall apply to hospitals as defined herein

26

that are duly licensed on July 1, 2020, and shall be in addition to the inspection fee imposed by §

27

23-17-38 and to any licensing fees previously imposed in accordance with this section.

28

     (g)(h) The licensing fee imposed by subsection (c) shall apply to hospitals as defined herein

29

that are duly licensed on July 1, 2021, and shall be in addition to the inspection fee imposed by §

30

23-17-38 and to any licensing fees previously imposed in accordance with this section.

31

     (i) The licensing fee imposed by subsection (d) of this section shall apply to hospitals as

32

defined herein that are duly licensed on July 1, 2022, and shall be in addition to the inspection fee

33

imposed by § 23-17-38 and to any licensing fees previously imposed in accordance with this

34

section; provided, however, that the Medicaid director shall be empowered and directed to adjust

 

LC005714 - Page 20 of 92

1

the licensing fee rate to prevent any loss of federal Medicaid reimbursement pursuant to 42 CFR §

2

433.68.

3

     SECTION 4. Section 27-34.3-7 of the General Laws in Chapter 27-34.3 entitled "Rhode

4

Island Life and Health Insurance Guaranty Association Act" is hereby amended to read as follows:

5

     27-34.3-7. Board of directors.

6

     (a) The board of directors of the association shall consist of:

7

     (1) Nine (9) members appointed by the governor with advice and consent of the senate;

8

Not less than five (5) nor more than nine (9) member insurers serving terms as established in the

9

plan of operation; and

10

     (2) The commissioner or the commissioner's designee, who shall chair the board in a non-

11

voting ex officio capacity. Only member insurers shall be eligible to vote. The members of the

12

board shall be selected by member insurers subject to the approval of the commissioner. The board

13

of directors, previously established under § 27-34.1-8 [Repealed], shall continue to operate in

14

accordance with the provision of this section. Vacancies on the board shall be filled for the

15

remaining period of the term by a majority vote of the remaining board members, subject to the

16

approval of the commissioner.

17

     (b) In approving selections to the board, the commissioner shall consider, among other

18

things, whether all member insurers are fairly represented.

19

     (c) Members of the board may be reimbursed from the assets of the association for expenses

20

incurred by them as members of the board of directors but members of the board shall not be

21

compensated by the association for their services.

22

     SECTION 5. Section 27-66-24 of the General Laws in Chapter 27-66 entitled "The Health

23

Insurance Conversions Act" is hereby amended to read as follows:

24

     27-66-24. Exceptions -- Rehabilitation, liquidation or conservation.

25

     No proposed conversion shall be subject to this chapter inIn the event that the health

26

insurance corporation, health maintenance corporation, a nonprofit hospital service corporation,

27

nonprofit medical service corporation or affiliate or subsidiary of them, hereinafter "the insurer,"

28

is subject to an order from the superior court directing the director to rehabilitate, liquidate or

29

conserve, as provided in §§ 27-19-28, 27-20-24, 27-41-18, or chapter 14.1, 14.2,14.3 or 14.4 of this

30

title., certain additional conditions shall apply to the insurer:

31

     (1) The insolvency, financial condition, or default of the insurer at any time shall not permit

32

the insurer to fail to pay claims in a timely manner.

33

     (2) Should the insurer fail to pay claims in a timely manner, those claims shall become a

34

temporary obligation of the state, who shall pay them in a timely manner. Should the state be

 

LC005714 - Page 21 of 92

1

compelled to pay claims for this reason, the insurer shall owe the state a fine ten (10) times the

2

value of all claims paid.

3

     (3) The insolvency, financial condition, or default of the insurer at any time shall not permit

4

the insurer to fail to pay state taxes on time. Should the insurer fail to pay taxes on time, the size of

5

the tax obligation owed shall increase by a factor of ten (10).

6

     (4) The Medicaid office shall be guaranteed a right of first refusal to acquire the insurer

7

before alternate buyers are considered. Any obligations due to the state by the insurer shall be

8

counted towards the purchase price of the insurer. The Rhode Island life and health insurance

9

guaranty association, created pursuant to § 27-34.3-6, shall pay the costs of the acquisition, but all

10

ownership shares shall be held by the Medicaid office.

11

     SECTION 6. Title 27 of the General Laws entitled "INSURANCE" is hereby amended by

12

adding thereto the following chapter:

13

CHAPTER 82

14

PRIOR AUTHORIZATION OF CERTAIN HEALTH INSURANCE POLICY CHANGES

15

     (a) Prior authorization of the general assembly shall be required for certain policy changes

16

by health insurers:

17

     (1) Any change that increases the average amount charged annually to consumers on a per

18

beneficiary basis;

19

     (2) Any change that in any way reduces any benefits offered to plan beneficiaries;

20

     (3) Any change that increases any premiums, deductibles, or copays; or

21

     (4) Ceasing offering any plan a health insurer offers within the State of Rhode Island.

22

     (b) No rate review pursuant to § 42-62-13 shall be construed to exempt any health insurer

23

from the prior authorization requirements of this chapter.

24

     SECTION 7. Section 28-57-5 of the General Laws in Chapter 28-57 entitled "Healthy and

25

Safe Families and Workplaces Act" is hereby amended to read as follows:

26

     28-57-5. Accrual of paid sick and safe leave time.

27

     (a) All employees employed by an employer of eighteen (18) or more employees in Rhode

28

Island shall accrue a minimum of one hour of paid sick and safe leave time for every thirty five

29

(35) hours worked up to a maximum of twenty-four (24) hours during the calendar year of 2018,

30

thirty-two (32) hours during calendar year 2019, and up to a maximum of forty (40) hours per year

31

during the calendar years 2020 and 2021 and up to a maximum of one hundred sixty (160) hours

32

per year thereafter, unless the employer chooses to provide a higher annual limit in both accrual

33

and use. In determining the number of employees who are employed by an employer for

34

compensation, all employees defined in § 28-57-3(7) shall be counted.

 

LC005714 - Page 22 of 92

1

     (b) Employees who are exempt from the overtime requirements under 29 U.S.C. §

2

213(a)(1) of the Federal Fair Labor Standards Act, 29 U.S.C. § 201 et seq., will be assumed to work

3

forty (40) hours in each work week for purposes of paid sick and safe leave time accrual unless

4

their normal work week is less than forty (40) hours, in which case paid sick and safe leave time

5

accrues based upon that normal work week.

6

     (c) Paid sick and safe leave time as provided in this chapter shall begin to accrue at the

7

commencement of employment or pursuant to the law's effective date [July 1, 2018], whichever is

8

later. An employer may provide all paid sick and safe leave time that an employee is expected to

9

accrue in a year at the beginning of the year.

10

     (d) An employer may require a waiting period for newly hired employees of up to ninety

11

(90) days. During this waiting period, an employee shall accrue earned sick time pursuant to this

12

section or the employer's policy, if exempt under § 28-57-4(b), but shall not be permitted to use the

13

earned sick time until after he or she has completed the waiting period.

14

     (e) Paid sick and safe leave time shall be carried over to the following calendar year;

15

however, an employee's use of paid sick and safe leave time provided under this chapter in each

16

calendar year shall not exceed twenty-four (24) hours during calendar year 2018, and thirty-two

17

(32) hours during calendar year 2019, and forty (40) hours per year thereafter. Alternatively, in lieu

18

of carryover of unused earned paid sick and safe leave time from one year to the next, an employer

19

may pay an employee for unused earned paid sick and safe leave time at the end of a year and

20

provide the employee with an amount of paid sick and safe leave that meets or exceeds the

21

requirements of this chapter that is available for the employee's immediate use at the beginning of

22

the subsequent year.

23

     (f) Nothing in this chapter shall be construed as requiring financial or other reimbursement

24

to an employee from an employer upon the employee's termination, resignation, retirement, or other

25

separation from employment for accrued paid sick and safe leave time that has not been used.

26

     (g) If an employee is transferred to a separate division, entity, or location within the state,

27

but remains employed by the same employer as defined in 29 C.F.R. § 791.2 of the Federal Fair

28

Labor Standards Act, 29 U.S.C. § 201 et seq., the employee is entitled to all paid sick and safe leave

29

time accrued at the prior division, entity, or location and is entitled to use all paid sick and safe

30

leave time as provided in this act. When there is a separation from employment and the employee

31

is rehired within one hundred thirty-five (135) days of separation by the same employer, previously

32

accrued paid sick and safe leave time that had not been used shall be reinstated. Further, the

33

employee shall be entitled to use accrued paid sick and safe leave time and accrue additional sick

34

and safe leave time at the re-commencement of employment.

 

LC005714 - Page 23 of 92

1

     (h) When a different employer succeeds or takes the place of an existing employer, all

2

employees of the original employer who remain employed by the successor employer within the

3

state are entitled to all earned paid sick and safe leave time they accrued when employed by the

4

original employer, and are entitled to use earned paid sick and safe leave time previously accrued.

5

     (i) At its discretion, an employer may loan sick and safe leave time to an employee in

6

advance of accrual by such employee.

7

     (j) Temporary employees shall be entitled to use accrued paid sick and safe leave time

8

beginning on the one hundred eightieth (180) calendar day following commencement of their

9

employment, unless otherwise permitted by the employer. On and after the one hundred eightieth

10

(180) calendar day of employment, employees may use paid sick and safe leave time as it is

11

accrued. During this waiting period, an employee shall accrue earned sick time pursuant to this

12

chapter, but shall not be permitted to use the earned sick time until after he or she has completed

13

the waiting period.

14

     (k) Seasonal employees shall be entitled to use accrued paid sick and safe leave time

15

beginning on the one hundred fiftieth (150) calendar day following commencement of their

16

employment, unless otherwise permitted by the employer. On and after the one hundred fiftieth

17

(150) calendar day of employment, employees may use paid sick and safe leave time as it is

18

accrued. During this waiting period, an employee shall accrue earned sick time pursuant to this

19

chapter, but shall not be permitted to use the earned sick time until after he or she has completed

20

the waiting period.

21

     SECTION 8. Section 36-12-2.1 of the General Laws in Chapter 36-12 entitled "Insurance

22

Benefits" is hereby repealed.

23

     36-12-2.1. Health insurance benefits -- Coverage for abortions excluded.

24

     (a) The state of Rhode Island shall not include in any health insurance contracts, plans, or

25

policies covering employees, any provision which shall provide coverage for induced abortions

26

(except where the life of the mother would be endangered if the fetus were carried to term, or where

27

the pregnancy resulted from rape or incest). This section shall be applicable to all contracts, plans

28

or policies of:

29

     (1) All health insurers subject to title 27;

30

     (2) All group and blanket health insurers subject to title 27;

31

     (3) All nonprofit hospital, medical, surgical, dental, and health service corporations;

32

     (4) All health maintenance organizations; and

33

     (5) Any provision of medical, hospital, surgical, and funeral benefits and of coverage

34

against accidental death or injury when the benefits or coverage are incidental to or part of other

 

LC005714 - Page 24 of 92

1

insurance authorized by the statutes of this state.

2

     (b) Provided, however, that the provisions of this section shall not apply to benefits

3

provided under existing collective bargaining agreements entered into prior to June 30, 1982.

4

     (c) Nothing contained herein shall be construed to pertain to insurance coverage for

5

complications as the result of an abortion.

6

     SECTION 9. Sections 40-8-2, 40-8-6, 40-8-10, 40-8-13, 40-8-13.4, 40-8-16, 40-8-19, 40-

7

8-26 and 40-8-32 of the General Laws in Chapter 40-8 entitled "Medical Assistance" are hereby

8

amended to read as follows:

9

     40-8-2. Definitions.

10

     As used in this chapter, unless the context shall otherwise require:

11

     (1) "Dental service" means and includes emergency care, X-rays for diagnoses, extractions,

12

palliative treatment, and the refitting and relining of existing dentures and prosthesis.

13

     (2) "Department" means the department of human services.

14

     (3) "Director" means the director of human services Medicaid director.

15

     (4) "Drug" means and includes only drugs and biologicals prescribed by a licensed dentist

16

or physician as are either included in the United States pharmacopoeia, national formulary, or are

17

new and nonofficial drugs and remedies.

18

     (5) "Inpatient" means a person admitted to and under treatment or care of a physician or

19

surgeon in a hospital or nursing facility that meets standards of and complies with rules and

20

regulations promulgated by the director.

21

     (6) "Inpatient hospital services" means the following items and services furnished to an

22

inpatient in a hospital other than a hospital, institution, or facility for tuberculosis or mental

23

diseases:

24

     (i) Bed and board;

25

     (ii) Nursing services and other related services as are customarily furnished by the hospital

26

for the care and treatment of inpatients and drugs, biologicals, supplies, appliances, and equipment

27

for use in the hospital, as are customarily furnished by the hospital for the care and treatment of

28

patients;

29

     (iii) (A) Other diagnostic or therapeutic items or services, including, but not limited to,

30

pathology, radiology, and anesthesiology furnished by the hospital or by others under arrangements

31

made by the hospital, as are customarily furnished to inpatients either by the hospital or by others

32

under such arrangements, and services as are customarily provided to inpatients in the hospital by

33

an intern or resident-in-training under a teaching program having the approval of the Council on

34

Medical Education and Hospitals of the American Medical Association or of any other recognized

 

LC005714 - Page 25 of 92

1

medical society approved by the director.

2

     (B) The term "inpatient hospital services" shall be taken to include medical and surgical

3

services provided by the inpatient's physician, but shall not include the services of a private-duty

4

nurse or services in a hospital, institution, or facility maintained primarily for the treatment and

5

care of patients with tuberculosis or mental diseases. Provided, further, it shall be taken to include

6

only the following organ transplant operations: kidney, liver, cornea, pancreas, bone marrow, lung,

7

heart, and heart/lung, and other organ transplant operations as may be designated by the director

8

after consultation with medical advisory staff or medical consultants; and provided that any such

9

transplant operation is determined by the director or his or her designee to be medically necessary.

10

Prior written approval of the director, or his or her designee, shall be required for all covered organ

11

transplant operations.

12

     (C) In determining medical necessity for organ transplant procedures, the state plan shall

13

adopt a case-by-case approach and shall focus on the medical indications and contra-indications in

14

each instance; the progressive nature of the disease; the existence of any alternative therapies; the

15

life-threatening nature of the disease; the general state of health of the patient apart from the

16

particular organ disease; and any other relevant facts and circumstances related to the applicant and

17

the particular transplant procedure.

18

     (7) "Medicare equivalent rate" means the amount that would be paid for the relevant

19

services as furnished by the relevant group of facilities under Medicare payment principles

20

delineated in subchapter B of 42 CFR Chapter IV. Should no direct Medicare rates be available for

21

the particular service and facility group, the Medicaid director will estimate the rate. Providers will

22

have standing to bring an action in superior court for a higher rate, but intermediary insurers such

23

as managed care entities shall have no standing to bring an action for a lower rate.

24

     (7)(8) "Nursing services" means the following items and services furnished to an inpatient

25

in a nursing facility:

26

     (i) Bed and board;

27

     (ii) Nursing care and other related services as are customarily furnished to inpatients

28

admitted to the nursing facility, and drugs, biologicals, supplies, appliances, and equipment for use

29

in the facility, as are customarily furnished in the facility for the care and treatment of patients;

30

     (iii) Other diagnostic or therapeutic items or services, legally furnished by the facility or

31

by others under arrangements made by the facility, as are customarily furnished to inpatients either

32

by the facility or by others under such arrangement;

33

     (iv) Medical services provided in the facility by the inpatient's physician, or by an intern

34

or resident-in-training of a hospital with which the facility is affiliated or that is under the same

 

LC005714 - Page 26 of 92

1

control, under a teaching program of the hospital approved as provided in subsection (6); and

2

     (v) A personal-needs allowance of fifty dollars ($50.00) two hundred dollars ($200) per

3

month.

4

     (8)(9) "Relative with whom the dependent child is living" means and includes the father,

5

mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister,

6

uncle, aunt, first cousin, nephew, or niece of any dependent child who maintains a home for the

7

dependent child.

8

     (9)(10) "Visiting nurse service" means part-time or intermittent nursing care provided by

9

or under the supervision of a registered professional nurse other than in a hospital or nursing home.

10

     40-8-6. Review of application for benefits.

11

     The director, or someone designated by him or her, shall review each application for

12

benefits filed in accordance with regulations, and shall make a determination of whether the

13

application will be honored and the extent of the benefits to be made available to the applicant, and

14

shall, within thirty (30) fifteen (15) days after the filing, notify the applicant, in writing, of the

15

determination. If the application is rejected, the notice to the applicant shall set forth therein the

16

reason therefor. The director may at any time reconsider any determination.

17

     40-8-10. Recovery of benefits paid in error.

18

     Any person, who through error or mistake of himself or herself or another, receives medical

19

care benefits to which he or she is not entitled or with respect to which he or she was ineligible,

20

shall be required to reimburse the state for the benefits paid through error or mistake within the

21

previous three (3) years.

22

     40-8-13. Rules, regulations, and fee schedules.

23

     The director shall make and promulgate rules, regulations, and fee schedules not

24

inconsistent with state law and fiscal procedures as he or she deems necessary for the proper

25

administration of this chapter and to carry out the policy and purposes thereof, and to make the

26

department's plan conform to the provisions of the federal Social Security Act, 42 U.S.C. § 1396

27

et seq., and any rules or regulations promulgated pursuant thereto. Except where explicitly

28

authorized by this title, the director shall have no power to set any fee schedule below the Medicare

29

equivalent rate; provided, however, that the director shall be empowered to provide a lower rate

30

equal to the maximum rate where federal reimbursement can be obtained in the event that federal

31

reimbursement cannot be obtained for the Medicare equivalent rate. For outpatient behavioral

32

health services, the minimum fee schedule shall be set at one hundred fifty percent (150%) of the

33

Medicare equivalent rate. The director shall attempt to obtain federal reimbursement for billing

34

outpatient behavioral health services at one hundred fifty percent (150%) of the Medicare

 

LC005714 - Page 27 of 92

1

equivalent rate, but the state shall bear the costs of this higher rate for outpatient behavioral health

2

services even if federal reimbursement cannot be obtained. Should federal financial participation

3

be impossible to obtain for outpatient behavioral health services rate of one hundred fifty percent

4

(150%) of the Medicare equivalent rate, the director shall impose a surtax on the tax imposed on

5

health insurers pursuant to chapter 17 of title 44 in the amount necessary to defray the costs of the

6

inability to obtain federal reimbursement for an outpatient behavioral health services rate of one

7

hundred fifty percent (150%) of the Medicare equivalent rate.

8

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

9

services.

10

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

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

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

20

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

21

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

22

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

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

1, 2022, payments for inpatient services in fee-for-service Medicaid shall cease utilizing the DRG

32

method of payment, and payments shall take place on a pure fee-for-services basis, unless a

33

provider shall elect to utilize the DRG payment methodology. DRG rates shall be set equal to ninety

34

percent (90%) of a reasonable estimate of the Medicare equivalent rate. Non-DRG rates shall be

 

LC005714 - Page 28 of 92

1

set by the Medicaid director through regulation in order that the projected overall per capita

2

expenditures shall equal ninety-five percent (95%) of a reasonable estimate of the equivalent

3

overall per capital expenditures that would have been reached under the Medicare equivalent rate.

4

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

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

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

20

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

21

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

22

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

23

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

24

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

25

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

26

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

27

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

28

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

29

managed care plans; (F) All hospitals licensed in Rhode Island shall accept such payment rates as

30

payment in full; and (G) For all such hospitals, compliance with the provisions of this section shall

31

be a condition of participation in the Rhode Island Medicaid program. Beginning July 1, 2022,

32

Medicaid managed care payment rates shall equal one hundred five percent (105%) of the fee-for-

33

service rates set in subsection (b)(1)(i) of this section.

34

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

 

LC005714 - Page 29 of 92

1

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

2

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

3

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

4

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

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

Prospective Payment System (OPPS) Hospital Input Price Index. With respect to the outpatient

15

rate, (i) It is required as of January 1, 2011, until December 31, 2011, that the Medicaid managed

16

care payment rates between each hospital and health plan shall not exceed one hundred percent

17

(100%) of the rate in effect as of June 30, 2010; (ii) Increases in hospital outpatient payments for

18

each annual twelve-month (12) period beginning January 1, 2012, until July 1, 2017, may not

19

exceed the Centers for Medicare and Medicaid Services national CMS Outpatient Prospective

20

Payment System OPPS hospital price index for the applicable period; (iii) Provided, however, for

21

the twenty-four-month (24) period beginning July 1, 2013, the Medicaid managed care outpatient

22

payment rates between each hospital and health plan shall not exceed the payment rates in effect

23

as of January 1, 2013, and for the twelve-month (12) period beginning July 1, 2015, the Medicaid

24

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

25

ninety-seven and one-half percent (97.5%) of the payment rates in effect as of January 1, 2013; (iv)

26

Increases in outpatient hospital payments for each annual twelve-month (12) period beginning July

27

1, 2017, shall be the Centers for Medicare and Medicaid Services national CMS OPPS Hospital

28

Input Price Index, less Productivity Adjustment, for the applicable period and shall be paid to each

29

hospital retroactively to July 1; (v) Beginning July 1, 2019, the Medicaid managed care outpatient

30

payment rates between each hospital and health plan shall be one hundred seven and two-tenths

31

percent (107.2%) of the payment rates in effect as of January 1, 2019 and shall be paid to each

32

hospital retroactively to July 1; (vi) Increases in outpatient hospital payments for each annual

33

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

34

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

 

LC005714 - Page 30 of 92

1

Services national CMS OPPS Hospital Input Price Index, less Productivity Adjustment, for the

2

applicable period and shall be paid to each hospital retroactively to July 1. Beginning July 1, 2022,

3

fee-for-service and managed care outpatient rates shall equal the Medicare equivalent rate.

4

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

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

contract.

20

     (c) It is intended that payment utilizing the phasing out the DRG method shall reward

21

hospitals for providing the most efficient highest quality care, and provide the executive office the

22

opportunity to conduct value-based purchasing of inpatient care.

23

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

24

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

25

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

26

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

27

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

28

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

29

eligible recipients in accordance with this chapter.

30

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

31

implement these rate changes.

32

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

33

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

34

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

 

LC005714 - Page 31 of 92

1

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

2

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

3

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

4

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

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

19-16 shall be repealed in their entirety.

13

     40-8-16. Notification of long-term care alternative.

14

     (a) The department of human services, before authorizing care in a nursing home or

15

intermediate-care facility for a person who is eligible to receive benefits pursuant to Title XIX of

16

the federal Social Security Act, 42 U.S.C. § 1396 et seq., and who is being discharged from a

17

hospital to a nursing home, shall notify the person, in writing, of the provisions of the long-term-

18

care alternative, a home- and a community-based program.

19

     (b) If a person, eligible to receive benefits pursuant to Title XIX of the federal Social

20

Security Act, requires services in a nursing home and desires to remain in his or her own home or

21

the home of a responsible relative or other adult, the person or his or her representative shall so

22

inform the department.

23

     (c) The department shall not make payments pursuant to Title XIX of the federal Social

24

Security Act for benefits until written notification documenting the person's choice as to a nursing

25

home or home- and community-based services has been filed with the department.

26

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

27

     (a) Rate reform.

28

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

29

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

30

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

31

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

32

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

33

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

34

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

 

LC005714 - Page 32 of 92

1

of the Social Security Act.

2

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

3

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

4

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

5

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

6

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

7

developed by the executive office:

8

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

9

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

10

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

11

may or may not result in automatic per diem revisions;

12

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

13

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

14

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

15

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

16

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

17

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

18

2019. Effective July 1, 2018, rates paid to nursing facilities from the rates approved by the Centers

19

for Medicare and Medicaid Services and in effect on October 1, 2017, both fee-for-service and

20

managed care, will be increased by one and one-half percent (1.5%) and further increased by one

21

percent (1%) on October 1, 2018, and further increased by one percent (1%) on October 1, 2019.

22

The inflation index shall be applied without regard for the transition factors in subsections (b)(1)

23

and (b)(2). For purposes of October 1, 2016, adjustment only, any rate increase that results from

24

application of the inflation index to subsections (a)(2)(i) and (a)(2)(ii) shall be dedicated to increase

25

compensation for direct-care workers in the following manner: Not less than 85% of this aggregate

26

amount shall be expended to fund an increase in wages, benefits, or related employer costs of direct-

27

care staff of nursing homes. For purposes of this section, direct-care staff shall include registered

28

nurses (RNs), licensed practical nurses (LPNs), certified nursing assistants (CNAs), certified

29

medical technicians, housekeeping staff, laundry staff, dietary staff, or other similar employees

30

providing direct-care services; provided, however, that this definition of direct-care staff shall not

31

include: (i) RNs and LPNs who are classified as "exempt employees" under the Federal Fair Labor

32

Standards Act (29 U.S.C. § 201 et seq.); or (ii) CNAs, certified medical technicians, RNs, or LPNs

33

who are contracted, or subcontracted, through a third-party vendor or staffing agency. By July 31,

34

2017, nursing facilities shall submit to the secretary, or designee, a certification that they have

 

LC005714 - Page 33 of 92

1

complied with the provisions of this subsection (a)(2)(vi) with respect to the inflation index applied

2

on October 1, 2016. Any facility that does not comply with terms of such certification shall be

3

subjected to a clawback, paid by the nursing facility to the state, in the amount of increased

4

reimbursement subject to this provision that was not expended in compliance with that certification.

5

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

6

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

7

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

8

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

9

the following components:

10

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

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

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

20

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

21

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

22

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

23

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

24

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

25

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

26

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

27

     (c) Effective July 1, 2022, and for each subsequent year, the executive office of health and

28

human services is hereby authorized and directed to amend its regulations for reimbursement to

29

nursing facilities in order that each nursing facility in the State of Rhode Island shall receive a

30

quarterly adjustment payment each state fiscal year of an amount determined as follows:

31

     (1) Determine the percent of the state's total Medicaid outpatient and emergency

32

department services (exclusive of physician services) provided by each nursing home during each

33

nursing facility's prior fiscal year;

34

     (2) Determine the sum of all Medicaid payments to nursing facilities made for services

 

LC005714 - Page 34 of 92

1

provided during each nursing facility's prior fiscal year;

2

     (3) Multiply the sum of all Medicaid payments as determined in subsection (c)(2) of this

3

section by a percentage defined as the total identified upper payment limit for all nursing facilities

4

divided by the sum of all Medicaid payments as determined in subsection (c)(2) of this section; and

5

then multiply that result by each nursing facility's percentage of the state's total Medicaid services

6

as determined in subsection (c)(1) of this section to obtain the total adjustment for each nursing

7

facility to be paid each year; and

8

     (4) Pay each nursing facility on or before July 20, October 20, January 20, and April 20

9

one quarter (1/4) of its total adjustment as determined in subsection (c)(3) of this section.

10

     40-8-26. Community health centers.

11

     (a) For the purposes of this section, the term community health centers refers to federally

12

qualified health centers and rural health centers.

13

     (b) To support the ability of community health centers to provide high-quality medical care

14

to patients, the executive office of health and human services ("executive office") may adopt and

15

implement an alternative payment methodology (APM) for determining a Medicaid per-visit

16

reimbursement for community health centers that is compliant with the prospective payment system

17

(PPS) provided for in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection

18

Act of 2000. The following principles are to ensure that the APM PPS rate determination

19

methodology is part of the executive office overall value purchasing approach. For community

20

health centers that do not agree to the principles of reimbursement that reflect the APM PPS,

21

EOHHS shall reimburse such community health centers at the federal PPS rate, as required per

22

section 1902(bb)(3) of the Social Security Act, 42 U.S.C. § 1396a(bb)(3). For community health

23

centers that are reimbursed at the federal PPS rate, subsections (d) through (f) of this section apply.

24

     (c) The APM PPS rate determination methodology will (i) Fairly recognize the reasonable

25

costs of providing services. Recognized reasonable costs will be those appropriate for the

26

organization, management, and direct provision of services and (ii) Provide assurances to the

27

executive office that services are provided in an effective and efficient manner, consistent with

28

industry standards. Except for demonstrated cause and at the discretion of the executive office, the

29

maximum reimbursement rate for a service (e.g., medical, dental) provided by an individual

30

community health center shall not exceed one hundred twenty-five percent (125%) of the median

31

rate for all community health centers within Rhode Island. not only bill the community health center

32

on a fee-for-service basis at ninety percent (90%) of the federal PPS rate but also make a series of

33

quality incentive payments if the community health center meets certain quality incentives. Quality

34

incentive payments shall be set at a percentage of the aggregate monthly billing that would be

 

LC005714 - Page 35 of 92

1

reached under the traditional federal PPS methodology. The quality incentive payments shall be as

2

follows:

3

     (1) Ten percent (10%) for meeting benchmarks set by the Medicaid director for screening

4

patients for Medicaid eligibility or having added one-tenth percent (0.1%) of its monthly patients

5

to the Medicaid rolls.

6

     (2) Five percent (5%) for enrolling at least five percent (5%) of patients who identified as

7

tobacco smokers in smoking cessation programs.

8

     (3) Ten percent (10%) for meeting benchmarks set by the director of human services for

9

screening patients for supplemental nutrition assistance program eligibility or having added one-

10

tenth percent (0.1%) of its monthly patients to the supplemental nutrition assistance program rolls.

11

     (4) Ten percent (10%) for ensuring that no more than one percent (1%) of patients are ever

12

not offered an appointment within a month if they request one.

13

     (5) Up to fifteen percent (15%) for meeting benchmarks set by the Medicaid director for

14

the improvement of air quality in patients' homes through directly funding interventions such as:

15

air quality inspections, the installation of air filters, the installation of ventilation, and the

16

replacement of gas stoves with electric stoves.

17

     (6) Up to fifteen percent (15%) for meeting benchmarks set by the Medicaid director for

18

the removal or mitigation of environmental toxins in patients' homes through the direct funding of

19

removal or mitigation of environmental toxins. These toxins shall include, but shall not be limited

20

to, lead, radon, asbestos, and carbon monoxide.

21

     (d) Community health centers will cooperate fully and timely with reporting requirements

22

established by the executive office.

23

     (e) Reimbursement rates established through this methodology shall be incorporated into

24

the PPS reconciliation for services provided to Medicaid-eligible persons who are enrolled in a

25

health plan on the date of service. Monthly payments by the executive office related to PPS for

26

persons enrolled in a health plan shall be made directly to the community health centers.

27

     (f) Reimbursement rates established through thisthe APM methodology shall not be

28

incorporated into the actuarially certified capitation rates paid to a health plan. The health plan shall

29

be responsible for paying the full amount of the reimbursement rate to the community health center

30

for each service eligible for reimbursement under the Medicare, Medicaid, and SCHIP Benefits

31

Improvement and Protection Act of 2000. If the health plan has an alternative payment arrangement

32

with the community health center opts to utilize the APM methodology, the health plan shall bear

33

the full upside and downside risk of decreased or increased costs from the APM methodologymay

34

establish a PPS reconciliation process for eligible services and make monthly payments related to

 

LC005714 - Page 36 of 92

1

PPS for persons enrolled in the health plan on the date of service. The executive office will review,

2

at least annually, the Medicaid reimbursement rates and reconciliation methodology used by the

3

health plans for community health centers to ensure payments to each are made in compliance with

4

the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000.

5

     40-8-32. Support for certain patients of nursing facilities.

6

     (a) Definitions. For purposes of this section:

7

     (1) "Applied income" shall mean the amount of income a Medicaid beneficiary is required

8

to contribute to the cost of his or her care.

9

     (2) "Authorized individual" shall mean a person who has authority over the income of a

10

patient of a nursing facility, such as a person who has been given or has otherwise obtained

11

authority over a patient's bank account; has been named as or has rights as a joint account holder;

12

or is a fiduciary as defined below.

13

     (3) "Costs of care" shall mean the costs of providing care to a patient of a nursing facility,

14

including nursing care, personal care, meals, transportation, and any other costs, charges, and

15

expenses incurred by a nursing facility in providing care to a patient. Costs of care shall not exceed

16

the customary rate the nursing facility charges to a patient who pays for his or her care directly

17

rather than through a governmental or other third-party payor.

18

     (4) "Fiduciary" shall mean a person to whom power or property has been formally entrusted

19

for the benefit of another, such as an attorney-in-fact, legal guardian, trustee, or representative

20

payee.

21

     (5) "Nursing facility" shall mean a nursing facility licensed under chapter 17 of title 23,

22

that is a participating provider in the Rhode Island Medicaid program.

23

     (6) "Penalty period" means the period of Medicaid ineligibility imposed pursuant to 42

24

U.S.C. § 1396p(c), as amended from time to time, on a person whose assets have been transferred

25

for less than fair market value.

26

     (7) "Uncompensated care" — Care and services provided by a nursing facility to a

27

Medicaid applicant without receiving compensation therefore from Medicaid, Medicare, the

28

Medicaid applicant, or other source. The acceptance of any payment representing actual or

29

estimated applied income shall not disqualify the care and services provided from qualifying as

30

uncompensated care.

31

     (b) Penalty period resulting from transfer. Any transfer or assignment of assets resulting in

32

the establishment or imposition of a penalty period shall create a debt that shall be due and owing

33

to a nursing facility for the unpaid costs of care provided during the penalty period to a patient of

34

that facility who has been subject to the penalty period. The amount of the debt established shall

 

LC005714 - Page 37 of 92

1

not exceed the fair market value of the transferred assets at the time of transfer that are the subject

2

of the penalty period. A nursing facility may bring an action to collect a debt for the unpaid costs

3

of care given to a patient who has been subject to a penalty period, against either the transferor or

4

the transferee, or both. The provisions of this section shall not affect other rights or remedies of the

5

parties.

6

     (c) Applied income. A nursing facility may provide written notice to a patient who is a

7

Medicaid recipient and any authorized individual of that patient:

8

     (1) Of the amount of applied income due;

9

     (2) Of the recipient's legal obligation to pay the applied income to the nursing facility; and

10

     (3) That the recipient's failure to pay applied income due to a nursing facility not later than

11

thirty (30) days after receiving notice from the nursing facility may result in a court action to

12

recover the amount of applied income due.

13

     A nursing facility that is owed applied income may, in addition to any other remedies

14

authorized under law, bring a claim to recover the applied income against a patient and any

15

authorized individual. If a court of competent jurisdiction determines, based upon clear and

16

convincing evidence, that a defendant willfully failed to pay or withheld applied income due and

17

owing to a nursing facility for more than thirty (30) days after receiving notice pursuant to

18

subsection (c), the court may award the amount of the debt owed, court costs, and reasonable

19

attorney's fees to the nursing facility.

20

     (d) Effects. Nothing contained in this section shall prohibit or otherwise diminish any other

21

causes of action possessed by any such nursing facility. The death of the person receiving nursing

22

facility care shall not nullify or otherwise affect the liability of the person or persons charged with

23

the costs of care rendered or the applied income amount as referenced in this section.

24

     SECTION 10. Sections 40-8-3.1, 40-8-9.1, 40-8-13.5, 40-8-15, 40-8-19.2 and 40-8-27 of

25

the General Laws in Chapter 40-8 entitled "Medical Assistance" are hereby repealed.

26

     40-8-3.1. Life estate in property -- Retained powers.

27

     When an applicant or recipient of Medicaid owns a life estate in property that is his or her

28

principal place of residence with the reserved power and authority, during his or her lifetime, to

29

sell, convey, mortgage, or otherwise dispose of the real property without the consent or joinder by

30

the holder(s) of the remainder interest, the principal place of residence shall not be regarded as an

31

excluded resource for the purpose of Medicaid eligibility, unless the applicant or recipient

32

individually, or through his or her guardian, conservator, or attorney in fact, conveys all outstanding

33

remainder interest to him or herself.

34

     An applicant or recipient who, by a deed created, executed and recorded on or before June

 

LC005714 - Page 38 of 92

1

30, 2014, has reserved a life estate in property that is his or her principal place of residence with

2

the reserved power and authority, during his or her lifetime, to sell, convey, mortgage, or otherwise

3

dispose of the real property without the consent or joinder by the holder(s) of the remainder interest,

4

shall not be ineligible for Medicaid on the basis of the deed, regardless of whether the transferee of

5

the remainder interest is a person or persons, trust, or entity.

6

     40-8-9.1. Notice.

7

     Whenever an individual who is receiving medical assistance under this chapter transfers

8

an interest in real or personal property, the individual shall notify the executive office of health and

9

human services within ten (10) days of the transfer. The notice shall be sent to the individual's local

10

office and the legal office of the executive office of health and human services and include, at a

11

minimum, the individual's name, social security number or, if different, the executive office of

12

health and human services identification number, the date of transfer, and the dollar value, if any,

13

paid or received by the individual who received benefits under this chapter. In the event an

14

individual fails to provide notice required by this section to the executive office of health and human

15

services and in the event an individual has received medical assistance, any individual and/or entity,

16

who knew or should have known that the individual failed to provide the notice and who receives

17

any distribution of value as a result of the transfer, shall be liable to the executive office of health

18

and human services to the extent of the value of the transfer. Moreover, any such individual shall

19

be subject to the provisions of § 40-6-15 and any remedy provided by applicable state and federal

20

laws and rules and regulations. Failure to comply with the notice requirements set forth in the

21

section shall not affect the marketability of title to real estate transferred while the transferor is

22

receiving medical assistance.

23

     40-8-13.5. Hospital Incentive Program (HIP).

24

     The secretary of the executive office of health and human services is authorized to seek the

25

federal authorities required to implement a hospital incentive program (HIP). The HIP shall provide

26

the participating licensed hospitals the ability to obtain certain payments for achieving performance

27

goals established by the secretary. HIP payments shall commence no earlier than July 1, 2016.

28

     40-8-15. Lien on deceased recipient's estate for assistance.

29

     (a)(1) Upon the death of a recipient of Medicaid under Title XIX of the federal Social

30

Security Act (42 U.S.C. § 1396 et seq. and referred to hereinafter as the "Act"), the total sum for

31

Medicaid benefits so paid on behalf of a beneficiary who was fifty-five (55) years of age or older

32

at the time of receipt shall be and constitute a lien upon the estate, as defined in subsection (a)(2),

33

of the beneficiary in favor of the executive office of health and human services ("executive office").

34

The lien shall not be effective and shall not attach as against the estate of a beneficiary who is

 

LC005714 - Page 39 of 92

1

survived by a spouse, or a child who is under the age of twenty-one (21), or a child who is blind or

2

permanently and totally disabled as defined in Title XVI of the federal Social Security Act, 42

3

U.S.C. § 1381 et seq. The lien shall attach against property of a beneficiary, which is included or

4

includable in the decedent's probate estate, regardless of whether or not a probate proceeding has

5

been commenced in the probate court by the executive office or by any other party. Provided,

6

however, that such lien shall only attach and shall only be effective against the beneficiary's real

7

property included or includable in the beneficiary's probate estate if such lien is recorded in the

8

land evidence records and is in accordance with subsection (e). Decedents who have received

9

Medicaid benefits are subject to the assignment and subrogation provisions of §§ 40-6-9 and 40-6-

10

10.

11

     (2) For purposes of this section, the term "estate" with respect to a deceased individual

12

shall include all real and personal property and other assets included or includable within the

13

individual's probate estate.

14

     (b) The executive office is authorized to promulgate regulations to implement the terms,

15

intent, and purpose of this section and to require the legal representative(s) and/or the heirs-at-law

16

of the decedent to provide reasonable written notice to the executive office of the death of a

17

beneficiary of Medicaid benefits who was fifty-five (55) years of age or older at the date of death,

18

and to provide a statement identifying the decedent's property and the names and addresses of all

19

persons entitled to take any share or interest of the estate as legatees or distributees thereof.

20

     (c) The amount of reimbursement for Medicaid benefits imposed under this section shall

21

also become a debt to the state from the person or entity liable for the payment thereof.

22

     (d) Upon payment of the amount of reimbursement for Medicaid benefits imposed by this

23

section, the secretary of the executive office, or his or her designee, shall issue a written discharge

24

of lien.

25

     (e) Provided, however, that no lien created under this section shall attach nor become

26

effective upon any real property unless and until a statement of claim is recorded naming the

27

debtor/owner of record of the property as of the date and time of recording of the statement of

28

claim, and describing the real property by a description containing all of the following: (1) Tax

29

assessor's plat and lot; and (2) Street address. The statement of claim shall be recorded in the records

30

of land evidence in the town or city where the real property is situated. Notice of the lien shall be

31

sent to the duly appointed executor or administrator, the decedent's legal representative, if known,

32

or to the decedent's next of kin or heirs at law as stated in the decedent's last application for

33

Medicaid benefits.

34

     (f) The executive office shall establish procedures, in accordance with the standards

 

LC005714 - Page 40 of 92

1

specified by the Secretary, United States Department of Health and Human Services, under which

2

the executive office shall waive, in whole or in part, the lien and reimbursement established by this

3

section if the lien and reimbursement would cause an undue hardship, as determined by the

4

executive office, on the basis of the criteria established by the secretary in accordance with 42

5

U.S.C. § 1396p(b)(3).

6

     (g) Upon the filing of a petition for admission to probate of a decedent's will or for

7

administration of a decedent's estate, when the decedent was fifty-five (55) years or older at the

8

time of death, a copy of the petition and a copy of the death certificate shall be sent to the executive

9

office. Within thirty (30) days of a request by the executive office, an executor or administrator

10

shall complete and send to the executive office a form prescribed by that office and shall provide

11

such additional information as the office may require. In the event a petitioner fails to send a copy

12

of the petition and a copy of the death certificate to the executive office and a decedent has received

13

Medicaid benefits for which the executive office is authorized to recover, no distribution and/or

14

payments, including administration fees, shall be disbursed. Any person and/or entity that receives

15

a distribution of assets from the decedent's estate shall be liable to the executive office to the extent

16

of such distribution.

17

     (h) Compliance with the provisions of this section shall be consistent with the requirements

18

set forth in § 33-11-5 and the requirements of the affidavit of notice set forth in § 33-11-5.2. Nothing

19

in these sections shall limit the executive office from recovery, to the extent of the distribution, in

20

accordance with all state and federal laws.

21

     (i) To ensure the financial integrity of the Medicaid eligibility determination, benefit

22

renewal, and estate recovery processes in this and related sections, the secretary of health and

23

human services is authorized and directed to, by no later than August 1, 2018: (1) Implement an

24

automated asset verification system, as mandated by § 1940 of the Act, that uses electronic data

25

sources to verify the ownership and value of countable resources held in financial institutions and

26

any real property for applicants and beneficiaries subject to resource and asset tests pursuant to the

27

Act in § 1902(e)(14)(D); (2) Apply the provisions required under §§ 1902(a)(18) and 1917(c) of

28

the Act pertaining to the disposition of assets for less than fair market value by applicants and

29

beneficiaries for Medicaid long-term services and supports and their spouses, without regard to

30

whether they are subject to or exempted from resources and asset tests as mandated by federal

31

guidance; and (3) Pursue any state plan or waiver amendments from the United States Centers for

32

Medicare and Medicaid Services and promulgate such rules, regulations, and procedures he or she

33

deems necessary to carry out the requirements set forth herein and ensure the state plan and

34

Medicaid policy conform and comply with applicable provisions of Title XIX.

 

LC005714 - Page 41 of 92

1

     40-8-19.2. Nursing Facility Incentive Program (HIP).

2

     The secretary of the executive office of health and human services is authorized to seek the

3

federal authority required to implement a nursing facility incentive program (NFIP). The NFIP

4

shall provide the participating licensed nursing facilities the ability to obtain certain payments for

5

achieving performance goals established by the secretary. NFIP payments shall commence no

6

earlier than July 1, 2016.

7

     40-8-27. Cooperation by providers.

8

     Medicaid providers who employ individuals applying for benefits under any chapter of this

9

title shall comply in a timely manner with requests made by the department for any documents

10

describing employer-sponsored health insurance coverage or benefits the provider offers that are

11

necessary to determine eligibility for the state's premium assistance program pursuant to § 40-8.4-

12

12. Documents requested by the department may include, but are not limited to, certificates of

13

coverage or a summary of benefits and employee obligations. Upon receiving notification that the

14

department has determined that the employee is eligible for premium assistance under § 40-8.4-12,

15

the provider shall accept the enrollment of the employee and his or her family in the employer-

16

based health insurance plan without regard to any seasonal enrollment restrictions, including open-

17

enrollment restrictions, and/or the impact on the employee's wages. Additionally, the Medicaid

18

provider employing such persons shall not offer "pay in lieu of benefits." Providers who do not

19

comply with the provisions set forth in this section shall be subject to suspension as a participating

20

Medicaid provider.

21

     SECTION 11. Sections 40-8.4-4, 40-8.4-5, 40-8.4-10, 40-8.4-12, 40-8.4-15 and 40-8.4-19

22

of the General Laws in Chapter 40-8.4 entitled "Health Care for Families" are hereby amended to

23

read as follows:

24

     40-8.4-4. Eligibility.

25

     (a) Medical assistance for families. There is hereby established a category of medical

26

assistance eligibility pursuant to § 1931 of Title XIX of the Social Security Act, 42 U.S.C. § 1396u-

27

1, for families whose income and resources are no greater than the standards in effect in the aid to

28

families with dependent children program on July 16, 1996, or such increased standards as the

29

department may determine. The executive office of health and human services is directed to amend

30

the medical assistance Title XIX state plan and to submit to the United States Department of Health

31

and Human Services an amendment to the RIte Care waiver project to provide for medical

32

assistance coverage to families under this chapter in the same amount, scope, and duration as

33

coverage provided to comparable groups under the waiver. The department is further authorized

34

and directed to submit amendments and/or requests for waivers to the Title XXI state plan as may

 

LC005714 - Page 42 of 92

1

be necessary to maximize federal contribution for provision of medical assistance coverage

2

provided pursuant to this chapter, including providing medical coverage as a "qualified state" in

3

accordance with Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. Implementation

4

of expanded coverage under this chapter shall not be delayed pending federal review of any Title

5

XXI amendment or waiver.

6

     (b) Income. The secretary of the executive office of health and human services is

7

authorized and directed to amend the medical assistance Title XIX state plan or RIte Care waiver

8

to provide medical assistance coverage through expanded income disregards or other methodology

9

for parents or relative caretakers whose income levels are below one hundred thirty-three percent

10

(133%) of the federal poverty level.

11

     (c) Health care coverage provided under this section shall also be provided without regard

12

to availability of federal financial participation to a noncitizen family member who is a resident of

13

Rhode Island, and who is otherwise eligible for such assistance. The department is further

14

authorized to promulgate any regulations necessary, and in accord with title XIX [42 U.S.C. § 1396

15

et seq.] and title XXI [42 U.S.C. § 1397 et seq.] of the Social Security Act as necessary in order to

16

implement the state plan amendment. The executive office of health and human services is directed

17

to ensure that federal financial participation is assessed to the maximum extent allowable to provide

18

coverage pursuant to this section, at least every two (2) years, and that state-only funds will be used

19

only if federal financial participation is not available.

20

     40-8.4-5. Managed care.

21

     The delivery and financing of the healthcare services provided under this chapter shall may

22

be provided through a system of managed care. A managed care system integrates an efficient

23

financing mechanism with quality service delivery; provides a "medical home" to ensure

24

appropriate care and deter unnecessary and inappropriate care; and places emphasis on preventive

25

and primary health care. Beginning July 1, 2027, all payments shall be provided directly by the

26

state without an intermediate payment to a managed care entity or other form of health insurance

27

company. Beginning July 1, 2022, no new contracts may be entered into between the Medicaid

28

office and an intermediate payor such as a managed care entity or other form of health insurance

29

company for the payment of health care services pursuant to this chapter.

30

     40-8.4-10. Regulations.

31

     (a) The department of human services Medicaid director is authorized to promulgate any

32

regulations necessary to implement this chapter.

33

     (b) When promulgating any rule or regulation necessary to implement this chapter, or any

34

rule or regulation related to RIte Care, the department Medicaid director shall send the notice

 

LC005714 - Page 43 of 92

1

referred to in § 42-35-3 and a true copy of the rule referred to in § 42-35-4 of the Rhode Island

2

administrative procedures act to each of the co-chairpersons of the permanent joint committee on

3

health care oversight established by § 40-8.4-14.

4

     40-8.4-12. RIte Share health insurance premium assistance program.

5

     (a) Basic RIte Share health insurance premium assistance program. Under the terms of

6

Section 1906 of Title XIX of the U.S. Social Security Act, 42 U.S.C. § 1396e, states are permitted

7

to pay a Medicaid-eligible person's share of the costs for enrolling in employer-sponsored health

8

insurance (ESI) coverage if it is cost-effective to do so. Pursuant to the general assembly's direction

9

in the Rhode Island health reform act of 2000, the Medicaid agency requested and obtained federal

10

approval under § 1916, 42 U.S.C. § 1396o, to establish the RIte Share premium assistance program

11

to subsidize the costs of enrolling Medicaid-eligible persons and families in employer-sponsored

12

health insurance plans that have been approved as meeting certain cost and coverage requirements.

13

The Medicaid agency also obtained, at the general assembly's direction, federal authority to require

14

any such persons with access to ESI coverage to enroll as a condition of retaining eligibility

15

providing that doing so meets the criteria established in Title XIX for obtaining federal matching

16

funds.

17

     (b) Definitions. For the purposes of this section, the following definitions apply:

18

     (1) "Cost-effective" means that the portion of the ESI that the state would subsidize, as

19

well as wrap-around costs, would on average cost less to the state than enrolling that same

20

person/family in a managed-care delivery system.

21

     (2) "Cost sharing" means any co-payments, deductibles, or co-insurance associated with

22

ESI.

23

     (3) "Employee premium" means the monthly premium share a person or family is required

24

to pay to the employer to obtain and maintain ESI coverage.

25

     (4) "Employer-sponsored insurance" or "ESI" means health insurance or a group health

26

plan offered to employees by an employer. This includes plans purchased by small employers

27

through the state health insurance marketplace, healthsource, RI (HSRI).

28

     (5) "Policy holder" means the person in the household with access to ESI, typically the

29

employee.

30

     (6) "RIte Share-approved employer-sponsored insurance (ESI)" means an employer-

31

sponsored health insurance plan that meets the coverage and cost-effectiveness criteria for RIte

32

Share.

33

     (7) "RIte Share buy-in" means the monthly amount an Medicaid-ineligible policy holder

34

must pay toward RIte Share-approved ESI that covers the Medicaid-eligible children, young adults,

 

LC005714 - Page 44 of 92

1

or spouses with access to the ESI. The buy-in only applies in instances when household income is

2

above one hundred fifty percent (150%) of the FPL.

3

     (8) "RIte Share premium assistance program" means the Rhode Island Medicaid premium

4

assistance program in which the State pays the eligible Medicaid member's share of the cost of

5

enrolling in a RIte Share-approved ESI plan. This allows the state to share the cost of the health

6

insurance coverage with the employer.

7

     (9) "RIte Share unit" means the entity within the executive office of health and human

8

services (EOHHS) responsible for assessing the cost-effectiveness of ESI, contacting employers

9

about ESI as appropriate, initiating the RIte Share enrollment and disenrollment process, handling

10

member communications, and managing the overall operations of the RIte Share program.

11

     (10) "Third-party liability (TPL)" means other health insurance coverage. This insurance

12

is in addition to Medicaid and is usually provided through an employer. Since Medicaid is always

13

the payer of last resort, the TPL is always the primary coverage.

14

     (11) "Wrap-around services or coverage" means any healthcare services not included in

15

the ESI plan that would have been covered had the Medicaid member been enrolled in a RIte Care

16

or Rhody Health Partners plan. Coverage of deductibles and co-insurance is included in the wrap.

17

Co-payments to providers are not covered as part of the wrap-around coverage.

18

     (c) RIte Share populations. Medicaid beneficiaries subject to eligible for RIte Share

19

include: children, families, parent and caretakers eligible for Medicaid or the children's health

20

insurance program (CHIP) under this chapter or chapter 12.3 of title 42; and adults between the

21

ages of nineteen (19) and sixty-four (64) who are eligible under chapter 8.12 of this title, not

22

receiving or eligible to receive Medicare, and are enrolled in managed care delivery systems. The

23

following conditions apply:

24

     (1) The income of Medicaid beneficiaries shall affect whether and in what manner they

25

must may participate in RIte Share as follows:

26

     (i) Income at or below one hundred fifty percent (150%) of FPL — Persons and families

27

determined to have household income at or below one hundred fifty percent (150%) of the federal

28

poverty level (FPL) guidelines based on the modified adjusted gross income (MAGI) standard or

29

other standard approved by the secretary are required to participate in RIte Share if a Medicaid-

30

eligible adult or parent/caretaker has access to cost-effective ESI. Enrolling in ESI through RIte

31

Share shall be a condition of maintaining Medicaid health coverage for any eligible adult with

32

access to such coverage.

33

     (ii) Income above one hundred fifty percent (150%) of FPL and policy holder is not

34

Medicaid-eligible — Premium assistance is available when the household includes Medicaid-

 

LC005714 - Page 45 of 92

1

eligible members, but the ESI policy holder (typically a parent/caretaker, or spouse) is not eligible

2

for Medicaid. Premium assistance for parents/caretakers and other household members who are not

3

Medicaid-eligible may be provided in circumstances when enrollment of the Medicaid-eligible

4

family members in the approved ESI plan is contingent upon enrollment of the ineligible policy

5

holder and the executive office of health and human services (executive office) determines, based

6

on a methodology adopted for such purposes, that it is cost-effective to provide premium assistance

7

for family or spousal coverage.

8

     (d) RIte Share enrollment not condition of eligibility. RIte Share enrollment shall be

9

purely voluntary and shall never be a condition of eligibility for Medicaid. For Medicaid

10

beneficiaries over the age of nineteen (19), enrollment in RIte Share shall be a condition of

11

eligibility except as exempted below and by regulations promulgated by the executive office.

12

     (1) Medicaid-eligible children and young adults up to age nineteen (19) shall not be

13

required to enroll in a parent/caretaker relative's ESI as a condition of maintaining Medicaid

14

eligibility if the person with access to RIte Share-approved ESI does not enroll as required. These

15

Medicaid-eligible children and young adults shall remain eligible for Medicaid and shall be

16

enrolled in a RIte Care plan.

17

     (2) There shall be a limited six-month (6) exemption from the mandatory enrollment

18

requirement for persons participating in the RI works program pursuant to chapter 5.2 of this title.

19

     (e) Approval of health insurance plans for premium assistance. The executive office of

20

health and human services shall adopt regulations providing for the approval of employer-based

21

health insurance plans for premium assistance and shall approve employer-based health insurance

22

plans based on these regulations. In order for an employer-based health insurance plan to gain

23

approval, the executive office must determine that the benefits offered by the employer-based

24

health insurance plan are substantially similar in amount, scope, and duration to the benefits

25

provided to Medicaid-eligible persons enrolled in a Medicaid managed care plan, when the plan is

26

evaluated in conjunction with available supplemental benefits provided by the office. The office

27

shall obtain and make available to persons otherwise eligible for Medicaid identified in this section

28

as supplemental benefits those benefits not reasonably available under employer-based health

29

insurance plans that are required for Medicaid beneficiaries by state law or federal law or

30

regulation. Once it has been determined by the Medicaid agency that the ESI offered by a particular

31

employer is RIte Share-approved, all Medicaid members with access to that employer's plan are

32

required to participate in RIte Share. Failure to meet the mandatory enrollment requirement shall

33

result in the termination of the Medicaid eligibility of the policy holder and other Medicaid

34

members nineteen (19) or older in the household who could be covered under the ESI until the

 

LC005714 - Page 46 of 92

1

policy holder complies with the RIte Share enrollment procedures established by the executive

2

office.

3

     (f) Premium assistance. The executive office shall provide premium assistance by paying

4

all or a portion of the employee's cost for covering the eligible person and/or his or her family under

5

such a RIte Share-approved ESI plan subject to the buy-in provisions in this section.

6

     (g) Buy-in. Persons who can afford it shall share in the cost. — The executive office is

7

authorized and directed to apply for and obtain any necessary state plan and/or waiver amendments

8

from the Secretary of the United States Department of Health and Human Services (DHHS) to

9

require that persons enrolled in a RIte Share-approved employer-based health plan who have

10

income equal to or greater than one hundred fifty percent (150%) of the FPL to buy-in to pay a

11

share of the costs based on the ability to pay, provided that the buy-in cost shall not exceed five

12

percent (5%) of the person's annual income. The executive office shall implement the buy-in by

13

regulation, and shall consider co-payments, premium shares, or other reasonable means to do so.

14

     (h) Maximization of federal contribution. The executive office of health and human

15

services is authorized and directed to apply for and obtain federal approvals and waivers necessary

16

to maximize the federal contribution for provision of medical assistance coverage under this

17

section, including the authorization to amend the Title XXI state plan and to obtain any waivers

18

necessary to reduce barriers to provide premium assistance to recipients as provided for in Title

19

XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq.

20

     (i) Implementation by regulation. The executive office of health and human services is

21

authorized and directed to adopt regulations to ensure the establishment and implementation of the

22

premium assistance program in accordance with the intent and purpose of this section, the

23

requirements of Title XIX, Title XXI, and any approved federal waivers.

24

     (j) Outreach and reporting. The executive office of health and human services shall develop

25

a plan to identify Medicaid-eligible individuals who have access to employer-sponsored insurance

26

and increase the use of RIte Share benefits. Beginning October 1, 2019, the executive office shall

27

submit the plan to be included as part of the reporting requirements under § 35-17-1. Starting

28

January 1, 2020, the executive office of health and human services shall include the number of

29

Medicaid recipients with access to employer-sponsored insurance, the number of plans that did not

30

meet the cost-effectiveness criteria for RIte Share, and enrollment in the premium assistance

31

program as part of the reporting requirements under § 35-17-1.

32

     (k) Employer-sponsored insurance. The executive office of health and human services shall

33

dedicate staff and resources to reporting monthly as part of the requirements under § 35-17-1 which

34

employer-sponsored insurance plans meet the cost-effectiveness criteria for RIte Share.

 

LC005714 - Page 47 of 92

1

Information in the report shall be used for screening for Medicaid enrollment to encourage Rite

2

Share participation. By October 1, 2021, the report shall include any employers with 300 or more

3

employees. By January 1, 2022, the report shall include employers with 100 or more employees.

4

The January report shall also be provided to the chairperson of the house finance committee; the

5

chairperson of the senate finance committee; the house fiscal advisor; the senate fiscal advisor; and

6

the state budget officer.

7

     40-8.4-15. Advisory commission on health care.

8

     (a) There is hereby established an advisory commission to be known as the "advisory

9

commission on health care" to advise the director of the department of human services on all

10

matters relating to the RIte Care and RIte Share programs, and other matters concerning access for

11

all Rhode Islanders to quality health care in the most affordable, economical manner. The director

12

of the department of human services shall serve ex officio as chairperson. The director shall appoint

13

the eighteen (18) members:

14

     (1) Three (3) of whom shall represent the healthcare providers;

15

     (2) Three (3) of whom shall represent the members of the public with significant health

16

care conditions healthcare insurers;

17

     (3) Three (3) of whom shall represent healthcare consumers or consumer organizations;

18

     (4) Two (2) of whom shall represent organized labor;

19

     (5) One of whom shall be the health care advocate in the office of the attorney general;

20

     (6) Three (3) of whom shall represent employers; and

21

     (7) Three (3) of whom shall be other members of the public.

22

     (b) The commission may study all aspects of the provisions of the RIte Care and RIte Share

23

programs involving purchasers of health care, including employers, consumers, and the state, health

24

insurers, providers of health care, and healthcare facilities, and all matters related to the interaction

25

among these groups, including methods to achieve more effective and timely resolution of disputes,

26

better communication, speedier, more reliable and less-costly administrative processes, claims,

27

payments, and other reimbursement matters, and the application of new processes or technologies

28

to such issues.

29

     (c) Members of the commission shall be appointed in the month of July, each to hold office

30

until the last day of June in the second year of his or her appointment or until his or her successor

31

is appointed by the director.

32

     (d) The commission shall meet at least quarterly, and the initial meeting of the commission

33

shall take place on or before September 15, 2000. The commission may meet more frequently than

34

quarterly at the call of the chair or at the call of any three (3) members of the commission.

 

LC005714 - Page 48 of 92

1

     (e) Members of the permanent joint committee on health care oversight established

2

pursuant to § 40-8.4-14 shall be notified of each meeting of the commission and shall be invited to

3

participate.

4

     40-8.4-19. Managed healthcare delivery systems for families.Cost sharing.

5

     (a) Notwithstanding any other provision of state law, the delivery and financing of the

6

healthcare services provided under this chapter shall be provided through a system of managed

7

care. "Managed care" is defined as systems that: integrate an efficient financing mechanism with

8

quality service delivery; provide a "medical home" to ensure appropriate care and deter unnecessary

9

services; and place emphasis on preventive and primary care.

10

     (b) Enrollment in managed care health delivery systems is mandatory for individuals

11

eligible for medical assistance under this chapter. This includes children in substitute care, children

12

receiving medical assistance through an adoption subsidy, and children eligible for medical

13

assistance based on their disability. Beneficiaries with third-party medical coverage or insurance

14

may be exempt from mandatory managed care in accordance with rules and regulations

15

promulgated by the department of human services for such purposes.

16

     (c) Individuals who can afford to contribute shall share in the cost. The department of

17

human services is authorized and directed to apply for and obtain any necessary waivers and/or

18

state plan amendments from the Secretary of the United States Department of Health and Human

19

Services, including, but not limited to, a waiver of the appropriate sections of Title XIX, 42 U.S.C.

20

§ 1396 et seq., to require that beneficiaries eligible under this chapter or chapter 12.3 of title 42,

21

with incomes equal to or greater than one hundred fifty percent (150%) of the federal poverty level,

22

pay a share of the costs of health coverage based on the ability to pay. The department of human

23

services shall implement this cost-sharing obligation by regulation, and shall consider co-payments,

24

premium shares, or other reasonable means to do so in accordance with approved provisions of

25

appropriate waivers and/or state plan amendments approved by the Secretary of the United States

26

Department of Health and Human Services.

27

     SECTION 12. Section 40-8.4-13 of the General Laws in Chapter 40-8.4 entitled "Health

28

Care for Families" is hereby repealed in its entirety.

29

     40-8.4-13. Utilization of available employer-based health insurance.

30

     To the extent permitted under Titles XIX and XXI of the Social Security Act, 42 U.S.C. §

31

1396 et seq. and 42 U.S.C. § 1397aa et seq., or by waiver from the Secretary of the United States

32

Department of Health and Human Services, the department of human services shall adopt

33

regulations to restrict eligibility for RIte Care under this chapter and/or chapter 12.3 of title 42, or

34

the RIte Share program under § 40-8.4-12, for certain periods of time for certain individuals or

 

LC005714 - Page 49 of 92

1

families who have access to, or have refused or terminated employer-based health insurance and

2

for certain periods of time for certain individuals but not including children whose employer has

3

terminated their employer-based health insurance. The department is authorized and directed to

4

amend the medical assistance Title XIX and XXI state plans, and/or to seek and obtain appropriate

5

federal approvals or waivers to implement this section.

6

     SECTION 13. Sections 40-8.5-1 and 40-8.5-1.1 of the General Laws in Chapter 40-8.5

7

entitled "Health Care for Elderly and Disabled Residents Act" are hereby amended to read as

8

follows:

9

     40-8.5-1. Categorically needy medical assistance coverage.

10

     The department of human services is hereby authorized and directed to amend its Title XIX

11

state plan to provide for categorically needy medical assistance coverage as permitted pursuant to

12

Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., as amended, to individuals who are

13

sixty-five (65) years or older or are disabled, as determined under § 1614(a)(3) of the Social

14

Security Act, 42 U.S.C. § 1382c(a)(3), as amended, whose income does not exceed one hundred

15

percent (100%) one hundred thirty-three percent (133%) of the federal poverty level (as revised

16

annually) applicable to the individual's family size, and whose resources do not exceed four

17

thousand dollars ($4,000) per individual, or six thousand dollars ($6,000) per couple. The

18

department shall provide medical assistance coverage to such elderly or disabled persons in the

19

same amount, duration, and scope as provided to other categorically needy persons under the state's

20

Title XIX state plan.

21

     40-8.5-1.1. Managed health care delivery systems.

22

     (a) The delivery and financing of the health care services provided under this chapter may

23

be provided through a system of managed care. Beginning July 1, 2027, all payments shall be

24

provided directly by the state without an intermediate payment to a managed care entity or other

25

form of health insurance company. Beginning July 1, 2022, no new contracts may be entered into

26

between the Medicaid office and an intermediate payor such as a managed care entity or other form

27

of health insurance company for the payment of health care services pursuant to this chapter. To

28

ensure that all medical assistance beneficiaries, including the elderly and all individuals with

29

disabilities, have access to quality and affordable health care, the executive office of health and

30

human services ("executive office") is authorized to implement mandatory managed-care health

31

systems.

32

     (b) "Managed care" is defined as systems that: integrate an efficient financing mechanism

33

with quality service delivery; provide a "medical home" to ensure appropriate care and deter

34

unnecessary services; and place emphasis on preventive and primary care. For purposes of this

 

LC005714 - Page 50 of 92

1

section, managed care systems may also be defined to include a primary care case-management

2

model, community health teams, and/or other such arrangements that meet standards established

3

by the executive office and serve the purposes of this section. Managed care systems may also

4

include services and supports that optimize the health and independence of beneficiaries who are

5

determined to need Medicaid-funded long-term care under chapter 8.10 of this title or to be at risk

6

for the care under applicable federal state plan or waiver authorities and the rules and regulations

7

promulgated by the executive office. Any Medicaid beneficiaries who have third-party medical

8

coverage or insurance may be provided such services through an entity certified by, or in a

9

contractual arrangement with, the executive office or, as deemed appropriate, exempt from

10

mandatory managed care in accordance with rules and regulations promulgated by the executive

11

office.

12

     (c) In accordance with § 42-12.4-7, the executive office is authorized to obtain any approval

13

through waiver(s), category II or III changes, and/or state-plan amendments, from the Secretary of

14

the United States Department of Health and Human Services, that are necessary to implement

15

mandatory, managed healthcare delivery systems for all Medicaid beneficiaries. The waiver(s),

16

category II or III changes, and/or state-plan amendments shall include the authorization to extend

17

managed care to cover long-term-care services and supports. Authorization shall also include, as

18

deemed appropriate, exempting certain beneficiaries with third-party medical coverage or

19

insurance from mandatory managed care in accordance with rules and regulations promulgated by

20

the executive office.

21

     (d)(b) To ensure the delivery of timely and appropriate services to persons who become

22

eligible for Medicaid by virtue of their eligibility for a United States Social Security Administration

23

program, the executive office is authorized to seek any and all data-sharing agreements or other

24

agreements with the Social Security Administration as may be necessary to receive timely and

25

accurate diagnostic data and clinical assessments. This information shall be used exclusively for

26

the purpose of service planning, and shall be held and exchanged in accordance with all applicable

27

state and federal medical record confidentiality laws and regulations.

28

     SECTION 14. Sections 40-8.12-2 and 40-8.12-3 of the General Laws in Chapter 40-8.12

29

entitled "Health Care for Adults" are hereby amended to read as follows:

30

     40-8.12-2. Eligibility.

31

     (a) Medicaid coverage for nonpregnant adults without children. There is hereby

32

established, effective January 1, 2014, a category of Medicaid eligibility pursuant to Title XIX of

33

the Social Security Act, as amended by the U.S. Patient Protection and Affordable Care Act (ACA)

34

of 2010, 42 U.S.C. § 1396u-1, for adults ages nineteen (19) to sixty-four (64) who do not have

 

LC005714 - Page 51 of 92

1

dependent children and do not qualify for Medicaid under Rhode Island general laws applying to

2

families with children and adults who are blind, aged, or living with a disability. The executive

3

office of health and human services is directed to make any amendments to the Medicaid state plan

4

and waiver authorities established under Title XIX necessary to implement this expansion in

5

eligibility and ensure the maximum federal contribution for health insurance coverage provided

6

pursuant to this chapter.

7

     (b) Income. The secretary of the executive office of health and human services is

8

authorized and directed to amend the Medicaid Title XIX state plan and, as deemed necessary, any

9

waiver authority to effectuate this expansion of coverage to any Rhode Islander who qualifies for

10

Medicaid eligibility under this chapter with income at or below one hundred and thirty-three

11

percent (133%) of the federal poverty level, based on modified adjusted-gross income.

12

     (c) Delivery system. The executive office of health and human services is authorized and

13

directed to apply for and obtain any waiver authorities necessary to provide persons eligible under

14

this chapter with managed, coordinated healthcare coverage consistent with the principles set forth

15

in chapter 12.4 of title 42, pertaining to a healthcare home. Beginning July 1, 2027, all payments

16

shall be provided directly by the state without an intermediate payment to a managed care entity or

17

other form of health insurance company. Beginning July 1, 2022, no new contracts may be entered

18

into between the Medicaid office and an intermediate payor such as a managed care entity or other

19

form of health insurance company for the payment of health care services pursuant to this chapter.

20

     40-8.12-3. Premium assistance program.

21

     (a) The executive office of health and human services is directed to amend its rules and

22

regulations to implement a premium assistance program for adults with dependent children,

23

enrolled in the state's health-benefits exchange, whose annual income and resources meet the

24

guidelines established in § 40-8.4-4 in effect on December 1, 2013. The premium assistance will

25

pay one-half of the cost of a commercial plan that a parent may incur after subtracting the cost-

26

sharing requirement under § 40-8.4-4 as of December 31, 2013, and any applicable federal tax

27

credits available. The office is also directed to amend the 1115 waiver demonstration extension and

28

the medical assistance Title XIX state plan for this program if it is determined that it is eligible for

29

funding pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq.

30

     (b) The executive office of health and human services shall require any individual receiving

31

benefits under a state-funded, healthcare assistance program to apply for any health insurance for

32

which he or she is eligible, including health insurance available through the health benefits

33

exchange. Nothing shall preclude the state from using funds appropriated for Affordable Care Act

34

transition expenses to reduce the impact on an individual who has been transitioned from a state

 

LC005714 - Page 52 of 92

1

program to a health insurance plan available through the health benefits exchange. It shall not be

2

deemed cost-effective for the state if it would result in a loss of benefits or an increase in the cost

3

of healthcare services for the person above an amount deemed de minimus as determined by state

4

regulation.

5

     SECTION 15. Chapter 44-8.13 of the General Law entitled "Long-Term Managed Care

6

Arrangements" is hereby repealed in its entirety.

7

     40-8.13-1. Definitions.

8

     For purposes of this section the following terms shall have the meanings indicated:

9

     (1) "Beneficiary" means an individual who is eligible for medical assistance under the

10

Rhode Island Medicaid state plan established in accordance with 42 U.S.C. § 1396, and includes

11

individuals who are additionally eligible for benefits under the Medicare program (42 U.S.C. §

12

1395 et seq.) or other health plan.

13

     (2) "Duals demonstration project" means a demonstration project established pursuant to

14

the financial alignment demonstration established under section 2602 of the Patient Protection and

15

Affordable Care Act (Pub. L. No. 111-148) [42 U.S.C. § 1315b], involving a three-way contract

16

between Rhode Island, the federal Centers for Medicare and Medicaid Services ("CMS"), and

17

qualified health plans, and covering healthcare services provided to beneficiaries.

18

     (3) "EOHHS" means the Rhode Island executive office of health and human services.

19

     (4) "EOHHS level-of-care tool" refers to a set of criteria established by EOHHS and used

20

in January, 2014 to determine the long-term-care needs of a beneficiary as well as the appropriate

21

setting for delivery of that care.

22

     (5) "Long-term-care services and supports" means a spectrum of services covered by the

23

Rhode Island Medicaid program and/or the Medicare program, that are required by individuals with

24

functional impairments and/or chronic illness, and includes skilled or custodial nursing facility

25

care, as well as various home- and community-based services.

26

     (6) "Managed care organization" means any health plan, health-maintenance organization,

27

managed care plan, or other person or entity that enters into a contract with the state under which

28

it is granted the authority to arrange for the provision of, and/or payment for, long-term-care

29

supports and services to eligible beneficiaries under a managed long-term-care arrangement.

30

     (7) "Managed long-term-care arrangement" means any arrangement under which a

31

managed care organization is granted some or all of the responsibility for providing and/or paying

32

for long-term-care services and supports that would otherwise be provided or paid under the Rhode

33

Island Medicaid program. The term includes, but is not limited to, a duals demonstration project,

34

and/or phase I and phase II of the integrated care initiative established by the executive office of

 

LC005714 - Page 53 of 92

1

health and human services.

2

     (8) "Plan of care" means a care plan established by a nursing facility in accordance with

3

state and federal regulations and that identifies specific care and services provided to a beneficiary.

4

     40-8.13-2. Beneficiary choice.

5

     Any managed long-term-care arrangement shall offer beneficiaries the option to decline

6

participation and remain in traditional Medicaid and, if a duals demonstration project, traditional

7

Medicare. Beneficiaries must be provided with sufficient information to make an informed choice

8

regarding enrollment, including:

9

     (1) Any changes in the beneficiary's payment or other financial obligations with respect to

10

long-term-care services and supports as a result of enrollment;

11

     (2) Any changes in the nature of the long-term-care services and supports available to the

12

beneficiary as a result of enrollment, including specific descriptions of new services that will be

13

available or existing services that will be curtailed or terminated;

14

     (3) A contact person who can assist the beneficiary in making decisions about enrollment;

15

     (4) Individualized information regarding whether the managed care organization's network

16

includes the healthcare providers with whom beneficiaries have established provider relationships.

17

Directing beneficiaries to a website identifying the plan's provider network shall not be sufficient

18

to satisfy this requirement; and

19

     (5) The deadline by which the beneficiary must make a choice regarding enrollment, and

20

the length of time a beneficiary must remain enrolled in a managed care organization before being

21

permitted to change plans or opt out of the arrangement.

22

     40-8.13-3. Ombudsman process.

23

     EOHHS shall designate an ombudsperson to advocate for beneficiaries enrolled in a

24

managed long-term-care arrangement. The ombudsperson shall advocate for beneficiaries through

25

complaint and appeal processes and ensure that necessary healthcare services are provided. At the

26

time of enrollment, a managed care organization must inform enrollees of the availability of the

27

ombudsperson, including contact information.

28

     40-8.13-4. Provider/plan liaison.

29

     EOHHS shall designate an individual, not employed by or otherwise under contract with a

30

participating managed care organization, who shall act as liaison between healthcare providers and

31

managed care organizations, for the purpose of facilitating communications and ensuring that issues

32

and concerns are promptly addressed.

33

     40-8.13-5. Financial principles under managed care.

34

     (a) To the extent that financial savings are a goal under any managed long-term-care

 

LC005714 - Page 54 of 92

1

arrangement, it is the intent of the legislature to achieve savings through administrative efficiencies,

2

care coordination, improvements in care outcomes and in a way that encourages the highest quality

3

care for patients and maximizes value for the managed-care organization and the state. Therefore,

4

any managed long-term-care arrangement shall include a requirement that the managed care

5

organization reimburse providers for services in accordance with these principles. Notwithstanding

6

any law to the contrary, for the twelve-month (12) period beginning July 1, 2015, Medicaid

7

managed long-term-care payment rates to nursing facilities established pursuant to this section shall

8

not exceed ninety-eight percent (98.0%) of the rates in effect on April 1, 2015.

9

     (1) For a duals demonstration project, the managed care organization:

10

     (i) Shall not combine the rates of payment for post-acute skilled and rehabilitation care

11

provided by a nursing facility and long-term and chronic care provided by a nursing facility in order

12

to establish a single-payment rate for dual eligible beneficiaries requiring skilled nursing services;

13

     (ii) Shall pay nursing facilities providing post-acute skilled and rehabilitation care or long-

14

term and chronic care rates that reflect the different level of services and intensity required to

15

provide these services; and

16

     (iii) For purposes of determining the appropriate rate for the type of care identified in

17

subsection (a)(1)(ii) of this section, the managed care organization shall pay no less than the rates

18

that would be paid for that care under traditional Medicare and Rhode Island Medicaid for these

19

service types. The managed care organization shall not, however, be required to use the same

20

payment methodology.

21

     The state shall not enter into any agreement with a managed care organization in connection

22

with a duals demonstration project unless that agreement conforms to this section, and any existing

23

such agreement shall be amended as necessary to conform to this subsection.

24

     (2) For a managed long-term-care arrangement that is not a duals demonstration project,

25

the managed care organization shall reimburse providers in an amount not less than the amount that

26

would be paid for the same care by the executive office of health and human services under the

27

Medicaid program. The managed care organization shall not, however, be required to use the same

28

payment methodology as the executive office of health and human services.

29

     (3) Notwithstanding any provisions of the general or public laws to the contrary, the

30

protections of subsections (a)(1) and (a)(2) of this section may be waived by a nursing facility in

31

the event it elects to accept a payment model developed jointly by the managed care organization

32

and skilled nursing facilities, that is intended to promote quality of care and cost-effectiveness,

33

including, but not limited to, bundled-payment initiatives, value-based purchasing arrangements,

34

gainsharing, and similar models.

 

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1

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

2

July 1, 2015, Medicaid managed long-term-care payment rates to nursing facilities established

3

pursuant to this section shall not exceed ninety-eight percent (98.0%) of the rates in effect on April

4

1, 2015.

5

     40-8.13-6. Payment incentives.

6

     In order to encourage quality improvement and promote appropriate utilization incentives

7

for providers in a managed long-term-care arrangement, a managed care organization may use

8

incentive or bonus payment programs that are in addition to the rates identified in § 40-8.13-5.

9

     40-8.13-7. Willing provider.

10

     A managed care organization must contract with and cover services furnished by any

11

nursing facility licensed under chapter 17 of title 23 and certified by CMS that provides Medicaid-

12

covered nursing facility services pursuant to a provider agreement with the state, provided that the

13

nursing facility is not disqualified under the managed care organization's quality standards that are

14

applicable to all nursing facilities; and the nursing facility is willing to accept the reimbursement

15

rates described in § 40-8.13-5.

16

     40-8.13-8. Level-of-care tool.

17

     A managed long-term-care arrangement must require that all participating managed care

18

organizations use only the EOHHS level-of-care tool in determining coverage of long-term-care

19

supports and services for beneficiaries. EOHHS may amend the level-of-care tool provided that

20

any changes are established in consultation with beneficiaries and providers of Medicaid-covered

21

long-term-care supports and services, and are based upon reasonable medical evidence or

22

consensus, in consideration of the specific needs of Rhode Island beneficiaries. Notwithstanding

23

any other provisions herein, however, in the case of a duals demonstration project, a managed care

24

organization may use a different level-of-care tool for determining coverage of services that would

25

otherwise be covered by Medicare, since the criteria established by EOHHS are directed towards

26

Medicaid-covered services; provided, that the level-of-care tool is based on reasonable medical

27

evidence or consensus in consideration of the specific needs of Rhode Island beneficiaries.

28

     40-8.13-9. Case management/plan of care.

29

     No managed care organization acting under a managed long-term-care arrangement may

30

require a provider to change a plan of care if the provider reasonably believes that such an action

31

would conflict with the provider's responsibility to develop an appropriate care plan under state and

32

federal regulations.

33

     40-8.13-10. Care transitions.

34

     In the event that a beneficiary:

 

LC005714 - Page 56 of 92

1

     (1) Has been determined to meet level-of-care requirements for nursing facility coverage

2

as of the date of his or her enrollment in a managed care organization; or

3

     (2) Has been determined to meet level of care requirements for nursing facility coverage

4

by a managed care organization after enrollment; and there is a change in condition whereby the

5

managed care organization determines that the beneficiary no longer meets such level-of-care

6

requirements, the nursing facility shall promptly arrange for an appropriate and safe discharge (with

7

the assistance of the managed care organization if the facility requests it), and the managed care

8

organization shall continue to pay for the beneficiary's nursing facility care at the same rate until

9

the beneficiary is discharged.

10

     40-8.13-11. Reporting requirements.

11

     EOHHS shall report to the general assembly and shall make available to interested persons

12

a separate accounting of state expenditures for long-term-care supports and services under any

13

managed long-term-care arrangement, specifically and separately identifying expenditures for

14

home- and community-based services, assisted-living services, hospice services within nursing

15

facilities, hospice services outside of nursing facilities, and nursing facility services. Such reports

16

shall be made twice annually, six (6) months apart, beginning six (6) months following the

17

implementation of any managed long-term-care arrangement, and shall include a detailed report of

18

utilization of each service. In order to facilitate reporting, any managed long-term-care arrangement

19

shall include a requirement that a participating managed care organization make timely reports of

20

the data necessary to compile the reports.

21

     SECTION 16. Sections 42-7.2-10, 42-7.2-16 and 42-7.2-16.1 of the General Laws in

22

Chapter 42-7.2 entitled "Office of Health and Human Services" are hereby amended to read as

23

follows:

24

     42-7.2-10. Appropriations and disbursements.

25

     (a) The general assembly shall annually appropriate such sums as it may deem necessary

26

for the purpose of carrying out the provisions of this chapter. The state controller is hereby

27

authorized and directed to draw his or her orders upon the general treasurer for the payment of such

28

sum or sums, or so much thereof as may from time to time be required, upon receipt by him or her

29

of proper vouchers approved by the secretary of the executive office of health and human services,

30

or his or her designee.

31

     (b) The general assembly shall, through the utilization of federal Medicaid reimbursement

32

for administrative costs, and additional funds, appropriate such funds as may be necessary to hire

33

additional personnel for the Medicaid office as follows: one hundred (100) outreach social workers

34

to encourage, assist and expedite individuals applying for Medicaid benefits; one hundred (100)

 

LC005714 - Page 57 of 92

1

new programmers in order to build digital infrastructure for the Medicaid office; thirty (30) new

2

social workers and ten (10) new programmers to help increase spend down program utilization and

3

feasibility and examine possible legal changes necessary to increase spend down program

4

eligibility; and fifty (50) additional personnel for building administrative capacity. The Medicaid

5

office shall be exempt from any limitations placed on the number of full-time equivalent personnel

6

employed by the executive office of health and human services.

7

     (b)(c) For the purpose of recording federal financial participation associated with

8

qualifying healthcare workforce development activities at the state's public institutions of higher

9

education, and pursuant to the Rhode Island designated state health programs (DSHP), as approved

10

by the Centers for Medicare & Medicaid Services (CMC) October 20, 2016, in the 11-W-00242/1

11

amendment to Rhode Island's section 1115 Demonstration Waiver, there is hereby established a

12

restricted-receipt account entitled "Health System Transformation Project" in the general fund of

13

the state and included in the budget of the office of health and human services. Due to the COVID-

14

19 pandemic, the office of health and human services is forbidden from utilizing any funds within

15

the health system transformation project restricted receipts account for any imposition of downside

16

risk for providers. No payment models that impose downside risk or in any way deviate from fee-

17

for-service shall be utilized for the Medicaid program without explicit authorization by the general

18

assembly.

19

     42-7.2-16. Medicaid System Reform 2008 Medicaid System Reform.

20

     (a) The executive office of health and human services, in conjunction with the department

21

of human services, the department of children, youth and families, the department of health and the

22

department of behavioral healthcare, developmental disabilities and hospitals, is authorized to

23

design options that further the reforms in Medicaid initiated in 2008 Medicaid reform to ensure that

24

the program: transitions to a Medicare level of care as a first step in the transition to a state-level

25

Medicare for All system; phases out the use of intermediary insurance companies such as managed

26

care entities; transitions to the management of health insurers acquired due to insolvency, smoothly

27

integrating publicly owned health insurers with the Medicaid system; utilizes payment models such

28

as fee-for-service that incentivize higher quality of care and more utilization of care; provides for

29

the financial health of Rhode Island health care providers; encourages fair wages and benefits for

30

Rhode Island's health care workforce; develops and builds out the Medicaid office's human capital,

31

technological infrastructure, expertise, and general ability to manage health care payments to

32

prepare for the transition to a single-payer Medicare-for-All system; and guides the transition of

33

the Rhode Island health care funding system to a state-level Medicare-for-All system.utilizes

34

competitive and value based purchasing to maximize the available service options, promotes

 

LC005714 - Page 58 of 92

1

accountability and transparency, and encourages and rewards healthy outcomes, independence, and

2

responsible choices; promotes efficiencies and the coordination of services across all health and

3

human services agencies; and ensures the state will have a fiscally sound source of publicly-

4

financed health care for Rhode Islanders in need.

5

     (b) Principles and goals. In developing and implementing this system of reform, the

6

executive office of health and human services and the four (4) health and human services

7

departments shall pursue the following principles and goals:

8

     (1) Empower consumers to make reasoned and cost-effective choices about their health by

9

providing them with the information and array of service options they need and offering rewards

10

for healthy decisions;

11

     (2) Encourage personal responsibility by assuring the information available to beneficiaries

12

is easy to understand and accurate, provide that a fiscal intermediary is provided when necessary,

13

and adequate access to needed services;

14

     (3) When appropriate, promote community-based care solutions by transitioning

15

beneficiaries from institutional settings back into the community and by providing the needed

16

assistance and supports to beneficiaries requiring long-term care or residential services who wish

17

to remain, or are better served in the community;

18

     (4) Enable consumers to receive individualized health care that is outcome-oriented,

19

focused on prevention, disease management, recovery and maintaining independence;

20

     (5) Promote competition between healthcare providers to ensure best value purchasing, to

21

leverage resources and to create opportunities for improving service quality and performance;

22

     (6) Redesign purchasing and payment methods to promote payment models such as fee-

23

for-service that incentivize higher quality of care and more utilization of care and phase out the use

24

of payment models that shift risk to providers assure fiscal accountability and encourage and to

25

reward service quality and cost-effectiveness by tying reimbursements to evidence-based

26

performance measures and standards, including those related to patient satisfaction; and

27

     (7) Continually improve technology to take advantage of recent innovations and advances

28

that help decision makers, consumers and providers to make informed and cost-effective decisions

29

regarding health care.

30

     (c) The executive office of health and human services shall annually submit a report to the

31

governor and the general assembly describing the status of the administration and implementation

32

of the Medicaid Section 1115 demonstration waiver.

33

     42-7.2-16.1. Reinventing Medicaid Act of 2015.

34

     (a) Findings. The Rhode Island Medicaid program is an integral component of the state's

 

LC005714 - Page 59 of 92

1

healthcare system that provides crucial services and supports to many Rhode Islanders. As the

2

program's reach has expanded, the costs of the program have continued to rise and the delivery of

3

care has become more fragmented and uncoordinated. Given the crucial role of the Medicaid

4

program to the state, it is of compelling importance that the state conduct a fundamental

5

restructuring of its Medicaid program that achieves measurable improvement in health outcomes

6

for the people and transforms the healthcare system to one that pays for the outcomes and quality

7

they deserve at a sustainable, predictable and affordable cost. The Reinventing Medicaid Act of

8

2015, as implemented in the budget for fiscal year two thousand sixteen (FY2016), involved drastic

9

cuts to the Medicaid program, along with policies that shifted risk to providers away from

10

intermediary insurers. Since the passage of that act, the finances of health care providers in Rhode

11

Island have deteriorated significantly, and it is therefore the duty of the general assembly to seek

12

corrective action to restore critical investments in the Medicaid system and redesign payment

13

models to remove risk from providers and concentrate risk in private insurance companies during

14

their phase-out period along the transition to Medicare-for-All.

15

     (b) The Working Group to Reinvent Medicaid, which was established to refine the

16

principles and goals of the Medicaid reforms begun in 2008, was directed to present to the general

17

assembly and the governor initiatives to improve the value, quality, and outcomes of the health care

18

funded by the Medicaid program.

19

     SECTION 17. Chapter 42-12.1 of the General Laws entitled "Department of Behavioral

20

Healthcare, Developmental Disabilities, and Hospitals" is hereby amended by adding thereto the

21

following section:

22

     42-12.1-10. The Rhode Island institute for mental disease.

23

     (a) There is hereby established a state hospital for the care for Rhode Islanders in need of

24

hospital-level inpatient behavioral health care known as the Rhode Island institute for mental

25

disease. The Rhode Island institute for mental disease shall fall within the purview of the

26

department, and the chief executive officer, chief financial officer, and chief medical officer shall

27

be appointed by the governor with advice and consent of the senate.

28

     (b) All forensic patients in the care of the Eleanor Slater Hospital shall be immediately

29

transferred to the Rhode Island institute for mental disease.

30

     (c) The Reagan Building of the Eleanor Slater Hospital shall be immediately transferred to

31

the Rhode Island institute for mental disease.

32

     (d) A section of the Zambarano Building of the Eleanor Slater Hospital shall be designated

33

by the department for the use of the Rhode Island institute for mental disease.

34

     (e) In the event that the director determines that the patient mix at the Eleanor Slater

 

LC005714 - Page 60 of 92

1

Hospital may be at risk of jeopardizing federal Medicaid reimbursement through the classification

2

of the Eleanor Slater Hospital as an institution for mental disease, the director shall be empowered

3

to administratively transfer inpatient behavioral health patients at Eleanor Slater Hospital to the

4

Rhode Island institute for mental disease.

5

     (f) The Medicaid director is hereby directed to apply for a waiver to allow for Medicaid

6

reimbursement of some or all inpatient behavioral health patients at the Rhode Island institute for

7

mental disease.

8

     SECTION 18. Sections 42-12.3-2, 42-12.3-3, 42-12.3-4, 42-12.3-5, 42-12.3-7, 42-12.3-9

9

and 42-12.3-15 of the General Laws in Chapter 42-12.3 entitled "Health Care for Children and

10

Pregnant Women" are hereby amended to read as follows:

11

     42-12.3-2. Purposes.

12

     (a) It is the intent of the general assembly to assure access to the comprehensive health care

13

by providing health insurance to all Rhode Islanders who are uninsured;

14

     Universal comprehensive coverage for all Rhode Islanders is a goal to be achieved over

15

the course of several years;

16

     The first step in providing comprehensive health coverage is to assure coverage for the

17

most vulnerable residents of the state;

18

     Uninsured pregnant women and children under age eight (8)nineteen (19) are among the

19

most vulnerable residents of the state; and

20

     The governor's health care advisory committee has provided advice and recommendations

21

in its report of January, 1993 to improve access to health care for pregnant women and children up

22

to age six (6);

23

     The objectives to meet the goal of comprehensive health coverage are:

24

     (1) Every child under age eight (8)nineteen(19) in Rhode Island will have a reliable source

25

of health coverage and health care;

26

     (2) Every pregnant woman in Rhode Island will have early and comprehensive prenatal

27

and maternity care services;

28

     (3) All low income families will have improved access to family planning and reproductive

29

services; and

30

     (4) Every pregnant woman and child in Rhode Island will receive effective, preventive

31

primary care.

32

     (b) To assure access to care and availability of services, the following principles will guide

33

the design of the health care act:

34

     (1) There will be equal access to health care for children and pregnant women, regardless

 

LC005714 - Page 61 of 92

1

of the type of coverage;

2

     (2) There shall be an emphasis on primary and preventive care which will include a

3

"medical home" for every child;

4

     (3) Current deficiencies in the fee for service delivery system will be addressed;

5

     (4) In addition to accessibility of health care, provisions must be made to address language,

6

cultural and transportation barriers;

7

     (5) Enrollment must be both timely and accomplished in a user friendly fashion;

8

     (6) An adequate source of primary care providers should be developed;

9

     (7) An enhanced set of services should be developed to support and address the needs of

10

families at risk.

11

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

12

     (a) The director of the department of human services is authorized to amend its Title XIX

13

state plan pursuant to Title XIX of the Social Security Act to provide Medicaid coverage and to

14

amend its Title XXI state plan pursuant to Title XXI of the Social Security Act to provide medical

15

assistance coverage through expanded family income disregards for pregnant women persons

16

whose family income levels are between one hundred eighty-five percent (185%) and two hundred

17

fifty percent (250%) of the federal poverty level. The department is further authorized to

18

promulgate any regulations necessary and in accord with Title XIX [42 U.S.C. § 1396 et seq.] and

19

Title XXI [ 42 U.S.C. § 1397aa et seq.] of the Social Security Act necessary in order to implement

20

said state plan amendment. The services provided shall be in accord with Title XIX [42 U.S.C. §

21

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

22

     (b) The director of the department of human services is authorized and directed to establish

23

a payor of last resort program to cover prenatal, delivery and postpartum care. The program shall

24

cover the cost of maternity care for any woman person who lacks health insurance coverage for

25

maternity care and who is not eligible for medical assistance under Title XIX [42 U.S.C. § 1396 et

26

seq.] and Title XXI [ 42 U.S.C. § 1397aa et seq.] of the Social Security Act including, but not

27

limited to, a noncitizen pregnant woman person lawfully admitted for permanent residence on or

28

after August 22, 1996, without regard to the availability of federal financial participation, provided

29

such pregnant woman person satisfies all other eligibility requirements. The director shall

30

promulgate regulations to implement this program. Such regulations shall include specific

31

eligibility criteria; the scope of services to be covered; procedures for administration and service

32

delivery; referrals for non-covered services; outreach; and public education. Excluded services

33

under this subsection will include, but not be limited to, induced abortion except in cases of rape

34

or incest or to save the life of the pregnant individual.

 

LC005714 - Page 62 of 92

1

     (c) The department of human services may enter into cooperative agreements with the

2

department of health and/or other state agencies to provide services to individuals eligible for

3

services under subsections (a) and (b) above.

4

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

5

     (1) Ante-partum and postpartum care;

6

     (2) Delivery;

7

     (3) Cesarean section;

8

     (4) Newborn hospital care;

9

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

10

provider; and

11

     (6) Prescription medications and laboratory tests.

12

     (e) The department of human services shall provide enhanced services, as appropriate, to

13

pregnant women persons as defined in subsections (a) and (b), as well as to other pregnant women

14

persons eligible for medical assistance. These services shall include: care coordination, nutrition

15

and social service counseling, high risk obstetrical care, childbirth and parenting preparation

16

programs, smoking cessation programs, outpatient counseling for drug-alcohol use, interpreter

17

services, mental health services, and home visitation. The provision of enhanced services is subject

18

to available appropriations. In the event that appropriations are not adequate for the provision of

19

these services, the department has the authority to limit the amount, scope and duration of these

20

enhanced services.

21

     (f) The department of human services shall provide for extended family planning services

22

for up to twenty-four (24) months postpartum. These services shall be available to women persons

23

who have been determined eligible for RIte Start or for medical assistance under Title XIX [42

24

U.S.C. § 1396 et seq.] or Title XXI [ 42 U.S.C. § 1397aa et seq.] of the Social Security Act.

25

     (g) Individuals eligible for RIte Start pursuant to this section or for medical assistance

26

under Title XIX or Title XXI of the Social Security Act while pregnant (including during a period

27

of retroactive eligibility), are eligible for full Medicaid benefits through the last day of the month

28

in which their twelve (12) month postpartum period ends. This benefit will be provided to eligible

29

Rhode Island residents without regard to the availability of federal financial participation. The

30

executive office of health and human services is directed to ensure that federal financial

31

participation is used to the maximum extent allowable to provide coverage pursuant to this section,

32

and that state-only funds will be used only if federal financial participation is not available.

33

     (h) Any person eligible for services under subsections (a) and (b) of this section, or

34

otherwise eligible for medical assistance under title XIX [42 U.S.C. § 1396 et seq.] and title XXI

 

LC005714 - Page 63 of 92

1

[42 U.S.C. § 1397 et seq.] of the Social Security Act, shall also be entitled to services for any

2

termination of pregnancy permitted under § 23-4.13-2; provided, however, that no federal funds

3

shall be used to pay for such services, except as authorized under federal law.

4

     42-12.3-4. "RIte track" program.

5

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

6

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

7

department of human services is hereby authorized to amend its title XIX state plan pursuant to

8

title XIX [42 U.S.C. § 1396 et seq.] and title XXI [42 U.S.C. § 1397 et seq.] of the Social Security

9

Act as necessary to provide for expanded Medicaid coverage through expanded family income

10

disregards for children, until they reach nineteen (19) years of age, whose family income levels are

11

up to two hundred fifty percent (250%) of the federal poverty level. Provided, however, that

12

healthcare coverage provided under this section shall also be provided without regard to availability

13

of federal financial participation in accordance to Title XIX of the Social Security Act, 42 U.S.C.

14

§ 1396 et seq., to a noncitizen child who is a resident of Rhode Island lawfully residing in the

15

United States, and who is otherwise eligible for such assistance. The department is further

16

authorized to promulgate any regulations necessary, and in accord with title XIX [42 U.S.C. § 1396

17

et seq.] and title XXI [42 U.S.C. § 1397 et seq.] of the Social Security Act as necessary in order to

18

implement the state plan amendment. For those children who lack health insurance, and whose

19

family incomes are in excess of two hundred fifty percent (250%) of the federal poverty level, the

20

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

21

The department of human services is further directed to ascertain and promulgate the scope of

22

services that will be available to those children whose family income exceeds the maximum family

23

income specified in the approved title XIX [42 U.S.C. § 1396 et seq.] and title XXI [42 U.S.C. §

24

1397 et seq.] state plan amendment.

25

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

26

financial participation is assessed to the maximum extent allowable to provide coverage to children

27

pursuant to this section, at least every two (2) years, and that state-only funds will be used only if

28

federal financial participation is not available.

29

     42-12.3-5. Managed care.

30

     The delivery and financing of the health care services provided pursuant to §§ 42-12.3-3

31

and 42-12.3-4 shall may be provided through a system of managed care. The delivery and financing

32

of the health care services provided under this chapter may be provided through a system of

33

managed care. Beginning July 1, 2027, all payments shall be provided directly by the state without

34

an intermediate payment to a managed care entity or other form of health insurance company.

 

LC005714 - Page 64 of 92

1

Beginning July 1, 2022, no new contracts may be entered into between the Medicaid office and an

2

intermediate payor such as a managed care entity or other form of health insurance company for

3

the payment of health care services pursuant to this chapter.

4

     A managed care system integrates an efficient financing mechanism with quality service

5

delivery, provides a "medical home" to assure appropriate care and deter unnecessary and

6

inappropriate care, and places emphasis on preventive and primary health care. In developing a

7

managed care system the department of human services shall consider managed care models

8

recognized by the health care financing administration. The department of human services is hereby

9

authorized and directed to seek any necessary approvals or waivers from the U.S. Department of

10

Health and Human Services, Health Care Financing Administration, needed to assure that services

11

are provided through a mandatory managed care system. Certain health services may be provided

12

on an interim basis through a fee for service arrangement upon a finding that there are temporary

13

barriers to implementation of mandatory managed care for a particular population or particular

14

geographic area. Nothing in this section shall prohibit the department of human services from

15

providing enhanced services to medical assistance recipients within existing appropriations.

16

     42-12.3-7. Financial contributions.

17

     The department of human services may not require the payment of enrollment fees, sliding

18

fees, deductibles, co-payments, and/or other contributions based on ability to pay. These fees shall

19

be established by rules and regulations to be promulgated by the department of human services or

20

the department of health, as appropriate.

21

     42-12.3-9. Insurance coverage -- Third party insurance.

22

     (a) No payment will be made nor service provided in the RIte Start or RIte Track program

23

with respect to any health care that is covered or would be covered, by any employee welfare benefit

24

plan under which a woman or child is either covered or eligible to be covered either as an employee

25

or dependent, whether or not coverage under such plan is elected.

26

     (b) A premium may be charged for participation in the RIte Track or RIte Start programs

27

for eligible individuals whose family incomes are in excess of two hundred fifty percent (250%) of

28

the federal poverty level and who have voluntarily terminated health care insurance within one year

29

of the date of application for benefits under this chapter.

30

     (c)(b) Every family who is eligible to participate in the RIte Track program, who has an

31

additional child who because of age is not eligible for RIte Track, or whose child becomes ineligible

32

for RIte Track because of his or her age, may be offered by the managed care provider with whom

33

the family is enrolled, the opportunity to enroll such ineligible child or children in the same

34

managed care program on a self-pay basis at the same cost, charge or premium as is being charged

 

LC005714 - Page 65 of 92

1

to the state under the provisions of this chapter for other covered children within the managed care

2

program. The family may also purchase a package of enhanced services at the same cost or charge

3

to the department.

4

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

5

     (a) The Department of Human Services is hereby authorized and directed to submit to the

6

United States Department of Health and Human Services an amendment to the "RIte Care" waiver

7

project number 11-W-0004/1-01 to provide for expanded Medicaid coverage for children until they

8

reach eight (8) years of age, whose family income levels are to two hundred fifty percent (250%)

9

of the federal poverty level. Expansion of the RIte track program from the age of six (6) until they

10

reach eighteen (18) years of age in accordance with this chapter shall be subject to the approval of

11

the amended waiver by the United States Department of Health and Human Services. Healthcare

12

coverage under this section shall also be provided to a noncitizen child who is a resident of Rhode

13

Island lawfully residing in the United States, and who is otherwise eligible for such assistance under

14

title XIX [42 U.S.C. § 1396 et seq.] or title XXI [42 U.S.C. § 1397 et seq.]

15

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

16

financial participation is assessed to the maximum extent allowable to provide coverage to children

17

pursuant to this section, at least every two (2) years, and that state-only funds will be used only if

18

federal financial participation is not available.

19

     SECTION 19. Section 42-12.3-14 of the General Laws in Chapter 42-12.3 entitled "Health

20

Care for Children and Pregnant Women" is hereby repealed in its entirety.

21

     42-12.3-14. Benefits and coverage -- Exclusion.

22

     For as long as the United States Department of Health and Human Services, Health Care

23

Financing Administration Project No. 11-W-0004/1-01 entitled "RIte Care" remains in effect, any

24

health care services provided pursuant to this chapter shall be exempt from all mandatory benefits

25

and coverage as may otherwise be provided for in the general laws.

26

     SECTION 20. Sections 42-14.5-2 and 42-14.5-3 of the General Laws in Chapter 42-14.5

27

entitled "The Rhode Island Health Care Reform Act of 2004 - Health Insurance Oversight" are

28

hereby amended to read as follows:

29

     42-14.5-2. Purpose.

30

     With respect to health insurance as defined in § 42-14-5, the health insurance commissioner

31

shall discharge the powers and duties of office to:

32

     (1) Claw back excessive profits, reserves charges, and other monies that health insurers

33

may have accumulated against the public interest of the people of Rhode Island Guard the solvency

34

of health insurers;

 

LC005714 - Page 66 of 92

1

     (2) Protect the interests of consumers;

2

     (3) Encourage fair treatment of health care providers;

3

     (4) Encourage policies and developments that improve the quality and efficiency of health

4

care service delivery and outcomes; and

5

     (5) View the health care system as a comprehensive entity and encourage and direct

6

insurers towards policies that advance the welfare of the public through overall efficiency,

7

improved health care quality, and appropriate access; and

8

     (6) Facilitate the transformation of the health care payments system to a state-level

9

Medicare-for-All system.

10

     42-14.5-3. Powers and duties.

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

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

20

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

21

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

22

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

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

reserves.

32

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

33

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

34

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

 

LC005714 - Page 67 of 92

1

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

2

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

3

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

4

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

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

the full advisory council.

16

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

17

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

18

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

19

include in it's The health insurance commissioner shall provide in an annual report and presentation

20

before the house and senate finance committees the following information:

21

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

22

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

23

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

24

purpose of verifying professional qualifications of participating healthcare providers;

25

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

26

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

27

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

28

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

29

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

30

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

31

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

32

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

33

comparisons;

34

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

 

LC005714 - Page 68 of 92

1

mechanisms for resolving health plan/provider disputes;

2

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

3

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

4

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

5

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

6

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

7

their networks; and

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

current products.

19

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

20

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

21

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

22

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

23

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

24

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

25

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

26

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

27

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

28

merged market.

29

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

30

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

31

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

32

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

33

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

34

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

 

LC005714 - Page 69 of 92

1

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

2

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

3

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

4

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

5

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

6

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

7

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

8

care and proprietary information.

9

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

10

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

11

senate finance committees.

12

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

13

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

14

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

15

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

16

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

17

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

18

labor union representing health care workers, and other affected entities. The workgroup shall also

19

include at least one designee each from the Rhode Island Medical Society, Rhode Island Council

20

of Community Mental Health Organizations, the Rhode Island Health Center Association, and the

21

Hospital Association of Rhode Island. The workgroup shall consider and make recommendations

22

for:

23

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

24

Such standard shall:

25

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

26

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

27

for Medicare and Medicaid Services;

28

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

29

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

30

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

31

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

32

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

33

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

34

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

 

LC005714 - Page 70 of 92

1

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

2

and benefits information;

3

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

4

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

5

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

6

request of eligibility.

7

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

8

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

9

providers in the state;

10

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

11

manner that makes for simple retrieval and implementation by providers;

12

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

13

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

14

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

15

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

16

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

17

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

18

providers.

19

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

20

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

21

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

22

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

23

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

24

process to challenge the payor's adjudication decision.

25

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

26

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

27

prosecution under applicable law of potentially fraudulent billing activities.

28

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

29

to:

30

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

31

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

32

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

33

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

34

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

 

LC005714 - Page 71 of 92

1

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

2

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

3

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

4

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

5

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

6

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

7

requirements;

8

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

9

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

10

authorization number; and transmit an admission notification.

11

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

12

recommendations for establishing guidelines and regulations for systems that give patients

13

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

14

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

15

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

16

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

17

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

18

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

19

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

20

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

21

utilization and cost-sharing expense.

22

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

23

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

24

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

25

to the public.

26

     (k) To monitor the prevent by regulation any transition from fee-for-service and toward

27

global and other alternative payment methodologies for the payment for healthcare services that

28

the health insurance commissioner shall deem against the interest of public health. The health

29

insurance commissioner shall have no power to impose, encourage, or in any way incentivize any

30

rate caps, global budgets, episode-based payments, or capitation structures in the payment models

31

utilized in contracts between health insurers and providers. Alternative payment methodologies

32

should be assessed for their likelihood to promote damage access to affordable health care health

33

insurance, health outcomes, and performance.

34

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

 

LC005714 - Page 72 of 92

1

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

2

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

3

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

4

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

5

information:

6

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

7

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

8

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

9

insurance for fully insured employers, subject to available resources;

10

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

11

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

12

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

13

Rhode Island mandates exceed other states benefits; and

14

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

15

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

16

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

17

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

18

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

19

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

20

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

21

     (1) Utilization review;

22

     (2) Contracting; and

23

     (3) Licensing and regulation.

24

     (o) On or before February 3, 2015, the office of the health insurance commissioner shall

25

submit a report to the general assembly and the governor that describes, analyzes, and proposes

26

recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard

27

to patients with mental health and substance use disorders.

28

     (p) To work to ensure the health insurance coverage of behavioral health care under the

29

same terms and conditions as other health care, and to integrate behavioral health parity

30

requirements into the office of the health insurance commissioner insurance oversight and health

31

care transformation efforts.

32

     (q) To work with other state agencies to seek delivery system improvements that enhance

33

access to a continuum of mental health and substance use disorder treatment in the state; and

34

integrate that treatment with primary and other medical care to the fullest extent possible.

 

LC005714 - Page 73 of 92

1

     (r) To direct insurers toward policies and practices that address the behavioral health needs

2

of the public and greater integration of physical and behavioral health care delivery.

3

     (s) The office of the health insurance commissioner shall conduct an analysis of the impact

4

of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and

5

submit a report of its findings to the general assembly on or before June 1, 2023.

6

     (t) To approve or deny any compensation of employees of health insurers subject to the

7

laws of the State of Rhode Island in excess of one million dollars ($1,000,000) per employee.

8

     (u) To approve or deny any dividends or stock buybacks of health insurers subject to the

9

laws of the State of Rhode Island.

10

     SECTION 20. Section 44-17-1 of the General Laws in Chapter 44-17 entitled "Taxation of

11

Insurance Companies" is hereby amended to read as follows:

12

     44-17-1. Companies required to file -- Payment of tax -- Retaliatory rates.

13

     (a) Every domestic, foreign, or alien insurance company, mutual association, organization,

14

or other insurer, including any health maintenance organization as defined in § 27-41-2, any

15

medical malpractice insurance joint underwriters association as defined in § 42-14.1-1, any

16

nonprofit dental service corporation as defined in § 27-20.1-2 and any nonprofit hospital or medical

17

service corporation as defined in chapters 19 and 20 of title 27, except companies mentioned in §

18

44-17-6 and organizations defined in § 27-25-1, transacting business in this state, shall, on or before

19

April 15 in each year, file with the tax administrator, in the form that he or she may prescribe, a

20

return under oath or affirmation signed by a duly authorized officer or agent of the company,

21

containing information that may be deemed necessary for the determination of the tax imposed by

22

this chapter, and shall at the same time pay an annual tax to the tax administrator of two percent

23

(2%) three percent (3%) of the gross premiums on contracts of insurance, except for ocean marine

24

insurance as referred to in § 44-17-6, covering property and risks within the state, written during

25

the calendar year ending December 31st next preceding.

26

     (b) Qualifying insurers for purposes of this section means every domestic, foreign, or alien

27

insurance company, mutual association, organization, or other insurer and excludes:

28

     (1) Health maintenance organizations, as defined in § 27-41-2;

29

     (2) Nonprofit dental service corporations, as defined in § 27-20.1-2; and

30

     (3) Nonprofit hospital or medical service corporations, as defined in §§ 27-19-1 and 27-

31

20-1.

32

     (c) For tax years 2018 and thereafter, the rate of taxation may be reduced as set forth below

33

and, if so reduced, shall be fully applicable to qualifying insurers instead of the two percent (2%)

34

rate listed in subsection (a). In the case of foreign or alien companies, except as provided in § 27-

 

LC005714 - Page 74 of 92

1

2-17(d), the tax shall not be less in amount than is imposed by the laws of the state or country under

2

which the companies are organized upon like companies incorporated in this state or upon its

3

agents, if doing business to the same extent in the state or country. The tax rate shall not be reduced

4

for gross premiums written on contracts of health insurance as defined in § 42-14-5(c) but shall

5

remain at two percent (2%) three percent (3%) or the appropriate retaliatory tax rate, whichever is

6

higher.

7

     (d) For qualifying insurers, the premium tax rate may be decreased based upon Rhode

8

Island jobs added by the industry as detailed below:

9

     (1) A committee shall be established for the purpose of implementing tax rates using the

10

framework established herein. The committee shall be comprised of the following persons or their

11

designees: the secretary of commerce, the director of the department of business regulation, the

12

director of the department of revenue, and the director of the office of management and budget. No

13

rule may be issued pursuant to this section without the prior, unanimous approval of the committee;

14

     (2) On the timetable listed below, the committee shall determine whether qualifying

15

insurers have added new qualifying jobs in this state in the preceding calendar year. A qualifying

16

job for purposes of this section is any employee with total annual wages equal to or greater than

17

forty percent (40%) of the average annual wages of the Rhode Island insurance industry, as

18

published by the annual employment and wages report of the Rhode Island department of labor and

19

training, in NAICS code 5241;

20

     (3) If the committee determines that there has been a sufficient net increase in qualifying

21

jobs in the preceding calendar year(s) to offset a material reduction in the premium tax, it shall

22

calculate a reduced premium tax rate. Such rate shall be determined via a method selected by the

23

committee and designed such that the estimated personal income tax generated by the increase in

24

qualifying jobs is at least one hundred and twenty-five percent (125%) of the anticipated reduction

25

in premium tax receipts resulting from the new rate. For purposes of this calculation, the committee

26

may consider personal income tax withholdings or receipts, but in no event may the committee

27

include for the purposes of determining revenue neutrality income taxes that are subject to

28

segregation pursuant to § 44-48.3-8(f) or that are otherwise available to the general fund;

29

     (4) Any reduced rate established pursuant to this section must be established in a

30

rulemaking proceeding pursuant to chapter 35 of title 42, subject to the following conditions:

31

     (i) Any net increase in qualifying jobs and the resultant premium tax reduction and revenue

32

impact shall be determined in any rulemaking proceeding conducted under this section and shall

33

be set forth in a report included in the rulemaking record, which report shall also include a

34

description of the data sources and calculation methods used. The first such report shall also include

 

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1

a calculation of the baseline level of employment of qualifying insurers for the calendar year 2015;

2

and

3

     (ii) Notwithstanding any provision of the law to the contrary, no rule changing the tax rate

4

shall take effect until one hundred and twenty (120) days after notice of the rate change is provided

5

to the speaker of the house, the president of the senate, the house and senate fiscal advisors, and

6

the auditor general, which notice shall include the report required under the preceding provision.

7

     (5) For each of the first three (3) rulemaking proceedings required under this section, the

8

tax rate may remain unchanged or be decreased consistent with the requirements of this section,

9

but may not be increased. These first three (3) rulemaking proceedings shall be conducted by the

10

division of taxation and occur in the following manner:

11

     (i) The first rulemaking proceeding shall take place in calendar year 2017. This proceeding

12

shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the requirements

13

of this section, which rate shall take effect in 2018, and (B) A method for calculating the number

14

of jobs at qualifying insurers;

15

     (ii) The second rulemaking proceeding shall take place in calendar year 2018. This

16

proceeding shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the

17

requirements of this section, which rate shall take effect in 2019, and (B) The changes, if any, to

18

the method for calculating the number of jobs at qualifying insurers; and

19

     (iii) The third rulemaking proceeding shall take place in calendar year 2019. This

20

proceeding shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the

21

requirements of this section, which rate shall take effect in 2020, and (B) The changes, if any, to

22

the method for calculating the number of jobs at qualifying insurers.

23

     (6) The tax rate established in the regulation following regulatory proceedings that take

24

place in 2019 shall remain in effect through and including 2023. In calendar year 2023, the

25

department of business regulation will conduct a rulemaking proceeding and issue a rule that sets

26

forth: (A) A new premium tax rate, if allowed under the requirements of this section, which rate

27

shall take effect in 2024, and (B) The changes, if any, to the method for calculating the number of

28

jobs at qualifying insurers. A rule issued by the department of business regulation may decrease

29

the tax rate if the requirements for a rate reduction contained in this section are met, or it may

30

increase the tax rate to the extent necessary to achieve the overall revenue level sought when the

31

then-existing tax rate was established. Any rate established shall be no lower than one percent (1%)

32

and no higher than two percent (2%). This proceeding shall be repeated every three (3) calendar

33

years thereafter, however, the base for determination of job increases or decreases shall remain the

34

number of jobs existing during calendar year 2022;

 

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1

     (7) No reduction in the premium tax rate pursuant to this section shall be allowed absent a

2

determination that qualifying insurers have added in this state at least three hundred fifty (350)

3

new, full-time, qualifying jobs above the baseline level of employment of qualifying insurers for

4

the calendar year 2015;

5

     (8) Notwithstanding any provision of this section to the contrary, the premium tax rate shall

6

never be set lower than one percent (1%);

7

     (9) The division of taxation may adopt implementation guidelines, directives, criteria, rules

8

and regulations pursuant to chapter 35 of title 42 as are necessary to implement this section; and

9

     (10) The calculation of revenue impacts under this section is at the sole discretion of the

10

committee established under subsection (d)(1). Notwithstanding any provision of law to the

11

contrary, any administrative action or rule setting a tax rate pursuant to this section or failing or

12

declining to alter a tax rate pursuant to this section shall not be subject to judicial review under

13

chapter 35 of title 42.

14

     (d) The department of revenue shall calculate the impacts of changes made to Medicaid

15

taking effect in fiscal year two thousand twenty three (FY2023) on state funds, excluding increased

16

federal reimbursements, hereinafter the "FY23 Medicaid adjustment." Should the Medicaid

17

adjustment exceed the revenue impact of raising the gross premiums tax rate from two percent (2%)

18

to three percent (3%), hereinafter the "insurance premium tax rate adjustment revenue bonus"

19

surtax shall be imposed on gross premiums written on contracts of health insurance as defined in §

20

42-14-5(c) at the rate that shall raise aggregate revenue equal to the Medicaid adjustment minus

21

the insurance premium tax rate adjustment revenue bonus.

22

     SECTION 21. Section 44-51-3 of the General Laws in Chapter 44-51 entitled "Nursing

23

Facility Provider Assessment Act" is hereby amended to read as follows:

24

     44-51-3. Imposition of assessment -- Nursing facilities.

25

     (a) For purposes of this section, a "nursing facility" means a person or governmental unit

26

licensed in accordance with chapter 17 of title 23 to establish, maintain, and operate a nursing

27

facility.

28

     (b) An assessment is imposed upon the gross patient revenue received by every nursing

29

facility in each month beginning January 1, 2008, at a rate of five and one-half percent (5.5%) six

30

percent (6%) for services provided on or after January 1, 2008. Every provider shall pay the

31

monthly assessment no later than the twenty-fifth (25th) day of each month following the month of

32

receipt of gross patient revenue.

33

     (c) The assessment imposed by this section shall be repealed on the effective date of the

34

repeal or a restricted amendment of those provisions of the Medicaid Voluntary Contribution and

 

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1

Provider-Specific Tax Amendments of 1991 (P.L. 102-234) that permit federal financial

2

participation to match state funds generated by taxes.

3

     (d) If, after applying the applicable federal law and/or rules, regulations, or standards

4

relating to health care providers, the tax administrator determines that the assessment rate

5

established in subsection (b) of this section exceeds the maximum rate of assessment that federal

6

law will allow without reduction in federal financial participation, then the tax administrator is

7

directed to reduce the assessment to a rate equal to the maximum rate which the federal law will

8

allow without reduction in federal participation. Provided, however, that the authority of the tax

9

administrator to lower the assessment rate established in subsection (b) of this section shall be

10

limited solely to such determination.

11

     (e) In order that the tax administrator may properly carry out his/her responsibilities under

12

this section, the director of the department of human services shall notify the tax administrator of

13

any damages in federal law and/or any rules, regulations, or standards which affect any rates for

14

health care provider assessments.

15

     SECTION 22. Title 44 of the General Laws entitled "TAXATION" is hereby amended by

16

adding thereto the following chapter:

17

CHAPTER 70

18

PRIVATE HEALTH CARE PROVIDERS ASSESSMENT ACT

19

     44-51-1. Short title.

20

     This chapter shall be known and may be cited as the "Private Health Care Providers

21

Assessment Act."

22

     44-51-2. Definitions.

23

     Except where the context otherwise requires, the following words and phrases as used in

24

this chapter shall have the following meaning:

25

     (1) "Administrator" means the tax administrator.

26

     (2) "Assessment" means the assessment imposed upon gross patient revenue pursuant to

27

this chapter.

28

     (3) "Eligible provider" means a privately operated health care facility, which is eligible for

29

taxation up to six percent (6%) of gross patient revenue pursuant to 42 CFR 433.68. Nursing

30

facilities taxed pursuant to § 44-51-3 and hospital facilities taxed pursuant to § 23-17-38.1 shall not

31

be considered providers subject to taxation under this chapter.

32

     (4) "Gross patient revenue" means the gross amount received on a cash basis by the

33

provider from all patient care services. Charitable contributions, donated goods and services, fund

34

raising proceeds, endowment support, income from meals on wheels, income from investments,

 

LC005714 - Page 78 of 92

1

and other nonpatient revenues defined by the tax administrator upon the recommendation of the

2

department of human services shall not be considered as "gross patient revenue".

3

     (5) "Person" means any individual, corporation, company, association, partnership, joint

4

stock association, and the legal successor thereof.

5

     44-51-3. Imposition of assessment.

6

     (a) An assessment is imposed upon the gross patient revenue received by every eligible

7

provider in each month beginning July 1, 2022, at a rate of six percent (6%) for services provided

8

on or after July 1, 2022. Every eligible provider shall pay the monthly assessment no later than the

9

twenty-fifth day of each month following the month of receipt of gross patient revenue.

10

     (b) The assessment rate established in subsection (a) of this section shall be reduced by the

11

effective rate of any tax subject to the six percent (6%) limit established pursuant to 42 CFR 433.68

12

imposed on the eligible provider in other chapters of the general laws in order that the total

13

aggregate tax shall be at a rate of six percent (6%).

14

     (c) If, after applying the applicable federal law and/or rules, regulations, or standards

15

relating to health care providers, the tax administrator determines that the assessment rate

16

established in subsection (a) of this section exceeds the maximum rate of assessment that federal

17

law will allow without reduction in federal financial participation, then the tax administrator is

18

directed to reduce the assessment to a rate equal to the maximum rate which the federal law will

19

allow without reduction in federal participation. Provided, however, that the authority of the tax

20

administrator to lower the assessment rate established in subsection (a) of this section shall be

21

limited solely to such determination. In order that the tax administrator may properly carry out

22

his/her responsibilities under this section, the director of the department of human services shall

23

notify the tax administrator of any changes in federal law and/or any rules, regulations, or standards

24

which affect any rates for health care provider assessments.

25

     44-51-4. Returns.

26

     (a) Every eligible provider shall on or before the twenty-fifth day of the month following

27

the month of receipt of gross patient revenue make a return to the tax administrator.

28

     (b) The tax administrator shall adopt rules, pursuant to this chapter, relative to the form of

29

the return and the data which it must contain for the correct computation of gross patient revenue

30

and the assessment upon that amount. All returns shall be signed by the eligible provider or by its

31

authorized representative, subject to the pains and penalties of perjury. If a return shows an

32

overpayment of the assessment due, the tax administrator shall refund or credit the overpayment to

33

the eligible provider.

34

     (c) For good cause, the tax administrator may extend the time within which an eligible

 

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1

provider is required to file a return, and if the return is filed during the period of extension, no

2

penalty or late filing charge may be imposed for failure to file the return at the time required by this

3

chapter, but the provider may be liable for interest as prescribed in this chapter. Failure to file the

4

return during the period for the extension shall void the extension.

5

     44-51-5. Set-off for delinquent assessments.

6

     If an eligible provider shall fail to pay an assessment within thirty (30) days of its due date,

7

the tax administrator may request any agency of state government making payments to the eligible

8

provider to set off the amount of the delinquency against any payment due the provider from the

9

agency of state government and remit the sum to the tax administrator. Upon receipt of the set off

10

request from the tax administrator, any agency of state government is authorized and empowered

11

to set off the amount of the delinquency against any payment or amounts due the eligible provider.

12

The amount of set-off shall be credited against the assessment due from the eligible provider.

13

     44-51-6. Assessment on available information -- Interest on delinquencies -- Penalties

14

-- Collection powers.

15

     If any eligible provider shall fail to file a return within the time required by this chapter, or

16

shall file an insufficient or incorrect return, or shall not pay the assessment imposed by this chapter

17

when it is due, the tax administrator shall assess upon the information as may be available, which

18

shall be payable upon demand and shall bear interest at the annual rate provided by § 44-1-7 from

19

the date when the assessment should have been paid. If any part of the assessment made is due to

20

negligence or intentional disregard of the provisions of this chapter, a penalty of ten percent (10%)

21

of the amount of the determination shall be added to the assessment. The tax administrator shall

22

collect the assessment with interest in the same manner and with the same powers as are prescribed

23

for collection of taxes in this title.

24

     44-51-7. Claims for refund -- Hearing upon denial.

25

     (a) Any eligible provider subject to the provisions of this chapter may file a claim for refund

26

with the tax administrator at any time within two (2) years after the assessment has been paid. If

27

the tax administrator shall determine that the assessment has been overpaid, he or she shall make a

28

refund with interest from the date of overpayment.

29

     (b) Any eligible provider whose claim for refund has been denied may, within thirty (30)

30

days from the date of the mailing by the tax administrator of the notice of the decision, request a

31

hearing and the tax administrator shall, as soon as practicable, set a time and place for the hearing

32

and shall notify the eligible provider.

33

     44-51-8. Hearing by administrator on application.

34

     Any eligible provider aggrieved by the action of the tax administrator in determining the

 

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1

amount of any assessment or penalty imposed under the provisions of this chapter may apply to the

2

tax administrator, in writing, within thirty (30) days after the notice of the action is mailed to it, for

3

a hearing relative to the assessment or penalty. The tax administrator shall fix a time and place for

4

the hearing and shall notify the provider. Upon the hearing, the tax administrator shall correct

5

manifest errors, if any, disclosed at the hearing and assess and collect the amount lawfully due

6

together with any penalty or interest.

7

     44-51-9. Appeals.

8

     Appeals from administrative orders or decisions made pursuant to any provisions of this

9

chapter shall be to the sixth division district court pursuant to §§ 8-8-24 through 8-8-29. The eligible

10

provider's right to appeal under this section shall be expressly made conditional upon prepayment

11

of all assessments, interest, and penalties unless the provider moves for and is granted an exemption

12

from the prepayment requirement pursuant to § 8-8-26. If the court, after appeal, holds that the

13

eligible provider is entitled to a refund, the eligible provider shall also be paid interest on the amount

14

at the rate provided in § 44-1-7.1.

15

     44-51-10. Eligible provider records.

16

     Every eligible provider shall:

17

     (1) Keep records as may be necessary to determine the amount of its liability under this

18

chapter.

19

     (2) Preserve those records for the period of three (3) years following the date of filing of

20

any return required by this chapter, or until any litigation or prosecution under this chapter is finally

21

determined.

22

     (3) Make those records available for inspection by the tax administrator or the

23

administrator's authorized agents, upon demand, at reasonable times during regular business hours.

24

     44-51-11. Method of payment and deposit of assessment.

25

     (a) The payments required by this chapter may be made by electronic transfer of monies to

26

the general treasurer and deposited to the general fund.

27

     (b) The general treasurer is authorized to establish an account or accounts and to take all

28

steps necessary to facilitate the electronic transfer of monies. The general treasurer shall provide

29

the tax administrator with a record of any monies transferred and deposited.

30

     44-51-12. Rules and regulations.

31

     The tax administrator shall make and promulgate rules, regulations, and procedures not

32

inconsistent with state law and fiscal procedures as the tax administrator deems necessary for the

33

proper administration of this chapter and to implement the provisions, policy, and purposes of this

34

chapter.

 

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1

     44-51-13. Release of assessment information.

2

     Notwithstanding any other provisions of the general laws, the tax administrator shall not

3

be prohibited from providing assessment information to the director of the department of human

4

services or his or her designee, with respect to the assessment imposed by this chapter; provided

5

that, the director of human services and the director's agents and employees may use or disclose

6

that information only for purposes directly connected with the administration of the duties and

7

programs of the department of human services.

8

     44-51-14. Severability.

9

     If any provision of this chapter or the application of this chapter to any person or

10

circumstances is held invalid, that invalidity shall not affect other provisions or applications of the

11

chapter which can be given effect without the invalid provision or application, and to this end the

12

provisions of this chapter are declared to be severable.

13

     SECTION 23. Relating To Capital Development Programs - Statewide Referendum.

14

     Section 1. Proposition to be submitted to the people. -- At the general election to be held

15

on the Tuesday next after the first Monday in November, 2022, there shall be submitted to the

16

people of the State of Rhode Island, for their approval or rejection, the following proposition:

17

     "Shall the action of the general assembly, by an act passed at the January 2022 session,

18

authorizing the issuance of a bond, refunding bond, and/or temporary note of the State of Rhode

19

Island for the local capital projects and in the total amount with respect to the projects listed below

20

be approved, and the issuance of a bond, refunding bond, and/or temporary note authorized in

21

accordance with the provisions of said act?

22

     Funding

23

     The bond, refunding bond and/or temporary note shall be allocated to the Medicaid office

24

for oversight of the funds.

25

     Project

26

     (1) Group homes, assisted living facilities, and recovery beds $300,000,000

27

     Approval of this question will allow the State of Rhode Island to issue general obligation

28

bonds, refunding bonds, and/or temporary notes in an amount not to exceed three hundred million

29

dollars ($300,000,000) for expansion of and investment in Rhode Island Community Living and

30

Supports. One hundred million dollars ($100,000,000) shall be allocated for investment in and

31

expansion of state group homes operated by Rhode Island Community Living and Supports. One

32

hundred million dollars ($100,000,000) shall be allocated for the construction of assisted living-

33

level care facilities for people with mental illnesses and developmental disabilities operated by

34

Rhode Island Community Living and Supports for persons who are eligible for Medicaid. One

 

LC005714 - Page 82 of 92

1

hundred million dollars ($100,000,000) shall be allocated for the construction of inpatient recovery

2

facilities operated by Rhode Island Community Living and Supports for persons who are eligible

3

for Medicaid and suffering from substance abuse issues in need of inpatient recovery services.

4

None of these funds may be allocated to private facilities.

5

     (2) Hospital facilities expansion $50,000,000

6

     Approval of this question will allow the State of Rhode Island to issue general obligation

7

bonds, refunding bonds, and/or temporary notes in an amount not to exceed fifty million dollars

8

($50,000,000) for the improvement of state operated hospital facilities.

9

     (3) University of Rhode Island Medical School $500,000,000

10

     Approval of this question will allow the State of Rhode Island to issue a general obligation

11

bond, refunding bond, and/or temporary note in an amount not to exceed five hundred million

12

dollars ($500,000,000) for the construction of a medical school at the University of Rhode Island.

13

The Medicaid office shall work with the University of Rhode Island Medical School to establish a

14

reasonable annual contribution to fund the debt service on this bond from tuition revenue. While

15

these contributions shall continue until the entire debt service costs are paid, the Medicaid office

16

may allow for an amortization schedule that lasts for up to fifty (50) years.

17

     Section 2. Ballot labels and applicability of general election laws. -- The secretary of state

18

shall prepare and deliver to the state board of elections ballot labels for each of the projects provided

19

for in Section 1 hereof with the designations "approve" or "reject" provided next to the description

20

of each such project to enable voters to approve or reject each such proposition. The general

21

election laws, so far as consistent herewith, shall apply to this proposition.

22

     Section 3. Approval of projects by people. -- If a majority of the people voting on the

23

proposition in Section 1 hereof shall vote to approve any project stated therein, said project shall

24

be deemed to be approved by the people. The authority to issue bonds, refunding bonds and/or

25

temporary notes of the state shall be limited to the aggregate amount for all such projects as set

26

forth in the proposition, which have been approved by the people.

27

     Section 4. Bonds for capital development program. -- The general treasurer is hereby

28

authorized and empowered, with the approval of the governor, and in accordance with the

29

provisions of this act to issue capital development bonds in serial form, in the name of and on behalf

30

of the State of Rhode Island, in amounts as may be specified by the governor in an aggregate

31

principal amount not to exceed the total amount for all projects approved by the people and

32

designated as "capital development loan of 2023 bonds." Provided, however, that the aggregate

33

principal amount of such capital development bonds and of any temporary notes outstanding at any

34

one time issued in anticipation thereof pursuant to Section 7 hereof shall not exceed the total amount

 

LC005714 - Page 83 of 92

1

for all such projects approved by the people. All provisions in this act relating to "bonds" shall also

2

be deemed to apply to "refunding bonds."

3

     Capital development bonds issued under this act shall be in denominations of one thousand

4

dollars ($1,000) each, or multiples thereof, and shall be payable in any coin or currency of the

5

United States which at the time of payment shall be legal tender for public and private debts.

6

     These capital development bonds shall bear such date or dates, mature at specified time or

7

times, but not mature beyond the end of the twentieth state fiscal year following the fiscal year in

8

which they are issued; bear interest payable semi-annually at a specified rate or different or varying

9

rates; be payable at designated time or times at specified place or places; be subject to express terms

10

of redemption or recall, with or without premium; be in a form, with or without interest coupons

11

attached; carry such registration, conversion, reconversion, transfer, debt retirement, acceleration

12

and other provisions as may be fixed by the general treasurer, with the approval of the governor,

13

upon each issue of such capital development bonds at the time of each issue. Whenever the

14

governor shall approve the issuance of such capital development bonds, the governor's approval

15

shall be certified to the secretary of state; the bonds shall be signed by the general treasurer and

16

countersigned by the secretary of state and shall bear the seal of the state. The signature approval

17

of the governor shall be endorsed on each bond.

18

     Section 5. Refunding bonds for 2023 capital development program. -- The general treasurer

19

is hereby authorized and empowered, with the approval of the governor, and in accordance with

20

the provisions of this act, to issue bonds to refund the 2023 capital development program bonds, in

21

the name of and on behalf of the state, in amounts as may be specified by the governor in an

22

aggregate principal amount not to exceed the total amount approved by the people, to be designated

23

as "capital development program loan of 2023 refunding bonds" (hereinafter "refunding bonds").

24

The general treasurer with the approval of the governor shall fix the terms and form of any

25

refunding bonds issued under this act in the same manner as the capital development bonds issued

26

under this act, except that the refunding bonds may not mature more than twenty (20) years from

27

the date of original issue of the capital development bonds being refunded. The proceeds of the

28

refunding bonds, exclusive of any premium and accrual interest and net the underwriters' cost, and

29

cost of bond insurance, shall, upon their receipt, be paid by the general treasurer immediately to

30

the paying agent for the capital development bonds which are to be called and prepaid. The paying

31

agent shall hold the refunding bond proceeds in trust until they are applied to prepay the capital

32

development bonds. While the proceeds are held in trust, the proceeds may be invested for the

33

benefit of the state in obligations of the United States of America or the State of Rhode Island.

34

     If the general treasurer shall deposit with the paying agent for the capital development

 

LC005714 - Page 84 of 92

1

bonds the proceeds of the refunding bonds, or proceeds from other sources, amounts that, when

2

invested in obligations of the United States or the State of Rhode Island, are sufficient to pay all

3

principal, interest, and premium, if any, on the capital development bonds until these bonds are

4

called for prepayment, then such capital development bonds shall not be considered debts of the

5

State of Rhode Island for any purpose starting from the date of deposit of such monies with the

6

paying agent. The refunding bonds shall continue to be a debt of the state until paid.

7

     The term "bond" shall include "note," and the term "refunding bonds" shall include

8

"refunding notes" when used in this act.

9

     Section 6. Proceeds of capital development program. -- The general treasurer is directed to

10

deposit the proceeds from the sale of capital development bonds issued under this act, exclusive of

11

premiums and accrued interest and net the underwriters' cost, and cost of bond insurance, in one or

12

more of the depositories in which the funds of the state may be lawfully kept in special accounts

13

(hereinafter cumulatively referred to as "such capital development bond fund") appropriately

14

designated for each of the projects set forth in Section 1 hereof which shall have been approved by

15

the people to be used for the purpose of paying the cost of all such projects so approved.

16

     All monies in the capital development bond fund shall be expended for the purposes

17

specified in the proposition provided for in Section 1 hereof under the direction and supervision of

18

the director of administration (hereinafter referred to as "director"). The director, or designee, shall

19

be vested with all power and authority necessary or incidental to the purposes of this act, including,

20

but not limited to, the following authority:

21

     (1) To acquire land or other real property or any interest, estate, or right therein as may be

22

necessary or advantageous to accomplish the purposes of this act;

23

     (2) To direct payment for the preparation of any reports, plans and specifications, and

24

relocation expenses and other costs such as for furnishings, equipment designing, inspecting, and

25

engineering, required in connection with the implementation of any projects set forth in Section 1

26

hereof;

27

     (3) To direct payment for the costs of construction, rehabilitation, enlargement, provision

28

of service utilities, and razing of facilities, and other improvements to land in connection with the

29

implementation of any projects set forth in Section 1 hereof; and

30

     (4) To direct payment for the cost of equipment, supplies, devices, materials, and labor for

31

repair, renovation, or conversion of systems and structures as necessary for the 2023 capital

32

development program bonds or notes hereunder from the proceeds thereof. No funds shall be

33

expended in excess of the amount of the capital development bond fund designated for each project

34

authorized in Section 1 hereof.

 

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1

     Section 7. Sale of bonds and notes. --Any bonds or notes issued under the authority of this

2

act shall be sold at not less than the principal amount thereof, in such mode and on such terms and

3

conditions as the general treasurer, with the approval of the governor, shall deem to be in the best

4

interests of the state.

5

     Any bonds or notes issued under the provisions of this act and coupons on any capital

6

development bonds, if properly executed by the manual or electronic signatures of officers of the

7

state in office on the date of execution, shall be valid and binding according. to their tenor,

8

notwithstanding that before the delivery thereof and payment therefor, any or all such officers shall

9

for any reason have ceased to hold office.

10

     Section 8. Bonds and notes to be tax exempt and general obligations of the state. -- All

11

bonds and notes issued under the authority of this act shall be exempt from taxation in the state and

12

shall be general obligations of the state, and the full faith and credit of the state is hereby pledged

13

for the due payment of the principal and interest on each of such bonds and notes as the same shall

14

become due.

15

     Section 9. Investment of monies in fund. -- All monies in the capital development fund not

16

immediately required for payment pursuant to the provisions of this act may be invested by the

17

investment commission, as established by chapter 10 of title 35, entitled "state investment

18

commission," pursuant to the provisions of such chapter; provided, however, that the securities in

19

which the capital development fund is invested shall remain a part of the capital development fund

20

until exchanged for other securities; and provided further, that the income from investments of the

21

capital development fund shall become a part of the general fund of the state and shall be applied

22

to the payment of debt service charges of the state, unless directed by federal law or regulation to

23

be used for some other purpose, or to the extent necessary, to rebate to the United States treasury

24

any income from investments (including gains from the disposition of investments) of proceeds of

25

bonds or notes to the extent deemed necessary to exempt (in whole or in part) the interest paid on

26

such bonds or notes from federal income taxation.

27

     Section 10. Appropriation. -- To the extent the debt service on these bonds is not otherwise

28

provided, a sum sufficient to pay the interest and principal due each year on bonds and notes

29

hereunder is hereby annually appropriated out of any money in the treasury not otherwise

30

appropriated.

31

     Section 11. Advances from general fund. -- The general treasurer is authorized, with the

32

approval of the director and the governor, in anticipation of the issuance of bonds or notes under

33

the authority of this act, to advance to the capital development bond fund for the purposes specified

34

in Section 1 hereof, any funds of the state not specifically held for any particular purpose; provided,

 

LC005714 - Page 86 of 92

1

however, that all advances made to the capital development bond fund shall be returned to the

2

general fund from the capital development bond fund forthwith upon the receipt by the capital

3

development fund of proceeds resulting from the issue of bonds or notes to the extent of such

4

advances.

5

     Section 12. Federal assistance and private funds. -- In carrying out this act, the director, or

6

designee, is authorized on behalf of the state, with the approval of the governor, to apply for and

7

accept any federal assistance which may become available for the purpose of this act, whether in

8

the form of a loan or grant or otherwise, to accept the provision of any federal legislation therefor,

9

to enter into, act and carry out contracts in connection therewith, to act as agent for the federal

10

government in connection therewith, or to designate a subordinate so to act. Where federal

11

assistance is made available, the project shall be carried out in accordance with applicable federal

12

law, the rules and regulations thereunder and the contract or contracts providing for federal

13

assistance, notwithstanding any contrary provisions of state law. Subject to the foregoing, any

14

federal funds received for the purposes of this act shall be deposited in the capital development

15

bond fund and expended as a part thereof. The director or designee may also utilize any private

16

funds that may be made available for the purposes of this act.

17

     Section 13. Effective Date. -- Sections 1, 2, 3, 11, 12 and 13 of this act shall take effect

18

upon passage. The remaining sections of this act shall take effect when and if the state board of

19

elections shall certify to the secretary of state that a majority of the qualified electors voting on the

20

proposition contained in Section 1 hereof have indicated their approval of all or any projects

21

thereunder.

22

     SECTION 24. Rhode Island Medicaid Reform Act of 2008 Joint Resolution.

23

     WHEREAS, The General Assembly enacted chapter 12.4 of title 42 entitled "The Rhode

24

Island Medicaid Reform Act of 2008"; and

25

     WHEREAS, A legislative enactment is required pursuant to Rhode Island General Laws

26

chapter 12.4 of title 42; and

27

     WHEREAS, Rhode Island General Laws § 42-7.2-5(3)(i) provides that the Secretary of the

28

Executive Office of Health and Human Services ("Executive Office") is responsible for the review

29

and coordination of any Medicaid section 1115 demonstration waiver requests and renewals as well

30

as any initiatives and proposals requiring amendments to the Medicaid state plan or category II or

31

III changes as described in the demonstration, "with potential to affect the scope, amount, or

32

duration of publicly-funded health care services, provider payments or reimbursements, or access

33

to or the availability of benefits and services provided by Rhode Island general and public laws";

34

and

 

LC005714 - Page 87 of 92

1

     WHEREAS, In pursuit of a more cost-effective consumer choice system of care that is

2

fiscally sound and sustainable, the Secretary requests legislative approval of the following

3

proposals to amend the demonstration; and

4

     WHEREAS, Implementation of adjustments may require amendments to Rhode Island's

5

Medicaid state plan and/or section 1115 waiver under the terms and conditions of the

6

demonstration. Further, adoption of new or amended rules, regulations and procedures may also be

7

required:

8

     (a) Section 1115 Demonstration Waiver – Extension Request. The Executive Office

9

proposes to seek approval from the federal Centers for Medicare and Medicaid Services ("CMS")

10

to extend the Medicaid section 1115 demonstration waiver as authorized in Rhode Island General

11

Laws Chapter 12.4 of Title 42. In the Medicaid section 1115 demonstration waiver extension

12

request due to CMS by December 31, 2022, in addition to maintaining existing Medicaid section

13

1115 demonstration waiver authorities, the Executive Office proposes to seek additional federal

14

authorities including, but not limited to, promoting choice and community integration.

15

     (b) Raising Hospital Licensing Fee. The Executive Office proposes raising the hospital

16

licensing fee to six percent (6%) and eliminating the reduced rate in Washington County.

17

     (c) Raising Nursing Facility Personal Needs Allowance. The Executive Office proposes

18

raising the personal needs allowance for nursing facility residents to two hundred dollars ($200).

19

     (d) Medicare Equivalent Rate. The Executive Office proposes raising all Medicaid rates,

20

except for hospital rates, nursing home rates, dental rates, and outpatient behavioral health rates to

21

equal the Medicare equivalent rate. Specific to early intervention services, a fifty dollars ($50.00)

22

per member per month payment shall be established in addition to these rates, and a floor of a fifty

23

percent (50%) rate increase shall be established within the calculation of the Medicare equivalent

24

rate.

25

     (e) Setting Outpatient Behavioral Healthcare Rates at one hundred fifty percent (150%) of

26

Medicare Equivalent Rates. The Executive Office proposes to set outpatient behavioral health rates

27

at one hundred fifty percent (150%) of the Medicare equivalent rate. The Executive Office will

28

maximize federal financial participation if and when available, though state-only funds will be used

29

if federal financial participation is not available.

30

     (f) Establishing a Nursing Facility Upper Payment Limit Payment. The Executive Office

31

proposes to establish an upper payment limit payment for nursing facilities.

32

     (g) FQHC APM Modernization. The Executive Office proposes certain modifications to

33

modernize and standardize the alternative payment methodology option for federally qualified

34

health centers.

 

LC005714 - Page 88 of 92

1

     (h) Hospital Payment Modernization. The Executive Office proposes certain changes to

2

hospital payment rates to modernize payment methodologies to encourage utilization and quality.

3

Inpatient FFS DRG rates will be set at ninety percent (90%) of the Medicare equivalent rate,

4

inpatient non-DRG FFS rates will be established at ninety-five percent (95%) of the Medicare

5

equivalent rate, inpatient managed care rates will be set at one hundred five percent (105%) of FFS

6

rates, and outpatient rates will be set at one hundred percent (100%) of Medicare rates.

7

     (i) RIteShare Freedom of Choice. The Executive Office proposes to make employee

8

participation in the RIteShare program voluntary.

9

     (j) Elderly and Disabled Eligibility Expansion. The Executive Office proposes expanding

10

Medicaid eligibility for elderly and disabled residents to one hundred thirty-three percent (133%)

11

of the federal poverty level.

12

     (k) Payments Streamlining. The Executive Office proposes a multifaceted initiative to

13

begin the phase-out of intermediary payers such as managed care entities, streamlining payments

14

and reducing wasteful expenditures on intermediary payers.

15

     (l) Medicaid Office Expansion. The Executive Office proposes an expansion of Medicaid

16

office staffing to improve administrative capacities.

17

     (m) COVID-19 Adjustments to Health System Transformation Project. The Executive

18

Office proposes to eliminate the imposition of downside risk as part of the Health System

19

Transformation Project to protect the solvency of providers in light of the COVID-19 pandemic.

20

     (n) Rhode Island Institute for Mental Disease. The Executive Office proposes to construct

21

a new Institution for Mental Disease (IMD) to serve vulnerable Rhode Island residents. The

22

Executive Office seeks a waiver of the IMD exclusion rule similar to that granted to Vermont to

23

allow federal Medicaid reimbursement.

24

     (o) Extend Post-Partum Medicaid Coverage. The Executive Office proposes extending the

25

continuous coverage of full benefit medical assistance from sixty (60) days to twelve (12) months

26

postpartum to women who are: (1) Not eligible for Medicaid under another Medicaid eligibility

27

category; or (2) Do not have qualified immigrant status for Medicaid whose births are financed by

28

Medicaid through coverage of the child and currently only receive state-only extended family

29

planning benefits postpartum.

30

     (p) Extending Medical Coverage to Residents Previously Ineligible. The Executive Office

31

proposes to expand access to Medicaid to all residents without regard to immigration status. The

32

Executive Office will maximize federal financial participation if and when available, though state-

33

only funds will be used if federal financial participation is not available.

34

     (q) Raising Nursing Facility Assessment Rate. The Executive Office proposes to raise the

 

LC005714 - Page 89 of 92

1

nursing facility assessment rate to six percent (6%).

2

     (r) Universal Provider Assessment. Consistent with overall goals of transitioning all

3

services to a model where rates are at the Medicare equivalent rate, the Executive Office proposes

4

to extend the existing nursing facility assessment model to cover all providers eligible for taxation

5

under federal regulations to help defray the costs of the state component.

6

     (s) Dental Optimization. The Executive Office proposes to make an array of changes to

7

dental benefits offered under Medicaid. Rates will be pegged to the rates utilized in Massachusetts;

8

billing will be extended to teledentistry services, Silver Diamine Fluoride (code D1354), and

9

denture billing (codes D5130, D5140, D5221, D5222, D5213, and D5214); the mobile dentistry

10

encounter rate will be raised to the FQHC rate; and a fifty percent (50%) payment shall be

11

established for undeliverable dentures.

12

     (t) Commencement of Inpatient Substance Use Disorder Recovery Bed Federal Billing.

13

The Executive Office proposes to utilize the IMD waiver authority granted in 2019 to begin federal

14

reimbursement billing for inpatient substance use disorder recovery beds, a service that will also

15

see a rate increase pursuant to subsection (d). The Executive Office also proposes a general

16

obligation bond referendum to fund the necessary capital expenditures associated with the

17

expansion of RICLAS to inpatient substance use disorder recovery services.

18

     (u) Coverage of Abortion Services. The Executive Office proposes to end the exclusion of

19

abortion care from covered Medicaid services. The Executive Office will maximize federal

20

financial participation if and when available, though state-only funds will be used if federal

21

financial participation is not available.

22

     (v) Transition to State-Level Medicare for All. The Executive Office proposes to begin the

23

process of negotiating the necessary waivers for a transition to a state-level Medicare for All health

24

care payments system for Rhode Island. These waivers shall include the combining of all federal

25

health care funding streams into the system financing including, but not limited to, Medicaid,

26

Medicare, federal health care tax exemptions, and exchange subsides established pursuant to the

27

U.S. Patient Protection and Affordable Care Act of 2010. The Executive Office plans to begin the

28

transition process after the completion of the raising of the Medicaid system to a Medicare standard

29

of care and the associated stabilization of the Rhode Island health care workforce and provider

30

network; provided, however, that the Executive Office, understanding the complexity of the

31

proposed waiver application, reserves the right to begin the waiver negotiation process before the

32

transition of Medicaid to a Medicare standard is complete. The Executive Office shall only proceed

33

with the waiver and transition should waiver conditions be favorable to the state as a whole, in the

34

judgment of the Executive Office. In the event that a full waiver cannot be complete, and health

 

LC005714 - Page 90 of 92

1

insurers have been acquired by the Medicaid Office due to insolvency and the Medicaid Office's

2

goal of payer system stabilization, the Executive Office is empowered to seek limited waivers for

3

the streamlining and integration of acquired health insurers with the Medicaid system. The

4

Executive Office shall submit the final approved waiver and transition plan to the general assembly

5

for final approval.

6

     (w) Federal Financing Opportunities. The Executive Office proposes to review Medicaid

7

requirements and opportunities under the U.S. Patient Protection and Affordable Care Act of 2010

8

(PPACA) and various other recently enacted federal laws and pursue any changes in the Rhode

9

Island Medicaid program that promote service quality, access and cost-effectiveness that may

10

warrant a Medicaid state plan amendment or amendment under the terms and conditions of Rhode

11

Island's section 1115 waiver, its successor, or any extension thereof. Any such actions by the

12

Executive Office shall not have an adverse impact on beneficiaries.

13

     Now, therefore, be it:

14

     RESOLVED, That the General Assembly hereby approves the proposals stated above in

15

the recitals; and be it further;

16

     RESOLVED, That the Secretary of the Executive Office of Health and Human Services is

17

authorized to pursue and implement any waiver amendments, state plan amendments, and/or

18

changes to the applicable department's rules, regulations and procedures approved herein and as

19

authorized by chapter 12.4 of title 42; and be it further;

20

     RESOLVED, That this Joint Resolution shall take effect upon passage.

21

     SECTION 25. This act shall take effect upon passage; however, the RICHIP program shall

22

not come into operation until the necessary waivers are obtained, and the final financing proposal

23

is approved by the general assembly.

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LC005714 - Page 91 of 92

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HEALTH AND SAFETY -- COMPREHENSIVE HEALTH INSURANCE

PROGRAM

***

1

     This act would establish a universal, comprehensive, affordable single-payer health care

2

insurance program and help control health care costs, which would be referred to as, "the Rhode

3

Island Comprehensive Health Insurance Program" (RICHIP). The program would be paid for by

4

consolidating government and private payments to multiple insurance carriers into a more

5

economical and efficient improved Medicare-for-all style single-payer program and substituting

6

lower progressive taxes for higher health insurance premiums, co-pays, deductibles and costs due

7

to caps. This program would save Rhode Islanders from the current overly expensive, inefficient

8

and unsustainable multi-payer health insurance system that unnecessarily prevents access to

9

medically necessary health care.

10

     This act would take effect upon passage; however, the RICHIP program would not come

11

into operation until the necessary waivers are obtained, and the final financing proposal is approved

12

by the general assembly.

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LC005714 - Page 92 of 92