ARTICLE 23 SUBSTITUTE A AS AMENDED
RELATING TO
MEDICAL ASSISTANCE
SECTION
1. Section 40-8-19 of the General Laws in Chapter 40-8 entitled “Medical
Assistance” is hereby
amended to read as follows:
40-8-19.
Rates of payment to nursing facilities. -- (a) Rate reform. (1)
The rates to be
paid by the state to nursing facilities licensed
pursuant to chapter 17 of title 23, and certified to
participate in the Title XIX Medicaid program for
services rendered to Medicaid-eligible
residents, shall be reasonable and adequate to meet
the costs which must be incurred by
efficiently and economically operated facilities in
accordance with 42 U.S.C. § 1396a(a)(13). The
department of human services shall promulgate or
modify the principles of reimbursement for
nursing facilities currently in effect on July 1, 2003
to be consistent with the provisions of this
section and Title XIX, 42 U.S.C. § 1396 et seq., of
the Social Security Act.
(2) The department of
human services shall review the current methodology for providing
Medicaid payments to nursing facilities, including
other long-term care services providers, and is
authorized to modify the principles of reimbursement
to provide for an acuity based rate
adjustment to nursing facilities. The department of
human services is authorized to implement
changes to the payment structure for the purpose of
basing compensation for Medicaid services to
nursing facilities and long term care service
providers for services which shall be based upon
performance, quality, and the scope and the intensity
of the services required by the provider to
meet the Medicaid recipient’s level of care needs. The
acuity based rate adjustment shall take
effect on January 15, 2010, provided the Department of
Human Services has held public hearings
and submitted the final implementation plan to the
Chairpersons of the House and Senate Finance
Committees no later than December 1, 2009.
(b)
Rate reform. Subject to the phase-in provisions in subsections (c) and (d), the
department shall, on or before October 1, 2005, modify
the principles of reimbursement for
nursing facilities to include the following elements:
(1)
Annual base years;
(2)
Four (4) cost centers: direct labor, property, other operating, and pass
through items;
(3)
Re-array of costs of all facilities in the labor and other operating cost
centers every
three (3) years beginning with calendar year 2002;
(4) A
ceiling maximum for allowable costs in the direct labor cost center to be
established by the department between one hundred ten
percent (110%) and one hundred twenty-
five percent (125%) of the median for all facilities
for the most recent array year.
(5) A
ceiling maximum for allowable costs in the other operating cost center to be
established by the department between ninety percent
(90%) and one hundred fifteen percent
(115%) of the median for all facilities for the most
recent array year;
(6)
Adjustment of costs and ceiling maximums by the increase in the National
Nursing
Home Price Index ("NNHPI") for the direct
labor cost center and the other operating cost center
for year between array years; such adjustments to be
applied on October 1st of each year
beginning October 1, 2003 for the direct labor cost
center and October 1, 2005 for the other
operating cost center, except for the fiscal year
beginning July 1, 2006 for which the price index
shall be applied on February 1, 2007 and for the
fiscal year beginning October 1, 2007 for which
the adjustment of costs and ceiling maximums shall be
one and one-tenth percent (1.1%). For the
fiscal year beginning July 1, 2008, the price index
shall be applied on April 1, 2009.
(7)
Application of a fair rental value system to be developed by the department for
calculating allowable reimbursement for the property
cost center;
(8)
Such quality of care and cost containment incentives as may be established by
departmental regulations.
(c)
Phase I Implementation. The department shall file a state plan amendment with
the
U.S. Department of Health and Human Services on or
before August 1, 2003 to modify the
principles of reimbursement for nursing facilities, to
be effective on October 1, 2003, or as soon
thereafter as is authorized by an approved state plan
amendment, to establish the direct labor cost
center and the pass through items cost center
utilizing calendar year 2002 cost data, and to apply
the ceiling maximums in subsections (b)(4) and (b)(5).
Nursing facilities whose allowable 2002
direct labor costs are below the median in the direct
labor cost center may make application to the
department for a direct labor cost interim payment
adjustment equal to twenty-five percent (25%)
of the amount such allowable 2002 direct labor costs
are below the median in the direct labor cost
center, provided that the interim payment adjustment
granted by the department on or after
October 1, 2003 must be expended by the facility on
expenses allowable within the direct labor
cost center, and any portion of the interim payment
not expended on allowable direct labor cost
center expenses shall be subject to retroactive
adjustment and recoupment by the department
upon the department's determination of a final direct
labor payment adjustment after review of the
facility's actual direct labor expenditures. The final
direct labor payment adjustment will be
included in the facility's October 1, 2004 rate until
the facility's next base year.
(d)
Phase II Implementation. The department shall file a state plan amendment with
the
U.S. Department of Health and Human Services to modify
the principles of reimbursement for
nursing facilities, to be effective on September 1,
2004, or as soon thereafter as is authorized by
an approved state plan amendment, to establish a fair
rental value system for calculating
allowable reimbursement for the property cost center
in accordance with subsection (b)(7);
provided, however, that no facility shall receive a
payment as of September 1, 2004 for property-
related expenses pursuant to the fair rental value
system that is less than the property-related
payment they would have received for the other
property-related ("OPR") cost center system in
effect as of June 30, 2004.
SECTION
2. Section 40-8-29 of the General Laws in Chapter 40-8 entitled “Medical
Assistance” is hereby
amended to read as follows:
40-8-29. Selective
contracting. -- (a) Notwithstanding any other provision of state law,
the department of human services is authorized to
utilize selective contracting with prior general
assembly approval for the purpose of purchasing for
Medicaid recipients shared living provider
services, durable medical equipment and supplies, and
any other Medicaid services, when
appropriate, in order to assure that all service expenditures under this
chapter have the maximum
benefit of competition, and afford Rhode Islanders the
overall best value, optimal quality, and the
most cost-effective care possible. Beneficiaries
will be limited to using the services/products of
only those providers determined in a competitive
bidding process to meet the standards for best
quality, performance and price set by the department
in accordance with applicable federal and
state laws.
(b) Any approved
medical assistance provider who declines to participate in contracting
for benefits in any one of the department's medical
assistance programs, including, but not limited
to any and all managed care programs, may be suspended
as a participating provider and denied
participation in all state operated medical assistance
programs at the discretion of the department.
(b) For purposes of
this section "selective contracting" shall mean the process for
choosing providers to serve Medicaid beneficiaries
based on their ability to deliver the best
quality products or services, at the best value or
price.
(c) To ensure all
services allowable for Medicare reimbursement for beneficiaries who
are dually eligible, selective contractors must be
willing and able to accept Medicare.
SECTION
3. Section 40-8-1 of the General Laws in Chapter 40-8 entitled “Medical
Assistance” is hereby
amended to read as follows:
40-8-1. Declaration
of policy. -- (a) Whereas, in the state of
many persons who do not have sufficient income and
resources to meet the cost of medical care
and who, except for income and resource requirements,
would be eligible for aid or assistance
under § 40-5.1-9 or § 40-6-27; and
(b)
Whereas, it is in the best interest of all the citizens of this state to
promote the
welfare of persons with the characteristics of persons
eligible to receive public assistance and
ensure that they will receive adequate medical care
and treatment in time of need;
(c)
Now, therefore, it is declared to be the policy of this state to provide
medical
assistance for those persons in this state who possess
the characteristics of persons receiving
public assistance under the provisions of § 40-5.1-9
or § 40-6-27, and who do not have the
income and resources to provide it for themselves or
who can do so only at great financial
sacrifice. Provided, further, that such medical
assistance, must qualify for federal financial
participation pursuant to the provisions of Title XIX
of the federal Social Security Act, 42 U.S.C.
§ 1396 et seq., as such provisions apply to medically
needy only applicants and recipients.
(d)
Medical assistance shall be provided under this chapter without regard to the
availability of federal financial participation: (1)
to a person who does not meet the citizenship or
alienage criteria under Title XIX of the Social
Security Act, 42 U.S.C. § 1396 et seq., and who
was lawfully residing in the
state prior to July 1, 1997; and provided, however,
that such person meets all other eligibility
requirements under this chapter or under Title XIX or
Title XXI of the Social Security Act.
(e) Medical
assistance shall also be provided under this chapter to a non citizen child
who was lawfully admitted for permanent residence on
or after August 22, 1996 or who first
becomes otherwise entitled to reside in the
however, that such person meets all other eligibility
requirements under this chapter or under
Title XIX or Title XXI of the Social Security Act.
SECTION 4. Sections 40-8.4-2, 40-8.4-4, and 40-8.4-12 of the General Laws in
Chapter 40-8.4 entitled
“Health Care for Families” are hereby amended to read as follows:
40-8.4-2. Purpose.
-- It is the intent of the general assembly to continue to meet the
goal
established in 1993 pursuant to § 42-12.3-1 to assure
access to comprehensive health care by
providing or creating access to health insurance to
all Rhode Islanders who are uninsured. Over
the course of several years, health insurance through
the RIte Care program has been extended to
pregnant women and children living in families whose
income is less than two hundred fifty
percent (250%) of the federal poverty level. Many of
the parents of these children are uninsured
and without the means to purchase health insurance.
Federal funds are available to help pay for
health insurance for low-income families through the
medical assistance program under § 1931 of
Title XIX of the Social Security Act, 42 U.S.C. §
1396u-1, which de-links medical assistance
from cash assistance and allows for expanded income
and resource methodologies. It is the intent
of the general assembly, therefore, to implement §
1931 of Title XIX of the Social Security Act
and in addition to provide expanded access to health
insurance for eligible families. Federal funds
for some children and their parents pregnant
women may also be available under Title XXI of the
Social Security Act, 42 U.S.C. § 1397 aa et seq., and
it is further the intent of the general
assembly to access these funds as appropriate and
as authorized in accordance with the legal
authority provided by the Children’s Health Insurance
Program Reauthorization Act of 2009
(CHIPRA), and Title XXI of the Social Security Act, 42
U.S.C. § 1397 et seq.
40-8.4-4. Eligibility.
-- (a) Medical assistance for families. There is hereby established a
category of medical assistance eligibility pursuant to
§ 1931 of Title XIX of the Social Security
Act, 42 U.S.C. § 1396u-1, for families whose income
and resources are no greater than the
standards in effect in the aid to families with
dependent children program on July 16, 1996 or
such increased standards as the department may determine.
The department of human services is
directed to amend the medical assistance Title XIX
state plan and to submit to the
Department of Health and Human Services an amendment
to the RIte Care waiver project to
provide for medical assistance coverage to families
under this chapter in the same amount, scope
and duration as coverage provided to comparable groups
under the waiver. The department is
further authorized and directed to submit such
amendments and/or requests for waivers to the
Title XXI state plan as may be necessary to maximize
federal contribution for provision of
medical assistance coverage under this chapter provided
pursuant to this chapter, including
providing medical coverage as a “qualified state” in
accordance with Title XXI of the Social
Security Act, 42 U.S.C. § 1397 et seq. However, implementation Implementation
of expanded
coverage under this chapter shall not be delayed
pending federal review of any Title XXI
amendment or waiver.
(b) Income. The director
of the department of human services is authorized and directed
to amend the medical assistance Title XIX state plan
or RIte Care waiver to provide medical
assistance coverage through expanded income disregards
or other methodology for parents or
relative caretakers whose income levels are below one
hundred seventy-five percent (175%) of
the federal poverty level.
(c) Waiver. The
department of human services is authorized and directed to apply for and
obtain appropriate waivers from the Secretary of the
U.S. Department of Health and Human
Services, including, but not limited to, a waiver of
the appropriate provisions of Title XIX, to
require that individuals with incomes equal to or
greater than one hundred thirty-three percent
(133%) one
hundred fifty percent (150%) of the federal poverty level pay a share of
the costs of
their medical assistance coverage provided through
enrollment in either the RIte Care Program or
under the premium assistance program under §
40-8.4-12, in a manner and at an amount
consistent with comparable cost-sharing provisions
under § 40-8.4-12, provided that such cost
sharing shall not exceed five percent (5%) of annual
income for those with annual income in
excess of one hundred thirty-three percent (133%)
one hundred fifty percent (150%); and
provided, further, that cost-sharing shall not be
required for pregnant women or children under
age one.
40-8.4-12. RIte
Share Health Insurance Premium Assistance Program. -- (1) The
department of human services is authorized and
directed to amend the medical assistance Title
XIX state plan to implement the provisions of § 1906
of Title XIX of the Social Security Act, 42
U.S.C. § 1396e, and establish the
RIte Care eligible parents with incomes up to one
hundred seventy-five percent (175%) of the
federal poverty level who have access to
employer-based health insurance. The state plan
amendment shall require eligible individuals with
access to employer-based health insurance to
enroll themselves and/or their family in the
employer-based health insurance plan as a condition
of participation in the RIte Share program under this
chapter and as a condition of retaining
eligibility for medical assistance under chapters 5.1
and 8.4 of this title and/or chapter 12.3 of title
42 and/or premium assistance under this chapter,
provided that doing so meets the criteria
established in § 1906 of Title XIX for obtaining
federal matching funds and the department has
determined that the individual's and/or the family's
enrollment in the employer-based health
insurance plan is cost-effective and the department
has determined that the employer-based health
insurance plan meets the criteria set forth in
subsection (d). The department shall provide
premium assistance by paying all or a portion of the
employee's cost for covering the eligible
individual or his or her family under the
employer-based health insurance plan, subject to the cost
sharing provisions in subsection (b), and provided
that the premium assistance is cost-effective in
accordance with Title XIX, 42 U.S.C. § 1396 et seq.
(b)
Individuals who can afford it shall share in the cost. The department of human
services is authorized and directed to apply for and
obtain any necessary waivers from the
secretary of the United States Department of Health
and Human Services, including, but not
limited to, a waiver of the appropriate sections of
Title XIX, 42 U.S.C. § 1396 et seq., to require
that individuals eligible for RIte Care under this
chapter or chapter 12.3 of title 42 with incomes
equal to or greater than one hundred thirty-three
percent (133%) one hundred fifty percent
(150%) of
the federal poverty level pay a share of the costs of health insurance based on
the
individual's ability to pay, provided that the cost
sharing shall not exceed five percent (5%) of the
individual's annual income. The department of human
services shall implement the cost-sharing
by regulation, and shall consider co-payments, premium
shares or other reasonable means to do
so.
(c)
Current RIte Care enrollees with access to employer-based health insurance. The
department of human services shall require any
individual who receives RIte Care or whose
family receives RIte Care on the effective date of the
applicable regulations adopted in
accordance with subsection (f) to enroll in an
employer-based health insurance plan at the
individual's eligibility redetermination date or at an
earlier date determined by the department,
provided that doing so meets the criteria established
in the applicable sections of Title XIX, 42
U.S.C. § 1396 et seq., for obtaining federal matching
funds and the department has determined
that the individual's and/or the family's enrollment
in the employer-based health insurance plan is
cost-effective and has determined that the health
insurance plan meets the criteria in subsection
(d). The insurer shall accept the enrollment of the
individual and/or the family in the employer-
based health insurance plan without regard to any
enrollment season restrictions.
(d)
Approval of health insurance plans for premium assistance. The department of
human services shall adopt regulations providing for
the approval of employer-based health
insurance plans for premium assistance and shall
approve employer-based health insurance plans
based on these regulations. In order for an
employer-based health insurance plan to gain approval,
the department must determine that the benefits
offered by the employer-based health insurance
plan are substantially similar in amount, scope, and
duration to the benefits provided to RIte Care
eligible persons by the RIte Care program, when the
plan is evaluated in conjunction with
available supplemental benefits provided by the
department. The department shall obtain and
make available to persons otherwise eligible for RIte
Care as supplemental benefits those benefits
not reasonably available under employer-based health
insurance plans which are required for RIte
Care eligible persons by state law or federal law or
regulation.
(e)
Maximization of federal contribution. The department of human services is
authorized and directed to apply for and obtain
federal approvals and waivers necessary to
maximize the federal contribution for provision of
medical assistance coverage under this section,
including the authorization to amend the Title XXI
state plan and to obtain any waivers
necessary to reduce barriers to provide premium
assistance to recipients as provided for in Title
XXI of the Social Security Act, 42 U.S.C. § 1397 et
seq.
(f)
Implementation by regulation. The department of human services is authorized
and
directed to adopt regulations to ensure the establishment
and implementation of the premium
assistance program in accordance with the intent and
purpose of this section, the requirements of
Title XIX, Title XXI and any approved federal
waivers.
SECTION
5. Sections 42-12.3-3, 42-12.3-4 and 42-12.3-15 of the General Laws in
Chapter 42-12 entitled
“Health Care for Children and Pregnant Women” are hereby amended to
read as follows:
42-12.3-3. Medical
assistance expansion for pregnant women/RIte Start. -- (a) The
director of the department of human services is
authorized to amend its title XIX state plan
pursuant to title XIX of the Social Security Act to
provide Medicaid coverage and to amend its
title XXI state plan pursuant to Title XXI of the
Social Security Act to provide medical assistance
coverage
through expanded family income disregards for pregnant women whose family
income
levels are between one hundred eighty-five percent
(185%) and two hundred fifty percent (250%)
of the federal poverty level. The department is
further authorized to promulgate any regulations
necessary and in accord with title XIX [42 U.S.C. §
1396 et seq.] and title XXI [42 U.S.C. §1397
et seq.] of
the Social Security Act necessary in order to implement said state plan
amendment.
The services provided shall be in accord with
title XIX [42 U.S.C. § 1396 et seq.] and title XXI
[42 U.S.C. §1397 et seq.] of the Social Security Act.
(b)
The director of the department of human services is authorized and directed to
establish a payor of last resort program to cover
prenatal, delivery and postpartum care. The
program shall cover the cost of maternity care for any
woman who lacks health insurance
coverage for maternity care and who is not eligible
for medical assistance under title XIX [42
U.S.C. § 1396 et seq.] and title XXI [42 U.S.C. §1397
et seq.] of the Social Security Act
including, but not limited to, a non-citizen pregnant
woman lawfully admitted for permanent
residence on or after August 22, 1996, without regard
to the availability of federal financial
participation, provided such pregnant woman satisfies
all other eligibility requirements. The
director shall promulgate regulations to implement
this program. Such regulations shall include
specific eligibility criteria; the scope of services
to be covered; procedures for administration and
service delivery; referrals for non-covered services;
outreach; and public education. Excluded
services under this paragraph will include, but not be
limited to, induced abortion except to
prevent the death of the mother.
(c)
The department of human services may enter into cooperative agreements with the
department of health and/or other state agencies to
provide services to individuals eligible for
services under subsections (a) and (b) above.
(d)
The following services shall be provided through the program:
(1)
Ante-partum and postpartum care;
(2)
Delivery;
(3)
Cesarean section;
(4)
Newborn hospital care;
(5)
Inpatient transportation from one hospital to another when authorized by a
medical
provider;
(6)
Prescription medications and laboratory tests;
(e)
The department of human services shall provide enhanced services, as
appropriate,
to pregnant women as defined in subsections (a) and
(b), as well as to other pregnant women
eligible for medical assistance. These services shall
include: care coordination, nutrition and
social service counseling, high risk obstetrical care,
childbirth and parenting preparation
programs, smoking cessation programs, outpatient
counseling for drug-alcohol use, interpreter
services, mental health services, and home visitation.
The provision of enhanced services is
subject to available appropriations. In the event that
appropriations are not adequate for the
provision of these services, the department has the
authority to limit the amount, scope and
duration of these enhanced services.
(f) The department
of human services shall provide for extended family planning
services for up to twenty-four (24) months postpartum.
These services shall be available to
women who have been determined eligible for RIte Start
or for medical assistance under title XIX
[42 U.S.C. § 1396 et seq.] or title XXI [42 U.S.C. §1397
et seq.] of the Social Security Act
42-12.3-4. "RIte
track" program. -- There is hereby established a payor of last
resort
program for comprehensive health care for children
until they reach nineteen (19) years of age, to
be known as "RIte track". The department of
human services is hereby authorized to amend its
title XIX state plan pursuant to title XIX [42 U.S.C.
§ 1396 et seq.] and title XXI [42 U.S.C.
§1397
et seq.] of the Social Security Act as
necessary to provide for expanded Medicaid coverage
through expanded family income disregards for
children, until they reach nineteen (19) years of
age, whose family income levels are up to two hundred
fifty percent (250%) of the federal
poverty level. Provided, however, that health care
coverage provided under this section shall also
be provided in accordance to Title XIX of the Social
Security Act, 42 U.S.C. § 1396 et seq., to a
non citizen child who is lawfully residing in the
such assistance. The department is further authorized to promulgate any regulations
necessary,
and in accord with title XIX [42 U.S.C. § 1396 et
seq.] and title XXI [42 U.S.C. §1397 et seq.] of
the Social Security Act as necessary in order
to implement the state plan amendment. For those
children who lack health insurance, and whose family
incomes are in excess of two hundred fifty
percent (250%) of the federal poverty level, the
department of human services shall promulgate
necessary regulations to implement the program. The
department of human services is further
directed to ascertain and promulgate the scope of
services that will be available to those children
whose family income exceeds the maximum family income
specified in the approved title XIX
[42 U.S.C. § 1396 et seq.] and title XXI [42 U.S.C.
§1397 et seq.] state plan amendment.
42-12.3-15. Expansion
of RIte track program. -- The Department of Human Services
is hereby authorized and directed to submit to the
United States Department of Health and Human
Services an amendment to the "RIte Care"
waiver project number 11-W-0004/1-01 to provide for
expanded Medicaid coverage for children until they
reach eight (8) years of age, whose family
income levels are to two hundred fifty percent (250%)
of the federal poverty level. Expansion of
the RIte track program from the age of six (6) until
they reach eighteen (18) years of age in
accordance with this chapter shall be subject to the
approval of the amended waiver by the United
States Department of Health and Human Services. Health
care coverage under this section shall
also be provided to a non-citizen child lawfully
residing in the
otherwise eligible for such assistance under title XIX
[42 U.S.C. § 1396 et seq.] or title XXI [42
U.S.C. §1397 et seq.]
SECTION
6. Sections 40-8-13.1 and 40-8-13.2 of the General Laws in Charter 40-8
entitled “Medical
Assistance” are hereby amended to read as follows:
40-8-13.1.
Reimbursement for out-of-state hospital services. -- (a) The department
of
human services is hereby authorized and directed to
amend, effective July 1, 1995, its regulations,
fee schedules and the
XIX of the federal Social Security Act to provide for
reimbursement to out-of-state hospitals for
services provided to eligible recipients in accordance
with this section.
(b)
Authorized inpatient hospital services shall be reimbursed at a rate equal to
fifty
percent (50%) of the out-of-state hospital's customary
charge(s) for such services to Title XIX
recipients in that state; provided, however, that
in-patient hospital organ transplant services shall
be reimbursed at sixty-one percent (61%) of the
out-of-state hospital's customary charge(s) for
such organ transplant services to Title XIX recipients
in that state. Authorized outpatient hospital
services (other than laboratory services) shall be
reimbursed at a rate equal to fifty-three percent
(53%) of the out-of-state hospital's customary
charge(s) for such services to Title XIX recipients
in that state; outpatient laboratory services shall be
reimbursed at the Medicare allowable rate.
(c)
The department may periodically adjust the inpatient and/or outpatient service
reimbursement rate(s) based upon a medical care cost
index to be determined by the department.
(e) The provisions of this section shall
be repealed upon the promulgation of
amendments and new methodology pursuant to sections
40-8-13.3 and 40-8-13.4, but in any
event no later than March 30, 2010.
40-8-13.2.
Prospective rate methodology for in-state hospital services. -- As a
condition of participation in the established
prospective rate methodology for reimbursement of
in-state hospital services, every hospital shall
submit year-end settlement reports to the
department within one year from the close of a
hospital's fiscal year. In the event that a
participating hospital fails to timely submit a
year-end settlement report as required, the
department shall withhold financial cycle payments due
by any state agency with respect to this
hospital by not more than ten percent (10%) until the
report is received. The provisions of this
section shall be repealed upon the promulgation of
amendments and new methodology pursuant
to sections 40-8-13.3 and 40-8-13.4, but in any event no
later than March 30, 2010.
SECTION
7. Chapter 40-8 of the General Laws entitled “Medical Assistance” is hereby
amended by adding thereto
the following sections:
40-8-13.3. Payment
for Services provided by in state and out of state hospitals.-- (a)
The department of human services and/or the secretary
of executive office of health and human
services is hereby authorized and directed to amend
its rules and regulations and amend the
Social Security Act in order to provide for payment to
hospitals for services provided to eligible
recipients in accordance with this chapter. The
provisions of this section shall be effective upon
the promulgation of the amendments and new payment
methodology pursuant to this section and
section 40-8-13.4, which shall in any event be no
later than March 30, 2010, at which time the
provisions of sections 40-8-13.2, 27-19-14, 27-19-15
and 27-19-16 shall be repealed in their
entirety.
40-8-13.4. Rate
methodology for payment for in state and out of state hospital
services.--
(a) The department of
human services shall implement a new methodology for payment
for in state and out of state hospital services in
order to ensure access to and the provision of high
quality and cost-effective hospital care to its
eligible recipients.
(b) In order to
improve efficiency and cost effectiveness, the department of human
services shall:
(1) With respect to
inpatient services: Implement a new payment methodology for
inpatient services utilizing the Diagnosis Related
Groups (DRG) method of payment, which is, a
patient classification method which provides a means
of relating payment to the hospitals to the
type of patients cared for by the hospitals. It is
understood that a payment method based on
Diagnosis Related Groups may include cost outlier
payments and other specific exceptions.
(2) With respect to
outpatient services. Notwithstanding any provisions of the law to the
contrary, the department will reimburse hospitals for
outpatient services using a rate methodology
determined by the department and in accordance with
federal regulations.
(c) It is intended
that payment utilizing the Diagnosis Related Groups method shall
reward hospitals for providing the most efficient
care, and provide the department the opportunity
to conduct value based purchasing of inpatient care.
(d) The director of
the department of human services and/or the secretary of executive
office of health and human services is hereby
authorized to promulgate such rules and regulations
consistent with this chapter, and to establish fiscal
procedures he or she deems necessary for the
proper implementation and administration of this
chapter in order to provide payment to hospitals
using the Diagnosis Related Group payment methodology.
Furthermore, amendment of the
Social Security Act is hereby authorized to provide
for payment to hospitals for services provided
to eligible recipients in accordance with this
chapter.
(e) The department
shall comply with all public notice requirements necessary to
implement these rate changes.
(f) As a
condition of participation in the DRG methodology for payment of hospital
services, every hospital shall submit year-end
settlement reports to the department within one
year from the close of a hospital's fiscal year.
Should a participating hospital fail to timely submit
a year-end settlement report as required by this
section, the department shall withhold financial
cycle payments due by any state agency with respect to
this hospital by not more than ten percent
(10%) until said report is submitted.
(g) The provisions of
this section shall be effective upon implementation of the
amendments and new payment methodology pursuant to
this section and section 40-8-13.3,
which shall in any event be no later than March 30,
2010, at which time the provisions of sections
40-8-13.2, 27-19-14, 27-19-15 and 27-19-16 shall be
repealed in their entirety.
SECTION
8. Sections 27-19-14, 27-19-15 and 27-19-16 of the General Laws in Chapter
27-19 entitled “Nonprofit
Hospital Service Corporations” are hereby amended to read as follows:
27-19-14.
Negotiation of hospital cost.-- The state, acting through the budget
officer
or his or her designated representative, hospitals,
and hospital service corporations incorporated
under this chapter shall be parties to annual budget
negotiations held for the purpose of
determining payment rates for hospital costs by the
state and those corporations. The parties to
the negotiations shall know the total operating
expenses for hospitals. The negotiations shall
commence no later than one hundred eighty (180) days
prior to the beginning of each hospital
fiscal year. The negotiations, which shall be
considered collective bargaining for the purposes of
§ 42-46-5(a)(2), shall be held for each hospital
fiscal year and individual budget negotiations
shall commence not later than ninety (90) days prior
to the beginning of each hospital fiscal year.
The parties shall employ mediation and arbitration
services as an aid to the negotiations. The
provisions of this section shall be repealed upon the
implementation of amendments and new
methodology pursuant to sections 40-8-13.3 and
40-8-13.4, but in any event no later than March
30, 2010.
27-19-15.
Agreement on budgets. -- (a) The budgets and/or each hospital's
projected
expenses and related statistics shall be agreed upon
not later than thirty (30) days prior to the
beginning of each hospital fiscal year. The agreement
shall be prima facie evidence that the
budgets and related statistics are:
(1)
Consistent with the proper conduct of the business of the corporations and the
interest of the public to the extent that the budgets
constitute in the aggregate a component of
hospital service rates filed for approval in any rate
hearing; and
(2)
Reasonable as a component of rates paid by the state as a purchaser of hospital
services.
(b)
Each hospital shall file its proposed budget to the state budget office which
shall
include projected expenses for the current fiscal year
and planned expenses for the next fiscal
year. Each hospital will also file with the state
budget office a copy of its audited financial
statements with rates within thirty (30) days of
acceptance by the hospital's board of trustees. The
provisions of this section shall not apply and shall
be repealed upon the implementation of
amendments and new methodology pursuant to sections
40-8-13.3 and 40-8-13.4, but in any
event no later than March 30, 2010.
27-19-16.
Severability. -- If a court of competent jurisdiction shall adjudge
that the
requirement in § 27-19-14 that the state be a party to
negotiations in which the
party or otherwise interested is invalid or
unconstitutional, that judgment shall not impair or
invalidate § 27-19-14 insofar as it requires the state
to be a party to negotiations between
hospitals and hospital service corporations; and if
any other clause, sentence, or section of §§ 27-
19-14, 27-19-15, or this section is adjudged invalid
or unconstitutional by a court of competent
jurisdiction, the remaining provisions of the sections
will not be impaired or invalidated by that
invalidity, but the effect of the judgment shall be
confined to the clause, sentence, or section so
adjudged to be invalid or unconstitutional. If the
agencies requires that funds supplied by it to the
state for the purchase or reimbursement of
hospital services be disbursed in a manner
inconsistent with any agreement reached by the parties
pursuant to §§ 27-19-14 and 27-19-15, that requirement
shall not affect any agreement as to other
funds to be paid by the state or by hospital service
corporations. The provisions of this section
shall be repealed upon the implementation of
amendments and new methodology pursuant to
sections 40-8-13.3 and 40-8-13.4, but in any event no
later than March 30, 2010.
SECTION
9. Title 40 of the General Laws entitled “HUMAN SERVICES” is hereby
amended by adding thereto
the following chapter:
CHAPTER
40-8.10
LONG
TERM CARE SERVICE REFORM FOR MEDICAID ELIGIBLE INDIVIDUALS
40-8.10-1.
Purpose. -- (a) In order to ensure that all Medicaid recipients
eligible for long-
term care have access to the full continuum of
services they need, the secretary of the executive
office of health and human services, in collaboration
with the director of the department of human
services and the directors of the departments of
children youth and families, elderly affairs,
health, and mental health, retardation and hospitals,
shall offer eligible Medicaid recipients the
full range of services as allowed under the terms and
conditions of the
Consumer Choice Compact 1115a Demonstration Waiver,
including institutional services and the
home and community based services provided for under
the previous Medicaid Section 1915 (c)
waivers, as well as additional services for medication
management, transition services and other
authorized services as defined in this chapter, in
order to meet the individual needs of the
Medicaid recipient.
40-8.10-2.
Definitions.-- As used in this chapter,
(a) “Core services”
mean homemaker services, environmental modifications (home
accessibility adaptations, special medical equipment
(minor assistive devices), meals on wheels (
home delivered meals), personal emergency response
(PERS), licensed practical nurse services,
community transition services, residential supports,
day supports, supported employment,
supported living arrangements, private duty nursing,
supports for consumer direction (supports
facilitation), participant directed goods and
services, case management, senior companion
services, assisted living, personal care assistance
services and respite.
(b) “Preventive
services” mean homemaker services, minor environmental modifications,
physical therapy evaluation and services and respite
services.
40-8.10-3. Levels
of Care.-- (a) The secretary of the executive office of
health and
human services shall coordinate responsibilities for
long-term care assessment in accordance with
the provisions of this chapter within the department
of human services, and with the cooperation
of the directors of the department of elderly affairs,
the department of children, youth and
families , and the department of mental health,
retardation and hospitals. Assessments conducted
by each department’s staff shall be coordinated
through the Assessment Coordination Unit
(ACU). Members of each department’s staff responsible
for assessing level of care, developing
care plans, and determining budgets will meet on a
regular basis in order to ensure that services
are provided in a uniform and consistent manner.
Importance shall be placed upon the proper and
consistent determination of levels of care across the
state departments for each long-term care
setting, including behavioral health residential
treatment facilities, long-term care hospitals,
intermediate care facilities, and/or skilled nursing
facilities. Three (3) appropriate plans of care
that meet the needs of the individual Medicaid
recipients shall be coordinated and consistent
across all state departments. The development of care
plans shall be person-centered and shall
support individual self-determination, family
involvement, when appropriate, individual choice
and interdepartmental collaboration.
(b) Levels of care
for long-term care institutions (behavioral health residential treatment
facilities, long-term care hospitals, intermediate
care facilities and /or skilled nursing facilities),
for which alternative community-based services and
supports are available, shall be established
pursuant to the section 40-8.9-9. The structure of the
three (3) levels of care is as follows:
(i) Highest level of
care. Individuals who are determined, based on medical need, to
require the institutional level of care will have the
choice to receive services in a long-term care
institution or in a home and community-based setting.
(ii) High level of
care. Individuals who are determined, based on medical need, to benefit
from home and community-based services.
(iii) Preventive
level of care. Individuals who do not presently need an institutional level
of care but who need services targeted at preventing
admission, re-admissions or reducing lengths
of stay in an institution.
(c) Determinations of
levels of care and the provision of long term care health services
shall be determined in accordance with this section
and shall be in accordance with the applicable
provisions of section 40-8.9-9.
40-8.10-4. Assessment
and Coordination Unit (ACU). -- (a) The department of human
services, in collaboration with the executive office
of health and human services, shall implement
a long-term care options counseling program to provide
individuals or their representative, or
both, with long-term care consultations that shall
include, at a minimum, information about long-
term care options, sources and methods of both public
and private payment for long term care
services, and an assessment of an individual’s
functional capabilities and opportunities for
maximizing independence. Each individual admitted to
or seeking admission to a long- term
care facility, regardless of the payment source, shall
be informed by the facility of the availability
of the long-term care options counseling program and
shall be provided with a long-term care
options consultation, if he or she so requests. Each
individual who applies for Medicaid long-term
care services shall be provided with a long-term care
consultation.
(b) Core and
preventative home and community based services defined and delineated in
section 40-8.10-2 shall be provided only to those
individuals who meet one of the levels of care
provided for in this chapter. Other long term care
services authorized by the federal government,
such as medication management, may also be provided to
Medicaid eligible recipients who have
established the requisite need as determined by the
Assessment and Coordination Unit (ACU).
Access to institutional and community based supports
and services shall be through the
Assessment and Coordination Unit (ACU). The provision
of Medicaid-funded long-term care
services and supports shall be based upon a
comprehensive assessment that shall include, but not
be limited to, an evaluation of the medical, social
and environmental needs of each applicant for
these services or programs. The assessment shall serve
as the basis for the development and
provision of an appropriate plan of care for the
applicant.
(c) The ACU shall
assess the financial eligibility of beneficiaries to receive long-term
care services and supports in accordance with the
applicable provisions of section 40-8.9-9.
(d) The ACU shall be
responsible for conducting assessments; determining a level of care
for applicants for medical assistance; developing
service plans; pricing a service budget and
developing a voucher when appropriate; making
referrals to appropriate settings; maintaining a
component of the unit that will provide training to
and will educate consumers, discharge
planners and providers; tracking utilization;
monitoring outcomes; and reviewing service/care
plan changes. The ACU shall provide interdisciplinary
high cost case reviews and choice
counseling for eligible recipients.
(e) The assessments
for individuals conducted in accordance with this section shall serve
as the basis for individual budgets for those medical
assistance recipients eligible to receive
services utilizing a self-directed delivery system.
(f) Nothing in this
section shall prohibit the secretary of the executive office of health and
human services, or the directors of that office’s
departments from utilizing community agencies
or contractors when appropriate to perform assessment
functions outlined in this chapter.
40-8.10-5.
Payments.-- The department of human services shall not make payment
for a
person receiving a long-term home health care program,
while payments are being made for that
person for inpatient care in a skilled nursing and/or
intermediate care facility or hospital.
40-8.10-6. Rules
and Regulations.-- The secretary of the executive office of health
and
human services, the directors of the department of
human services, the department of elderly
affairs, the department of children youth and families
and the department of mental health
retardation and hospitals are hereby authorized to
promulgate rules and regulations necessary to
implement all provisions of this chapter and to seek
necessary federal approvals in accordance
with the provisions of the Global Compact Waiver.
SECTION
10. Section 40-8.9-9 of the General Laws in Chapter 40-8.9 entitled
"Medical
Assistance - Long-Term Care
Service and Finance Reform" is hereby amended to read as
follows:
40-8.9-9. Long-term
care re-balancing system reform goal. -- (a) Notwithstanding any
other provision of state law, the department of human
services is authorized and directed to apply
for and obtain any necessary waiver(s), waiver
amendment(s) and/or state plan amendments from
the secretary of the
rules necessary to adopt an affirmative plan of
program design and implementation that addresses
the goal of allocating a minimum of fifty percent
(50%) of Medicaid long-term care funding for
persons aged sixty-five (65) and over and adults with
disabilities in addition to services for
persons with developmental disabilities and mental
disabilities to home and
community-based
care on or before December 31, 2012 2013;
provided, further, the executive office of health and
human services shall report annually as part of its
budget submission, the percentage distribution
between institutional care and home and
community-based care by population and shall report
current and projected waiting lists for long-term care
and home and community-based care
services.
The department is further authorized and directed to prioritize investments in
home and
community-based care and to maintain the integrity and
financial viability of all current long-
term care services while pursuing this goal.
(b)
The long-term care re-balancing goal is person-centered and encourages
individual
self-determination, family involvement, interagency
collaboration, and individual choice through
the provision of highly specialized and individually
tailored home-based services. Additionally,
individuals with severe behavioral, physical, or
developmental disabilities must have the
opportunity to live safe and healthful lives through
access to a wide range of supportive services
in an array of community-based settings, regardless of
the complexity of their medical condition,
the severity of their disability, or the challenges of
their behavior. Delivery of services and
supports in less costly and less restrictive community
settings, will enable children, adolescents
and adults to be able to curtail, delay or avoid
lengthy stays in long-term care institutions, such as
behavioral health residential treatment facilities, juvenile detention centers,
psychiatric facilities,
and/or long-term
care hospitals, intermediate care facilities and/or skilled nursing
facilities.
(c) (1)
Pursuant to federal authority procured under § 42-7.2-16 of the general laws,
the
department of human services is directed and
authorized to adopt a tiered set of criteria to be used
to determine eligibility for services. Such criteria
shall be developed in collaboration with the
state's health and human services departments and
shall encompass need based eligibility
determinations for services in nursing facilities,
hospitals, and intermediate care facilities for the
mentally retarded as well as home institutions for long-term care and community-based
alternatives,. Separate needs based
criteria may be established taking into account the long-term
care institution for which alternative community-based
services and supports are available. The
department is authorized to adopt criteria for
admission to long-term care institutions that are
more stringent than those employed for access to home
and community-based services. The
department is also authorized to promulgate rules that
define the frequency of re-assessments for
services provided for under this section.
(2) The department is
authorized, subject to prior approval of the general assembly, to
and shall
provide a common standard of income financial eligibility for both
institutional and
home and community-based care. The department is
authorized to adopt criteria for admission to
a nursing facility, hospital, or intermediate care
facility for the mentally retarded that are more
stringent than those employed for access to home and
community-based services. The department
is also authorized to promulgate rules that define the
frequency of re-assessments for services
provided for under this section. Legislatively
approved levels of care may be applied in
accordance with the following:
(i) Any Medicaid
recipient deemed eligible for nursing facility, hospital, or intermediate
care facility for the mentally retarded as of January
15, 2009, shall continue, throughout that
individual's life, to be assessed utilizing the level
of care criteria in place for that care as of
January 15, 2009;
(ii) Any Medicaid
recipient deemed eligible for home and community services prior to
January 15, 2009, shall continue to be assessed for
that care utilizing the level of care criteria in
place as of January 15, 2009;
(iii) Persons meeting
or who would have met the level of care criteria for nursing facility
care as of January 15, 2009, shall continue to be
deemed to meet the institutional level of care and
shall only be transitioned to home and community
services on a voluntary basis, and shall not be
subject to any wait list for home and community
services; and
(iv) No resident of a
nursing facility, hospital, or intermediate care facility for the
mentally retarded shall be removed involuntarily from
said facility even if the condition of the
resident improves.
(v) No nursing home,
hospital, or intermediate care facility for the mentally retarded shall
be denied payment for services rendered to a Medicaid
recipient on the grounds that the recipient
does not meet level of care criteria unless and until
the department of human services has: (i)
Performed an individual assessment of the recipient at
issue and provided written notice to the
nursing home, hospital, or intermediate care facility
for the mentally retarded that the recipient
does not meet level of care criteria; and (ii) The
recipient has either appealed that level of care
determination and been unsuccessful, or any appeal
period available to the recipient regarding
that level of care determination has expired.
(d) The department of
human services is further authorized and directed to consolidate all
home and community-based services currently provided
pursuant to § 1915(c) of title XIX of the
Untied United
States Code into a single program of home and community-based services that
include options for consumer direction and shared
living. The resulting single home and
community-based services program shall replace and
supersede all § 1915(c) programs when
fully implemented. Notwithstanding the foregoing, the
resulting single program home and
community-based services program shall include the
continued funding of assisted living services
at any assisted living facility financed by the
corporation prior to January 1, 2006, and shall be in
accordance with chapter 66.8 of title 42 of
the general laws as long as assisted living services
are a covered Medicaid benefit.
(e) The department
of human services is authorized to promulgate rules that permit
certain optional services including, but not limited
to, homemaker services, home modifications,
respite, and physical therapy evaluations to be
offered subject to availability of state-appropriated
funding for these purposes.
(f) To promote the
expansion of home and community-based service capacity, the
department of human services is authorized and
directed to pursue rate reform for providers of
homemaker, personal care (home health aide) and adult
day care services, as follows: (1) A
prospective base adjustment effective, not later than
July 1, 2008, across all departments and
programs, of ten percent (10%) of the existing
standard or average rate, contingent upon a
demonstrated increase in the state-funded or Medicaid
caseload by June 30, 2009;
(2)
Development, not later than September 30, 2008, of certification standards
supporting and defining targeted rate increments to
encourage service specialization and
scheduling accommodations including, but not limited
to, medication and pain management,
wound management, certified Alzheimer's Syndrome
treatment and support programs, and shift
differentials for night and week-end services; and
(3)
Development and submission to the governor and the general assembly, not later
than December 31, 2008, of a proposed rate-setting
methodology for home and community-based
services to assure coverage of the base cost of
service delivery as well as reasonable coverage of
changes in cost caused by wage inflation.
(h) The department
of human services is also authorized, subject to availability of
appropriation of funding, to pay for certain non-Medicaid
reimbursable expenses necessary to
transition residents back to the community; provided, however,
payments shall not exceed an
annual or per person amount.
(i)
To assure the continued financial viability of nursing facilities, the
department of
human services is
authorized and directed to develop a proposal for revisions to § 40-8-19 that
reflect the changes in cost
and resident acuity that result from implementation of this re-balancing
goal. Said proposal shall
be submitted to the governor and the general assembly on or before
January 1, 2010
SECTION
11. Section 40-8-17 of the General Laws in Chapter 40-8 entitled “Medical
Assistance” is hereby
amended to read as follows:
40-8-17. Waiver
request – Formulation. -- (a) Formation. The department
of human
services, in conjunction with the executive office of
health and human services, is directed and
authorized to apply for and obtain any necessary
waiver(s), waiver amendment(s) and/or state
plan amendments from the secretary of the
services, including, but not limited to, a § 1115(a)
global demonstration waiver that provides
program flexibility in exchange for federal budgetary
certainty and under which
will operate all facets of the state's Medicaid
program, except as may be explicitly exempted
under any applicable public or general laws.
(b) Effective July 1,
2009, any provision presently in effect in the Rhode Island General
Laws where the department of human services, in
conjunction with the executive office of health
and human services, is authorized to apply for and
obtain any necessary waiver(s), waiver
amendment(s) and/or state plan amendment(s) for the
purpose of providing medical assistance to
recipients, shall authorize the department of human
services, in conjunction with the executive
office of health and human services, to proceed with
appropriate category changes in accordance
with the special terms and conditions of the
section 1115(a) Demonstration Waiver, which became
effective January 16, 2009.
SECTION
12. Chapter 40-8 of the General Laws entitled “Medical Assistance” is hereby
amended by adding thereto
the following section:
40-8-4.1. Lowest
Price. -- (a) Notwithstanding any provision of law to the contrary,
no
medical assistance provider shall bill or charge the
department of human services more than the
provider's usual and customary charge, as defined
within.
(b) The term “usual
and customary” means the lowest charge, fee, or rate charged by a
provider for any product or service at the time such
product or service was provided. For the
purpose of determining the lowest charge, fee, or
rate:
(1) If the provider
offers discounts or rebates, the amount after applying discounts or
rebates shall be utilized;
(2) If the provider
offers a sale for a limited period of time on any good or service, the
sale price shall be utilized during the sale period;
(3) If the provider
regularly accepts less than its full charge from any customer, that
amount accepted shall be utilized;
(4) If any good or
service is offered free of charge by the provider, no charge shall be
made to the department for the provision of the
product or service to the department or a client of
the department who satisfies the terms of the offer;
(5) If any good or
service is covered under any warranty or guarantee offered by the
provider, the amount charged to the department shall
not exceed the amount which would
otherwise be payable solely by the customer; and
(6) If a provider
structures or packages its goods or services in a manner which is
exclusively or primarily used for Medicaid, Medicare,
or other third-party payors, the charge for
the most similar good or service offered to any other
consumer shall be utilized.
(c) The following
items shall not be utilized in determining the “usual and customary” or
lowest charge, fee, or rate:
(1) Discounts offered
solely to bona fide employees or family members of employees;
(2) Discounts offered
solely on the basis of age shall be utilized in determining the usual
and customary charge only when the client of the
department satisfies the age requirement;
(3) Free goods or
services or discounts provided to a limited number of persons on the
basis of financial hardship;
(4) Charges by an
organization on a sliding fee scale for a good or service where the
organization's charge is based on ability to pay;
(5) Charges not collected
as a result of bad debts incurred by the provider. A bad debt
exists where sound business judgment indicates that
there is no reasonable likelihood of recovery
of the amount owed; and
(6) Charges for
educational-related services governed by 42 U.S.C. 1396b(c).
(d) The department
may waive the application of this section, if the department
determines such action is necessary to ensure a
continuum of care and service to persons served
by community mental health centers, or to avert serious
economic hardships to mental health
centers.
SECTION
13. Sections 40-8.4-4 and 40-8.4-12 of the General Laws in Chapter 40-8.4
entitled "Health Care
For Families" are hereby amended to read as follows:
40-8.4-4.
Eligibility. -- (a) Medical assistance for families. - There is hereby
established
a category of medical assistance eligibility pursuant
to section 1931 of Title XIX of the Social
Security Act, 42 U.S.C. section 1396u-1, for families
whose income and resources are no greater
than the standards in effect in the aid to families
with dependent children program on July 16,
1996 or such increased standards as the department may
determine. The department of human
services is directed to amend the medical assistance
Title XIX state plan and to submit to the
Department of Health and Human Services an amendment
to the RIte Care waiver project to
provide for medical assistance coverage to families
under this chapter in the same amount, scope
and duration as coverage provided to comparable groups
under the waiver. The department is
further authorized and directed to submit such
amendments and/or requests for waivers to the
Title XXI state plan as may be necessary to maximize
federal contribution for provision of
medical assistance coverage under this chapter.
However, implementation of expanded coverage
under this chapter shall not be delayed pending
federal review of any Title XXI amendment or
waiver.
(b) Income. - The
director of the department of human services is authorized and
directed to amend the medical assistance Title XIX
state plan or RIte Care waiver to provide
medical assistance coverage through expanded income
disregards or other methodology for
parents or relative caretakers whose income levels are
below one hundred seventy-five percent
(175%) of the federal poverty level.
(c) Waiver. - The
department of human services is authorized and directed to apply for
and obtain appropriate waivers from the Secretary of
the U.S. Department of Health and Human
Services, including, but not limited to, a waiver of
the appropriate provisions of Title XIX, to
require that individuals with incomes equal to or
greater than one hundred thirty-three percent
(133%) one
hundred fifty percent (150%) of the federal poverty level pay a share of
the costs of
their medical assistance coverage provided through
enrollment in either the RIte Care Program or
under the premium assistance program under section
40-8.4-12, in a manner and at an amount
consistent with comparable cost-sharing provisions
under section 40-8.4-12, provided that such
cost sharing shall not exceed five percent (5%) of
annual income for those with annual income in
excess of one hundred thirty-three percent (133%)
one hundred fifty percent (150%); and
provided, further, that cost-sharing shall not be
required for pregnant women or children under
age one.
40-8.4-12. RIte
Share Health Insurance Premium Assistance Program. -- (1) The
department of human services is authorized and
directed to amend the medical assistance Title
XIX state plan to implement the provisions of section
1906 of Title XIX of the Social Security
Act, 42 U.S.C. section 1396e, and establish the
program for RIte Care eligible parents with incomes up
to one hundred seventy-five percent
(175%) of the federal poverty level who have access to
employer-based health insurance. The
state plan amendment shall require eligible
individuals with access to employer-based health
insurance to enroll themselves and/or their family in
the employer-based health insurance plan as
a condition of participation in the RIte Share program
under this chapter and as a condition of
retaining eligibility for medical assistance under
chapters 5.1 and 8.4 of this title and/or chapter
12.3 of title 42 and/or premium assistance under this
chapter, provided that doing so meets the
criteria established in section 1906 of Title XIX for
obtaining federal matching funds and the
department has determined that the individual's and/or
the family's enrollment in the employer-
based health insurance plan is cost-effective and the
department has determined that the
employer-based health insurance plan meets the
criteria set forth in subsection (d). The
department shall provide premium assistance by paying
all or a portion of the employee's cost for
covering the eligible individual or his or her family
under the employer-based health insurance
plan, subject to the cost sharing provisions in
subsection (b), and provided that the premium
assistance is cost-effective in accordance with Title
XIX, 42 U.S.C. section 1396 et seq.
(b) Individuals who can
afford it shall share in the cost. - The department of human
services is authorized and directed to apply for and
obtain any necessary waivers from the
secretary of the United States Department of Health
and Human Services, including, but not
limited to, a waiver of the appropriate sections of
Title XIX, 42 U.S.C. section 1396 et seq., to
require that individuals eligible for RIte Care under
this chapter or chapter 12.3 of title 42 with
incomes equal to or greater than one hundred
thirty-three percent (133%) one hundred fifty
percent (150%)
of the federal poverty level pay a share of the costs of health insurance based
on
the individual's ability to pay, provided that the
cost sharing shall not exceed five percent (5%) of
the individual's annual income. The department of
human services shall implement the cost-
sharing by regulation, and shall consider co-payments,
premium shares or other reasonable means
to do so.
(c) Current RIte Care
enrollees with access to employer-based health insurance. - The
department of human services shall require any
individual who receives RIte Care or whose
family receives RIte Care on the effective date of the
applicable regulations adopted in
accordance with subsection (f) to enroll in an
employer-based health insurance plan at the
individual's eligibility redetermination date or at an
earlier date determined by the department,
provided that doing so meets the criteria established
in the applicable sections of Title XIX, 42
U.S.C. section 1396 et seq., for obtaining federal
matching funds and the department has
determined that the individual's and/or the family's
enrollment in the employer-based health
insurance plan is cost-effective and has determined
that the health insurance plan meets the
criteria in subsection (d). The insurer shall accept
the enrollment of the individual and/or the
family in the employer-based health insurance plan
without regard to any enrollment season
restrictions.
(d) Approval of health
insurance plans for premium assistance. - The department of
human services shall adopt regulations providing for
the approval of employer-based health
insurance plans for premium assistance and shall
approve employer-based health insurance plans
based on these regulations. In order for an
employer-based health insurance plan to gain approval,
the department must determine that the benefits
offered by the employer-based health insurance
plan are substantially similar in amount, scope, and
duration to the benefits provided to RIte Care
eligible persons by the RIte Care program, when the
plan is evaluated in conjunction with
available supplemental benefits provided by the
department. The department shall obtain and
make available to persons otherwise eligible for RIte
Care as supplemental benefits those benefits
not reasonably available under employer-based health
insurance plans which are required for RIte
Care eligible persons by state law or federal law or
regulation.
(e) Maximization of
federal contribution. - The department of human services is
authorized and directed to apply for and obtain
federal approvals and waivers necessary to
maximize the federal contribution for provision of
medical assistance coverage under this section.
(f) Implementation by
regulation. - The department of human services is authorized and
directed to adopt regulations to ensure the
establishment and implementation of the premium
assistance program in accordance with the intent and
purpose of this section, the requirements of
Title XIX and any approved federal waivers.
SECTION
14. Section 13 shall take effect on May 31, 2009. The remainder of the article
shall take effect upon
passage. Any rules or regulations necessary or advisable to implement the
provisions of section 1
this article shall be effective immediately as an emergency rule upon the
department’s filing thereof
with the secretary of state as it is hereby found that the current fiscal
crisis in this state has
caused an imminent peril to public health, safety and welfare, and the
department is hereby
exempted from the requirements of sections 42-35-3(b) and 42-35-4(b)(2)
relating to agency findings
of imminent peril to public health, safety and welfare and the filing of
statements of the agency’s
reasons thereof.