Chapter 069
2009 -- H 5112 SUBSTITUTE C
Enacted 07/01/09
A N A C T
RELATING TO CENTERS FOR MEDICARE AND MEDICAID SERVICES WAIVER AND EXPENDITURE AUTHORITY
Introduced By: Representatives Costantino, Naughton, Slater, Giannini, and Almeida
Date Introduced: January 15, 2009
It is enacted by the
General Assembly as follows:
SECTION 1. Chapter 42-12.4 of the General Laws entitled
"The Rhode Island Medicaid
Reform Act of 2008" is
hereby amended by adding thereto the following sections:
42-12.4-7.
Demonstration implementation - Restrictions. -- The
executive office of
health and human services and the department of human
services may implement the global
consumer choice section 1115 demonstration ("the
demonstration"), project number 11W-
00242/1, subject to the following restrictions:
(1) Notwithstanding
the provisions of the demonstration, any change that requires the
implementation of a rule or regulation or modification of a rule or
regulation in existence prior to
the demonstration shall require prior approval of the
general assembly;
(2) Notwithstanding
the provisions of the demonstration, any Category II change or
Category III change, as defined in the demonstration,
shall require the prior approval of the
general assembly.
42-12.4-8.
Demonstration termination. -- In the event the
demonstration is suspended
or terminated for any reason, or in the event that the
demonstration expires, 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 all waivers in
existence prior to the acceptance of the
demonstration. The department of human services and the executive office
of health and human
services to the extent possible shall ensure that said waivers
are reinstated prior to any
suspension, termination, or expiration of the demonstration.
42-12.4-9.
Demonstration implementation taskforce. -- (a) Purpose. The general
assembly is committed to a public participatory process to
implement Medicaid reform through
the demonstration. To assure such a process, following
final acceptance of the demonstration by
the state, the executive office of health and human service
and the department of human services
shall establish a demonstration implementation taskforce.
The taskforce shall work
collaboratively with the executive office of health and human
services and the department of
human services to plan, design, and implement changes to
the Medicaid program under the
demonstration and to evaluate the impact of such changes and of the
demonstration.
(b) Chair. The
taskforce shall be co-chaired by a senior state official of EOHHS/DHS and
a member of the community who is knowledgeable about
the Medicaid program and the
populations and services it funds in
demonstration.
(c) Taskforce
composition. There are distinct populations that receive services funded
through the Medicaid program including: children and youth
with special health care needs,
adults and children with developmental disabilities, adults
with serious and persistent mental
illness and/or addiction disorders and children with severe
emotional disturbance, adults with
disabilities, adults age sixty-five (65) and older and low-income
children and families. It is the
intent of the general assembly that the taskforce includes
members who are knowledgeable about
the needs of these populations and the services currently
provided to them.
Members of the
taskforce shall be appointed by director of the department of human
services. The membership shall include: for each distinct
population two (2) consumers or family
members of consumers, one member of an advocacy organization
and one member of a policy
organization; a representative from organizations that either
provide or represent entities that
provide services to Medicaid beneficiaries including, but not
limited to, health plans, hospitals
community health centers, community mental health
organizations, licensed substance abuse
treatment providers, licensed health care practitioners,
nursing facilities, and home and
community-based service providers.
Total membership
shall not exceed forty-five (45) individuals. The executive office of
health and human services/department of human services shall
provide necessary staff support to
effectively operate the taskforce.
(d) Duration. The
taskforce shall remain in effect so long as the demonstration is in
effect.
(e) Meeting frequency
and relationship to the permanent joint committee of the
demonstration compact:
The taskforce shall
meet no less than monthly and shall report on its activities to the
permanent joint committee of the demonstration compact
established pursuant to section 42-12.4-
5. Permanent joint committee shall appoint a member to
serve as a liaison to the taskforce.
SECTION 2. Section 40-8.4-19 of the General Laws in Chapter
40-8.4 entitled "Health
Care For
Families" is hereby amended to read as follows:
40-8.4-19. Managed health care delivery systems for families. --
(a) Notwithstanding
any other provision of state law, the delivery and
financing of the health care services provided
under this chapter shall be provided through a system of
managed care. "Managed care" is
defined as systems that: integrate an efficient financing
mechanism with quality service delivery;
provide a "medical home" to assure appropriate care
and deter unnecessary services; and place
emphasis on preventive and primary care. For the purposes
of Medical Assistance, managed care
systems are defined to include a primary care case management
model in which ancillary services
are provided under the direction of a physician in a
practice that meets standards established by
the department of human services, including standards
pertaining to certification as an "advanced
medical home".
(b) Enrollment in managed
care health delivery systems is mandatory for individuals
eligible for medical assistance under this chapter. This
includes children in substitute care,
children receiving Medical Assistance through an adoption
subsidy, and children eligible for
medical assistance based on their disability. Beneficiaries
with third-party medical coverage or
insurance may be exempt from mandatory managed care in
accordance with rules and regulations
promulgated by the department of human services for such purposes.
(c) Individuals who can
afford to contribute shall share in the cost. - The department of
human services is authorized and directed to apply for and
obtain any necessary waivers and/or
state plan amendments from the secretary of the
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 beneficiaries
eligible 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 coverage based on
the ability to pay. The department of human services
shall implement this cost-sharing obligation
by regulation, and shall consider co-payments, premium
shares, or other reasonable means to do
so in accordance with approved provisions of appropriate
waivers and/or state plan amendments
approved by the secretary of the
(d) All children and
families receiving Medical Assistance under title 40 of the Rhode
Island general laws shall also be subject to
co-payments for certain medical services as approved
in the waiver and/or the applicable state plan
amendment, and in accordance with rules and
regulations promulgated by the department.
(e) The department
of human services may provide health benefits, similar to those
available through commercial health plans, to parents or
relative caretakers with an income above
one hundred percent (100%) of the federal poverty level
who are not receiving cash assistance
under the Rhode Island Temporary Assistance to Needy
Families (TANF program).
(f) The department
of human services is authorized to create consumer directed health
care accounts, including but not limited to health
opportunity accounts or health savings accounts,
in order to increase and encourage personal
responsibility, wellness and healthy decision-making,
disease management, and to provide tangible incentives for
beneficiaries who meet designated
wellness initiatives.
SECTION 3. Section 40-8.5-1.1 of the General Laws in Chapter
40-8.5 entitled "Health
Care for Elderly and
Disabled Residents Act" is hereby amended to read as follows:
40-8.5-1.1. Managed health care delivery systems. -- (a) To ensure that all medical
assistance beneficiaries, including the elderly and all
individuals with disabilities, have access to
quality and affordable health care, the department of human
services is authorized to implement
mandatory managed care health systems.
(b) "Managed
care" is defined as systems that: integrate an efficient financing
mechanism with quality service delivery; provides a "medical
home" to assure appropriate care
and deter unnecessary services; and place emphasis on
preventive and primary care. For purposes
of Medical Assistance, managed care systems are also
defined to include a primary care case
management model in which ancillary services are provided under
the direction of a physician in
a practice that meets standards established by the
department of human services. Those medical
assistance recipients who have third-party medical coverage or
insurance may be exempt from
mandatory managed care in accordance with rules and regulations
promulgated by the department
of human services. The department is further authorized
to redesign benefit packages for medical
assistance beneficiaries subject to appropriate federal approval.
(c) The department is
authorized to obtain any approval through waiver(s) and/or state
plan amendments, from the secretary of the
services, that are necessary to implement mandatory managed
health care delivery systems for all
medical assistance recipients, including the primary case
management model in which ancillary
services are provided under the direction of a physician in a
practice that meets standards
established by the department of human services. The waiver(s)
and/or state plan amendments
shall include the authorization to exempt beneficiaries
with third-party medical coverage or
insurance from mandatory managed care in accordance with rules
and regulations promulgated by
the department of human services. The department may
also redesign benefit packages for
medical assistance beneficiaries in accordance with rules and
regulations promulgated by the
department.
(d) To ensure the delivery
of timely and appropriate services to persons who become
eligible for Medicaid by virtue of their eligibility for a
program, the department of human services is authorized to
seek any and all data sharing
agreements or other agreements with the social security
administration as may be necessary to
receive timely and accurate diagnostic data and clinical
assessments. Such information shall be
used exclusively for the purpose of service planning, and
shall be held and exchanged in
accordance with all applicable state and federal medical record
confidentiality laws and
regulations.
(e) The department
of human services and/or the executive office of health and human
services is authorized and directed to apply for and obtain
any necessary waiver(s) and/or state
plan amendments from the secretary of the
services, including, but not limited to, a waiver of the
appropriate sections of law for the purpose
of administering and implementing the goals of the
Medicaid Reform Act 2008 as described in
section 42-7.2-16 of the
purchasing to maximize the available service options and to
promote accountability and
transparency in the delivery of services for all Medical
Assistance beneficiaries.
SECTION 4. 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 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.
SECTION 5. Chapter 40-8 of the General Laws entitled
"Medical Assistance" is hereby
amended by adding thereto the following section:
40-8-30.
Suspension of participating providers. -- 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. Prior to suspension, a
participating provider shall have the right to appeal such
suspension to a state administrative
hearing officer, in accordance with the rules of the
department of human services.
SECTION 6. 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 excluding services for persons
with developmental 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 residential treatment facilities,
juvenile detention centers, psychiatric facilities, and/or
intermediate care or skilled nursing
facilities.
(c)
Pursuant to federal authority procured under section 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 eligibility determinations
for services in nursing facilities, hospitals, and
intermediate care facilities for the mentally
retarded as well as home and community-based alternatives, and
shall provide a common
standard of income eligibility for both institutional and home
and community-based care. The
department is, subject to prior approval of the general
assembly, 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:
(1) The department
shall apply pre-waiver level of care criteria for any Medicaid
recipient eligible for a nursing facility, hospital, or
intermediate care facility for the mentally
retarded as of June 30, 2009, unless the recipient transitions
to home and community based
services because he or she: (a) Improves to a level where
he/she would no longer meet the pre-
waiver level of care criteria; or (b) The individual chooses
home and community based services
over the nursing facility, hospital, or intermediate care
facility for the mentally retarded. For the
purposes of this section, a failed community placement, as
defined in regulations promulgated by
the department, shall be considered a condition of
clinical eligibility for the highest level of care.
The department shall confer with the long-term care
ombudsperson with respect to the
determination of a failed placement under the ombudsperson’s
jurisdiction. Should any Medicaid
recipient eligible for a nursing facility, hospital, or intermediate
care facility for the mentally
retarded as of June 30, 2009 receive a determination of a
failed community placement, the
recipient shall have access to the highest level of care;
furthermore, a recipient who has
experienced a failed community placement shall be transitioned
back into his or her former
nursing home, hospital, or intermediate care facility for the
mentally retarded whenever possible.
Additionally, residents shall only be moved from a
nursing home, hospital, or intermediate care
facility for the mentally retarded in a manner consistent with
applicable state and federal laws.
(2) Any Medicaid
recipient eligible for the highest level of care who voluntarily leaves a
nursing home, hospital, or intermediate care facility for the
mentally retarded shall not be subject
to any wait list for home and community based services.
(3) 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 section 1915(c) of title
XIX of the Untied 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 section
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 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 section 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 7. This act shall take effect upon passage.
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LC00633/SUB C
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