ARTICLE 16 AS AMENDED
RELATING TO THE
MEDICAID REFORM ACT
SECTION 1. Medicaid Reform.
WHEREAS, The general assembly enacted Chapter 12.4 of Title 42
entitled “The Rhode
Island Medicaid Reform Act of 2008”; and
WHEREAS, A Joint Resolution
is required pursuant to Rhode Island General Laws § 42-
12.4-1, et seq.; and
WHEREAS, Rhode Island
General Law § 42-12.4-7 provides that any change that
requires the implementation of a rule or regulation or
modification of a rule or regulation in
existence prior to the implementation of the global consumer
choice section 1115 demonstration
(“the demonstration”) shall
require prior approval of the general assembly, and further provides
that any category II change or category III change as
defined in the demonstration shall also
require prior approval by the general assembly; and
WHEREAS, Rhode Island
General Law § 42-7.2-5 provides that the Secretary of the
Office of Health and Human Services is responsible for
the “review and coordination of any
Global Consumer Choice Compact Waiver requests and
renewals as well as any initiatives and
proposals requiring amendments to the Medicaid state plan or
category I or II changes” as
described in the demonstration, with “the potential to affect
the scope, amount, or duration of
publicly-funded health care services, provider payments or
reimbursements, or access to or the
availability of benefits and services provided by
WHEREAS, In pursuit of a
more cost-effective consumer choice system of care that is
fiscally sound and sustainable, the secretary requests general
assembly approval of the following
proposals to amend the demonstration:
(a) Nursing Facility Payment Rate Reform. The Medicaid single state
agency proposes to
reform the methodology used for determining rates by
revising completely the Principles of
Reimbursement to simplify and change the amount paid
to nursing facilities. Because
implementation of this proposal will result in a new payment process
and structure for a Medicaid
funded service, a Category II change is required under the
terms and conditions established for
the Global Consumer Choice Compact Waiver. Further,
effectuating such reforms in the
methodology for setting nursing facilities rates may also require
the adoption of new or amended
rules, regulations and procedures for providers and/or
beneficiaries.
(b) Selective Contracting –Medicaid Home Health Services. The
Medicaid single state
agency proposes to selectively contract with home health
agencies that meet specific standards
related to economy, efficiency and performance. This process
of selective contracting will result
in a change to the payment structure for a Medicaid
funded service. Therefore, a Category II
change is required for implementation under the terms and
conditions of the Global Consumer
Choice Waiver Compact.
(c) Pain Management Benefits for Medicaid Beneficiaries. The Medicaid
single state
agency proposes to include a pain management benefit for
targeted beneficiaries to reduce
utilization of pharmaceuticals, emergency departments and
inpatient hospital stays. Establishing a
targeted benefit requires amendments to or new rules,
regulations and procedures pertaining to
coverage for the Medicaid populations affected as well as a
Category II change to the Global
Consumer Choice Compact Waiver in those areas where
additional authority is warranted under
the terms and conditions of the demonstration agreement.
(d) Health Homes – EOHHS Departments. The Medicaid single state agency
proposes to
pursue authorization from the Centers for Medicare and
Medicaid Services (CMS) for the
purposes of accessing additional federal matching funds for
services provided through the
departments that are integrated in accordance with the Health
Home Initiative established under
the federal Patient Protection and Affordable Health Care
Act of 2010. This includes, but is not
limited to, behavioral healthcare services provided through
the department of behavioral
healthcare, developmental disabilities, and hospitals, and
CEDARR services available through the
department of human services as well as other services deemed
qualified under the Health Home
Initiative by the Medicaid single
state agency. As a condition of
obtaining approval to participate
in the Initiative, the single state agency is required
to submit a Medicaid state plan amendment
and any waiver changes that may be mandated by CMS thereafter.
Also, each of the EOHHS
departments participating may be required to adopt new or amended
rules, regulations and
procedures related to the populations and/or providers affected
upon implementation.
(e)
agency is proposing a restructuring of the payment
methodology for certain Medicaid funded out-
patient hospital services. Under the terms and conditions of
the Global Consumer Choice
Compact Waiver, provider rate reforms such as those
proposed require a Category II change.
Certain regulations, rules and procedures pertaining
to provider payment rates may also require
revision.
(f) Medicaid Money Follows the Person Demonstration. The Medicaid
single state
agency has been accepted to participate in the federal Money
Follows the Person Demonstration,
which provides enhanced funding for certain services
provided to Medicaid long-term care
beneficiaries receiving care and support at home or in the
community. Although no changes to the
Global Consumer Choice Compact Waiver are expected to
be necessary during implementation
of the demonstration, certain new or amended rules,
regulations and procedures may be required
to take full advantage of the federal funding available
for transition and diversion services
authorized under the Money Follows the Person Demonstration.
(g) System of Care Implementation -- Department of Children, Youth and
Families
(DCYF). The DCYF proposes to continue implementation of
comprehensive reform of the system
of care for children at risk for or requiring
out-of-home placement and their families. Components
of implementation involve restructuring the payment
methodology for certain Medicaid funded
services and establishing prior approval for the duration of
residential services, paid in part or in
full by Medicaid. Accordingly, the DCYF and Medicaid
single state agency are required to
pursue Category II changes to the Global Consumer Choice
Compact Waiver in those areas
where additional authority is warranted for implementation
to proceed under the terms and
conditions of the demonstration agreement. The DCYF may adopt or
amend rules, regulations
and procedures as appropriate, once such federal
authorities have been secured.
(h) Medicaid Coverage for Costs Not Otherwise Matchable
(CNOM) for DCYF parent
aides and other
home-based services. The DCYF
proposes to begin Medicaid claiming for certain
core home and community based services, approved under the
Global Consumer Choice Compact
Waiver, that are provided to children and families at risk for
Medicaid and/or out of home
placement. The DCYF and Medicaid single state agency are
required to obtain the necessary
Category I or Category II changes necessary to begin
this claiming.
(i)
Project Sustainability for Persons with
Development Disabilities –Department of
Behavioral
Healthcare, Developmental Disabilities, and Hospitals (DBHDDH). The
DBHDDH
proposes to continue system reforms that are changing how
beneficiaries are assessed for services
and the manner in which services are obtained as well as
the payment structure. Because
implementation of this proposal is related to adoption of a new
payment structure for a Medicaid
funded service, a Category II change is required under the
terms and conditions established for
the Global Consumer Choice Compact Waiver. Further,
implementation of Project Sustainability
may also require changes to the rules, regulations and
procedures related to Medicaid services for
persons with developmental disabilities served by the DBHDDH;
(j) RIte
Care Cost Sharing Requirements. The department of humans
services will make
the necessary changes to raise the RIte
Care monthly cost sharing requirement to five percent
(5%) of family income as outlined in
effective October 1, 2011. Implementation of these
modifications require changes to the rules,
regulations and procedures related to managed care for the populations
affected and category II
changes to the global consumer choice compact waiver in those
areas where additional authority
under the terms and conditions of the demonstration
agreement are warranted; now therefore, be
it
RESOLVED, That the general assembly hereby approves proposals (a)
through (j) listed
above to amend the demonstration; and be it further
RESOLVED, That the secretary of the office of health and human
services is authorized
to pursue and implement any waiver amendments, category
II or category III changes, state plan
amendments and/or changes to the applicable department’s rules,
regulations and procedures
approved herein and as authorized by § 42-12.4-7; and be it
further
RESOLVED,
That this Joint resolution shall take effect upon
passage.
SECTION 2. The state medical assistance program includes a
comprehensive managed
care design to deliver services to various populations.
The general assembly finds that a review of
the current system is necessary to determine if the
design meets the goals of increased efficiency,
reduced cost, curtailment of high cost services, and the
development of meaningful incentives to
promote the utilization of primary care services. The review shall
include measures of program
effectiveness, services utilization, quality measures, and
utilization patterns as compared to other
payers. Recommendations with respect to the design the state
medical assistance program should
include, but not be limited to, the scope of services
included in the medical assistance program
managed care contracts, alternatives that promote meaningful
innovation and cost efficiency, and
alternative designs to promote the goals stated therein.
The
executive office of health and human services is directed to report the
findings and
recommendations contained in the review no later than January 1,
2012, with copies to the
speaker of the house, senate president, chairs of the house
and senate finance committees and the
house and senate fiscal advisors.
SECTION 3. Integration of Care and
Financing for Medicare and Medicaid Beneficiaries.
(a)
Expansion and integration of care management strategies. By July 2012, the
department of human services shall establish a contractual
agreement between the Medicaid
agency and a contractor (e.g., managed care entity) to
manage primary, acute and long-term care
services for Medicaid-only beneficiaries and for individuals
dually eligible for Medicaid and
Medicare.
The
department is directed to seek federal authority from the Centers for Medicare
and
Medicaid Services,
including the negotiation of an agreement for the state to share in any savings
that accrue to the Medicare program as a result of this
initiative. The changes in service delivery
will require changes to the rules, regulations and
procedures governing this area for Medicaid-
only and dually eligible beneficiaries, as well as
Category II changes to the Global Consumer
Choice Compact Waiver
authorizing the expansion of managed care to new service areas and
populations.
The
department shall present a report on this initiative to the Permanent Joint
Legislative
Committee on Health Care
Oversight and Chairpersons of the House and Senate Finance
Committees
no later than December 31, 2011.