Chapter 341
2013 -- H 6283
Enacted 07/15/13
A N A C T
RELATING TO
HEALTH AND SAFETY - THE
Introduced By: Representatives Keable, Tanzi, Blazejewski, and Silva
Date Introduced: June 26, 2013
It is enacted by the
General Assembly as follows:
SECTION 1. Legislative findings.
The general assembly declares that:
(1)
It is the intention of the
to high quality health care at an affordable cost;
(2)
Transparency is key in achieving an accountable and
competitive health care system
with increased consumer confidence;
(3)
Attraction, retention and training of a diverse workforce is critically
important to the
evolution of health care service delivery;
(4)
Rhode Islanders would benefit from instituting healthcare reforms that are tied
to
patient centered care and values based outcomes; and
(5)
This act aims to build upon existing efforts in the state among health plans,
providers
and state entities to reduce costs, improve transparency
and enhance investments in the Rhode
Island healthcare system
while providing opportunities for innovation in the delivery of
healthcare services.
SECTION 2. Section 23-17-10.2 of the General Laws in Chapter
23-17 entitled
"Licensing of Health
Care Facilities" is hereby amended to read as follows:
23-17-10.2. Full
financial disclosure by hospitals. -- Any hospital licensed under this
chapter, other than state-operated hospitals, shall annually
submit to the director of business
regulation the department of health:
(a) public Public
audited financial statements containing information concerning all
hospital-related corporations, holding corporations and subsidiary
corporations, whether for-profit
or not-for-profit. Any hospital corporation, holding
corporation, or subsidiary corporation,
whether for-profit or not-for-profit, which is not audited by
an independent public auditor due to
limited activity or small size, shall submit a financial
statement certified by the chief executive
officer of that corporation. All information provided
shall be available to the public for
inspection.
(b) Any hospitals
licensed under this chapter, other than state operated hospitals shall on
or before January 1, 2014 and annually thereafter,
submit a summary of financial information in
accordance with the following: (1) Not-for-profit hospitals
shall submit a summary of the
information contained in section 501(c), 527, or 4947(a)(1) of
the internal revenue code 990 form
including:
(i)
Its statement of financial position;
(ii) The verified
total costs incurred by the hospital in providing health services;
(iii) Total payroll
including fringe benefits, and any other remuneration of the top five (5)
highest compensated employees and/or contractors, identified
by position description and
specialty;
(iv)
The verified net costs of medical education; and
(v) Administrative
expenses; as defined by the director of the department of health.
(2) For-profit
hospitals shall submit the information listed in (b)(1)
of this section in a
form approved by the department of health.
(c) All information provided
shall be made available to the healthcare planning and
accountability advisory council, as established in section 23-81-4
and shall be made available to
the public for inspection.
SECTION 3. Section 23-17-40 of the General Laws in Chapter
23-17 entitled "Licensing
of Health Care Facilities" is hereby amended to
read as follows:
23-17-40.
Hospital events reporting. -- (a) Definitions. As used in
this section, the
following terms shall have the following meanings:
(1) "Adverse event"
means injury to a patient resulting from a medical intervention, and
not to the underlying condition of the patient.
(2) "Checklist
of care" means predetermined steps to be followed by a team of healthcare
providers before, during or after a given procedure to decrease
the possibility of adverse effects
and other patient harm by articulating standards of care.
(b) Reportable
events as defined in subsection (b)(c)
shall be reported to the department
of health division of facilities regulation on a
telephone number maintained for that purpose.
Hospitals shall report incidents as defined in
subsection (b)(c) within twenty-four (24) hours of
when the accident occurred or if later, within twenty-four
(24) hours of receipt of information
causing the hospital to believe that a reportable event has
occurred.
(b)(c) (1)
Reportable events are defined as follows:
(i)(1) Fires or internal disasters in the
facility which disrupt the provisions of patient care
services or cause harm to patients or personnel;
(ii)(2)
Poisoning involving patients of the facility;
(iii)(3)
Infection outbreaks as defined by the department in regulation;
(iv)(4)
Kidnapping and inpatient psychiatric elopements and elopements by minors;
(v)(5)
Strikes by personnel;
(vi)(6)
Disasters or other emergency situations external to the hospital environment
which adversely affect facility operations; and
(vii)(7)
Unscheduled termination of any services vital to the continued safe operation
of
the facility or to the health and safety of its patients
and personnel.
(2)(d)
Any hospital filing a report with the attorney general's office concerning
abuse,
neglect and mistreatment of patients as defined in chapter 17.8
of this title shall forward a copy of
the report to the department of health. In addition, a
copy of all hospital notifications and reports
made in compliance with the federal Safe Medical Devices
Act of 1990, 21 U.S.C. section 301 et
seq., shall be forwarded to
the department of health within the time specified in the federal law.
(c)(e) Any
reportable incident in a hospital that results in patient injury as defined in
subsection (d)(f) shall be reported to the
department of health with seventy-two (72) hours or
when the hospital has reasonable cause to believe that an
incident as defined in subsection (d) (f)
has occurred. The department of health shall promulgate
rules and regulations to include the
process whereby health care professionals with knowledge of
an incident shall report it to the
hospital, requirements for the hospital to conduct a root
cause analysis of the incident or other
appropriate process for incident investigation and to develop and
file a performance improvement
plan, and additional incidents to be reported that are in
addition to those listed in subsection
(d)(f). In its reports, no personal
identifiers shall be included. The hospital shall require the
appropriate committee within the hospital to carry out a peer
review process to determine whether
the incident was within the normal range of outcomes,
given the patient's condition. The hospital
shall notify the department of the outcome of the internal
review, and if the findings determine
that the incident was within the normal range of patient
outcomes no further action is required. If
the findings conclude that the incident was not within
the normal range of patient outcomes, the
hospital shall conduct a root cause analysis or other
appropriate process for incident investigation
to identify causal factors that may have lead to the
incident and develop a performance
improvement plan to prevent similar incidents from occurring in
the future. The hospital shall
also provide to the department of health the following
information:
(1) An explanation of
the circumstances surrounding the incident;
(2) An updated
assessment of the effect of the incident on the patient;
(3) A summary of
current patient status including follow-up care provided and post-
incident diagnosis; and
(4) A summary of all
actions taken to correct identified problems to prevent recurrence
of the incident and/or to improve overall patient care
and to comply with other requirements of
this section.
(d)(f) Incidents
to be reported are those causing or involving:
(1) Brain injury;
(2) Mental impairment;
(3) Paraplegia;
(4) Quadriplegia;
(5) Any type of
paralysis;
(6) Loss of use of limb
or organ;
(7) Hospital stay extended
due to serious or unforeseen complications;
(8) Birth injury;
(9) Impairment of sight
or hearing;
(10) Surgery on the
wrong patient;
(11) Subjecting a
patient to a procedure other than that ordered or intended by the
patient's attending physician;
(12) Any other incident
that is reported to their malpractice insurance carrier or self-
insurance program;
(13) Suicide of a
patient during treatment or within five (5) days of discharge from an
inpatient or outpatient unit (if known);
(14) Blood transfusion
error; and
(15) Any serious or
unforeseen complication, that is not expected or probable, resulting
in an extended hospital stay or death of the patient.
(e)(g)
This section does not replace other reporting required by this chapter.
(f)(h)
Nothing in this section shall prohibit the department from investigating any
event
or incident.
(g)(i) All reports to the department under this section
shall be subject to the provisions of
section 23-17-15. In addition, all reports under this
section, together with the peer review records
and proceedings related to events and incidents so
reported and the participants in the proceedings
shall be deemed entitled to all the privileges and
immunities for peer review records set forth in
section 23-17-25.
(h)(j)
The department shall issue an annual report by March 31 each year providing
aggregate summary information on the events and incidents
reported by hospitals as required by
this chapter. A copy of the report shall be forwarded to
the governor, the speaker of the house, the
senate president and members of the health care quality
steering committee established pursuant
to section 23-17.17-6.
(i)(k) The director shall review the list
of incidents to be reported in subsection (d)(f)
above at least biennially to ascertain whether any
additions, deletions or modifications to the list
are necessary. In conducting the review, the director
shall take into account those adverse events
identified on the National Quality Forum's List of Serious
Reportable Events. In the event the
director determines that incidents should be added, deleted or
modified, the director shall make
such recommendations for changes to the legislature.
SECTION 4. Section 23-81-4 of the General Laws in Chapter
23-81 entitled "Rhode
Island Coordinated Health
Planning Act of 2006" is hereby amended to read as follows:
23-81-4. Powers of
the health care planning and accountability advisory council. --
Powers of the council shall include, but not be
limited to the following:
(a) The authority to
develop and promote studies, advisory opinions and to recommend a
unified health plan on the state's health care delivery and
financing system, including but not
limited to:
(1) Ongoing assessments
of the state's health care needs and health care system capacity
that are used to determine the most appropriate capacity
of and allocation of health care
providers, services, including transportation services, and
equipment and other resources, to meet
advise the "determination of need for new health care
equipment and new institutional health
services" or "certificate of need" process
through the health services council;
(2) The establishment
of
recommendation of innovative models of health care delivery, that
should be encouraged in
(3) Health care payment
models that reward improved health outcomes;
(4) Measurements of
quality and appropriate use of health care services that are designed
to evaluate the impact of the health planning process;
(5) Plans for promoting
the appropriate role of technology in improving the availability
of health information across the health care system,
while promoting practices that ensure the
confidentiality and security of health records; and
(6) Recommendations of
legislation and other actions that achieve accountability and
adherence in the health care community to the council's plans
and recommendations.
(b) Convene meetings of
the council no less than every sixty (60) days, which shall be
subject to the open meetings laws and public records laws of
the state, and shall include a process
for the public to place items on the council's agenda.
(c) Appoint advisory
committees as needed for technical assistance throughout the
process.
(d) Modify
recommendations in order to reflect changing health care systems needs.
(e) Promote
responsiveness to recommendations among all state agencies that provide
health service programs, not limited to the five (5) state
agencies coordinated by the executive
office of the health and human services.
(f) Coordinate the
review of existing data sources from state agencies and the private
sector that are useful to developing a unified health plan.
(g) Formulating,
testing, and selecting policies and standards that will achieve desired
objectives.
(h) In consultation
with the office of the health insurance commissioner, the council shall
review health system total cost drivers and provide
findings, and, if appropriate related
recommendations to the governor and general assembly on or before
July 1, 2014.
(i)
Coordinate a comprehensive review of mental health and substance abuse
incidence
rates, service use rates, capacity and potentially high and
rising spending.
(j) Examine the
volume and spending trends for pediatric inpatient and outpatient
services, including the evolving role of intensive care units
(ICUs).
(k)
Subject to available resources and time, in consultation with the department of
health,
provide periodic assessments beginning on or before October
1, 2014, to the general assembly on
the appropriate mix of
analyses of current and future primary care professional
supply and demand, recruitment, scope
of practice and licensure, workforce training issues,
and potential incentives with
recommendations to enhance the supply and diversity of the primary
care workforce.
(h)(l)
Provide an annual report each July, after the convening of the council, to the
governor and general assembly on implementation of the plan
adopted by the council. This
annual report shall:
(1) Present the
strategic recommendations, updated annually;
(2) Assess
the implementation of strategic recommendations in the health care market;
(3) Compare and analyze
the difference between the guidance and the reality;
(4) Recommend to the
governor and general assembly legislative or regulatory revisions
necessary to achieve the long-term goals and values adopted by
the council as part of its strategic
recommendations, and assess the powers needed by the council or
governmental entities of the
state deemed necessary and appropriate to carry out the
responsibilities of the council. The initial
priority of the council shall be an assessment of the needs of
the state with regard to hospital
services and to present recommendations, if any, for modifications
to the Hospital Conversion
Act and the Certificate of Need
Program to execute the strategic recommendations of the council.
The council shall provide an initial report and
recommendations to the governor and general
assembly on or before March 1, 2013.
(5) Include the request
for a hearing before the appropriate committees of the general
assembly.
(6) Include a response
letter from each state agency that is affected by the state health
plan describing the actions taken and planned to implement
the plans recommendations.
SECTION 5. Chapter 27-69 of the General Laws entitled
"Mandated Benefits" is hereby
amended by adding thereto the following section:
27-69-7. Mandated benefit statement of intent. – Notwithstanding any
general law
enacted after January 1, 2014, any legislation that would
create a new state health benefit
mandate, or expand upon an existing health benefit, shall
contain a statement of intent that clearly
provides the purpose and objectives of the health benefit
mandate, including measurable goals
expected to be achieved by the new or expanded benefit
mandate. These goals should address
both commercial insurance affordability and population
health outcomes.
SECTION 6. Section 42-14.5-3 of the General Laws in Chapter
42-14.5 entitled "The
Rhode Island Health Care
Reform Act of 2004 - Health Insurance Oversight" is hereby amended
to read as follows:
42-14.5-3.
Powers and duties. [Contingent effective date; see
effective dates under
this section.] -- The health insurance commissioner shall have the following powers and
duties:
(a) To conduct
quarterly public meetings throughout the state, separate and distinct from
rate hearings pursuant to section 42-62-13, regarding the
rates, services and operations of insurers
licensed to provide health insurance in the state the effects
of such rates, services and operations
on consumers, medical care providers, patients, and the
market environment in which such
insurers operate and efforts to bring new health insurers into
the
not less than ten (10) days of said hearing(s) shall go
to the general assembly, the governor, the
Rhode Island Medical Society, the Hospital Association
of Rhode Island, the director of health,
the attorney general and the chambers of commerce. Public
notice shall be posted on the
department's web site and given in the newspaper of general
circulation, and to any entity in
writing requesting notice.
(b) To make
recommendations to the governor and the house of
representatives and
senate finance committees regarding health care insurance
and the regulations, rates, services,
administrative expenses, reserve requirements, and operations of
insurers providing health
insurance in the state, and to prepare or comment on, upon the
request of the governor, or
chairpersons of the house or senate finance committees, draft
legislation to improve the regulation
of health insurance. In making such recommendations, the
commissioner shall recognize that it is
the intent of the legislature that the maximum disclosure
be provided regarding the
reasonableness of individual administrative expenditures as well as
total administrative costs. The
commissioner shall also make recommendations on the levels
of reserves including consideration
of: targeted reserve levels; trends in the increase or
decrease of reserve levels; and insurer plans
for distributing excess reserves.
(c) To establish a
consumer/business/labor/medical advisory council to obtain
information and present concerns of consumers, business and
medical providers affected by
health insurance decisions. The council shall develop
proposals to allow the market for small
business health insurance to be affordable and fairer. The
council shall be involved in the
planning and conduct of the quarterly public meetings in
accordance with subsection (a) above.
The advisory council shall develop measures to inform
small businesses of an insurance
complaint process to ensure that small businesses that
experience rate increases in a given year
may request and receive a formal review by the
department. The advisory council shall assess
views of the health provider community relative to
insurance rates of reimbursement, billing and
reimbursement procedures, and the insurers' role in promoting
efficient and high quality health
care. The advisory council shall issue an annual report of
findings and recommendations to the
governor and the general assembly and present their findings at
hearings before the house and
senate finance committees. The advisory council is to be
diverse in interests and shall include
representatives of community consumer organizations; small
businesses, other than those
involved in the sale of insurance products; and hospital,
medical, and other health provider
organizations. Such representatives shall be nominated by their
respective organizations. The
advisory council shall be co-chaired by the health insurance
commissioner and a community
consumer organization or small business member to be elected
by the full advisory council.
(d) To establish and
provide guidance and assistance to a subcommittee ("The
Professional Provider-Health Plan Work Group") of
the advisory council created pursuant to
subsection (c) above, composed of health care providers and
Rhode
This subcommittee shall include in its annual report
and presentation before the house and senate
finance committees the following information:
(i)(1) A method whereby health plans shall
disclose to contracted providers the fee
schedules used to provide payment to those providers for
services rendered to covered patients;
(ii)(2) A
standardized provider application and credentials verification process, for the
purpose of verifying professional qualifications of
participating health care providers;
(iii)(3)
The uniform health plan claim form utilized by participating providers;
(iv)(4)
Methods for health maintenance organizations as defined by section 27-41-1, and
nonprofit hospital or medical service corporations as defined
by chapters 27-19 and 27-20, to
make facility-specific data and other medical
service-specific data available in reasonably
consistent formats to patients regarding quality and costs. This
information would help consumers
make informed choices regarding the facilities and/or
clinicians or physician practices at which to
seek care. Among the items considered would be the unique
health services and other public
goods provided by facilities and/or clinicians or physician
practices in establishing the most
appropriate cost comparisons.;
(v)(5)
All activities related to contractual disclosure to participating providers of
the
mechanisms for resolving health plan/provider disputes; and
(vi)(6)
The uniform process being utilized for confirming in real time patient
insurance
enrollment status, benefits coverage, including co-pays and
deductibles.;
(vii)(7) Information
related to temporary credentialing of providers seeking to participate
in the plan's network and the impact of said activity on
health plan accreditation;
(viii)(8)
The feasibility of regular contract renegotiations between plans and the
providers in their networks.; and
(ix)(9)
Efforts conducted related to reviewing impact of silent PPOs
on physician
practices.
(e) To enforce the
provisions of Title 27 and Title 42 as set forth in section 42-14-5(d).
(f) To provide analysis
of the
The fund shall be used to effectuate the provisions of
sections 27-18.5-8 and 27-50-17.
(g) To analyze the
impact of changing the rating guidelines and/or merging the individual
health insurance market as defined in chapter 27-18.5 and
the small employer health insurance
market as defined in chapter 27-50 in accordance with the
following:
(i)(1) The analysis shall forecast the
likely rate increases required to effect the changes
recommended pursuant to the preceding subsection (g) in the
direct pay market and small
employer health insurance market over the next five (5) years,
based on the current rating
structure, and current products.
(ii)(2)
The analysis shall include examining the impact of merging the individual and
small employer markets on premiums charged to individuals
and small employer groups.
(iii)(3)
The analysis shall include examining the impact on rates in each of the
individual
and small employer health insurance markets and the
number of insureds in the context of
possible changes to the rating guidelines used for small
employer groups, including: community
rating principles; expanding small employer rate bonds
beyond the current range; increasing the
employer group size in the small group market; and/or adding
rating factors for broker and/or
tobacco use.
(iv)(4)
The analysis shall include examining the adequacy of current statutory and
regulatory oversight of the rating process and factors employed
by the participants in the
proposed new merged market.
(v)(5)
The analysis shall include assessment of possible reinsurance mechanisms and/or
federal high-risk pool structures and funding to support the
health insurance market in Rhode
Island by reducing the risk of adverse selection and
the incremental insurance premiums charged
for this risk, and/or by making health insurance
affordable for a selected at-risk population.
(vi)(6)
The health insurance commissioner shall work with an insurance market merger
task force to assist with the analysis. The task force
shall be chaired by the health insurance
commissioner and shall include, but not be limited to,
representatives of the general assembly, the
business community, small employer carriers as defined in
section 27-50-3, carriers offering
coverage in the individual market in
general public.
(vii)(7)
For the purposes of conducting this analysis, the commissioner may contract
with an outside organization with expertise in fiscal
analysis of the private insurance market. In
conducting its study, the organization shall, to the extent
possible, obtain and use actual health
plan data. Said data shall be subject to state and federal
laws and regulations governing
confidentiality of health care and proprietary information.
(viii)(8)
The task force shall meet as necessary and include their findings in the annual
report and the commissioner shall include the information in
the annual presentation before the
house and senate finance committees.
(h) To establish and
convene a workgroup representing health care providers and health
insurers for the purpose of coordinating the development of
processes, guidelines, and standards
to streamline health care administration that are to be
adopted by payors and providers of health
care services operating in the state. This workgroup shall
include representatives with expertise
that would contribute to the streamlining of health care
administration and that are selected from
hospitals, physician practices, community behavioral health
organizations, each health insurer
and other affected entities. The workgroup shall also
include at least one designee each from the
Organizations, the
(1) Establishing a
consistent standard for electronic eligibility and coverage verification.
Such standard shall:
(i) Include standards for eligibility inquiry and
response and, wherever possible, be
consistent with the standards adopted by nationally recognized
organizations, such as the centers
for Medicare and Medicaid services;
(ii) Enable providers
and payors to exchange eligibility requests and
responses on a
system-to-system basis or using a payor
supported web browser;
(iii) Provide
reasonably detailed information on a consumer's eligibility for health care
coverage, scope of benefits, limitations and exclusions
provided under that coverage, cost-sharing
requirements for specific services at the specific time of the
inquiry, current deductible amounts,
accumulated or limited benefits, out-of-pocket maximums, any
maximum policy amounts, and
other information required for the provider to collect the
patient's portion of the bill;
(iv)
Reflect the necessary limitations imposed on payors
by the originator of the
eligibility and benefits information;
(v) Recommend a
standard or common process to protect all providers from the costs of
services to patients who are ineligible for insurance coverage
in circumstances where a payor
provides eligibility verification based on best information
available to the payor at the date of the
request of eligibility.
(2) Developing
implementation guidelines and promoting adoption of such guidelines
for:
(i)
The use of the national correct coding initiative code edit policy by payors and
providers in the state;
(ii) Publishing any
variations from codes and mutually exclusive codes by payors
in a
manner that makes for simple retrieval and implementation by
providers;
(iii)
Use of health insurance portability and accountability act standard group
codes,
reason codes, and remark codes by payors
in electronic remittances sent to providers;
(iv)
The processing of corrections to claims by providers and payors.
(v) A standard payor denial review process for providers when they request
a
reconsideration of a denial of a claim that results from differences
in clinical edits where no
single, common standards body or process exists and multiple
conflicting sources are in use by
payors and providers.
(vi)
Nothing in this section or in the guidelines developed shall inhibit an
individual
payor's ability to employ, and not disclose to providers,
temporary code edits for the purpose of
detecting and deterring fraudulent billing activities. The
guidelines shall require that each payor
disclose to the provider its adjudication decision on a claim
that was denied or adjusted based on
the application of such edits and that the provider have
access to the payor's review and appeal
process to challenge the payor's
adjudication decision.
(vii) Nothing in this
subsection shall be construed to modify the rights or obligations of
payors or providers with respect to procedures relating to
the investigation, reporting, appeal, or
prosecution under applicable law of potentially fraudulent
billing activities.
(3) Developing and
promoting widespread adoption by payors and providers
of
guidelines to:
(i)
Ensure payors do not automatically deny claims for
services when extenuating
circumstances make it impossible for the provider to obtain a
preauthorization before services are
performed or notify a payor within an
appropriate standardized timeline of a patient's admission;
(ii) Require payors to use common and consistent processes and time
frames when
responding to provider requests for medical management
approvals. Whenever possible, such
time frames shall be consistent with those established by
leading national organizations and be
based upon the acuity of the patient's need for care or
treatment. For the purposes of this section,
medical management includes prior authorization of services,
preauthorization of services,
precertification of services, post service review, medical necessity
review, and benefits advisory;
(iii) Develop,
maintain, and promote widespread adoption of a single common website
where providers can obtain payors'
preauthorization, benefits advisory, and preadmission
requirements; and
(iv)
Establish guidelines for payors to develop and
maintain a website that providers can
use to request a preauthorization, including a
prospective clinical necessity review; receive an
authorization number; and transmit an admission notification.
(j) To monitor the
adequacy of each health plan's compliance with the provisions of the
federal mental health parity act, including a review of
related claims processing and
reimbursement procedures. Findings, recommendations and assessments
shall be made available
to the public.
(k) To monitor the
transition from fee for service and toward global and other alternative
payment methodologies for the payment for healthcare
services. Alternative payment
methodologies should be assessed for their likelihood to promote
access to affordable health
insurance, health outcomes and performance.
(l) To report
annually, no later than July 1, 2014, then biannually thereafter, on hospital
payment variation, including findings and recommendations,
subject to available resources.
(m) Notwithstanding
any provision of the general or public laws or regulation to the
contrary, provide a report with findings and recommendations
to the president of the senate and
the speaker of the house, on or before April 1, 2014,
including, but not limited to, the following
information:
(1) The impact of
the current mandated healthcare benefits as defined in sections 27-18-
48.1, 27-18-60, 27-18-62, 27-18-64, similar provisions
in title 27, chapters 19, 20 and 41, and
subsection 27-18-3(c), 27-38.2-1 et seq., or others as
determined by the commissioner, on the cost
of health insurance for fully insured employers, subject
to available resources;
(2) Current provider
and insurer mandates that are unnecessary and/or
duplicative due to
the existing standards of care and/or delivery of
services in the healthcare system;
(3) A state-by-state
comparison of health insurance mandates and the extent to which
(4) Recommendations
for amendments to existing mandated benefits based on the
findings in (1), (2) and (3) above.
(n) On or before
July 1, 2014, the office of the health insurance commissioner in
collaboration with the director of health and lieutenant governor's
office shall submit a report to
the general assembly and the governor to inform the
design of accountable care organizations
(ACOs) in
based payment arrangements, that shall include, but not
limited to:
(1) Utilization
review;
(2) Contracting; and
(3) Licensing and
regulation.
SECTION 7. Section 42-14.6-4 of the General Laws in Chapter
42-14.6 entitled "Rhode
Island All-Payer
Patient-Centered Medical Home Act" is hereby amended to read as follows:
42-14.6-4.
Promotion of the patient-centered medical home. --
(a) Care coordination
payments.
(1) The commissioner
and the secretary shall convene a patient-centered medical home
collaborative consisting of the entities described in subdivision
42-14.6-3(7). The commissioner
shall require participation in the collaborative by all of
the health insurers described above. The
collaborative shall propose, by January 1, 2012, a payment system,
to be adopted in whole or in
part by the commissioner and the secretary, that requires
all health insurers to make per-person
care coordination payments to patient-centered medical
homes, for providing care coordination
services and directly managing on-site or employing care
coordinators as part of all health
insurance plans offered in
health care program as to the appropriate payment system for
the state health care program to the
same patient-centered medical homes; the state health care
program must justify the reasons for
any departure from this guidance to the collaborative.
(2) The care
coordination payments under this shall be consistent across insurers and
patient-centered medical homes and shall be in addition to any other
incentive payments such as
quality incentive payments. In developing the criteria for
care coordination payments, the
commissioner shall consider the feasibility of including the
additional time and resources needed
by patients with limited English-language skills,
cultural differences, or other barriers to health
care. The commissioner may direct the collaborative to
determine a schedule for phasing in care
coordination fees.
(3) The care
coordination payment system shall be in place through July 1, 2016. Its
continuation beyond that point shall depend on results of the
evaluation reports filed pursuant to
section 42-14.6-6.
(4) Examination of
other payment reforms. - By January 1, 2013, the commissioner and
the secretary shall direct the collaborative to consider
additional payment reforms to be
implemented to support patient-centered medical homes including,
but not limited to, payment
structures (to medical home or other providers) that:
(i)
Reward high-quality, low-cost providers;
(ii) Create enrollee
incentives to receive care from high-quality, low-cost providers;
(iii) Foster
collaboration among providers to reduce cost shifting from one part of the
health continuum to another; and
(iv) Create incentives
that health care be provided in the least restrictive,
most
appropriate setting.
(5) The
patient-centered medical home collaborative shall examine and make
recommendations to the secretary regarding the designation of
patient-centered medical homes, in
order to promote diversity in the size of practices designated,
geographic locations of practices
designated and accessibility of the population throughout the
state to patient-centered medical
homes.
(b) The
patient-centered medical home collaborative shall propose to the secretary for
adoption, the standards for the patient-centered
medical home to be used in the payment system,
based on national models where feasible. In developing these standards, the existing
standards by
the national committee for quality assurance, or other
independent accrediting organizations may
be considered where feasible.
SECTION 8. Chapter 42-14.6 of the General Laws entitled
"Rhode Island All-Payer
Patient-Centered Medical
Home Act" is hereby amended by adding thereto the following section:
42-14.6-9.
State patient-centered medical home program expansion. --
(a) The
director of the department of administration is hereby
authorized to expand the current patient-
centered medical home program for state employees and retirees
with chronic health conditions
that are covered by the state employees health benefit
program and are high frequency healthcare
utilizers. This program shall be in addition to and shall not
alter the
Patient-Centered Medical Home Act as set forth in
section 42-14.6-4.
(b) For the purposes
of this program, "high utilizers" means individuals who are among
the top one to five percent (1-5%) of utilization within
their payer group.
(c)
"Patient-centered medical home" means a practice that satisfies the
characteristics
described in section 42-14.6-2.
SECTION 9. This act shall take effect upon passage.
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LC02899
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