law16142-07

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art.007/5/007/4/007/3/007/2/009/1

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ARTICLE 7 AS AMENDED

RELATING TO HEALTH AND HUMAN SERVICES

SECTION 1. Section 27-18-64 of the General Laws in Chapter 27-18 entitled “Accident

and Sickness Insurance Policies” is hereby amended to read as follows:

27-18-64. Coverage for early intervention services. -- (a) Every individual or group

hospital or medical expense insurance policy or contract providing coverage for dependent

children, delivered or renewed in this state on or after July 1, 2004, shall include coverage of

early-intervention services which coverage shall take effect no later than January 1, 2005. Such

coverage shall not be subject to deductibles and coinsurance factors. Any amount paid by an

insurer under this section for a dependent child shall not be applied to any annual or lifetime

maximum benefit contained in the policy or contract. For the purpose of this section, "early-

intervention services" means, but is not limited to, speech and language therapy, occupational

therapy, physical therapy, evaluation, case management, nutrition, service-plan development and

review, nursing services, and assistive technology services and devices for dependents from birth

to age three (3) who are certified by the executive office of health and human services as eligible

for services under part C of the Individuals with Disabilities Education Act (20 U.S.C. § 1471 et

seq.).

(b) Insurers shall reimburse certified, early intervention providers, who are designated as

such by the executive office of health and human services, for early intervention services as

defined in this section at rates of reimbursement equal to, or greater than, the prevailing

integrated state Medicaid rate for early intervention services as established by the executive office

of health and human services.

hHospital confinement indemnity; (2) dDisability income; (3) aAccident only; (4) lLong-term

care; (5) Medicare supplement; (6) lLimited-benefit health; (7) sSpecified disease indemnity; (8)

sSickness or bodily injury or death by accident or both; and (9) oOther limited-benefit policies.

SECTION 2. Sections 40-8-13.4 and 40-8-19 of the General Laws in Chapter 40-8

entitled “Medical Assistance” are hereby amended to read as follows:

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

services. -- (a) The executive office of health and human services ("executive office") 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 executive office of health

and human services shall:

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

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

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

which that 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 DRG

may include cost outlier payments and other specific exceptions. The executive office will review

the DRG-payment method and the DRG base price annually, making adjustments as appropriate

in consideration of such elements as trends in hospital input costs,; patterns in hospital coding,;

beneficiary access to care,; and the Centers for Medicare and Medicaid Services national CMS

Prospective Payment System (IPPS) Hospital Input Price index. For the twelve- (12) month (12)

period beginning July 1, 2015, the DRG base rate for Medicaid fee-for-service inpatient hospital

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

as of July 1, 2014.

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

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

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

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

(12) period beginning January 1, 2012 may not exceed the Centers for Medicare and Medicaid

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

applicable period; (B) pProvided, however, for the twenty-four- (24) month (24) period

beginning July 1, 2013, the Medicaid managed care payment rates between each hospital and

health plan shall not exceed the payment rates in effect as of January 1, 2013, and for the twelve-

(12) month (12) period beginning July 1, 2015, the Medicaid managed-care payment inpatient

rates between each hospital and health plan shall not exceed ninety-seven and one-half percent

(97.5%) of the payment rates in effect as of January 1, 2013; (C) nNegotiated increases in

inpatient hospital payments for each annual twelve- (12) month (12) period beginning July 1,

2016, may not exceed the Centers for Medicare and Medicaid Services national CMS Prospective

Payment System (IPPS) Hospital Input Price Index, less Productivity Adjustment, for the

applicable period; (D) The Rhode Island executive office of health and human services will

develop an audit methodology and process to assure that savings associated with the payment

reductions will accrue directly to the Rhode Island Medicaid program through reduced managed-

care-plan payments and shall not be retained by the managed-care plans; (E) All hospitals

licensed in Rhode Island shall accept such payment rates as payment in full; and (F) fFor all such

hospitals, compliance with the provisions of this section shall be a condition of participation in

the Rhode Island Medicaid program.

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

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

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

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

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

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

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

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

as of July 1, 2014. Thereafter, changes to outpatient rates will be implemented on July 1 each

year and shall align with Medicare payments for similar services from the prior federal fiscal year

increases in the outpatient hospital payments for each annual twelve-month (12) period beginning

July 1, 2016, may not exceed the CMS national Outpatient Prospective Payment System (OPPS)

Hospital Input Price Index for the applicable period. With respect to the outpatient rate, (i) iIt is

required as of January 1, 2011, until December 31, 2011, that the Medicaid managed-care

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

(100%) of the rate in effect as of June 30, 2010.; (ii) Negotiated increases in hospital outpatient

payments for each annual twelve- (12) month (12) period beginning January 1, 2012, may not

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

Payment System (OPPS) hospital price index for the applicable period; (ii) (iii) pProvided,

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

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

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

beginning July 1, 2015, the Medicaid managed-care outpatient payment rates between each

hospital and health plan shall not exceed ninety-seven and one-half percent (97.5%) of the

payment rates in effect as of January 1, 2013; (iii) (iv) negotiated increases in outpatient hospital

payments for each annual twelve- (12) month (12) period beginning July 1, 2016, may not exceed

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

System (OPPS) Hospital Input Price Index, less Productivity Adjustment, for the applicable

period.

(3) "Hospital", as used in this section, shall mean the actual facilities and buildings in

existence in Rhode Island, licensed pursuant to § 23-17-1 et seq. on June 30, 2010, and thereafter

any premises included on that license, regardless of changes in licensure status pursuant to

chapter 17.14 of title 23 § 23-17.14 (hospital conversions) and § 23-17-6(b) (change in effective

control), that provides short-term, acute inpatient and/or outpatient care to persons who require

definitive diagnosis and treatment for injury, illness, disabilities, or pregnancy. Notwithstanding

the preceding language, the negotiated Medicaid managed care payment rates for a court-

approved purchaser that acquires a hospital through receivership, special mastership or other

similar state insolvency proceedings (which court-approved purchaser is issued a hospital license

after January 1, 2013), shall be based upon the newly negotiated rates between the court-approved

purchaser and the health plan, and such rates shall be effective as of the date that the court-

approved purchaser and the health plan execute the initial agreement containing the newly

negotiated rate. The rate-setting methodology for inpatient-hospital payments and outpatient-

hospital payments set forth in the §§ subdivisions 40-8-13.4(b)(1)(ii)(C) and 40-8-13.4(b)(2),

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

(12) period as of July 1 following the completion of the first full year of the court-approved

purchaser's initial Medicaid managed care contract.

reward hospitals for providing the most efficient care, and provide the executive office the

opportunity to conduct value-based purchasing of inpatient care.

(d) The secretary of the 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 DRG-

payment methodology. Furthermore, amendment of the Rhode Island state plan for medical

assistance (Medicaid), pursuant to Title XIX of the federal 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 executive office 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 executive office 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 executive office 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. For hospital fiscal year 2010 and all subsequent

fiscal years, hospitals will not be required to submit year-end settlement reports on payments for

outpatient services. For hospital fiscal year 2011 and all subsequent fiscal years, hospitals will not

be required to submit year-end settlement reports on claims for hospital inpatient services.

Further, for hospital fiscal year 2010, hospital inpatient claims subject to settlement shall include

only those claims received between October 1, 2009, and June 30, 2010.

(g) The provisions of this section shall be effective upon implementation of the

amendments and new payment methodology set forth in pursuant to this section and § 40-8-13.3,

which shall in any event be no later than March 30, 2010, at which time the provisions of §§ 40-

8-13.2, 27-19-14, 27-19-15, and 27-19-16 shall be repealed in their entirety.

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 that must be incurred by

efficiently and economically operated facilities in accordance with 42 U.S.C. §1396a(a)(13). The

executive office of health and human services ("executive office") shall promulgate or modify the

principles of reimbursement for nursing facilities in effect as of July 1, 2011, 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 executive office of health and human services ("Executive Office") 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

replace the current cost-based methodology rates with rates based on a price-based methodology

to be paid to all facilities with recognition of the acuity of patients and the relative Medicaid

occupancy, and to include the following elements to be developed by the executive office:

(i) A direct-care rate adjusted for resident acuity;

(ii) An indirect-care rate comprised of a base per diem for all facilities;

(iii) A rearray of costs for all facilities every three (3) years beginning October, 2015,

which that may or may not result in automatic per diem revisions;

(iv) Application of a fair-rental-value system;

(v) Application of a pass-through system; and

(vi) Adjustment of rates by the change in a recognized national nursing home inflation

index to be applied on October 1st of each year, beginning October 1, 2012. This adjustment will

not occur on October 1, 2013, or October 1, 2015, but will occur on April 1, 2015. Said inflation

index shall be applied without regard for the transition factor in subsection (b)(2) below.

For purposes of October 1, 2016, adjustment only, any rate increase that results from

application of the inflation index to subparagraphs (a)(2)(i) and (a)(2)(ii) shall be dedicated to

increase compensation for direct-care workers in the following manner: Not less than 85% of this

aggregate amount shall be expended to fund an increase in wages, benefits, or related employer

costs of direct-care staff of nursing homes. For purposes of this section, direct-care staff shall

include registered nurses (RNs), licensed practical nurses (LPNs), certified nursing assistants

(CNAs), certified medical technicians, housekeeping staff, laundry staff, dietary staff, or other

similar employees providing direct care services; provided, however, that this definition of direct-

care staff shall not include: (i) RNs and LPNs who are classified as "exempt employees" under

the Federal Fair Labor Standards Act (29 U.S.C. §201 et seq.); or (ii) CNAs, certified medical

technicians, RNs, or LPNs who are contracted, or subcontracted, through a third-party vendor or

staffing agency. By July 31, 2017, nursing facilities shall submit to the secretary, or designee, a

certification that they have complied with the provisions of this subparagraph (a)(2) (vi) with

respect to the inflation index applied on October 1, 2016. Any facility that does not comply with

terms of such certification shall be subjected to a clawback, paid by the nursing facility to the

state, in the amount of increased reimbursement subject to this provision that was not expended in

compliance with that certification.

(b) Transition to full implementation of rate reform. For no less than four (4) years after

the initial application of the price-based methodology described in subdivision (a)(2) to payment

rates, the executive office of health and human services shall implement a transition plan to

moderate the impact of the rate reform on individual nursing facilities. Said transition shall

include the following components:

(1) No nursing facility shall receive reimbursement for direct-care costs that is less than

the rate of reimbursement for direct-care costs received under the methodology in effect at the

time of passage of this act; and for the year beginning October 1, 2017, the reimbursement for

direct-care costs under this provision will be phased out in twenty-five-percent (25%) increments

each year until October 1, 2021, when the reimbursement will no longer be in effect.

(2) No facility shall lose or gain more than five dollars ($5.00) in its total per diem rate

the first year of the transition. An adjustment to the per diem loss or gain may be phased out by

twenty-five percent (25%) each year; except, however, for the year beginning October 1, 2015,

there shall be no adjustment to the per diem gain or loss, but the phase out shall resume

thereafter; and

(3) The transition plan and/or period may be modified upon full implementation of

facility per diem rate increases for quality of care related measures. Said modifications shall be

submitted in a report to the general assembly at least six (6) months prior to implementation.

(4) Notwithstanding any law to the contrary, for the twelve- (12) month (12) period

beginning July 1, 2015, Medicaid payment rates for nursing facilities established pursuant to this

section shall not exceed ninety-eight percent (98%) of the rates in effect on April 1, 2015.

SECTION 3. Sections 40-8.3-2 and 40-8.3-3 of the General Laws in Chapter 40-8.3

entitled “Uncompensated Care” are hereby amended to read as follows:

40-8.3-2. Definitions. -- As used in this chapter:

(1) "Base year" means, for the purpose of calculating a disproportionate share payment

for any fiscal year ending after September 30, 2014 2015, the period from October 1, 2012 2013,

through September 30, 2013 2014, and for any fiscal year ending after September 30, 2015 2016,

the period from October 1, 2013 2014, through September 30, 2014 2015.

(2) "Medicaid inpatient utilization rate for a hospital" means a fraction (expressed as a

percentage), the numerator of which is the hospital's number of inpatient days during the base

year attributable to patients who were eligible for medical assistance during the base year and the

denominator of which is the total number of the hospital's inpatient days in the base year.

(3) "Participating hospital" means any nongovernment and nonpsychiatric hospital that:

(i) wWas licensed as a hospital in accordance with chapter 17 of title 23 during the base

year; and shall mean the actual facilities and buildings in existence in Rhode Island, licensed

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

license, regardless of changes in licensure status pursuant to chapter 17.14 of title 23 § 23-17.14

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

acute inpatient and/or outpatient care to persons who require definitive diagnosis and treatment

for injury, illness, disabilities, or pregnancy. Notwithstanding the preceding language, the

negotiated Medicaid managed care payment rates for a court-approved purchaser that acquires a

hospital through receivership, special mastership, or other similar state insolvency proceedings

(which court-approved purchaser is issued a hospital license after January 1, 2013) shall be based

upon the newly negotiated rates between the court-approved purchaser and the health plan, and

such rates shall be effective as of the date that the court-approved purchaser and the health plan

execute the initial agreement containing the newly negotiated rate. The rate-setting methodology

for inpatient hospital payments and outpatient hospital payments set for the §§ 40-8-13.4(b)(1)

(B)(iii) and 40-8-13.4(b)(2), respectively, shall thereafter apply to negotiated increases for each

annual twelve- (12) month (12) period as of July 1 following the completion of the first full year

of the court-approved purchaser's initial Medicaid managed care contract.

(ii) aAchieved a medical assistance inpatient utilization rate of at least one percent (1%)

during the base year; and

(iii) cContinues to be licensed as a hospital in accordance with chapter 17 of title 23

during the payment year.

(4) "Uncompensated-care costs" means, as to any hospital, the sum of: (i) tThe cost

incurred by such hospital during the base year for inpatient or outpatient services attributable to

charity care (free care and bad debts) for which the patient has no health insurance or other third-

party coverage less payments, if any, received directly from such patients; and (ii) tThe cost

incurred by such hospital during the base year for inpatient or out-patient services attributable to

Medicaid beneficiaries less any Medicaid reimbursement received therefor; multiplied by the

uncompensated care index.

(5) "Uncompensated-care index" means the annual percentage increase for hospitals

established pursuant to § 27-19-14 for each year after the base year, up to and including the

payment year, provided, however, that the uncompensated care index for the payment year ending

September 30, 2007, shall be deemed to be five and thirty-eight hundredths percent (5.38%), and

that the uncompensated-care index for the payment year ending September 30, 2008, shall be

deemed to be five and forty-seven hundredths percent (5.47%), and that the uncompensated-care

index for the payment year ending September 30, 2009, shall be deemed to be five and thirty-

eight hundredths percent (5.38%), and that the uncompensated-care index for the payment years

ending September 30, 2010, September 30, 2011, September 30, 2012, September 30, 2013,

September 30, 2014, and September 30, 2015, and September 30, 2016, and September 30, 2017,

shall be deemed to be five and thirty hundredths percent (5.30%).

40-8.3-3. Implementation. -- (a) For federal fiscal year 2014, commencing on October 1,

2013 and ending September 30, 2014, the executive office of health and human services shall

submit to the Secretary of the U.S. Department of Health and Human Services a state plan

amendment to the Rhode Island Medicaid state plan for disproportionate share hospital payments

(DSH Plan) to provide:

(1) That the disproportionate share hospital payments to all participating hospitals, not to

exceed an aggregate limit of $136.8 million, shall be allocated by the executive office of health

and human services to the Pool A, Pool C and Pool D components of the DSH Plan; and,

(2) That the Pool D allotment shall be distributed among the participating hospitals in

direct proportion to the individual participating hospital's uncompensated care costs for the base

year, inflated by the uncompensated care index to the total uncompensated care costs for the base

year inflated by uncompensated care index for all participating hospitals. The disproportionate

share payments shall be made on or before July 14, 2014 and are expressly conditioned upon

approval on or before July 7, 2014 by the Secretary of the U.S. Department of Health and Human

Services, or his or her authorized representative, of all Medicaid state plan amendments necessary

to secure for the state the benefit of federal financial participation in federal fiscal year 2014 for

the disproportionate share payments.

(b)(a) For federal fiscal year 2015, commencing on October 1, 2014, and ending

September 30, 2015, the executive office of health and human services shall submit to the

Secretary of the U.S. Department of Health and Human Services a state plan amendment to the

Rhode Island Medicaid state plan for disproportionate-share hospital payments (DSH Plan) to

provide:

(1) That the disproportionate share hospital payments DSH Plan to all participating

hospitals, not to exceed an aggregate limit of $140.0 million, shall be allocated by the executive

office of health and human services to the Pool A, Pool C, and Pool D components of the DSH

Plan; and,

(2) That the Pool D allotment shall be distributed among the participating hospitals in

direct proportion to the individual participating hospital's uncompensated care costs for the base

year, inflated by the uncompensated care index to the total uncompensated care costs for the base

year inflated by uncompensated care index for all participating hospitals. The disproportionate

share DSH Plan payments shall be made on or before July 13, 2015, and are expressly

conditioned upon approval on or before July 6, 2015, by the Secretary of the U.S. Department of

Health and Human Services, or his or her authorized representative, of all Medicaid state-plan

amendments necessary to secure for the state the benefit of federal financial participation in

federal fiscal year 2015 for the disproportionate share payments.

(c)(b) For federal fiscal year 2016, commencing on October 1, 2015, and ending

September 30, 2016, the executive office of health and human services shall submit to the

Secretary of the U.S. Department of Health and Human Services a state plan amendment to the

Rhode Island Medicaid state plan for disproportionate share hospital payments (DSH Plan) to

provide:

(1) That the disproportionate-share hospital payments to all participating hospitals, not to

exceed an aggregate limit of $138.2 million, shall be allocated by the executive office of health

and human services to the Pool A, Pool C and Pool D components of the DSH Plan; and,

(2) That the Pool D allotment shall be distributed among the participating hospitals in

direct proportion to the individual, participating hospital's uncompensated-care costs for the base

year, inflated by the uncompensated-care index to the total uncompensated-care costs for the base

year inflated by uncompensated-care index for all participating hospitals. The disproportionate

share payments DSH Plan shall be made on or before July 11, 2016, and are expressly

conditioned upon approval on or before July 5, 2016, by the Secretary of the U.S. Department of

Health and Human Services, or his or her authorized representative, of all Medicaid state plan

amendments necessary to secure for the state the benefit of federal financial participation in

federal fiscal year 2016 for the disproportionate share payments DSH Plan.

30, 2017, the executive office of health and human services shall submit to the Secretary of the

U.S. Department of Health and Human Services a state plan amendment to the Rhode Island

Medicaid DSH Plan to provide:

(1) That the DSH Plan to all participating hospitals, not to exceed an aggregate limit of

$139.7 million, shall be allocated by the executive office of health and human services to the Pool

D component of the DSH Plan; and,

(2) That the Pool D allotment shall be distributed among the participating hospitals in

direct proportion to the individual, participating hospital's uncompensated-care costs for the base

year, inflated by the uncompensated-care index to the total uncompensated-care costs for the base

year inflated by uncompensated-care index for all participating hospitals. The disproportionate-

share payments shall be made on or before July 11, 2017, and are expressly conditioned upon

approval on or before July 5, 2017 by the Secretary of the U.S. Department of Health and Human

Services, or his or her authorized representative, of all Medicaid state plan amendments necessary

to secure for the state the benefit of federal financial participation in federal fiscal year 2017 for

the disproportionate share payments.

(d) No provision is made pursuant to this chapter for disproportionate-share hospital

payments to participating hospitals for uncompensated-care costs related to graduate medical

education programs.

(e) The executive office of health and human services is directed, on at least a monthly

basis, to collect patient-level uninsured information, including, but not limited to, demographics,

services rendered, and reason for uninsured status from all hospitals licensed in Rhode Island.

(f) Beginning with federal FY 2016, Pool D DSH payments will be recalculated by the

state based on actual hospital experience. The final Pool D payments will be based on the data

from the final DSH audit for each federal fiscal year. Pool D DSH payments will be redistributed

among the qualifying hospitals in direct proportion to the individual, qualifying hospital's

uncompensated-care to the total uncompensated-care costs for all qualifying hospitals as

determined by the DSH audit. No hospital will receive an allocation that would incur funds

received in excess of audited uncompensated-care costs.

SECTION 4. 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 executive office of health

and human services ("executive office") 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 this section, managed care systems are also may also be defined to include a

primary care case-management model in which ancillary services are provided under the direction

of a physician in a practice, community health teams, and/or other such arrangements that meets

meet standards established by the department of human services executive office and serve the

purposes of this section. Managed-care systems may also include services and supports that

optimize the health and independence of recipients beneficiaries who are determined to need

Medicaid-funded long-term care under chapter 40-8.10 or to be at risk for such care under

applicable federal state plan or waiver authorities and the rules and regulations promulgated by

the department. Any medical assistance recipients executive office. Any Medicaid beneficiaries

who have third-party medical coverage or insurance may be provided such services through an

entity certified by or, in a contractual arrangement with, the department executive office or, as

deemed appropriate, exempt from mandatory managed care in accordance with rules and

regulations promulgated by the department of human services executive office.

obtain any approval through waiver(s), category II or III changes, and/or state-plan amendments,

from the secretary of the United States dDepartment of hHealth and hHuman sServices, 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 Medicaid beneficiaries. The waiver(s), category II or III

changes, and/or state-plan amendments shall include the authorization to extend managed care to

cover long-term-care services and supports. Such authorization shall also include, as deemed

appropriate, exempting certain 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 executive office.

(d) To ensure the delivery of timely and appropriate services to persons who become

eligible for Medicaid by virtue of their eligibility for a U.S. sSocial sSecurity aAdministration

program, the department of human services executive office is authorized to seek any and all

data-sharing agreements or other agreements with the sSocial sSecurity aAdministration 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.

SECTION 5. Sections 40-8.9-3, 40-8.9-4, 40-8.9-6, 40-8.9-7, 40-8.9-8 and 40-8.9-9 of

the General Laws in Chapter 40-8.9 entitled “Medical Assistance - Long-Term Care Service and

Finance Reform “ are hereby amended to read as follows:

40-8.9-3. Least restrictive setting requirement. -- Beginning on July 1, 2007, the

department of human services The executive office of health and human services (executive

office) is directed to recommend the allocation of existing Medicaid resources as needed to

ensure that those in need of long-term care and support services receive them in the least

restrictive setting appropriate to their needs and preferences. The department executive office is

hereby authorized to utilize screening criteria, to avoid unnecessary institutionalization of persons

during the full eligibility-determination process for Medicaid community-based care.

40-8.9-4. Unified long-term care budget. -- Beginning on July 1, 2007, a unified long-

term-care budget shall combine in a single, line-item appropriation within the department of

human services budget executive office of health and human services (executive office), annual

department of human services executive office Medicaid appropriations for nursing facility and

community-based, long-term care services for elderly sixty-five (65) years and older and younger

persons at risk of nursing home admissions (including adult day care, home health, pace, and

personal care in assisted living settings). Beginning on July 1, 2007, the total system savings

attributable to the value of the reduction in nursing home days including hospice nursing home

days paid for by Medicaid shall be allocated in the budget enacted by the general assembly for the

ensuing fiscal year for the express purpose of promoting and strengthening community-based

alternatives; provided, further, beginning July 1, 2009, said savings shall be allocated within the

budgets of the executive office and, as appropriate, the department of human services, and the

department division of elderly affairs. The allocation shall include, but not be limited to, funds to

support an on-going, statewide community education and outreach program to provide the public

with information on home and community services and the establishment of presumptive

eligibility criteria for the purposes of accessing home and community care. The home- and

community-care service presumptive eligibility criteria shall be developed through rule or

regulation on or before September 30, 2007. The allocation may also be used to fund home and

community services provided by the department division of elderly affairs for persons eligible for

Medicaid long-term care, and the co-pay program administered pursuant to section 42-chapter

66.3 of title 42. Any monies in the allocation that remain unexpended in a fiscal year shall be

carried forward to the next fiscal year for the express purpose of strengthening community-based

alternatives.

The caseload estimating conference pursuant to § 35-17-1 shall determine the amount of

general revenues to be added to the current service estimate of community-based, long-term care

services for elderly sixty-five (65) and older and younger persons at risk of nursing home

admissions for the ensuing budget year by multiplying the combined, cost per day of nursing

home and hospice nursing home days estimated at the caseload conference for that year by the

reduction in nursing home and hospice nursing home days from those in the second fiscal year

prior to the current fiscal year to those in the first fiscal year prior to the current fiscal year.

40-8.9-6. Reporting. -- Annual reports showing progress in long-term-care system

reform and rebalancing shall be submitted by April 1st of each year by the department executive

office of health and human services to the Jjoint Llegislative Ccommittee on Hhealth Ccare

Oversight as well as the finance committees of both the senate and the house of representatives

and shall include: the number of persons aged sixty-five (65) years and over and adults with

disabilities served in nursing facilities,; the number of persons transitioned from nursing homes to

Medicaid supported home- and community-based care,; the number of persons aged sixty-five

(65) years and over and adults with disabilities served in home and community care, to include

home care, adult day services, assisted living and shared living,; the dollar amounts and percent

of expenditures spent on nursing facility care and home- and community-based care,; and

estimates of the continued investments necessary to provide stability to the existing system and

establish the infrastructure and programs required to achieve system-wide systemwide reform

and the targeted goal of spending fifty percent (50%) of Medicaid long-term care dollars on

nursing facility care and fifty percent (50%) on home and community-based services.

40-8.9-7. Rate reform. -- By January 2008 the department of human services The

executive office of health and human services shall design, and require to be submitted by all

service providers, cost reports for all community-based, long-term services, including patient

liability owed and collected.

40-8.9-8. System screening. -- By January 2008 the department of human services The

executive office of health and human services shall develop and implement a screening strategy

for the purpose of identifying entrants to the publicly financed, long-term-care system prior to

application for eligibility as well as defining their potential service needs.

40-8.9-9. Long-term care re-balancing system reform goal. -- (a) Notwithstanding any

other provision of state law, the executive office of health and 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 United States Ddepartment of Hhealth and Hhuman

Sservices, and to promulgate 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 , to home- and

community-based care ; provided, further, the executive office 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 executive office 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 reformed long-term-care system 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, long- term

care hospitals, intermediate-care facilities and/or skilled nursing facilities.

executive office of health and 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, to the extent feasible,

any consumer group, advisory board, or other entity designated for such purposes, and shall

encompass eligibility determinations for long-term care services in nursing facilities, hospitals,

and intermediate-care facilities for persons with intellectual disabilities, 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 executive office is authorized to

adopt clinical and/or functional criteria for admission to a nursing facility, hospital, or

intermediate- care facility for persons with intellectual disabilities that are more stringent than

those employed for access to home- and community-based services. The executive office is also

authorized to promulgate rules that define the frequency of re-assessments for services provided

for under this section. Levels of care may be applied in accordance with the following:

(1) The executive office shall continue to apply the level of care criteria in effect on June

30, 2015, for any recipient determined eligible for and receiving Medicaid-funded, long-term

services in supports in a nursing facility, hospital, or intermediate-care facility for persons with

intellectual disabilities on or before that date, unless:

(a) tThe recipient transitions to home- and community-based services because he or she

would no longer meet the level of care criteria in effect on June 30, 2015; or

(b) tThe recipient chooses home- and community-based services over the nursing facility,

hospital, or intermediate-care facility for persons with intellectual disabilities. For the purposes of

this section, a failed community placement, as defined in regulations promulgated by the

executive office, shall be considered a condition of clinical eligibility for the highest level of care.

The executive office 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 persons with

intellectual disabilities as of June 30, 2015, 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 persons with intellectual

disabilities whenever possible. Additionally, residents shall only be moved from a nursing home,

hospital, or intermediate-care facility for persons with intellectual disabilities 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 persons with intellectual disabilities shall

not be subject to any wait list for home and community-based services.

(3) No nursing home, hospital, or intermediate-care facility for persons with intellectual

disabilities 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 executive office has:

(i) pPerformed an individual assessment of the recipient at issue and provided written

notice to the nursing home, hospital, or intermediate-care facility for persons with intellectual

disabilities that the recipient does not meet level of care criteria; and

(ii) tThe 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 executive office is further authorized to consolidate all home and community-

based services currently provided pursuant to § 1915( c) of title XIX of the United States Code

into a single system of home- and community-based services that include options for consumer

direction and shared living. The resulting single-home and community-based services system

shall replace and supersede all §1915(c) programs when fully implemented. Notwithstanding the

foregoing, the resulting single-program home and community-based services system shall include

the continued funding of assisted-living services at any assisted-living facility financed by the

Rhode Island housing and mortgage finance 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 executive office 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 to persons at risk for Medicaid-funded, long-term care

subject to availability of state-appropriated funding for these purposes.

(f) To promote the expansion of home- and community-based service capacity, the

executive office is authorized to pursue payment methodology reforms that increase access to

homemaker, personal care (home health aide), assisted living, adult, supportive-care homes, and

adult day services, as follows:

(1) Development, of revised or new Medicaid certification standards that increase access

to service specialization and scheduling accommodations by using payment strategies designed to

achieve specific quality and health outcomes.

(2) Development of Medicaid certification standards for state-authorized providers of

adult-day services, excluding such providers of services authorized under § 40.1-24-1(3), assisted

living, and adult supportive care (as defined under § 23-17.24 chapter 17.24 of title 23) that

establish for each, an acuity-based, tiered service and payment methodology tied to: licensure

authority,; level of beneficiary needs; the scope of services and supports provided; and specific

quality and outcome measures.

The standards for adult-day services for persons eligible for Medicaid-funded, long-term

services may differ from those who do not meet the clinical/functional criteria set forth in § 40-

8.10-3.

(3) By October 1, 2016, institute an increase in the base-payment rates for home-care

service providers, in an amount to be determined through the appropriations process, for the

purpose of implementing a wage pass-through program for personal-care attendants and home

health aides assisting long-term-care beneficiaries. On or before September 1, 2016, Medicaid-

funded home health providers seeking to participate in the program shall submit to the secretary,

for his or her approval, a written plan describing and attesting to the manner in which the

increased payment rates shall be passed through to personal-care attendants and home health

aides in their salaries or wages less any attendant costs incurred by the provider for additional

payroll taxes, insurance contributions, and other costs required by federal or state law, regulation,

or policy and directly attributable to the wage pass-through program established in this section.

Any such providers contracting with a Medicaid managed-care organization shall develop the

plan for the wage pass-through program in conjunction with the managed-care entity and shall

include an assurance by the provider that the base-rate increase is implemented in accordance

with the goal of raising the wages of the health workers targeted in this subsection. Participating

providers who do not comply with the terms of their wage pass-through plan shall be subject to a

clawback, paid by the provider to the state, for any portion of the rate increase administered under

this section that the secretary deems appropriate.

(g) The executive office shall implement a long-term-care-options counseling program to

provide individuals, or their representatives, 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 long-term-care options consultation if they so request. Each individual

who applies for Medicaid long-term-care services shall be provided with a long-term care

consultation.

(h) The executive office is also authorized, subject to availability of appropriation of

funding, and federal, Medicaid-matching funds, to pay for certain services and supports necessary

to transition or divert beneficiaries from institutional or restrictive settings and optimize their

health and safety when receiving care in a home or the community . The secretary is authorized to

obtain any state plan or waiver authorities required to maximize the federal funds available to

support expanded access to such home- and community-transition and stabilization services;

provided, however, payments shall not exceed an annual or per person amount.

(i) To ensure persons with long-term-care needs who remain living at home have

adequate resources to deal with housing maintenance and unanticipated housing-related costs, the

secretary is authorized to develop higher resource eligibility limits for persons or obtain any state

plan or waiver authorities necessary to change the financial eligibility criteria for long-term

services and supports to enable beneficiaries receiving home and community waiver services to

have the resources to continue living in their own homes or rental units or other home-based

settings.

(j) The executive office shall implement, no later than January 1, 2016, the following

home- and community-based service and payment reforms:

(1) Community-based, supportive-living program established in § 40-8.13-2.1;

(2) Adult day services level of need criteria and acuity-based, tiered-payment

methodology; and

(3) Payment reforms that encourage home- and community-based providers to provide

the specialized services and accommodations beneficiaries need to avoid or delay institutional

care.

(k) The secretary is authorized to seek any Medicaid section 1115 waiver or state-plan

amendments and take any administrative actions necessary to ensure timely adoption of any new

or amended rules, regulations, policies, or procedures and any system enhancements or changes,

for which appropriations have been authorized, that are necessary to facilitate implementation of

the requirements of this section by the dates established. The secretary shall reserve the discretion

to exercise the authority established under §§ 42-7.2-5(6)(v) and 42-7.2-6.1, in consultation with

the governor, to meet the legislative directives established herein.

SECTION 6. Section 40-8.13-5 of the General Laws in Chapter 40-8.13 entitled "Long-

Term Managed Care Arrangements" is hereby amended to read as follows:

40-8.13-5. Financial principles under managed care. -- (a) To the extent that financial

savings are a goal under any managed long-term-care arrangement, it is the intent of the

legislature to achieve such savings through administrative efficiencies, care coordination,

improvements in care outcomes and in a way that encourages the highest quality care for patients

and maximizes value for the managed-care organization and the state. Therefore, any managed-

long-term-care arrangement shall include a requirement that the managed-care organization

reimburse providers for services in accordance with these principles. Notwithstanding any law to

the contrary, for the twelve- (12) month (12) period beginning July 1, 2015, Medicaid managed

long-term-care payment rates to nursing facilities established pursuant to this section shall not

exceed ninety-eight percent (98.0%) of the rates in effect on April 1, 2015.

(1) For a duals demonstration project, the managed-care organization:

(i) Shall not combine the rates of payment for post-acute skilled and rehabilitation care

provided by a nursing facility and long-term and chronic care provided by a nursing facility in

order to establish a single-payment rate for dual eligible beneficiaries requiring skilled nursing

services;

(ii) Shall pay nursing facilities providing post-acute skilled and rehabilitation care or

long-term and chronic care rates that reflect the different level of services and intensity required

to provide these services; and

(iii) For purposes of determining the appropriate rate for the type of care identified in

subsection (a)(1)(ii) of this section, the managed-care organization shall pay no less than the rates

which that would be paid for that care under traditional Medicare and Rhode Island Medicaid for

these service types. The managed-care organization shall not, however, be required to use the

same payment methodology as EOHHS.

The state shall not enter into any agreement with a managed-care organization in

connection with a duals demonstration project unless that agreement conforms to this section, and

any existing such agreement shall be amended as necessary to conform to this subsection.

(2) For a managed long-term-care arrangement that is not a duals demonstration project,

the managed-care organization shall reimburse providers in an amount not less than the amount

that would be paid for the same care by the executive office of health and human services

EOHHS under the Medicaid program. The managed-care organization shall not, however, be

required to use the same payment methodology as the executive office of health and human

services EOHHS.

(3) Notwithstanding any provisions of the general or public laws to the contrary, the

protections of subsections subdivisions (1) and (2) of this section may be waived by a nursing

facility in the event it elects to accept a payment model developed jointly by the managed-care

organization and skilled nursing facilities, that is intended to promote quality of care and cost

effectiveness, including, but not limited to, bundled-payment initiatives, value-based purchasing

arrangements, gainsharing, and similar models.

(b) Notwithstanding any law to the contrary, for the twelve- (12) month (12) period

beginning July 1, 2015, Medicaid managed long-term-care payment rates to nursing facilities

established pursuant to this section shall not exceed ninety-eight percent (98.0%) of the rates in

effect on April 1, 2015.

SECTION 7. Section 40-5.2-20 of the General Laws in Chapter 40-5.2 entitled "The

Rhode Island Works Program" is hereby amended to read as follows:

40-5.2-20. Child-care assistance. -- Families or assistance units eligible for child-care

assistance.

(a) The department shall provide appropriate child care to every participant who is

eligible for cash assistance and who requires child care in order to meet the work requirements in

accordance with this chapter.

(b) Low-Income child care. - The department shall provide child care to all other

working families with incomes at or below one hundred eighty percent (180%) of the federal

poverty level if, and to the extent, such other families require child care in order to work at paid

employment as defined in the department's rules and regulations. Beginning October 1, 2013, the

department shall also provide child care to families with incomes below one hundred eighty

percent (180%) of the federal poverty level if, and to the extent, such families require child care

to participate on a short-term basis, as defined in the department's rules and regulations, in

training, apprenticeship, internship, on-the-job training, work experience, work immersion, or

other job-readiness/job-attachment program sponsored or funded by the human resource

investment council (governor's workforce board) or state agencies that are part of the coordinated

program system pursuant to § 42-102-11.

if the combined value of its liquid resources exceeds ten thousand dollars ($10,000). Liquid

resources are defined as any interest(s) in property in the form of cash or other financial

instruments or accounts that are readily convertible to cash or cash equivalents. These include,

but are not limited to, cash, bank, credit union, or other financial institution savings, checking,

and money market accounts; certificates of deposit or other time deposits; stocks; bonds; mutual

funds; and other similar financial instruments or accounts. These do not include educational

savings accounts, plans, or programs; retirement accounts, plans, or programs; or accounts held

jointly with another adult, not including a spouse. The department is authorized to promulgate

rules and regulations to determine the ownership and source of the funds in the joint account.

(d) As a condition of eligibility for child-care assistance under this chapter, the parent or

caretaker relative of the family must consent to, and must cooperate with, the department in

establishing paternity, and in establishing and/or enforcing child support and medical support

orders for all children in the family in accordance with title 15, as amended, unless the parent or

caretaker relative is found to have good cause for refusing to comply with the requirements of this

subsection.

(e) For purposes of this section, "appropriate child care" means child care, including

infant, toddler, pre-school, nursery school, school-age, that is provided by a person or

organization qualified, approved, and authorized to provide such care by the department of

children, youth, and families, or by the department of elementary and secondary education, or

such other lawful providers as determined by the department of human services, in cooperation

with the department of children, youth and families and the department of elementary and

secondary education.

(f)(1) Families with incomes below one hundred percent (100%) of the applicable

federal poverty level guidelines shall be provided with free child care. Families with incomes

greater than one hundred percent (100%) and less than one hundred eighty (180%) of the

applicable federal poverty guideline shall be required to pay for some portion of the child care

they receive, according to a sliding-fee scale adopted by the department in the department's rules.

(2) For a thirty-six (36) month period beginning October 1, 2013, the child care subsidy

transition program shall function within the department of human services. Under this program,

families Families who are already receiving child-care assistance and who become ineligible for

child-care assistance as a result of their incomes exceeding one hundred eighty percent (180%) of

the applicable federal poverty guidelines shall continue to be eligible for child-care assistance

from October 1, 2013, to September 30, 2016 2017, or until their incomes exceed two hundred

twenty-five percent (225%) of the applicable federal poverty guidelines, whichever occurs first.

To be eligible, such families must continue to pay for some portion of the child care they receive,

as indicated in a sliding-fee scale adopted in the department's rules and in accordance with all

other eligibility standards.

(g) In determining the type of child care to be provided to a family, the department shall

take into account the cost of available child-care options; the suitability of the type of care

available for the child; and the parent's preference as to the type of child care.

(h) For purposes of this section, "income" for families receiving cash assistance under §

40-5.2-11 means gross, earned income and unearned income, subject to the income exclusions in

subdivisions §§ 40-5.2-10(g)(2) and 40-5.2-10(g)(3), and income for other families shall mean

gross, earned and unearned income as determined by departmental regulations.

(i) The caseload estimating conference established by chapter 17 of title 35 shall forecast

the expenditures for child-care in accordance with the provisions of § 35-17-1.

(j) In determining eligibility for child-care assistance for children of members of reserve

components called to active duty during a time of conflict, the department shall freeze the family

composition and the family income of the reserve component member as it was in the month prior

to the month of leaving for active duty. This shall continue until the individual is officially

discharged from active duty.

SECTION 8. Section 40.1-22-39 of the General Laws in Chapter 40.1-22 entitled

"Developmental Disabilities" is hereby amended to read as follows:

40.1-22-39. Monthly reports to the general assembly. -- On or before the fifteenth

(15th) day of each month, the department shall provide a monthly report of monthly caseload and

expenditure data, pertaining to eligible, developmentally disabled adults, to the chairperson of the

house finance committee,; the chairperson of the senate finance committee,; the house fiscal

advisor,; the senate fiscal advisor,; and the state budget officer. The monthly report shall be in

such form, and in such number of copies, and with such explanation as the house and senate fiscal

advisors may require. It shall include, but is not limited to, the number of cases and expenditures

from the beginning of the fiscal year at the beginning of the prior month,; cases added and denied

during the prior month,; expenditures made,; and the number of cases and expenditures at the end

of the month. The information concerning cases added and denied shall include summary

information and profiles of the service-demand request for eligible adults meeting the state

statutory definition for services from the division of developmental disabilities as determined by

the division, including age, Medicaid eligibility and agency selection placement with a list of the

services provided, and the reasons for the determinations of ineligibility for those cases denied.

The department shall also provide, monthly, the number of individuals in a shared-living

arrangement and how many may have returned to a 24-hour residential placement in that month.

The department shall also report, monthly, any and all information for the consent decree that has

been submitted to the federal court as well as the number of unduplicated individuals employed;

the place of employment; and the number of hours working.

The department shall also provide the amount of funding allocated to individuals above

the assigned resource levels; the number of individuals and the assigned resource level; and the

reasons for the approved additional resources.

The department shall also provide the amount of patient liability to be collected and the

amount collected as well as the number of individuals who have a financial obligation.

SECTION 9. Rhode Island Medicaid Reform Act of 2008 Resolution.

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 Law § 42-

12.4-1, et seq. for federal waiver requests and/or state plan amendments; and

WHEREAS, Rhode Island General Law § 42-7.2-5 provides that the Secretary of the

Executive Office of Health and Human Services (EOHHS) (hereafter “the Secretary’) is

responsible for the review and coordination of any Medicaid section 1115 demonstration waiver

requests and renewals as well as any initiatives and proposals requiring amendments to the

Medicaid state plan or category II or III changes as described in the demonstration, with “the

potential to affect the scope, amount, or duration of publicly-funded publicly funded health-

care services, provider payments or reimbursements, or access to or the availability of benefits

and services provided by Rhode Island general and public laws”; and

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) Beneficiary Liability Collection Enhancements – Federal laws and regulations require

beneficiaries who are receiving Medicaid-funded, long-term services and supports (LTSS) to pay

a portion of any excess income they may have once eligibility has been determined toward in the

cost of care. The amount the beneficiary is obligated to pay is referred to as a liability or cost-

share and must be used solely for the purpose of offsetting the agency’s payment for the LTSS

provided. The EOHHS is seeking to implement new methodologies that will make it easier for

beneficiaries to make these payments and enhance the agency’s capacity to collect them in a

timely and equitable manner. The EOHHS may require federal state plan and/or waiver authority

to implement these new methodologies. Amended rules, regulations, and procedures may also be

required.

(b) Increase in LTSS Home-Care Provider Wages. To further the goal of rebalancing the

long-term-care system to promote home- and community-based alternatives, the EOHHS

proposes to establish a wage-pass-through program targeting certain home-health-care

professionals. Implementation of the program may require amendments to the Medicaid Sstate

Pplan and/or section 1115 demonstration waiver due to changes in payment methodologies.

resources by repurposing funds derived from various savings initiatives and obtaining federal

financial participation for costs not otherwise matchable to expand the reach and enhance the

effectiveness of alternative payment arrangements that maximize value and cost-effectiveness,

and tie payments to improvements in service quality and health outcomes. Amendments to the

section 1115 waiver and/or the Medicaid state plan may be required to implement any alternative

payment arrangements the EOHHS is authorized to pursue. EOHHS proposes to fund the R.I.

Health System Transformation Program by seeking federal authority for federal financial

participation (FFP) in financing both Costs Not Otherwise Matchable (CNOMS) and Designated

State Health Programs (DSHPs) that either not previously utilized although authorized or were

not authorized for federal financial participation prior to June 1, 2016, and for which authority is

obtained after June 1, 2016. Utilizing the funds made available by this new authority for federal

financial participation, the R.I. Health System Transformation Program will make payments to

health-care providers to reward and encourage improvements in clinical quality, patient

experience, and health system integration. Eligibility for these Health System Transformation

Program payments will be made to health-care providers participating in Aalternative Ppayment

Aarrangements, including, but not limited to, accountable entities and to those engaged in

electronic exchange of clinical information necessary for optimal management of patient care.

(d) Federal Financing Opportunities. The EOHHS proposes to review Medicaid

requirements and opportunities under the U.S. Patient Protection and Affordable Care Act of

2010, and various other recently enacted federal laws, and pursue any changes in the Rhode

Island Medicaid program that promote service quality, access, and cost-effectiveness that may

warrant a Medicaid Sstate Pplan Aamendment or amendment under the terms and conditions of

Rhode Island’s section 1115 Waiver, its successor, or any extension thereof. Any such actions the

EOHHS takes shall not have an adverse impact on beneficiaries or cause an increase in

expenditures beyond the amount appropriated for state fiscal year 2017; now, therefore, be it

RESOLVED, that the general assembly hereby approves proposals (a) through (d) listed

above to amend the demonstration; and be it further

RESOLVED, that the Secretary is authorized to pursue and implement any waiver

amendments, 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 10. This article shall take effect upon passage, except as otherwise provided

herein.