Chapter 235
2023 -- H 5991 SUBSTITUTE A AS AMENDED
Enacted 06/23/2023

A N   A C T
RELATING TO HUMAN SERVICES -- QUALITY SELF-DIRECTED SERVICES

Introduced By: Representatives Slater, Diaz, Cruz, Potter, and Voas

Date Introduced: March 01, 2023

It is enacted by the General Assembly as follows:
     SECTION 1. This Act shall be known and may be cited as the Personal Choice Self-
directed Personal Care Services Act of 2023.
     (1) The State of Rhode Island is committed to rebalancing the provision of long-term care
away from institutional care and towards a home- and community-based care model by enhancing
self-direction and consumer choice.
     (2) The purpose of this chapter is to maximize the array of self-directed personal care
services available to Medicaid Long-term services and supports (LTSS) participants by merging
the Independent Provider program into the Personal Choice Program. Accordingly, upon the
implementation date set forth in this act, the Independent Provider program will cease operations;
providing, however, that the elements of the Independent Provider program specified in this chapter
related to collective bargaining and negotiations for self-directed personal care services are
incorporated into the reconstituted Personal Choice program.
     (3) The merger of these two (2) self-directed programs will further the State’s state’s
rebalancing goal by streamlining the delivery of personal care support services, increasing
administrative efficiency, making it easier for consumers to self-direct the care they need and want.
In addition, by incorporating into the Personal Choice program the collective bargaining rights that
were established in the Independent Provider program, the merger will enhance service access,
increase the availability of education and training options, and improve the recruitment and
retention of the people selected by Medicaid LTSS participants as individual providers. To ensure
the merger realizes these ends, the secretary is directed to facilitate a smooth transition of
Independent Provider participants opting to continue self-directed personal care services through
the Personal Choice program. At a minimum, at least sixty (60) days prior to the end of operations,
the executive office of health and human services must notify enrollees and advise them of their
option to change to another home and community-based service option or be auto-transitioned to
the Personal Choice program.
     (4) This act does not alter or limit the secretary’s authority to administer the Personal
Choice Program, enforce existing rules, regulations, and procedures or adopt amended rules,
regulations, and procedures for operating the program, determine a participant Medicaid eligibility
and appropriateness for self-directed personal care services, or assess the scope, amount and
duration of services authorized to meet a participant's needs, except as specifically set forth in this
chapter.
     (5) This act does not alter or limit the rights of participants and their representative to select,
direct, and terminate the services of individual providers or to determine the wages of individual
providers within a range set by the secretary in implementing regulations once the programs are
combined.
     (6) This act does not alter or impede the administration or delivery of self-directed
programs, including those self-directed programs for Medicaid LTSS participants operated by the
department of behavioral healthcare, development disabilities and hospitals for individuals with
intellectual disabilities.
     SECTION 2. Sections 40-8.14-1 and 40-8.14-3 of the General Laws in Chapter 40-8.14
entitled "Quality Self-Directed Services" are hereby amended to read as follows:
     40-8.14-1. Definitions.
     For purposes of this section:
     (1) “Activities of daily living” (ADL) means the routine activities that people tend to do
every day without needing assistance. There are six (6) basic ADLs: eating, bathing, dressing,
toileting, transferring (walking), and continence.
     (2) “Covered home- and community-based services (HCBS)” means any core, preventive,
or specialized long-term-care services and supports available in a person’s home or a community-
based living arrangement that the state is authorized to provide under the Medicaid state plan, the
Medicaid section 1115 waiver, or any similar program.
     (3) “Direct-support services” means the range of home- and community-based services
(HCBS) covered services that are identified in the Medicaid state plan, Rhode Island’s section 1115
waiver, or any similar program that may provide similar services in the future, and the rules and
regulations promulgated by the executive office of health and human services (EOHHS) or a
designated agency authorize individual home-care providers to provide. The direct-support services
must be provided in accordance with applicable federal and state law, rules, and regulations and
include, but are not limited to, personal care assistance, homemaker, and companion services that
the state is authorized to provide under the Medicaid state plan, the Medicaid section 1115 waiver,
or any similar program in the future, including:
     (i) Participant assistance with activities of daily living and instrumental activities of daily
living as defined in this chapter;
     (ii) Assistance with monitoring health status and physical condition;
     (iii) Assistance with preparation and eating of meals (not the cost of the meal itself);
     (iv) Assistance with housekeeping activities (bed making, dusting, vacuuming, laundry,
grocery shopping, cleaning);
     (v) Assistance with transferring, ambulation, and use of special mobility devices assisting
the participant by directly providing or arranging transportation; and
     (vi) Other similar, in-home, non-medical long-term services and supports provided to an
elderly person or individual with a disability by an individual provider to meet the person’s daily
living needs and ensure that the person may adequately function in the person’s home and have
safe access to the community.
     (4) “Director” means the director of the Rhode Island department of administration.
     (2) "Executive office of health and human services (EOHHS)" means the agency in the
executive branch of state government that is designated as the Medicaid single state agency and
which, in this capacity, oversees the administration of the Medicaid LTSS program.
     (5)(3) “Fiscal intermediary” means a third-party organization operating in accordance with
applicable federal and state requirements under contract with the EOHHS state that is responsible
for performing payroll and other employment-related functions on behalf of the participant as set
forth in the implementing regulations for the personal choice program promulgated by the secretary
of EOHHS.
     (i) The fiscal intermediary shall:
     (A) Be authorized by the secretary or a designated agency to receive and distribute support
funds on behalf of a participant in accordance with the participant’s service plan; and
     (B) Act as a fiscal intermediary on behalf of a participant in compliance with all rules,
regulations, and terms and conditions established by the secretary.
     (ii) The fiscal intermediary shall not make any decisions regarding hiring, supervising, or
firing individual providers.
     (6)(4) “Individual provider” means an individual selected by and working under the
direction of a Medicaid LTSS beneficiary participant or the beneficiary’s participant's duly
authorized representative to provide direct-support self-directed personal care services to the
participant in accordance with the beneficiary’s service plan, a person-centered plan and the
implementing regulations promulgated for the program by the secretary of EOHHS. Individual
provider does not mean or but does not include an employee of a provider agency, subject to the
agency’s direction and control commensurate with agency employee status or an individual
providing services to a participant electing the personal choice option in any program.
     (7) “Instrumental activities of daily living” means the skills a person needs to live safely
and successfully in a residential setting of choice without outside supports. These skills include,
but are not limited to, using the telephone, traveling, shopping, preparing meals, doing housework,
taking medications properly, and managing money.
     (8)(5) “Medicaid LTSS beneficiary participant” means a person who has been determined
by the state to obtain be eligible for Medicaid-funded long-term services and supports under the
Medicaid state plan and/or the RI section 1115 waiver demonstration and/or Medicaid authorities
created in the future.
     (9) “Participant” means a Medicaid LTSS beneficiary who receives direct-support services
from an individual provider.
     (10)(6) “Participant’s representative” means a participant’s legal guardian or an individual
having a person who has been designated by the participant or otherwise has the authority and
responsibility to act on behalf of a participant with respect to the provision of direct-support self-
directed services, including the self-directed personal care services subject to this act.
     (11)(7) “Provider representative” means a provider organization that is certified as the
exclusive negotiating representative of individual providers as provided in § 40-8.15-7.
     (12)(8) “Secretary” means the secretary of the Rhode Island executive office of health and
human services (EOHHS).
     (9) "Self-directed personal care services" means home and community-based personal care
services a Medicaid LTSS participant is authorized to self-direct to meet their daily living needs,
function adequately at home, safely access the community, or other nonprofessional services under
the personal choice program, independent provider program, or any similar program that may
provide similar services in the future under the Medicaid state plan, section 1115 demonstration
waiver, or future Medicaid authorities promulgated by the secretary.
     40-8.14-3. Use of employee workforce.
     The requirement under § 40-8.14-2 shall not restrict the state’s ability to afford participants
and participants’ representatives who choose not to employ an individual provider, or are unable to
do so, the option of receiving direct-support personal care services through a personal choice option
or through the employees of provider agencies, rather than through an individual provider.
     Nothing in this chapter shall restrict the state’s ability to afford Medicaid LTSS
beneficiaries authorized to receive HCBS-covered services participants with the freedom of choice
guaranteed under Title XIX to enter into service delivery agreements with any authorized Medicaid
provider.
     SECTION 3. Section 40-8.15-9 of the General Laws in Chapter 40-8.15 entitled
"Individual Providers of Direct-Support Services" is hereby amended to read as follows:
     40-8.15-9. Individual providers not state employees Duties of the executive office for
health and human services.
     (c) Notwithstanding the state’s obligations to meet and negotiate under chapter 7 of title
28, nothing in this chapter shall be construed to make individual providers employees of the state
for any purpose, including for the purposes of eligibility for the state employee pension program
or state employee health benefits.
     (a) The secretary has authority over the terms and conditions of individual providers'
employment, including compensation as required under § 40-8.15-14, payment, benefit terms,
provider qualification standards, other appropriate terms and conditions for the workforce of
individual providers without infringing on participants' or participant representatives' rights and
responsibilities to hire, direct, supervise, and/or terminate the employment of their individual
providers, and orientation, training, and the operation of a registry as required under § 40-8.15-15.
     (b) The secretary's authority in subsection (a) of this section only applies to self-directed
personal care services and is subject to the state's obligation to meet and negotiate with a provider
representative pursuant to § 40-8.15-16.
     SECTION 4. Chapter 40-8.15 of the General Laws entitled "Individual Providers of Direct-
Support Services" is hereby amended by adding thereto the following sections:
     40-8.15-14. Wage ranges.
     (a) The state shall set wage ranges for all individual providers. All self-directed personal
care services performed by individual providers must be compensated at a wage that is within the
range set by the secretary for the services provided, but the participant may choose what wage to
pay within the applicable range.
     (b) The wage range may be the subject of collective bargaining as provided in this chapter.
However, such collective bargaining shall be related solely to self-directed personal care services.
All other self-directed services available to personal choice participants other than personal care
are excluded from collective bargaining.
     (c) The provisions of this section shall take effect on the date of implementation, as
provided in § 40-8.15-16(c).
     40-8.15-15. Other duties of the executive office for health and human services.
     (a)(1) The secretary shall determine by regulation whether and to what extent individual
providers selected by personal choice participants to provide self-directed personal care are
required to complete an orientation, pursuant to the secretary’s authority under § 40-8.14-4(c)(2).
The secretary shall determine by regulation the specific types of education, experience, or training
that may be required for an individual provider to be included on a registry of persons qualified to
be self-directed individual providers.
     (12) The subjects of this section shall be collectively bargained with the provider
representative. Nothing in this act prohibits a personal choice participant from requiring an
individual provider to complete more training or education than is minimally required by the
secretary.
     (b) The secretary shall maintain a registry for individual providers pursuant to its authority
under § 40-8.14-4(c)(4) and shall collaborate with the provider representative to maintain this
registry.
     (c) The provisions of this section shall take effect on the date of implementation, as
provided in § 40-8.15-16(c).
     40-8.15-16. Implementation.
     (a) For purposes of this section, the independent provider (IP) program and the personal
choice program shall have the meanings that were set forth in 210-RICR-50-10-2.2(A)(1) and
(A)(2) as of the effective date of the personal choice in self-directed personal care services act of
2023.
     (b) The secretary shall merge the independent provider program into the personal choice
program, so that as of the date of implementation the independent provider program will cease
operations. All new Medicaid LTSS participants seeking self-directed personal care services in a
program included under this act will be enrolled in the personal choice program if all necessary
requirements are met. The secretary shall transition independent provider participants opting to
continue self-direction into the personal choice program no later than the date of their annual
reassessment.
     (1) The secretary shall make all changes to regulations and practices as needed to
implement this merger.
     (2) The secretary within one hundred and twenty (120) days of the effective date of this act
shall apply for any necessary federal approvals, including the submission of any necessary
Medicaid state pan plan amendments to the federal Centers for Medicare & Medicaid Services.
     (c) Once the secretary has implemented the merger of the programs, and no later than one
hundred twenty (120) days after any necessary federal approvals are obtained, the secretary shall
certify that the personal choice self-directed personal care services act of 2023 has been
implemented. The date of that certification shall be the “date of implementation” for all provisions
of this chapter.
     (d) Within ninety (90) days of the effective date of the personal choice self-directed
personal care services act of 2023, any provider organization that has previously been certified to
serve as the provider representative of any individual providers pursuant to § 40-8.15-7 shall be
furnished by the secretary with contact information for every person providing self-directed
personal care services under the personal choice program. The secretary shall provide any such
provider organization with updated contact information every sixty (60) days thereafter.
     (e) Any provider organization that has previously been certified to serve as the provider
representative of any individual providers pursuant to § 40-8.15-7 may, prior to the date of
implementation, petition to be certified as the provider representative of the bargaining unit that
will be comprised of all the individual providers in the personal choice program after the date of
implementation. The secretary shall hold an election to determine whether such a provider
organization shall be certified as the provider representative for that bargaining unit upon a ten
percent (10%) showing of interest. All persons who are providing self-direct self-directed services
under the personal choice program shall be considered part of the bargaining unit for purposes of
the showing of interest and shall be eligible to vote in the certification election. If a majority of
those casting ballots vote to be represented by that provider organization, then the provider
organization shall be certified as the provider representative to negotiate with the state over the
terms and conditions of individual providers' participation in providing self-directed personal care
services for all individual providers in the state as of the date of implementation. The provisions of
this chapter shall otherwise apply.
     (f) Nothing in this act shall be construed to alter or limit the rights of participants and their
representative to select, direct, and terminate the services of individual providers or to determine
individual providers’ wages within a range set by the secretary, or to alter or limit the secretary’s
authority to administer the personal choice program including to adopt rules and operate the
program, to determine participant budgets, to determine eligibility, or to authorize services, except
as specifically set forth in this chapter.
     (g) Nothing in this act shall be construed to affect the administration or delivery of self-
directed programs for individuals with intellectual disabilities.
     (h) Nothing in this act shall be construed to alter or limit the rights of participants and their
representative to select, direct, and terminate the services of individual providers or to determine
individual providers' wages within a range set by the secretary, or to alter or limit the secretary's
authority to administer the personal choice program, including to adopt rules and operate the
program, to determine participant budgets, to determine eligibility, or to authorize services, except
as specifically set forth in this chapter.
     (ih) No provision of any agreement or award resulting from collective bargaining and
negotiations under this act shall provide for a reduction in Medicaid federal financial participation
under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., nor shall any provision of
any agreement or award provide for a reduction in the self-directed personal care services for
eligible personal choice program Medicaid LTSS participants. Any provision in any agreement or
award which that would require an additional appropriation in order to maintain the levels of
services provided by existing appropriations shall be subject to the annual budget process.
     SECTION 5. This act shall take effect upon passage.
========
LC001993/SUB A/3
========