2024 -- S 2723 | |
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LC005628 | |
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STATE OF RHODE ISLAND | |
IN GENERAL ASSEMBLY | |
JANUARY SESSION, A.D. 2024 | |
____________ | |
A N A C T | |
RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND HEALTH | |
CARE REFORM ACT OF 2004 -- HEALTH INSURANCE OVERSIGHT | |
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Introduced By: Senator Ryan W. Pearson | |
Date Introduced: March 05, 2024 | |
Referred To: Senate Health & Human Services | |
It is enacted by the General Assembly as follows: | |
1 | SECTION 1. Sections 42-14.5-2.1 and 42-14.5-3 of the General Laws in Chapter 42-14.5 |
2 | entitled "The Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" are |
3 | hereby amended to read as follows: |
4 | 42-14.5-2.1. Definitions. |
5 | As used in this chapter: |
6 | (1) “Accountability standards” means measures including service processes, client and |
7 | population outcomes, practice standard compliance and fiscal integrity of social and human service |
8 | providers on the individual contractual level and service type for all state contacts of the state or |
9 | any subdivision or agency to include, but not limited to, the department of children, youth and |
10 | families (DCYF), the department of behavioral healthcare, developmental disabilities and hospitals |
11 | (BHDDH), the department of human services (DHS), the department of health (DOH), and |
12 | Medicaid. This may include mandatory reporting, consolidated, standardized reporting, audits |
13 | regardless of organizational tax status, and accountability dashboards of aforementioned state |
14 | departments or subdivisions that are regularly shared with the public. |
15 | (2) “Executive Office of Health and Human Services (EOHHS)” means the department |
16 | that serves as “principal agency of the executive branch of state government” (§ 42-7.2-2) |
17 | responsible for managing the departments and offices of: health (RIDOH), human services (DHS), |
18 | healthy aging (OHA), veterans services (VETS), children, youth and families (DCYF), and |
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1 | behavioral healthcare, developmental disabilities and hospitals (BHDDH). EOHHS is also |
2 | designated as the single state agency with authority to administer the Medicaid program in Rhode |
3 | Island. |
4 | (3) "Primary care services" means professional services rendered by primary care providers |
5 | at a primary care site of care. |
6 | (3)(4) “Rate review” means the process of reviewing and reporting of specific trending |
7 | factors that influence the cost of service that informs rate setting. |
8 | (4)(5) “Rate setting” means the process of establishing rates for social and human service |
9 | programs that are based on a thorough rate review process. |
10 | (5)(6) “Social and human service program” means a social, mental health, developmental |
11 | disability, child welfare, juvenile justice, prevention services, habilitative, rehabilitative, substance |
12 | use disorder treatment, residential care, adult or adolescent day services, vocational, employment |
13 | and training, or aging service program or accommodations purchased by the state. |
14 | (6)(7) “Social and human service provider” means a provider of social and human service |
15 | programs pursuant to a contract with the state or any subdivision or agency to include, but not be |
16 | limited to, the department of children, youth and families (DCYF), the department of behavioral |
17 | healthcare, developmental disabilities and hospitals (BHDDH), the department of human services |
18 | (DHS), the department of health (DOH), and Medicaid. |
19 | (7)(8) “State government and the provider network” refers to the contractual relationship |
20 | between a state agency or subdivision of a state agency and private companies the state contracts |
21 | with to provide the network of mandated and discretionary social and human services. |
22 | 42-14.5-3. Powers and duties. |
23 | The health insurance commissioner shall have the following powers and duties: |
24 | (a) To conduct quarterly public meetings throughout the state, separate and distinct from |
25 | rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers |
26 | licensed to provide health insurance in the state; the effects of such rates, services, and operations |
27 | on consumers, medical care providers, patients, and the market environment in which the insurers |
28 | operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less |
29 | than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island |
30 | Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney |
31 | general, and the chambers of commerce. Public notice shall be posted on the department’s website |
32 | and given in the newspaper of general circulation, and to any entity in writing requesting notice. |
33 | (b) To make recommendations to the governor and the house of representatives and senate |
34 | finance committees regarding healthcare insurance and the regulations, rates, services, |
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1 | administrative expenses, reserve requirements, and operations of insurers providing health |
2 | insurance in the state, and to prepare or comment on, upon the request of the governor or |
3 | chairpersons of the house or senate finance committees, draft legislation to improve the regulation |
4 | of health insurance. In making the recommendations, the commissioner shall recognize that it is |
5 | the intent of the legislature that the maximum disclosure be provided regarding the reasonableness |
6 | of individual administrative expenditures as well as total administrative costs. The commissioner |
7 | shall make recommendations on the levels of reserves, including consideration of: targeted reserve |
8 | levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess |
9 | reserves. |
10 | (c) To establish a consumer/business/labor/medical advisory council to obtain information |
11 | and present concerns of consumers, business, and medical providers affected by health insurance |
12 | decisions. The council shall develop proposals to allow the market for small business health |
13 | insurance to be affordable and fairer. The council shall be involved in the planning and conduct of |
14 | the quarterly public meetings in accordance with subsection (a). The advisory council shall develop |
15 | measures to inform small businesses of an insurance complaint process to ensure that small |
16 | businesses that experience rate increases in a given year may request and receive a formal review |
17 | by the department. The advisory council shall assess views of the health provider community |
18 | relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the |
19 | insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue |
20 | an annual report of findings and recommendations to the governor and the general assembly and |
21 | present its findings at hearings before the house and senate finance committees. The advisory |
22 | council is to be diverse in interests and shall include representatives of community consumer |
23 | organizations; small businesses, other than those involved in the sale of insurance products; and |
24 | hospital, medical, and other health provider organizations. Such representatives shall be nominated |
25 | by their respective organizations. The advisory council shall be co-chaired by the health insurance |
26 | commissioner and a community consumer organization or small business member to be elected by |
27 | the full advisory council. |
28 | (d) To establish and provide guidance and assistance to a subcommittee (“the professional- |
29 | provider-health-plan work group”) of the advisory council created pursuant to subsection (c), |
30 | composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall |
31 | include in its annual report and presentation before the house and senate finance committees the |
32 | following information: |
33 | (1) A method whereby health plans shall disclose to contracted providers the fee schedules |
34 | used to provide payment to those providers for services rendered to covered patients; |
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1 | (2) A standardized provider application and credentials verification process, for the |
2 | purpose of verifying professional qualifications of participating healthcare providers; |
3 | (3) The uniform health plan claim form utilized by participating providers; |
4 | (4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit |
5 | hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make |
6 | facility-specific data and other medical service-specific data available in reasonably consistent |
7 | formats to patients regarding quality and costs. This information would help consumers make |
8 | informed choices regarding the facilities and clinicians or physician practices at which to seek care. |
9 | Among the items considered would be the unique health services and other public goods provided |
10 | by facilities and clinicians or physician practices in establishing the most appropriate cost |
11 | comparisons; |
12 | (5) All activities related to contractual disclosure to participating providers of the |
13 | mechanisms for resolving health plan/provider disputes; |
14 | (6) The uniform process being utilized for confirming, in real time, patient insurance |
15 | enrollment status, benefits coverage, including copays and deductibles; |
16 | (7) Information related to temporary credentialing of providers seeking to participate in the |
17 | plan’s network and the impact of the activity on health plan accreditation; |
18 | (8) The feasibility of regular contract renegotiations between plans and the providers in |
19 | their networks; and |
20 | (9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. |
21 | (e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). |
22 | (f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The |
23 | fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. |
24 | (g) To analyze the impact of changing the rating guidelines and/or merging the individual |
25 | health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health |
26 | insurance market, as defined in chapter 50 of title 27, in accordance with the following: |
27 | (1) The analysis shall forecast the likely rate increases required to effect the changes |
28 | recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer |
29 | health insurance market over the next five (5) years, based on the current rating structure and |
30 | current products. |
31 | (2) The analysis shall include examining the impact of merging the individual and small- |
32 | employer markets on premiums charged to individuals and small-employer groups. |
33 | (3) The analysis shall include examining the impact on rates in each of the individual and |
34 | small-employer health insurance markets and the number of insureds in the context of possible |
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1 | changes to the rating guidelines used for small-employer groups, including: community rating |
2 | principles; expanding small-employer rate bonds beyond the current range; increasing the employer |
3 | group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. |
4 | (4) The analysis shall include examining the adequacy of current statutory and regulatory |
5 | oversight of the rating process and factors employed by the participants in the proposed, new |
6 | merged market. |
7 | (5) The analysis shall include assessment of possible reinsurance mechanisms and/or |
8 | federal high-risk pool structures and funding to support the health insurance market in Rhode Island |
9 | by reducing the risk of adverse selection and the incremental insurance premiums charged for this |
10 | risk, and/or by making health insurance affordable for a selected at-risk population. |
11 | (6) The health insurance commissioner shall work with an insurance market merger task |
12 | force to assist with the analysis. The task force shall be chaired by the health insurance |
13 | commissioner and shall include, but not be limited to, representatives of the general assembly, the |
14 | business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in |
15 | the individual market in Rhode Island, health insurance brokers, and members of the general public. |
16 | (7) For the purposes of conducting this analysis, the commissioner may contract with an |
17 | outside organization with expertise in fiscal analysis of the private insurance market. In conducting |
18 | its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said |
19 | data shall be subject to state and federal laws and regulations governing confidentiality of health |
20 | care and proprietary information. |
21 | (8) The task force shall meet as necessary and include its findings in the annual report, and |
22 | the commissioner shall include the information in the annual presentation before the house and |
23 | senate finance committees. |
24 | (h) To establish and convene a workgroup representing healthcare providers and health |
25 | insurers for the purpose of coordinating the development of processes, guidelines, and standards to |
26 | streamline healthcare administration that are to be adopted by payors and providers of healthcare |
27 | services operating in the state. This workgroup shall include representatives with expertise who |
28 | would contribute to the streamlining of healthcare administration and who are selected from |
29 | hospitals, physician practices, community behavioral health organizations, each health insurer, and |
30 | other affected entities. The workgroup shall also include at least one designee each from the Rhode |
31 | Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the |
32 | Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year |
33 | that the workgroup meets and submits recommendations to the office of the health insurance |
34 | commissioner, the office of the health insurance commissioner shall submit such recommendations |
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1 | to the health and human services committees of the Rhode Island house of representatives and the |
2 | Rhode Island senate prior to the implementation of any such recommendations and subsequently |
3 | shall submit a report to the general assembly by June 30, 2024. The report shall include the |
4 | recommendations the commissioner may implement, with supporting rationale. The workgroup |
5 | shall consider and make recommendations for: |
6 | (1) Establishing a consistent standard for electronic eligibility and coverage verification. |
7 | Such standard shall: |
8 | (i) Include standards for eligibility inquiry and response and, wherever possible, be |
9 | consistent with the standards adopted by nationally recognized organizations, such as the Centers |
10 | for Medicare & Medicaid Services; |
11 | (ii) Enable providers and payors to exchange eligibility requests and responses on a system- |
12 | to-system basis or using a payor-supported web browser; |
13 | (iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare |
14 | coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing |
15 | requirements for specific services at the specific time of the inquiry; current deductible amounts; |
16 | accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and |
17 | other information required for the provider to collect the patient’s portion of the bill; |
18 | (iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility |
19 | and benefits information; |
20 | (v) Recommend a standard or common process to protect all providers from the costs of |
21 | services to patients who are ineligible for insurance coverage in circumstances where a payor |
22 | provides eligibility verification based on best information available to the payor at the date of the |
23 | request of eligibility. |
24 | (2) Developing implementation guidelines and promoting adoption of the guidelines for: |
25 | (i) The use of the National Correct Coding Initiative code-edit policy by payors and |
26 | providers in the state; |
27 | (ii) Publishing any variations from codes and mutually exclusive codes by payors in a |
28 | manner that makes for simple retrieval and implementation by providers; |
29 | (iii) Use of Health Insurance Portability and Accountability Act standard group codes, |
30 | reason codes, and remark codes by payors in electronic remittances sent to providers; |
31 | (iv) Uniformity in the processing of claims by payors; and the processing of corrections to |
32 | claims by providers and payors; |
33 | (v) A standard payor-denial review process for providers when they request a |
34 | reconsideration of a denial of a claim that results from differences in clinical edits where no single, |
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1 | common-standards body or process exists and multiple conflicting sources are in use by payors and |
2 | providers. |
3 | (vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual |
4 | payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of |
5 | detecting and deterring fraudulent billing activities. The guidelines shall require that each payor |
6 | disclose to the provider its adjudication decision on a claim that was denied or adjusted based on |
7 | the application of such edits and that the provider have access to the payor’s review and appeal |
8 | process to challenge the payor’s adjudication decision. |
9 | (vii) Nothing in this subsection shall be construed to modify the rights or obligations of |
10 | payors or providers with respect to procedures relating to the investigation, reporting, appeal, or |
11 | prosecution under applicable law of potentially fraudulent billing activities. |
12 | (3) Developing and promoting widespread adoption by payors and providers of guidelines |
13 | to: |
14 | (i) Ensure payors do not automatically deny claims for services when extenuating |
15 | circumstances make it impossible for the provider to obtain a preauthorization before services are |
16 | performed or notify a payor within an appropriate standardized timeline of a patient’s admission; |
17 | (ii) Require payors to use common and consistent processes and time frames when |
18 | responding to provider requests for medical management approvals. Whenever possible, such time |
19 | frames shall be consistent with those established by leading national organizations and be based |
20 | upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical |
21 | management includes prior authorization of services, preauthorization of services, precertification |
22 | of services, post-service review, medical-necessity review, and benefits advisory; |
23 | (iii) Develop, maintain, and promote widespread adoption of a single, common website |
24 | where providers can obtain payors’ preauthorization, benefits advisory, and preadmission |
25 | requirements; |
26 | (iv) Establish guidelines for payors to develop and maintain a website that providers can |
27 | use to request a preauthorization, including a prospective clinical necessity review; receive an |
28 | authorization number; and transmit an admission notification; |
29 | (v) Develop and implement the use of programs that implement selective prior |
30 | authorization requirements, based on stratification of healthcare providers’ performance and |
31 | adherence to evidence-based medicine with the input of contracted healthcare providers and/or |
32 | provider organizations. Such criteria shall be transparent and easily accessible to contracted |
33 | providers. Such selective prior authorization programs shall be available when healthcare providers |
34 | participate directly with the insurer in risk-based payment contracts and may be available to |
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1 | providers who do not participate in risk-based contracts; |
2 | (vi) Require the review of medical services, including behavioral health services, and |
3 | prescription drugs, subject to prior authorization on at least an annual basis, with the input of |
4 | contracted healthcare providers and/or provider organizations. Any changes to the list of medical |
5 | services, including behavioral health services, and prescription drugs requiring prior authorization, |
6 | shall be shared via provider-accessible websites; |
7 | (vii) Improve communication channels between health plans, healthcare providers, and |
8 | patients by: |
9 | (A) Requiring transparency and easy accessibility of prior authorization requirements, |
10 | criteria, rationale, and program changes to contracted healthcare providers and patients/health plan |
11 | enrollees which may be satisfied by posting to provider-accessible and member-accessible |
12 | websites; and |
13 | (B) Supporting: |
14 | (I) Timely submission by healthcare providers of the complete information necessary to |
15 | make a prior authorization determination, as early in the process as possible; and |
16 | (II) Timely notification of prior authorization determinations by health plans to impacted |
17 | health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, |
18 | and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to |
19 | provider-accessible websites or similar electronic portals or services; |
20 | (viii) Increase and strengthen continuity of patient care by: |
21 | (A) Defining protections for continuity of care during a transition period for patients |
22 | undergoing an active course of treatment, when there is a formulary or treatment coverage change |
23 | or change of health plan that may disrupt their current course of treatment and when the treating |
24 | physician determines that a transition may place the patient at risk; and for prescription medication |
25 | by allowing a grace period of coverage to allow consideration of referred health plan options or |
26 | establishment of medical necessity of the current course of treatment; |
27 | (B) Requiring continuity of care for medical services, including behavioral health services, |
28 | and prescription medications for patients on appropriate, chronic, stable therapy through |
29 | minimizing repetitive prior authorization requirements; and which for prescription medication shall |
30 | be allowed only on an annual review, with exception for labeled limitation, to establish continued |
31 | benefit of treatment; and |
32 | (C) Requiring communication between healthcare providers, health plans, and patients to |
33 | facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied |
34 | by posting to provider-accessible websites or similar electronic portals or services; |
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1 | (D) Continuity of care for formulary or drug coverage shall distinguish between FDA |
2 | designated interchangeable products and proprietary or marketed versions of a medication; |
3 | (ix) Encourage healthcare providers and/or provider organizations and health plans to |
4 | accelerate use of electronic prior authorization technology, including adoption of national standards |
5 | where applicable; and |
6 | (x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the |
7 | workgroup meeting may be conducted in part or whole through electronic methods. |
8 | (4) To provide a report to the house and senate, on or before January 1, 2017, with |
9 | recommendations for establishing guidelines and regulations for systems that give patients |
10 | electronic access to their claims information, particularly to information regarding their obligations |
11 | to pay for received medical services, pursuant to 45 C.F.R. § 164.524. |
12 | (5) No provision of this subsection (h) shall preclude the ongoing work of the office of |
13 | health insurance commissioner’s administrative simplification task force, which includes meetings |
14 | with key stakeholders in order to improve, and provide recommendations regarding, the prior |
15 | authorization process. |
16 | (i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually |
17 | thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate |
18 | committee on health and human services, and the house committee on corporations, with: (1) |
19 | Information on the availability in the commercial market of coverage for anti-cancer medication |
20 | options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment |
21 | options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member |
22 | utilization and cost-sharing expense. |
23 | (j) To monitor the adequacy of each health plan’s compliance with the provisions of the |
24 | federal Mental Health Parity Act, including a review of related claims processing and |
25 | reimbursement procedures. Findings, recommendations, and assessments shall be made available |
26 | to the public. |
27 | (k) To monitor the transition from fee-for-service and toward global and other alternative |
28 | payment methodologies for the payment for healthcare services. Alternative payment |
29 | methodologies should be assessed for their likelihood to promote access to affordable health |
30 | insurance, health outcomes, and performance. |
31 | (l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital |
32 | payment variation, including findings and recommendations, subject to available resources. |
33 | (m) Notwithstanding any provision of the general or public laws or regulation to the |
34 | contrary, provide a report with findings and recommendations to the president of the senate and the |
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1 | speaker of the house, on or before April 1, 2014, including, but not limited to, the following |
2 | information: |
3 | (1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, |
4 | 27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27- |
5 | 18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health |
6 | insurance for fully insured employers, subject to available resources; |
7 | (2) Current provider and insurer mandates that are unnecessary and/or duplicative due to |
8 | the existing standards of care and/or delivery of services in the healthcare system; |
9 | (3) A state-by-state comparison of health insurance mandates and the extent to which |
10 | Rhode Island mandates exceed other states benefits; and |
11 | (4) Recommendations for amendments to existing mandated benefits based on the findings |
12 | in (m)(1), (m)(2), and (m)(3) above. |
13 | (n) On or before July 1, 2014, the office of the health insurance commissioner, in |
14 | collaboration with the director of health and lieutenant governor’s office, shall submit a report to |
15 | the general assembly and the governor to inform the design of accountable care organizations |
16 | (ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value- |
17 | based payment arrangements, that shall include, but not be limited to: |
18 | (1) Utilization review; |
19 | (2) Contracting; and |
20 | (3) Licensing and regulation. |
21 | (o) On or before February 3, 2015, the office of the health insurance commissioner shall |
22 | submit a report to the general assembly and the governor that describes, analyzes, and proposes |
23 | recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard |
24 | to patients with mental health and substance use disorders. |
25 | (p) To work to ensure the health insurance coverage of behavioral health care under the |
26 | same terms and conditions as other health care, and to integrate behavioral health parity |
27 | requirements into the office of the health insurance commissioner insurance oversight and |
28 | healthcare transformation efforts. |
29 | (q) To work with other state agencies to seek delivery system improvements that enhance |
30 | access to a continuum of mental health and substance use disorder treatment in the state; and |
31 | integrate that treatment with primary and other medical care to the fullest extent possible. |
32 | (r) To direct insurers toward policies and practices that address the behavioral health needs |
33 | of the public and greater integration of physical and behavioral healthcare delivery. |
34 | (s) The office of the health insurance commissioner shall conduct an analysis of the impact |
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1 | of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and |
2 | submit a report of its findings to the general assembly on or before June 1, 2023. |
3 | (t) To undertake the analyses, reports, and studies contained in this section: |
4 | (1) The office shall hire the necessary staff and prepare a request for proposal for a qualified |
5 | and competent firm or firms to undertake the following analyses, reports, and studies: |
6 | (i) The firm shall undertake a comprehensive review of all social and human service |
7 | programs having a contract with or licensed by the state or any subdivision of the department of |
8 | children, youth and families (DCYF), the department of behavioral healthcare, developmental |
9 | disabilities and hospitals (BHDDH), the department of human services (DHS), the department of |
10 | health (DOH), and Medicaid for the purposes of: |
11 | (A) Establishing a baseline of the eligibility factors for receiving services; |
12 | (B) Establishing a baseline of the service offering through each agency for those |
13 | determined eligible; |
14 | (C) Establishing a baseline understanding of reimbursement rates for all social and human |
15 | service programs including rates currently being paid, the date of the last increase, and a proposed |
16 | model that the state may use to conduct future studies and analyses; |
17 | (D) Ensuring accurate and adequate reimbursement to social and human service providers |
18 | that facilitate the availability of high-quality services to individuals receiving home and |
19 | community-based long-term services and supports provided by social and human service providers; |
20 | (E) Ensuring the general assembly is provided accurate financial projections on social and |
21 | human service program costs, demand for services, and workforce needs to ensure access to entitled |
22 | beneficiaries and services; |
23 | (F) Establishing a baseline and determining the relationship between state government and |
24 | the provider network including functions, responsibilities, and duties; |
25 | (G) Determining a set of measures and accountability standards to be used by EOHHS and |
26 | the general assembly to measure the outcomes of the provision of services including budgetary |
27 | reporting requirements, transparency portals, and other methods; and |
28 | (H) Reporting the findings of human services analyses and reports to the speaker of the |
29 | house, senate president, chairs of the house and senate finance committees, chairs of the house and |
30 | senate health and human services committees, and the governor. |
31 | (2) The analyses, reports, and studies required pursuant to this section shall be |
32 | accomplished and published as follows and shall provide: |
33 | (i) An assessment and detailed reporting on all social and human service program rates to |
34 | be completed by January 1, 2023, including rates currently being paid and the date of the last |
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1 | increase; |
2 | (ii) An assessment and detailed reporting on eligibility standards and processes of all |
3 | mandatory and discretionary social and human service programs to be completed by January 1, |
4 | 2023; |
5 | (iii) An assessment and detailed reporting on utilization trends from the period of January |
6 | 1, 2017, through December 31, 2021, for social and human service programs to be completed by |
7 | January 1, 2023; |
8 | (iv) An assessment and detailed reporting on the structure of the state government as it |
9 | relates to the provision of services by social and human service providers including eligibility and |
10 | functions of the provider network to be completed by January 1, 2023; |
11 | (v) An assessment and detailed reporting on accountability standards for services for social |
12 | and human service programs to be completed by January 1, 2023; |
13 | (vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed |
14 | and unlicensed personnel requirements for established rates for social and human service programs |
15 | pursuant to a contract or established fee schedule; |
16 | (vii) An assessment and reporting on access to social and human service programs, to |
17 | include any wait lists and length of time on wait lists, in each service category by April 1, 2023; |
18 | (viii) An assessment and reporting of national and regional Medicaid rates in comparison |
19 | to Rhode Island social and human service provider rates by April 1, 2023; |
20 | (ix) An assessment and reporting on usual and customary rates paid by private insurers and |
21 | private pay for similar social and human service providers, both nationally and regionally, by April |
22 | 1, 2023; and |
23 | (x) Completion of the development of an assessment and review process that includes the |
24 | following components: eligibility; scope of services; relationship of social and human service |
25 | provider and the state; national and regional rate comparisons and accountability standards that |
26 | result in recommended rate adjustments; and this process shall be completed by September 1, 2023, |
27 | and conducted biennially hereafter. On and after September 1, 2025, all biennial reports shall |
28 | include a review and recommendations of rates for primary care services. The biennial rate setting |
29 | shall be consistent with payment requirements established in § 1902(a)(30)(A) of the Social |
30 | Security Act, 42 U.S.C. § 1396a(a)(30)(A), and all federal and state law, regulations, and quality |
31 | and safety standards. The results and findings of this process shall be transparent, and public |
32 | meetings shall be conducted to allow providers, recipients, and other interested parties an |
33 | opportunity to ask questions and provide comment beginning in September 2023 and biennially |
34 | thereafter. |
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1 | (3) In fulfillment of the responsibilities defined in subsection (t), the office of the health |
2 | insurance commissioner shall consult with the Executive Office of Health and Human Services. |
3 | (u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall |
4 | include the corresponding components of the assessment and review (i.e., eligibility; scope of |
5 | services; relationship of social and human service provider and the state; and national and regional |
6 | rate comparisons and accountability standards including any changes or substantive issues between |
7 | biennial reviews) including the recommended rates from the most recent assessment and review |
8 | with their annual budget submission to the office of management and budget and provide a detailed |
9 | explanation and impact statement if any rate variances exist between submitted recommended |
10 | budget and the corresponding recommended rate from the most recent assessment and review |
11 | process starting October 1, 2023, and biennially thereafter. |
12 | (v) The general assembly shall appropriate adequate funding as it deems necessary to |
13 | undertake the analyses, reports, and studies contained in this section relating to the powers and |
14 | duties of the office of the health insurance commissioner. |
15 | SECTION 2. This act shall take effect upon passage. |
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| LC005628 - Page 13 of 14 |
EXPLANATION | |
BY THE LEGISLATIVE COUNCIL | |
OF | |
A N A C T | |
RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND HEALTH | |
CARE REFORM ACT OF 2004 -- HEALTH INSURANCE OVERSIGHT | |
*** | |
1 | This act would include the definition of "primary care services" and requires that all |
2 | biennial reports shall include a review and recommendation of rates for primary care services on |
3 | and after September 1, 2025. |
4 | This act would take effect upon passage. |
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| LC005628 - Page 14 of 14 |