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art.008/6/008/5/008/4/008/3/008/2/008/1

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     ARTICLE 8 AS AMENDED

RELATING TO MEDICAL ASSISTANCE

     SECTION 1. Section 23-17-38.1 of the General Laws in Chapter 23-17 entitled "Licensing

of Healthcare Facilities" is hereby amended to read as follows:

     23-17-38.1. Hospitals — Licensing fee.

     (a) There is imposed a hospital licensing fee for state fiscal year 2023 against each hospital

in the state. The hospital licensing fee is equal to five and forty-two hundredths percent (5.42%) of

the net patient-services revenue of every hospital for the hospital’s first fiscal year ending on or

after January 1, 2021, except that the license fee for all hospitals located in Washington County,

Rhode Island shall be discounted by thirty-seven percent (37%). The discount for Washington

County hospitals is subject to approval by the Secretary of the U.S. Department of Health and

Human Services of a state plan amendment submitted by the executive office of health and human

services for the purpose of pursuing a waiver of the uniformity requirement for the hospital license

fee. This licensing fee shall be administered and collected by the tax administrator, division of

taxation within the department of revenue, and all the administration, collection, and other

provisions of chapter 51 of title 44 shall apply. Every hospital shall pay the licensing fee to the tax

administrator on or before June 30, 2023, and payments shall be made by electronic transfer of

monies to the general treasurer and deposited to the general fund. Every hospital shall, on or before

May 25, 2023, make a return to the tax administrator containing the correct computation of net

patient-services revenue for the hospital fiscal year ending September 30, 2021, and the licensing

fee due upon that amount. All returns shall be signed by the hospital’s authorized representative,

subject to the pains and penalties of perjury.

     (b)(a) There is also imposed a hospital licensing fee described in subsections (c) through

(f) for state fiscal years 2024 and 2025 against net patient-services revenue of every non-

government owned hospital as defined herein for the hospital’s first fiscal year ending on or after

January 1, 2022. The hospital licensing fee shall have three (3) tiers with differing fees based on

inpatient and outpatient net patient-services revenue. The executive office of health and human

services, in consultation with the tax administrator, shall identify the hospitals in each tier, subject

to the definitions in this section, by July 15, 2023, and shall notify each hospital of its tier by August

1, 2023.

     (b) There is also imposed a hospital licensing fee described in subsections (c) through (f)

for state fiscal year 2026 against net patient-services revenue of every non-government owned

hospital as defined herein for the hospital’s first fiscal year ending on or after January 1, 2023. The

hospital licensing fee shall have three (3) tiers with differing fees based on inpatient and outpatient

net patient-services revenue. The executive office of health and human services, in consultation

with the tax administrator, shall identify the hospitals in each tier, subject to the definitions in this

section, by July 15, 2025, and shall notify each hospital of its assigned tier by August 1, 2025.

     (c) Tier 1 is composed of hospitals that do not meet the description of either Tier 2 or Tier

3.

     (1) The inpatient hospital licensing fee for Tier 1 is equal to thirteen and twelve hundredths

percent (13.12%) of the inpatient net patient-services revenue derived from inpatient net patient-

services revenue of every Tier 1 hospital.

     (2) The outpatient hospital licensing fee for Tier 1 is equal to thirteen and thirty hundredths

percent (13.30%) of the net patient-services revenue derived from outpatient net patient-services

revenue of every Tier 1 hospital.

     (d) Tier 2 is composed of high Medicaid/uninsured cost hospitals and independent

hospitals.

     (1) The inpatient hospital licensing fee for Tier 2 is equal to two and sixty-three hundredths

percent (2.63%) of the inpatient net patient-services revenue derived from inpatient net patient-

services revenue of every Tier 2 hospital.

     (2) The outpatient hospital licensing fee for Tier 2 is equal to two and sixty-six hundredths

percent (2.66%) of the outpatient net patient-services revenue derived from outpatient net patient-

services revenue of every Tier 2 hospital.

     (e) Tier 3 is composed of hospitals that are Medicare-designated low-volume hospitals and

rehabilitative hospitals.

     (1) The inpatient hospital licensing fee for Tier 3 is equal to one and thirty-one hundredths

percent (1.31%) of the inpatient net patient-services revenue derived from inpatient net patient-

services revenue of every Tier 3 hospital.

     (2) The outpatient hospital licensing fee for Tier 3 is equal to one and thirty-three

hundredths percent (1.33%) of the outpatient net patient-services revenue derived from outpatient

net patient-services revenue of every Tier 3 hospital.

     (f) There is also imposed a hospital licensing fee for state fiscal year 2024 against state-

government owned and operated hospitals in the state as defined herein. The hospital licensing fee

is equal to five and twenty-five hundredths percent (5.25%) of the net patient-services revenue of

every hospital for the hospital’s first fiscal year ending on or after January 1, 2022. There is also

imposed a hospital licensing fee for state fiscal year years 2025 and 2026 against state-government

owned and operated hospitals in the state as defined herein equal to five and twenty-five hundredths

percent (5.25%) of the net patient-services revenue of every hospital for the hospital’s first fiscal

year ending on or after January 1, 2023.

     (g) The hospital licensing fee described in subsections (b) through (f) is subject to U.S.

Department of Health and Human Services approval of a request to waive the requirement that

healthcare-related taxes be imposed uniformly as contained in 42 C.F.R. § 433.68(d).

     (h) This hospital licensing fee shall be administered and collected by the tax administrator,

division of taxation within the department of revenue, and all the administration, collection, and

other provisions of chapter 51 of title 44 shall apply. Every hospital shall pay the licensing fee to

the tax administrator before June 30 June 25 of each fiscal year, and payments shall be made by

electronic transfer of monies to the tax administrator and deposited to the general fund. Every

hospital shall, on or before August 1, 2023 of each fiscal year, make a return to the tax administrator

containing the correct computation of inpatient and outpatient net patient-services revenue for the

hospital fiscal year ending in 2022 data referenced in subsection (a) and or (b), and the licensing

fee due upon that amount. All returns shall be signed by the hospital’s authorized representative,

subject to the pains and penalties of perjury.

     (i) For purposes of this section the following words and phrases have the following

meanings:

     (1) “Gross patient-services revenue” means the gross revenue related to patient care

services.

     (2) “High Medicaid/uninsured cost hospital” means a hospital for which the hospital’s total

uncompensated care, as calculated pursuant to § 40-8.3-2(4), divided by the hospital’s total net

patient-services revenues, is equal to six percent (6.0%) or greater.

     (3) “Hospital” means 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 this title (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 §§ 40-8-13.4(b) and 40-8-13.4(b)(2),

respectively, shall thereafter apply to negotiated increases for each annual twelve-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.

     (4) “Independent hospitals” means a hospital not part of a multi-hospital system.

     (5) “Inpatient net patient-services revenue” means the charges related to inpatient care

services less (i) Charges attributable to charity care; (ii) Bad debt expenses; and (iii) Contractual

allowances.

     (6) “Medicare-designated low-volume hospital” means a hospital that qualifies under 42

C.F.R. 412.101(b)(2) for additional Medicare payments to qualifying hospitals for the higher

incremental costs associated with a low volume of discharges.

     (7) “Net patient-services revenue” means the charges related to patient care services less

(i) Charges attributable to charity care; (ii) Bad debt expenses; and (iii) Contractual allowances.

     (8) “Non-government owned hospitals” means a hospital not owned and operated by the

state of Rhode Island.

     (9) “Outpatient net patient-services revenue” means the charges related to outpatient care

services less (i) Charges attributable to charity care; (ii) Bad debt expenses; and (iii) Contractual

allowances.

     (10) “Rehabilitative hospital” means Rehabilitation Hospital Center licensed by the Rhode

Island department of health.

     (11) “State-government owned and operated hospitals” means a hospital facility licensed

by the Rhode Island department of health, owned and operated by the state of Rhode Island.

     (j) The tax administrator in consultation with the executive office of health and human

services shall make and promulgate any rules, regulations, and procedures not inconsistent with

state law and fiscal procedures that he or she deems necessary for the proper administration of this

section and to carry out the provisions, policy, and purposes of this section.

     (k) The licensing fee imposed by subsection subsections (a) through (f) shall apply to

hospitals as defined herein that are duly licensed on July 1, 2022 2024, and shall be in addition to

the inspection fee imposed by § 23-17-38 and to any licensing fees previously imposed in

accordance with this section.

     (l) The licensing fees imposed by subsections (b) through (f) shall apply to hospitals as

defined herein that are duly licensed on July 1, 2023, and shall be in addition to the inspection fee

imposed by § 23-17-38 and to any licensing fees previously imposed in accordance with this

section.

     SECTION 2. Section 35-17-1 of the General Laws in Chapter 35-17 entitled "Medical

Assistance and Public Assistance Caseload Estimating Conferences" is hereby amended to read as

follows:

     35-17-1. Purpose and membership.

     (a) In order to provide for a more stable and accurate method of financial planning and

budgeting, it is hereby declared the intention of the legislature that there be a procedure for the

determination of official estimates of anticipated medical assistance expenditures and public

assistance caseloads, upon which the executive budget shall be based and for which appropriations

by the general assembly shall be made.

     (b) The state budget officer, the house fiscal advisor, and the senate fiscal advisor shall

meet in regularly scheduled caseload estimating conferences (C.E.C.). These conferences shall be

open public meetings.

     (c) The chairpersonship of each regularly scheduled C.E.C. will rotate among the state

budget officer, the house fiscal advisor, and the senate fiscal advisor, hereinafter referred to as

principals. The schedule shall be arranged so that no chairperson shall preside over two (2)

successive regularly scheduled conferences on the same subject.

     (d) Representatives of all state agencies are to participate in all conferences for which their

input is germane.

     (e) The department of human services shall provide monthly data to the members of the

caseload estimating conference by the fifteenth day of the following month. Monthly data shall

include, but is not limited to, actual caseloads and expenditures for the following case assistance

programs: Rhode Island Works, SSI state program, general public assistance, and child care. For

individuals eligible to receive the payment under § 40-6-27(a)(1)(vi) [repealed], the report shall

include the number of individuals enrolled in a managed care plan receiving long-term care services

and supports and the number receiving fee-for-service benefits. The executive office of health and

human services shall report relevant caseload information and expenditures for the following

medical assistance categories: hospitals, long-term care, managed care, pharmacy, and other

medical services. In the category of managed care, caseload information and expenditures for the

following populations shall be separately identified and reported: children with disabilities,

children in foster care, and children receiving adoption assistance and RIte Share enrollees under §

40-8.4-12(j). The information shall include the number of Medicaid recipients whose estate may

be subject to a recovery and the anticipated amount to be collected from those subject to recovery,

the total recoveries collected each month and number of estates attached to the collections and each

month, the number of open cases and the number of cases that have been open longer than three

months. The executive office will also report separately the amount that the Medicaid expenditures

have been reduced by third-party liability payments to providers, supplemental income verification

tools, the department of administration's office of internal audit and program integrity unit, and

recoveries from ABLE accounts.

     (f) Beginning July 1, 2021, the department of behavioral healthcare, developmental

disabilities and hospitals shall provide monthly data to the members of the caseload estimating

conference by the twenty-fifth day of the following month. Monthly data shall include, but is not

limited to, actual caseloads and expenditures for the private community developmental disabilities

services program. Information shall include, but not be 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 twenty-four-hour (24) 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 will also collect and forward to the house fiscal advisor, the senate fiscal advisor,

and the state budget officer, by November 1 of each year, the annual cost reports for each

community-based provider for the prior fiscal year. 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. The department will also provide a list of community-based

providers awarded an advanced payment for residential and community-based day programs; the

address for each property; and the value of the advancement. If the property is sold, the department

must report the final sale, including the purchaser, the value of the sale, and the name of the agency

that operated the facility. If residential property, the department must provide the number of

individuals residing in the home at the time of sale and identify the type of residential placement

that the individual(s) will be moving to. The department must report if the property will continue

to be licensed as a residential facility. The department will also report any newly licensed twenty-

four-hour (24) group home; the provider operating the facility; and the number of individuals

residing in the facility. Prior to December 1, 2017, the department will provide the authorizations

for community-based and day programs, including the unique number of individuals eligible to

receive the services and at the end of each month the unique number of individuals who participated

in the programs and claims processed.

     (g) The executive office of health and human services shall provide direct assistance to the

department of behavioral healthcare, developmental disabilities and hospitals to facilitate

compliance with the monthly reporting requirements in addition to preparation for the caseload

estimating conferences.

     SECTION 3. Section 40-6-9.1 of the General Laws in Chapter 40-6 entitled "Public

Assistance Act" is hereby amended to read as follows:

     40-6-9.1. Data matching — Healthcare coverages.

     (a) For purposes of this section, the term “medical assistance program” shall mean medical

assistance provided in whole or in part by the department of human services executive office of

health and human services pursuant to chapters 5.1, 8, 8.4 of this title, 12.3 of title 42 and/or Title

XIX or XXI of the federal Social Security Act, as amended, 42 U.S.C. § 1396 et seq. and 42 U.S.C.

§ 1397aa et seq., respectively. Any references to the department office shall be to the department

of human services executive office of health and human services.

     (b) In furtherance of the assignment of rights to medical support to the department of

human services executive office of health and human services under § 40-6-9(b), (c), (d), and (e),

and in order to determine the availability of other sources of healthcare insurance or coverage for

beneficiaries of the medical assistance program, and to determine potential third-party liability for

medical assistance paid out by the department office, all health insurers, health-maintenance

organizations, including managed care organizations, and third-party administrators, self-insured

plans, pharmacy benefit managers (PBM), and other parties that are by statute, contract, or

agreement, legally responsible for payment of a claim for a healthcare item of service doing

business in the state of Rhode Island shall permit and participate in data matching with the

department of human services executive office of health and human services, as provided in this

section, to assist the department office to identify medical assistance program applicants,

beneficiaries, and/or persons responsible for providing medical support for applicants and

beneficiaries who may also have healthcare insurance or coverage in addition to that provided, or

to be provided, by the medical assistance program and to determine any third-party liability in

accordance with this section.

     The department office shall take all reasonable measures to determine the legal liability of

all third parties (including health insurers, self-insured plans, group health plans (as defined in § 

607(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1167(1)]), service

benefit plans, health-maintenance organizations, managed care organizations, pharmacy benefit

managers, or other parties that are, by statute, contract, or agreement, legally responsible for

payment of a claim for a healthcare item or service), to pay for care and services on behalf of a

medical assistance recipient, including collecting sufficient information to enable the department

office to pursue claims against such third parties.

     In any case where such a legal liability is found to exist and medical assistance has been

made available on behalf of the individual (beneficiary), the department office shall seek

reimbursement for the assistance to the extent of the legal liability and in accordance with the

assignment described in § 40-6-9.

     To the extent that payment has been made by the department office for medical assistance

to a beneficiary in any case where a third party has a legal liability to make payment for the

assistance, and to the extent that payment has been made by the department office for medical

assistance for healthcare items or services furnished to an individual, the department office (state)

is considered to have acquired the rights of the individual to payment by any other party for the

healthcare items or services in accordance with § 40-6-9.

     Any health insurer (including a group health plan, as defined in § 607(1) of the Employee

Retirement Income Security Act of 1974 [29 U.S.C. § 1167(1)], a self-insured plan, a service-

benefit plan, a managed care organization, a pharmacy benefit manager, or other party that is, by

statute, contract, or agreement, legally responsible for payment of a claim for a healthcare item or

service), in enrolling an individual, or in making any payments for benefits to the individual or on

the individual’s behalf, is prohibited from taking into account that the individual is eligible for, or

is provided, medical assistance under a plan under 42 U.S.C. § 1396 et seq. for this state, or any

other state.

     (c) All health insurers or liable third parties, including, but not limited to, health-

maintenance organizations, third-party administrators, nonprofit medical-service corporations,

nonprofit hospital-service corporations, subject to the provisions of chapters 18, 19, 20, and 41 of

title 27, as well as, self-insured plans, group health plans (as defined in § 607(1) of the Employee

Retirement Income Security Act of 1974 [29 U.S.C. § 1167(1)]), service-benefit plans, managed

care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or

agreement, legally responsible for payment of a claim for a healthcare item or service) doing

business in this state shall:

     (1) Provide member information within fourteen (14) calendar days of the request to the

department office to enable the medical assistance program to identify medical assistance program

recipients, applicants and/or persons responsible for providing medical support for those recipients

and applicants who are, or could be, enrollees or beneficiaries under any individual or group health

insurance contract, plan, or policy available or in force and effect in the state;

     (2) With respect to individuals who are eligible for, or are provided, medical assistance by

the department office, upon the request of the department office, provide member information

within fourteen (14) calendar days of the request to determine during what period the individual or

his or her spouse or dependents may be (or may have been) covered by a health insurer and the

nature of the coverage that is, or was provided by the health insurer (including the name, address,

and identifying number of the plan);

     (3) Accept the state’s right of recovery and the assignment to the state of any right of an

individual or other entity to payment from the party for an item or service for which payment has

been made by the department office;

     (4) Respond to any inquiry by the department office regarding a claim for payment for any

healthcare item or service that is submitted not later than three (3) years after the date of the

provision of the healthcare item or service; and

     (5) Agree not to deny a claim submitted by the state based solely on procedural reasons,

such as on the basis of the date of submission of the claim, the type or format of the claim form,

failure to obtain a prior authorization, or a failure to present proper documentation at the point-of-

sale that is the basis of the claim, if—

     (i) The claim is submitted by the state within the three-year (3) period beginning on the

date on which the item or service was furnished; and

     (ii) Any action by the state to enforce its rights with respect to the claim is commenced

within six (6) years of the state’s submission of such claim.

     (6) Agree to respond to any inquiry regarding claims within sixty (60) business days after

receipt of the written documentation by the Medicaid recipient.

     (7) Agree to not deny a claim for failure to obtain prior authorization for an item or service.

In the case of a responsible third party that requires prior authorization for an item or service

furnished to an individual eligible to receive medical assistance under the state Medicaid program,

the third-party health insurer shall accept authorization provided by state medical assistance

program that the item or service is covered by Medicaid as if that authorization is a prior

authorization made by the third-party health insurer for the item or service.

     (d) This information shall be made available by these insurers and health-maintenance

organizations and used by the department of human services executive office of health and human

services only for the purposes of, and to the extent necessary for, identifying these persons,

determining the scope and terms of coverage, and ascertaining third-party liability. The department

of human services executive office of health and human services shall provide information to the

health insurers, including health insurers, self-insured plans, group health plans (as defined in § 

607(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1167(1)]), service-

benefit plans, managed care organizations, pharmacy benefit managers, or other parties that are, by

statute, contract, or agreement, legally responsible for payment of a claim for a healthcare item or

service) only for the purposes described herein.

     (e) No health insurer, health-maintenance organization, or third-party administrator that

provides, or makes arrangements to provide, information pursuant to this section shall be liable in

any civil or criminal action or proceeding brought by beneficiaries or members on account of this

action for the purposes of violating confidentiality obligations under the law.

     (f) The department office shall submit any appropriate and necessary state plan provisions.

     (g) The department of human services executive office of health and human services is

authorized and directed to promulgate regulations necessary to ensure the effectiveness of this

section.

     SECTION 4. Section 40-8-19 of the General Laws in Chapter 40-8 entitled "Medical

Assistance" is hereby amended to read as follows:

     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 Title XIX of the Social Security Act for services rendered to

Medicaid-eligible residents, shall be reasonable and adequate to meet the costs 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 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 and other direct-care rate comprised of a base per diem for all facilities;

     (iii) Revision of rates as necessary based on increases in direct and indirect costs beginning

October 2024 utilizing data from the most recent finalized year of facility cost report. The per diem

rate components deferred in subsections (a)(2)(i) and (a)(2)(ii) of this section shall be adjusted

accordingly to reflect changes in direct and indirect care costs since the previous rate review;

     (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 1 of each year, beginning October 1, 2012. This adjustment will not

occur on October 1, 2013, October 1, 2014, or October 1, 2015, but will occur on April 1, 2015.

The adjustment of rates will also not occur on October 1, 2017, October 1, 2018, October 1, 2019,

and October 2022. Effective July 1, 2018, rates paid to nursing facilities from the rates approved

by the Centers for Medicare and Medicaid Services and in effect on October 1, 2017, both fee-for-

service and managed care, will be increased by one and one-half percent (1.5%) and further

increased by one percent (1%) on October 1, 2018, and further increased by one percent (1%) on

October 1, 2019. Effective October 1, 2022, rates paid to nursing facilities from the rates approved

by the Centers for Medicare and Medicaid Services and in effect on October 1, 2021, both fee-for-

service and managed care, will be increased by three percent (3%). In addition to the annual nursing

home inflation index adjustment, there shall be a base rate staffing adjustment of one-half percent

(0.5%) on October 1, 2021, one percent (1.0%) on October 1, 2022, and one and one-half percent

(1.5%) on October 1, 2023. For the twelve (12) month period beginning October 1, 2025, rates paid

to nursing facilities from the rates approved by the Centers for Medicare and Medicaid Services

and in effect on October 1, 2024, both fee-for-service and managed care, will be increased by two

and three-tenths percent (2.3%) There shall also be a base rate staffing adjustment of three percent

(3%) effective October 1, 2025. Not less than one hundred percent (100%) of this base-rate staffing

adjustment shall be expended by each nursing facility to increase compensation, wages, benefits,

and related employer costs, for eligible direct-care staff, including the cost of hiring additional

eligible direct-care positions, as defined in subsection (a)(2)(vi). The inflation index shall be

applied without regard for the transition factors in subsections (b)(1) and (b)(2). For purposes of

October 1, 2016, adjustment only, any rate increase that results from application of the inflation

index to subsections (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 subsection (a)(2)(vi) with respect to the inflation index applied on October 1,

2016. Any facility that does not comply with the 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.

     (3) Commencing on October 1, 2021, eighty percent (80%) of any rate increase that results

from application of the inflation index to subsections (a)(2)(i) and (a)(2)(ii) of this section shall be

dedicated to increase compensation for all eligible direct-care workers in the following manner on

October 1, of each year.

     (i) For purposes of this subsection, compensation increases shall include base salary or

hourly wage increases, benefits, other compensation, and associated payroll tax increases for

eligible direct-care workers. This application of the inflation index shall apply for Medicaid

reimbursement in nursing facilities for both managed care and fee-for-service. For purposes of this

subsection, direct-care staff shall include registered nurses (RNs), licensed practical nurses (LPNs),

certified nursing assistants (CNAs), certified medication technicians, licensed physical therapists,

licensed occupational therapists, licensed speech-language pathologists, mental health workers

who are also certified nurse assistants, physical therapist assistants, social worker, or any nurse aide

with a valid license, even if it is probationary, 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:

     (A) RNs and LPNs who are classified as “exempt employees” under the federal Fair Labor

Standards Act (29 U.S.C. § 201 et seq.); or

     (B) CNAs, certified medication technicians, RNs, or LPNs who are contracted or

subcontracted through a third-party vendor or staffing agency.

     (4)(i) By July 31, 2021, and July 31 of each year thereafter, nursing facilities shall submit

to the secretary or designee a certification that they have complied with the provisions of subsection

(a)(3) of this section with respect to the inflation index applied on October 1. The executive office

of health and human services (EOHHS) shall create the certification form nursing facilities must

complete with information on how each individual eligible employee’s compensation increased,

including information regarding hourly wages prior to the increase and after the compensation

increase, hours paid after the compensation increase, and associated increased payroll taxes. A

collective bargaining agreement can be used in lieu of the certification form for represented

employees. All data reported on the compliance form is subject to review and audit by EOHHS.

The audits may include field or desk audits, and facilities may be required to provide additional

supporting documents including, but not limited to, payroll records.

     (ii) Any facility that does not comply with the terms of certification shall be subjected to a

clawback and twenty-five percent (25%) penalty of the unspent or impermissibly spent funds, 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.

     (iii) In any calendar year where no inflationary index is applied, eighty percent (80%) of

the base rate staffing adjustment in that calendar year pursuant to subsection (a)(2)(vi) of this

section shall be dedicated to increase compensation for all eligible direct-care workers in the

manner referenced in subsections (a)(3)(i), (a)(3)(i)(A), and (a)(3)(i)(B) of this section.

     (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 subsection (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. The 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; 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; and

     (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 years 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-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. Consistent with the

other provisions of this chapter, nothing in this provision shall require the executive office to restore

the rates to those in effect on April 1, 2015, at the end of this twelve-month (12) period.

     SECTION 5. 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, 2023 2024, the period from October 1, 2021 2022,

through September 30, 2022 2023, and for any fiscal year ending after September 30, 2024 2025,

the period from October 1, 2022 2023, through September 30, 2023 2024.

     (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) Was 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 (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 the 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 §§ 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-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) Achieved a medical assistance inpatient utilization rate of at least one percent (1%)

during the base year; and

     (iii) Continues 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) The cost incurred

by the 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; (ii) The cost incurred by the hospital

during the base year for inpatient or outpatient services attributable to Medicaid beneficiaries less

any Medicaid reimbursement received therefor; and (iii) the sum of subsections (4)(i) and (4)(ii) of

this section shall be offset by the estimated hospital’s commercial equivalent rates state directed

payment for the current SFY in which the disproportionate share hospital (DSH) payment is made.

The sum of subsections (4)(i), (4)(ii), and (4)(iii) of this section shall be multiplied by the

uncompensated care index.

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

established pursuant to § 27-19-14 [repealed] 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, September 30, 2015, September 30, 2016, September 30, 2017, September 30, 2018,

September 30, 2019, September 30, 2020, September 30, 2021, September 30, 2022, September

30, 2023, September 30, 2024, and September 30, 2025, and September 30, 2026, shall be deemed

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

     40-8.3-3. Implementation.

     (a) For federal fiscal year 2023, commencing on October 1, 2022, and ending September

30, 2023, the executive office of health and human services shall submit to the Secretary of the

United States 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

$159.0 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 the uncompensated-care index for all participating hospitals. The disproportionate share

payments shall be made on or before June 15, 2023, and are expressly conditioned upon approval

on or before June 23, 2023, by the Secretary of the United States 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 2023 for

the disproportionate share payments.

     (b)(a) For federal fiscal year 2024, commencing on October 1, 2023, and ending September

30, 2024, the executive office of health and human services shall submit to the Secretary of the

United States 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

$14.8 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 the uncompensated-care index for all participating hospitals. The disproportionate share

payments shall be made on or before June 30, 2024, and are expressly conditioned upon approval

on or before June 23, 2024, by the Secretary of the United States 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 2024 for

the disproportionate share payments.

     (c)(b) For federal fiscal year 2025, commencing on October 1, 2024, and ending September

30, 2025, the executive office of health and human services shall submit to the Secretary of the

United States Department of Health and Human Services a state plan amendment to the Rhode

Island Medicaid DSH plan to provide:

     (1) The creation of Pool C which allots no more than nineteen million nine hundred

thousand dollars ($19,900,000) twelve million nine hundred thousand dollars ($12,900,000) to

Medicaid eligible government-owned hospitals;

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

$34.7 $27.7 million, shall be allocated by the executive office of health and human services to the

Pool C and D components of the DSH plan;

     (3) 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 the uncompensated-care index of all participating hospitals. The disproportionate share

payments shall be made on or before June 30, 2025, and are expressly conditioned upon approval

on or before June 23, 2025, by the Secretary of the United States Department of Health and Human

Services, or their authorized representative, of all Medicaid state plan amendments necessary to

secure for the state the benefit of federal financial participation in federal fiscal year 2025 for the

disproportionate share payments; and

     (4) That the Pool C 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 cost for the base year

inflated by the uncompensated-care index of all participating hospitals. The disproportionate share

payments shall be made on or before June 30, 2025, and are expressly conditioned upon approval

on or before June 23, 2025, by the Secretary of the United States Department of Health and Human

Services, or their authorized representative, of all Medicaid state plan amendments necessary to

secure for the state the benefit of federal financial participation in federal fiscal year 2025 for the

disproportionate share payments.

     (c) For federal fiscal year 2026, commencing on October 1, 2025, and ending September

30, 2026, the executive office of health and human services shall submit to the Secretary of the

United States 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

$13.9 million, shall be allocated by the executive office of health and human services to the Pool

C and D components of the DSH plan. Pool C shall not exceed an aggregate limit of $12.9 million.

Pool D shall not exceed an aggregate limit of $1.0 million.

     (2) That the Pool C 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 cost for the base year

inflated by the uncompensated-care index of all participating hospitals. The disproportionate share

payments shall be made on or before June 30, 2026, and are expressly conditioned upon approval

on or before June 23, 2026, by the Secretary of the United States Department of Health and Human

Services, or their authorized representative, of all Medicaid state plan amendments necessary to

secure for the state the benefit of federal financial participation in federal fiscal year 2026 for the

disproportionate share payments; and

     (3) 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 the uncompensated-care index of all participating hospitals. The disproportionate share

payments shall be made on or before June 30, 2026, and are expressly conditioned upon approval

on or before June 23, 2026, by the Secretary of the United States Department of Health and Human

Services, or their authorized representative, of all Medicaid state plan amendments necessary to

secure for the state the benefit of federal financial participation in federal fiscal year 2026 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) [Deleted by P.L. 2019, ch. 88, art. 13, § 6.]

     SECTION 6. Section 40-8.9-9 of the General Laws in Chapter 40-8.9 entitled "Medical

Assistance — Long-Term Care Service and Finance Reform" is hereby amended to read as follows:

     40-8.9-9. Long-term-care rebalancing 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 Department

of Health and Human Services, 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 rebalancing 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.

     (c) Pursuant to federal authority procured under § 42-7.2-16, the 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. The 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 these 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 April

1, 2021, for any recipient determined eligible for and receiving Medicaid-funded long-term services

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

disabilities on or before that date, unless:

     (i) The recipient transitions to home- and community-based services because he or she

would no longer meet the level-of-care criteria in effect on April 1, 2021; or

     (ii) The 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 April 1, 2021, 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) Performed 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) The 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 42 U.S.C. § 1396n 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 42

U.S.C. § 1396n 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 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 providers of services authorized under § 40.1-24-1(3), assisted living, and

adult supportive care (as defined under 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) As the state’s Medicaid program seeks to assist more beneficiaries requiring long-term

services and supports in home- and community-based settings, the demand for home-care workers

has increased, and wages for these workers has not kept pace with neighboring states, leading to

high turnover and vacancy rates in the state’s home-care industry, the executive office shall institute

a one-time increase in the base-payment rates for FY 2019, as described below, for home-care

service providers to promote increased access to and an adequate supply of highly trained home-

healthcare professionals, in amount to be determined by the appropriations process, for the purpose

of raising wages for personal care attendants and home health aides to be implemented by such

providers.

     (i) A prospective base adjustment, effective not later than July 1, 2018, of ten percent (10%)

of the current base rate for home-care providers, home nursing care providers, and hospice

providers contracted with the executive office of health and human services and its subordinate

agencies to deliver Medicaid fee-for-service personal care attendant services.

     (ii) A prospective base adjustment, effective not later than July 1, 2018, of twenty percent

(20%) of the current base rate for home-care providers, home nursing care providers, and hospice

providers contracted with the executive office of health and human services and its subordinate

agencies to deliver Medicaid fee-for-service skilled nursing and therapeutic services and hospice

care.

     (iii) Effective upon passage of this section, hospice provider reimbursement, exclusively

for room and board expenses for individuals residing in a skilled nursing facility, shall revert to the

rate methodology in effect on June 30, 2018, and these room and board expenses shall be exempted

from any and all annual rate increases to hospice providers as provided for in this section.

     (iv) On the first of July in each year, beginning on July 1, 2019, the executive office of

health and human services will initiate an annual inflation increase to the base rate for home-care

providers, home nursing care providers, and hospice providers contracted with the executive office

and its subordinate agencies to deliver Medicaid fee-for-service personal care attendant services,

skilled nursing and therapeutic services and hospice care. The base rate increase shall be a

percentage amount equal to the New England Consumer Price Index card as determined by the

United States Department of Labor for medical care and for compliance with all federal and state

laws, regulations, and rules, and all national accreditation program requirements., except as of July

1, 2025, and thereafter, when no annual inflation increase shall occur for these rates.

     (g) As the state’s Medicaid program seeks to assist more beneficiaries requiring long-term

services and supports in home- and community-based settings, the demand for home-care workers

has increased, and wages for these workers has not kept pace with neighboring states, leading to

high turnover and vacancy rates in the state’s home-care industry. To promote increased access to

and an adequate supply of direct-care workers, the executive office shall institute a payment

methodology change, in Medicaid fee-for-service and managed care, for FY 2022, that shall be

passed through directly to the direct-care workers’ wages who are employed by home nursing care

and home-care providers licensed by the Rhode Island department of health, as described below:

     (1) Effective July 1, 2021, increase the existing shift differential modifier by $0.19 per

fifteen (15) minutes for personal care and combined personal care/homemaker.

     (i) Employers must pass on one hundred percent (100%) of the shift differential modifier

increase per fifteen-minute (15) unit of service to the CNAs who rendered such services. This

compensation shall be provided in addition to the rate of compensation that the employee was

receiving as of June 30, 2021. For an employee hired after June 30, 2021, the agency shall use not

less than the lowest compensation paid to an employee of similar functions and duties as of June

30, 2021, as the base compensation to which the increase is applied.

     (ii) Employers must provide to EOHHS an annual compliance statement showing wages

as of June 30, 2021, amounts received from the increases outlined herein, and compliance with this

section by July 1, 2022. EOHHS may adopt any additional necessary regulations and processes to

oversee this subsection.

     (2) Effective January 1, 2022, establish a new behavioral healthcare enhancement of $0.39

per fifteen (15) minutes for personal care, combined personal care/homemaker, and homemaker

only for providers who have at least thirty percent (30%) of their direct-care workers (which

includes certified nursing assistants (CNA) and homemakers) certified in behavioral healthcare

training.

     (i) Employers must pass on one hundred percent (100%) of the behavioral healthcare

enhancement per fifteen (15) minute unit of service rendered by only those CNAs and homemakers

who have completed the thirty (30) hour behavioral health certificate training program offered by

Rhode Island College, or a training program that is prospectively determined to be compliant per

EOHHS, to those CNAs and homemakers. This compensation shall be provided in addition to the

rate of compensation that the employee was receiving as of December 31, 2021. For an employee

hired after December 31, 2021, the agency shall use not less than the lowest compensation paid to

an employee of similar functions and duties as of December 31, 2021, as the base compensation to

which the increase is applied.

     (ii) By January 1, 2023, employers must provide to EOHHS an annual compliance

statement showing wages as of December 31, 2021, amounts received from the increases outlined

herein, and compliance with this section, including which behavioral healthcare training programs

were utilized. EOHHS may adopt any additional necessary regulations and processes to oversee

this subsection.

     (h) 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.

     (i) The executive office shall implement, no later than January 1, 2024, a statewide network

and rate methodology for conflict-free case management for individuals receiving Medicaid-funded

home and community-based services. The executive office shall coordinate implementation with

the state’s health and human services departments and divisions authorized to deliver Medicaid-

funded home and community-based service programs, including the department of behavioral

healthcare, developmental disabilities and hospitals; the department of human services; and the

office of healthy aging. It is in the best interest of the Rhode Islanders eligible to receive Medicaid

home and community-based services under this chapter, title 40.1, title 42, or any other general

laws to provide equitable access to conflict-free case management that shall include person-

centered planning, service arranging, and quality monitoring in the amount, duration, and scope

required by federal law and regulations. It is necessary to ensure that there is a robust network of

qualified conflict-free case management entities with the capacity to serve all participants on a

statewide basis and in a manner that promotes choice, self-reliance, and community integration.

The executive office, as the designated single state Medicaid authority and agency responsible for

coordinating policy and planning for health and human services under § 42-7.2-1 et seq., is directed

to establish a statewide conflict-free case management network under the management of the

executive office and to seek any Medicaid waivers, state plan amendments, and changes in rules,

regulations, and procedures that may be necessary to ensure that recipients of Medicaid home and

community-based services have access to conflict-free case management in a timely manner and in

accordance with the federal requirements that must be met to preserve financial participation.

     (j) 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 home- and community-transition and stabilization services; provided, however,

payments shall not exceed an annual or per-person amount.

     (k) 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.

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

and community-based service and payment reforms:

     (1) [Deleted by P.L. 2021, ch. 162, art. 12, § 6.]

     (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.

     (m) 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 7. Sections 40-8.10-2, 40-8.10-3 and 40-8.10-4 of the General Laws in Chapter

40-8.10 entitled "Long-Term Care Service Reform for Medicaid Eligible Individuals" are hereby

amended to read as follows:

     40-8.10-2. Definitions.

     As used in this chapter:

     (1) “Core services” mean homemaker services, environmental modifications (home

accessibility adaptations, special medical equipment (minor assistive devices), meals on wheels

(home delivered meals), personal emergency response (PERS), licensed practical nurse services,

community transition services, residential supports, day supports, supported employment,

supported living arrangements, private duty nursing, supports for consumer direction (supports

facilitation), participant directed goods and services, case management, senior companion services,

assisted living, personal care assistance services and respite.

     (2) “Preventive services” mean homemaker services, minor environmental modifications,

physical therapy evaluation and services, and respite services.

     40-8.10-3. Levels of care.

     (a) The secretary of the executive office of health and human services shall coordinate

responsibilities for long-term-care assessment in accordance with the provisions of this chapter.

Importance shall be placed upon the proper and consistent determination of levels of care across

the state departments for each long-term-care setting, including behavioral health residential

treatment facilities, long-term-care hospitals, intermediate-care facilities, and/or skilled nursing

facilities. Specialized plans of care that meet the needs of the individual Medicaid recipients shall

be coordinated and consistent across all state departments. The development of care plans shall be

person-centered and shall support individual self-determination, family involvement, when

appropriate, individual choice, and interdepartmental collaboration.

     (b) Levels of care for long-term-care institutions (behavioral health residential treatment

facilities, long-term-care hospitals, intermediate-care facilities and/or skilled nursing facilities), for

which alternative community-based services and supports are available, shall be established

pursuant to § 40-8.9-9. The structure of the three (3) two (2) levels of care is as follows:

     (1) Highest level of care. Individuals who are determined, based on medical need, to require

the institutional level of care will have the choice to receive services in a long-term-care institution

or in a home- and community-based setting.

     (2) High level of care. Individuals who are determined, based on medical need, to benefit

from home- and community-based services.

     (3) Preventive level of care. Individuals who do not presently need an institutional level of

care but who need services targeted at preventing admission, re-admissions, or reducing lengths of

stay in an institution.

     (c) Determinations of levels of care and the provision of long-term-care health services

shall be determined in accordance with this section and shall be in accordance with the applicable

provisions of § 40-8.9-9.

     40-8.10-4. Long-term care assessment and coordination.

     (a) The executive office of health and human services shall implement a long-term-care-

options counseling program to provide individuals or their representative, 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; information

on caregiver support services, including respite care; 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 a long-term-care-options consultation, if he or she so requests. Each

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

care consultation.

     (b) Core and preventative home- and community-based services defined and delineated in

§ 40-8.10-2 shall be provided only to those individuals who meet one of the levels of care provided

for in this chapter. Other long-term-care services authorized by the federal government, such as

medication management, may also be provided to Medicaid-eligible recipients who have

established the requisite need.

     (c) The assessments for individuals conducted in accordance with this section shall serve

as the basis for individual budgets for those medical assistance recipients eligible to receive services

utilizing a self-directed delivery system.

     (d) Nothing in this section shall prohibit the secretary of the executive office of health and

human services, or the directors of that office’s departments from utilizing community agencies or

contractors when appropriate to perform assessment functions outlined in this chapter.

     SECTION 8. Section 42-7.2-5 of the General Laws in Chapter 42-7.2 entitled "Office of

Health and Human Services" is hereby amended to read as follows:

     42-7.2-5. Duties of the secretary.

     The secretary shall be subject to the direction and supervision of the governor for the

oversight, coordination, and cohesive direction of state-administered health and human services

and in ensuring the laws are faithfully executed, notwithstanding any law to the contrary. In this

capacity, the secretary of the executive office of health and human services (EOHHS) shall be

authorized to:

     (1) Coordinate the administration and financing of healthcare benefits, human services, and

programs including those authorized by the state’s Medicaid section 1115 demonstration waiver

and, as applicable, the Medicaid state plan under Title XIX of the U.S. Social Security Act.

However, nothing in this section shall be construed as transferring to the secretary the powers,

duties, or functions conferred upon the departments by Rhode Island public and general laws for

the administration of federal/state programs financed in whole or in part with Medicaid funds or

the administrative responsibility for the preparation and submission of any state plans, state plan

amendments, or authorized federal waiver applications, once approved by the secretary.

     (2) Serve as the governor’s chief advisor and liaison to federal policymakers on Medicaid

reform issues as well as the principal point of contact in the state on any such related matters.

     (3)(i) Review and ensure the coordination of the state’s Medicaid section 1115

demonstration waiver requests and renewals as well as any initiatives and proposals requiring

amendments to the Medicaid state plan or formal amendment changes, as described in the special

terms and conditions of the state’s Medicaid section 1115 demonstration waiver with the potential

to affect the scope, amount, or duration of publicly funded healthcare services, provider payments

or reimbursements, or access to or the availability of benefits and services as provided by Rhode

Island general and public laws. The secretary shall consider whether any such changes are legally

and fiscally sound and consistent with the state’s policy and budget priorities. The secretary shall

also assess whether a proposed change is capable of obtaining the necessary approvals from federal

officials and achieving the expected positive consumer outcomes. Department directors shall,

within the timelines specified, provide any information and resources the secretary deems necessary

in order to perform the reviews authorized in this section.

     (ii) Direct the development and implementation of any Medicaid policies, procedures, or

systems that may be required to assure successful operation of the state’s health and human services

integrated eligibility system and coordination with HealthSource RI, the state’s health insurance

marketplace.

     (iii) Beginning in 2015, conduct on a biennial basis a comprehensive review of the

Medicaid eligibility criteria for one or more of the populations covered under the state plan or a

waiver to ensure consistency with federal and state laws and policies, coordinate and align systems,

and identify areas for improving quality assurance, fair and equitable access to services, and

opportunities for additional financial participation.

     (iv) Implement service organization and delivery reforms that facilitate service integration,

increase value, and improve quality and health outcomes.

     (4) Beginning in 2020, prepare and submit to the governor, the chairpersons of the house

and senate finance committees, the caseload estimating conference, and to the joint legislative

committee for health-care oversight, by no later than September 15 of each year, a comprehensive

overview of all Medicaid expenditures outcomes, administrative costs, and utilization rates. The

overview shall include, but not be limited to, the following information:

     (i) Expenditures under Titles XIX and XXI of the Social Security Act, as amended;

     (ii) Expenditures, outcomes, and utilization rates by population and sub-population served

(e.g., families with children, persons with disabilities, children in foster care, children receiving

adoption assistance, adults ages nineteen (19) to sixty-four (64), and elders);

     (iii) Expenditures, outcomes, and utilization rates by each state department or other

municipal or public entity receiving federal reimbursement under Titles XIX and XXI of the Social

Security Act, as amended;

     (iv) Expenditures, outcomes, and utilization rates by type of service and/or service

provider;

     (v) Expenditures by mandatory population receiving mandatory services and, reported

separately, optional services, as well as optional populations receiving mandatory services and,

reported separately, optional services for each state agency receiving Title XIX and XXI funds; and

     (vi) Information submitted to the Centers for Medicare & Medicaid Services for the

mandatory annual state reporting of the Core Set of Children’s Health Care Quality Measures for

Medicaid and Children’s Health Insurance Program, behavioral health measures on the Core Set of

Adult Health Care Quality Measures for Medicaid and the Core Sets of Health Home Quality

Measures for Medicaid to ensure compliance with the Bipartisan Budget Act of 2018, Pub. L. No.

115-123.

     The directors of the departments, as well as local governments and school departments,

shall assist and cooperate with the secretary in fulfilling this responsibility by providing whatever

resources, information and support shall be necessary.

     (5) Resolve administrative, jurisdictional, operational, program, or policy conflicts among

departments and their executive staffs and make necessary recommendations to the governor.

     (6) Ensure continued progress toward improving the quality, the economy, the

accountability, and the efficiency of state-administered health and human services. In this capacity,

the secretary shall:

     (i) Direct implementation of reforms in the human resources practices of the executive

office and the departments that streamline and upgrade services, achieve greater economies of scale

and establish the coordinated system of the staff education, cross-training, and career development

services necessary to recruit and retain a highly-skilled, responsive, and engaged health and human

services workforce;

     (ii) Encourage EOHHS-wide consumer-centered approaches to service design and delivery

that expand their capacity to respond efficiently and responsibly to the diverse and changing needs

of the people and communities they serve;

     (iii) Develop all opportunities to maximize resources by leveraging the state’s purchasing

power, centralizing fiscal service functions related to budget, finance, and procurement,

centralizing communication, policy analysis and planning, and information systems and data

management, pursuing alternative funding sources through grants, awards, and partnerships and

securing all available federal financial participation for programs and services provided EOHHS-

wide;

     (iv) Improve the coordination and efficiency of health and human services legal functions

by centralizing adjudicative and legal services and overseeing their timely and judicious

administration;

     (v) Facilitate the rebalancing of the long-term system by creating an assessment and

coordination organization or unit for the expressed purpose of developing and implementing

procedures EOHHS-wide that ensure that the appropriate publicly funded health services are

provided at the right time and in the most appropriate and least restrictive setting;

     (vi) Strengthen health and human services program integrity, quality control and

collections, and recovery activities by consolidating functions within the office in a single unit that

ensures all affected parties pay their fair share of the cost of services and are aware of alternative

financing;

     (vii) Assure protective services are available to vulnerable elders and adults with

developmental and other disabilities by reorganizing existing services, establishing new services

where gaps exist, and centralizing administrative responsibility for oversight of all related

initiatives and programs.

     (7) Prepare and integrate comprehensive budgets for the health and human services

departments and any other functions and duties assigned to the office. The budgets shall be

submitted to the state budget office by the secretary, for consideration by the governor, on behalf

of the state’s health and human services agencies in accordance with the provisions set forth in §

35-3-4.

     (8) Utilize objective data to evaluate health and human services policy goals, resource use

and outcome evaluation and to perform short and long-term policy planning and development.

     (9) Establishment of an integrated approach to interdepartmental information and data

management that complements and furthers the goals of the unified health infrastructure project

initiative and that will facilitate the transition to a consumer-centered integrated system of state-

administered health and human services.

     (10) At the direction of the governor or the general assembly, conduct independent reviews

of state-administered health and human services programs, policies and related agency actions and

activities and assist the department directors in identifying strategies to address any issues or areas

of concern that may emerge thereof. The department directors shall provide any information and

assistance deemed necessary by the secretary when undertaking such independent reviews.

     (11) Provide regular and timely reports to the governor and make recommendations with

respect to the state’s health and human services agenda.

     (12) Employ such personnel and contract for such consulting services as may be required

to perform the powers and duties lawfully conferred upon the secretary.

     (13) Assume responsibility for complying with the provisions of any general or public law

or regulation related to the disclosure, confidentiality, and privacy of any information or records,

in the possession or under the control of the executive office or the departments assigned to the

executive office, that may be developed or acquired or transferred at the direction of the governor

or the secretary for purposes directly connected with the secretary’s duties set forth herein.

     (14) Hold the director of each health and human services department accountable for their

administrative, fiscal, and program actions in the conduct of the respective powers and duties of

their agencies.

     (15) Identify opportunities for inclusion with the EOHHS’ October 1, 2023 budget

,submission, to remove fixed eligibility thresholds for programs under its purview by establishing

sliding scale decreases in benefits commensurate with income increases up to four hundred fifty

percent (450%) of the federal poverty level. These shall include but not be limited to, medical

assistance, childcare assistance, and food assistance.

     (16) The secretary shall convene, in consultation with the governor, an advisory working

group to assist in the review and analysis of potential impacts of any adopted federal actions related

to Medicaid programs. The working group shall develop options for administrative action or

general assembly consideration that may be needed to address any federal funding changes that

impact Rhode Island's Medicaid programs.

     (i) The advisory working group may include, but not be limited to, the secretary of health

and human services, director of management and budget, and designees from the following: state

agencies, businesses, healthcare, public sector unions, and advocates.

     (ii) As soon as practicable after the enactment federal budget for fiscal year 2026, but no

later than October 31, 2025, the advisory working group shall forward a report to the governor,

speaker of the house, and president of the senate containing the findings, recommendations and

options for consideration to become compliant with federal changes prior to the governor's budget

submission pursuant to § 35-3-7.

     SECTION 9. Sections 42-14.5-2.1 and 42-14.5-3 of the General Laws in Chapter 42-14.5

entitled "The Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" are

hereby amended to read as follows:

     42-14.5-2.1. Definitions.

     As used in this chapter:

     (1) “Accountability standards” means measures including service processes, client and

population outcomes, practice standard compliance and fiscal integrity of social and human service

providers on the individual contractual level and service type for all state contacts of the state or

any subdivision or agency to include, but not limited to, the department of children, youth and

families (DCYF), the department of behavioral healthcare, developmental disabilities and hospitals

(BHDDH), the department of human services (DHS), the department of health (DOH), and

Medicaid. This may include mandatory reporting, consolidated, standardized reporting, audits

regardless of organizational tax status, and accountability dashboards of aforementioned state

departments or subdivisions that are regularly shared with the public.

     (2) “Executive Office of Health and Human Services (EOHHS)” means the department

that serves as “principal agency of the executive branch of state government” (§ 42-7.2-2)

responsible for managing the departments and offices of: health (RIDOH), human services (DHS),

healthy aging (OHA), veterans services (VETS), children, youth and families (DCYF), and

behavioral healthcare, developmental disabilities and hospitals (BHDDH). EOHHS is also

designated as the single state agency with authority to administer the Medicaid program in Rhode

Island.

     (3) "Primary care services" means, for the purposes of reporting required under § 42-14.5-

3(t), professional services rendered by primary care providers at a primary care site of care,

including care management services performed in the context of team-based primary care.

     (3)(4) “Rate review” means the process of reviewing and reporting of specific trending

factors that influence the cost of service that informs rate setting.

     (4)(5) “Rate setting” means the process of establishing rates for social and human service

programs that are based on a thorough rate review process.

     (5)(6) “Social and human service program” means a social, mental health, developmental

disability, child welfare, juvenile justice, prevention services, habilitative, rehabilitative, substance

use disorder treatment, residential care, adult or adolescent day services, vocational, employment

and training, or aging service program or accommodations purchased by the state.

     (6)(7) “Social and human service provider” means a provider of social and human service

programs pursuant to a contract with the state or any subdivision or agency to include, but not be

limited to, the department of children, youth and families (DCYF), the department of behavioral

healthcare, developmental disabilities and hospitals (BHDDH), the department of human services

(DHS), the department of health (DOH), and Medicaid.

     (7)(8) “State government and the provider network” refers to the contractual relationship

between a state agency or subdivision of a state agency and private companies the state contracts

with to provide the network of mandated and discretionary social and human services.

     42-14.5-3. Powers and duties.

     The health insurance commissioner shall have the following powers and duties:

     (a) To conduct quarterly public meetings throughout the state, separate and distinct from

rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers

licensed to provide health insurance in the state; the effects of such rates, services, and operations

on consumers, medical care providers, patients, and the market environment in which the insurers

operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less

than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island

Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney

general, and the chambers of commerce. Public notice shall be posted on the department’s website

and given in the newspaper of general circulation, and to any entity in writing requesting notice.

     (b) To make recommendations to the governor and the house of representatives and senate

finance committees regarding healthcare insurance and the regulations, rates, services,

administrative expenses, reserve requirements, and operations of insurers providing health

insurance in the state, and to prepare or comment on, upon the request of the governor or

chairpersons of the house or senate finance committees, draft legislation to improve the regulation

of health insurance. In making the recommendations, the commissioner shall recognize that it is

the intent of the legislature that the maximum disclosure be provided regarding the reasonableness

of individual administrative expenditures as well as total administrative costs. The commissioner

shall make recommendations on the levels of reserves, including consideration of: targeted reserve

levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess

reserves.

     (c) To establish a consumer/business/labor/medical advisory council to obtain information

and present concerns of consumers, business, and medical providers affected by health insurance

decisions. The council shall develop proposals to allow the market for small business health

insurance to be affordable and fairer. The council shall be involved in the planning and conduct of

the quarterly public meetings in accordance with subsection (a). The advisory council shall develop

measures to inform small businesses of an insurance complaint process to ensure that small

businesses that experience rate increases in a given year may request and receive a formal review

by the department. The advisory council shall assess views of the health provider community

relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the

insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue

an annual report of findings and recommendations to the governor and the general assembly and

present its findings at hearings before the house and senate finance committees. The advisory

council is to be diverse in interests and shall include representatives of community consumer

organizations; small businesses, other than those involved in the sale of insurance products; and

hospital, medical, and other health provider organizations. Such representatives shall be nominated

by their respective organizations. The advisory council shall be co-chaired by the health insurance

commissioner and a community consumer organization or small business member to be elected by

the full advisory council.

     (d) To establish and provide guidance and assistance to a subcommittee (“the professional-

provider-health-plan work group”) of the advisory council created pursuant to subsection (c),

composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall

include in its annual report and presentation before the house and senate finance committees the

following information:

     (1) A method whereby health plans shall disclose to contracted providers the fee schedules

used to provide payment to those providers for services rendered to covered patients;

     (2) A standardized provider application and credentials verification process, for the

purpose of verifying professional qualifications of participating healthcare providers;

     (3) The uniform health plan claim form utilized by participating providers;

     (4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit

hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make

facility-specific data and other medical service-specific data available in reasonably consistent

formats to patients regarding quality and costs. This information would help consumers make

informed choices regarding the facilities and clinicians or physician practices at which to seek care.

Among the items considered would be the unique health services and other public goods provided

by facilities and clinicians or physician practices in establishing the most appropriate cost

comparisons;

     (5) All activities related to contractual disclosure to participating providers of the

mechanisms for resolving health plan/provider disputes;

     (6) The uniform process being utilized for confirming, in real time, patient insurance

enrollment status, benefits coverage, including copays and deductibles;

     (7) Information related to temporary credentialing of providers seeking to participate in the

plan’s network and the impact of the activity on health plan accreditation;

     (8) The feasibility of regular contract renegotiations between plans and the providers in

their networks; and

     (9) Efforts conducted related to reviewing impact of silent PPOs on physician practices.

     (e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d).

     (f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The

fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17.

     (g) To analyze the impact of changing the rating guidelines and/or merging the individual

health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health

insurance market, as defined in chapter 50 of title 27, in accordance with the following:

     (1) The analysis shall forecast the likely rate increases required to effect the changes

recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer

health insurance market over the next five (5) years, based on the current rating structure and

current products.

     (2) The analysis shall include examining the impact of merging the individual and small-

employer markets on premiums charged to individuals and small-employer groups.

     (3) The analysis shall include examining the impact on rates in each of the individual and

small-employer health insurance markets and the number of insureds in the context of possible

changes to the rating guidelines used for small-employer groups, including: community rating

principles; expanding small-employer rate bonds beyond the current range; increasing the employer

group size in the small-group market; and/or adding rating factors for broker and/or tobacco use.

     (4) The analysis shall include examining the adequacy of current statutory and regulatory

oversight of the rating process and factors employed by the participants in the proposed, new

merged market.

     (5) The analysis shall include assessment of possible reinsurance mechanisms and/or

federal high-risk pool structures and funding to support the health insurance market in Rhode Island

by reducing the risk of adverse selection and the incremental insurance premiums charged for this

risk, and/or by making health insurance affordable for a selected at-risk population.

     (6) The health insurance commissioner shall work with an insurance market merger task

force to assist with the analysis. The task force shall be chaired by the health insurance

commissioner and shall include, but not be limited to, representatives of the general assembly, the

business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in

the individual market in Rhode Island, health insurance brokers, and members of the general public.

     (7) For the purposes of conducting this analysis, the commissioner may contract with an

outside organization with expertise in fiscal analysis of the private insurance market. In conducting

its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said

data shall be subject to state and federal laws and regulations governing confidentiality of health

care and proprietary information.

     (8) The task force shall meet as necessary and include its findings in the annual report, and

the commissioner shall include the information in the annual presentation before the house and

senate finance committees.

     (h) To establish and convene a workgroup representing healthcare providers and health

insurers for the purpose of coordinating the development of processes, guidelines, and standards to

streamline healthcare administration that are to be adopted by payors and providers of healthcare

services operating in the state. This workgroup shall include representatives with expertise who

would contribute to the streamlining of healthcare administration and who are selected from

hospitals, physician practices, community behavioral health organizations, each health insurer, and

other affected entities. The workgroup shall also include at least one designee each from the Rhode

Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the

Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year

that the workgroup meets and submits recommendations to the office of the health insurance

commissioner, the office of the health insurance commissioner shall submit such recommendations

to the health and human services committees of the Rhode Island house of representatives and the

Rhode Island senate prior to the implementation of any such recommendations and subsequently

shall submit a report to the general assembly by June 30, 2024. The report shall include the

recommendations the commissioner may implement, with supporting rationale. The workgroup

shall consider and make recommendations for:

     (1) Establishing a consistent standard for electronic eligibility and coverage verification.

Such standard shall:

     (i) Include standards for eligibility inquiry and response and, wherever possible, be

consistent with the standards adopted by nationally recognized organizations, such as the Centers

for Medicare & Medicaid Services;

     (ii) Enable providers and payors to exchange eligibility requests and responses on a system-

to-system basis or using a payor-supported web browser;

     (iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare

coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing

requirements for specific services at the specific time of the inquiry; current deductible amounts;

accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and

other information required for the provider to collect the patient’s portion of the bill;

     (iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility

and benefits information;

     (v) Recommend a standard or common process to protect all providers from the costs of

services to patients who are ineligible for insurance coverage in circumstances where a payor

provides eligibility verification based on best information available to the payor at the date of the

request of eligibility.

     (2) Developing implementation guidelines and promoting adoption of the guidelines for:

     (i) The use of the National Correct Coding Initiative code-edit policy by payors and

providers in the state;

     (ii) Publishing any variations from codes and mutually exclusive codes by payors in a

manner that makes for simple retrieval and implementation by providers;

     (iii) Use of Health Insurance Portability and Accountability Act standard group codes,

reason codes, and remark codes by payors in electronic remittances sent to providers;

     (iv) Uniformity in the processing of claims by payors; and the processing of corrections to

claims by providers and payors;

     (v) A standard payor-denial review process for providers when they request a

reconsideration of a denial of a claim that results from differences in clinical edits where no single,

common-standards body or process exists and multiple conflicting sources are in use by payors and

providers.

     (vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual

payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of

detecting and deterring fraudulent billing activities. The guidelines shall require that each payor

disclose to the provider its adjudication decision on a claim that was denied or adjusted based on

the application of such edits and that the provider have access to the payor’s review and appeal

process to challenge the payor’s adjudication decision.

     (vii) Nothing in this subsection shall be construed to modify the rights or obligations of

payors or providers with respect to procedures relating to the investigation, reporting, appeal, or

prosecution under applicable law of potentially fraudulent billing activities.

     (3) Developing and promoting widespread adoption by payors and providers of guidelines

to:

     (i) Ensure payors do not automatically deny claims for services when extenuating

circumstances make it impossible for the provider to obtain a preauthorization before services are

performed or notify a payor within an appropriate standardized timeline of a patient’s admission;

     (ii) Require payors to use common and consistent processes and time frames when

responding to provider requests for medical management approvals. Whenever possible, such time

frames shall be consistent with those established by leading national organizations and be based

upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical

management includes prior authorization of services, preauthorization of services, precertification

of services, post-service review, medical-necessity review, and benefits advisory;

     (iii) Develop, maintain, and promote widespread adoption of a single, common website

where providers can obtain payors’ preauthorization, benefits advisory, and preadmission

requirements;

     (iv) Establish guidelines for payors to develop and maintain a website that providers can

use to request a preauthorization, including a prospective clinical necessity review; receive an

authorization number; and transmit an admission notification;

     (v) Develop and implement the use of programs that implement selective prior

authorization requirements, based on stratification of healthcare providers’ performance and

adherence to evidence-based medicine with the input of contracted healthcare providers and/or

provider organizations. Such criteria shall be transparent and easily accessible to contracted

providers. Such selective prior authorization programs shall be available when healthcare providers

participate directly with the insurer in risk-based payment contracts and may be available to

providers who do not participate in risk-based contracts;

     (vi) Require the review of medical services, including behavioral health services, and

prescription drugs, subject to prior authorization on at least an annual basis, with the input of

contracted healthcare providers and/or provider organizations. Any changes to the list of medical

services, including behavioral health services, and prescription drugs requiring prior authorization,

shall be shared via provider-accessible websites;

     (vii) Improve communication channels between health plans, healthcare providers, and

patients by:

     (A) Requiring transparency and easy accessibility of prior authorization requirements,

criteria, rationale, and program changes to contracted healthcare providers and patients/health plan

enrollees which may be satisfied by posting to provider-accessible and member-accessible

websites; and

     (B) Supporting:

     (I) Timely submission by healthcare providers of the complete information necessary to

make a prior authorization determination, as early in the process as possible; and

     (II) Timely notification of prior authorization determinations by health plans to impacted

health plan enrollees, and healthcare providers, including, but not limited to, ordering providers,

and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to

provider-accessible websites or similar electronic portals or services;

     (viii) Increase and strengthen continuity of patient care by:

     (A) Defining protections for continuity of care during a transition period for patients

undergoing an active course of treatment, when there is a formulary or treatment coverage change

or change of health plan that may disrupt their current course of treatment and when the treating

physician determines that a transition may place the patient at risk; and for prescription medication

by allowing a grace period of coverage to allow consideration of referred health plan options or

establishment of medical necessity of the current course of treatment;

     (B) Requiring continuity of care for medical services, including behavioral health services,

and prescription medications for patients on appropriate, chronic, stable therapy through

minimizing repetitive prior authorization requirements; and which for prescription medication shall

be allowed only on an annual review, with exception for labeled limitation, to establish continued

benefit of treatment; and

     (C) Requiring communication between healthcare providers, health plans, and patients to

facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied

by posting to provider-accessible websites or similar electronic portals or services;

     (D) Continuity of care for formulary or drug coverage shall distinguish between FDA

designated interchangeable products and proprietary or marketed versions of a medication;

     (ix) Encourage healthcare providers and/or provider organizations and health plans to

accelerate use of electronic prior authorization technology, including adoption of national standards

where applicable; and

     (x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the

workgroup meeting may be conducted in part or whole through electronic methods.

     (4) To provide a report to the house and senate, on or before January 1, 2017, with

recommendations for establishing guidelines and regulations for systems that give patients

electronic access to their claims information, particularly to information regarding their obligations

to pay for received medical services, pursuant to 45 C.F.R. § 164.524.

     (5) No provision of this subsection (h) shall preclude the ongoing work of the office of

health insurance commissioner’s administrative simplification task force, which includes meetings

with key stakeholders in order to improve, and provide recommendations regarding, the prior

authorization process.

     (i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually

thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate

committee on health and human services, and the house committee on corporations, with: (1)

Information on the availability in the commercial market of coverage for anti-cancer medication

options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment

options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member

utilization and cost-sharing expense.

     (j) To monitor the adequacy of each health plan’s compliance with the provisions of the

federal Mental Health Parity Act, including a review of related claims processing and

reimbursement procedures. Findings, recommendations, and assessments shall be made available

to the public.

     (k) To monitor the transition from fee-for-service and toward global and other alternative

payment methodologies for the payment for healthcare services. Alternative payment

methodologies should be assessed for their likelihood to promote access to affordable health

insurance, health outcomes, and performance.

     (l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital

payment variation, including findings and recommendations, subject to available resources.

     (m) Notwithstanding any provision of the general or public laws or regulation to the

contrary, provide a report with findings and recommendations to the president of the senate and the

speaker of the house, on or before April 1, 2014, including, but not limited to, the following

information:

     (1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1,

27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-

18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health

insurance for fully insured employers, subject to available resources;

     (2) Current provider and insurer mandates that are unnecessary and/or duplicative due to

the existing standards of care and/or delivery of services in the healthcare system;

     (3) A state-by-state comparison of health insurance mandates and the extent to which

Rhode Island mandates exceed other states benefits; and

     (4) Recommendations for amendments to existing mandated benefits based on the findings

in (m)(1), (m)(2), and (m)(3) above.

     (n) On or before July 1, 2014, the office of the health insurance commissioner, in

collaboration with the director of health and lieutenant governor’s office, shall submit a report to

the general assembly and the governor to inform the design of accountable care organizations

(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-

based payment arrangements, that shall include, but not be limited to:

     (1) Utilization review;

     (2) Contracting; and

     (3) Licensing and regulation.

     (o) On or before February 3, 2015, the office of the health insurance commissioner shall

submit a report to the general assembly and the governor that describes, analyzes, and proposes

recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard

to patients with mental health and substance use disorders.

     (p) To work to ensure the health insurance coverage of behavioral health care under the

same terms and conditions as other health care, and to integrate behavioral health parity

requirements into the office of the health insurance commissioner insurance oversight and

healthcare transformation efforts.

     (q) To work with other state agencies to seek delivery system improvements that enhance

access to a continuum of mental health and substance use disorder treatment in the state; and

integrate that treatment with primary and other medical care to the fullest extent possible.

     (r) To direct insurers toward policies and practices that address the behavioral health needs

of the public and greater integration of physical and behavioral healthcare delivery.

     (s) The office of the health insurance commissioner shall conduct an analysis of the impact

of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and

submit a report of its findings to the general assembly on or before June 1, 2023.

     (t) To undertake the analyses, reports, and studies contained in this section:

     (1) The office shall hire the necessary staff and prepare a request for proposal for a qualified

and competent firm or firms to undertake the following analyses, reports, and studies:

     (i) The firm shall undertake a comprehensive review of all social and human service

programs having a contract with or licensed by the state or any subdivision of the department of

children, youth and families (DCYF), the department of behavioral healthcare, developmental

disabilities and hospitals (BHDDH), the department of human services (DHS), the department of

health (DOH), and Medicaid for the purposes of:

     (A) Establishing a baseline of the eligibility factors for receiving services;

     (B) Establishing a baseline of the service offering through each agency for those

determined eligible;

     (C) Establishing a baseline understanding of reimbursement rates for all social and human

service programs including rates currently being paid, the date of the last increase, and a proposed

model that the state may use to conduct future studies and analyses;

     (D) Ensuring accurate and adequate reimbursement to social and human service providers

that facilitate the availability of high-quality services to individuals receiving home and

community-based long-term services and supports provided by social and human service providers;

     (E) Ensuring the general assembly is provided accurate financial projections on social and

human service program costs, demand for services, and workforce needs to ensure access to entitled

beneficiaries and services;

     (F) Establishing a baseline and determining the relationship between state government and

the provider network including functions, responsibilities, and duties;

     (G) Determining a set of measures and accountability standards to be used by EOHHS and

the general assembly to measure the outcomes of the provision of services including budgetary

reporting requirements, transparency portals, and other methods; and

     (H) Reporting the findings of human services analyses and reports to the speaker of the

house, senate president, chairs of the house and senate finance committees, chairs of the house and

senate health and human services committees, and the governor.

     (2) The analyses, reports, and studies required pursuant to this section shall be

accomplished and published as follows and shall provide:

     (i) An assessment and detailed reporting on all social and human service program rates to

be completed by January 1, 2023, including rates currently being paid and the date of the last

increase;

     (ii) An assessment and detailed reporting on eligibility standards and processes of all

mandatory and discretionary social and human service programs to be completed by January 1,

2023;

     (iii) An assessment and detailed reporting on utilization trends from the period of January

1, 2017, through December 31, 2021, for social and human service programs to be completed by

January 1, 2023;

     (iv) An assessment and detailed reporting on the structure of the state government as it

relates to the provision of services by social and human service providers including eligibility and

functions of the provider network to be completed by January 1, 2023;

     (v) An assessment and detailed reporting on accountability standards for services for social

and human service programs to be completed by January 1, 2023;

     (vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed

and unlicensed personnel requirements for established rates for social and human service programs

pursuant to a contract or established fee schedule;

     (vii) An assessment and reporting on access to social and human service programs, to

include any wait lists and length of time on wait lists, in each service category by April 1, 2023;

     (viii) An assessment and reporting of national and regional Medicaid rates in comparison

to Rhode Island social and human service provider rates by April 1, 2023;

     (ix) An assessment and reporting on usual and customary rates paid by private insurers and

private pay for similar social and human service providers, both nationally and regionally, by April

1, 2023; and

     (x) Completion of the development of an assessment and review process that includes the

following components: eligibility; scope of services; relationship of social and human service

provider and the state; national and regional rate comparisons and accountability standards that

result in recommended rate adjustments; and this process shall be completed by September 1, 2023,

and conducted biennially hereafter. The biennial rate setting shall be consistent with payment

requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. §

1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The

results and findings of this process shall be transparent, and public meetings shall be conducted to

allow providers, recipients, and other interested parties an opportunity to ask questions and provide

comment beginning in September 2023 and biennially thereafter; and

     (xi) On or before September 1, 2026, the office shall publish and submit to the general

assembly and the governor a one-time report making and justifying recommendations for

adjustments to primary care services reimbursement and financing. The report shall include

consideration of Medicaid, Medicare, commercial, and alternative contracted payments.

     (3) In fulfillment of the responsibilities defined in subsection (t), the office of the health

insurance commissioner shall consult with the Executive Office of Health and Human Services.

     (u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall

include the corresponding components of the assessment and review (i.e., eligibility; scope of

services; relationship of social and human service provider and the state; and national and regional

rate comparisons and accountability standards including any changes or substantive issues between

biennial reviews) including the recommended rates from the most recent assessment and review

with their annual budget submission to the office of management and budget and provide a detailed

explanation and impact statement if any rate variances exist between submitted recommended

budget and the corresponding recommended rate from the most recent assessment and review

process starting October 1, 2023, and biennially thereafter.

     (v) The general assembly shall appropriate adequate funding as it deems necessary to

undertake the analyses, reports, and studies contained in this section relating to the powers and

duties of the office of the health insurance commissioner.

     SECTION 10. 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 legislative enactment is required pursuant to Rhode Island General Laws

section 42-12.4-1, et seq.; and

     WHEREAS, Rhode Island General Laws section 42-7.2-5(3)(i) provides that the secretary

of the executive office of health and human Services 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 potential to affect the scope, amount, or duration of publicly-

funded health care services, provider payments or reimbursements, or access to or the availability

of benefits and services provided by 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 legislative approval of the following proposals

to amend the demonstration; and

     WHEREAS, Implementation of adjustments may require amendments to the Rhode

Island’s Medicaid state plan and/or section 1115 waiver under the terms and conditions of the