2025 -- H 6046

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LC002257

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2025

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A N   A C T

RELATING TO HUMAN SERVICES -- MEDICAL ASSISTANCE

     Introduced By: Representatives Serpa, and Fellela

     Date Introduced: March 07, 2025

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

     SECTION 1. Section 40-8-26 of the General Laws in Chapter 40-8 entitled "Medical

Assistance" is hereby amended to read as follows:

     40-8-26. Community health centers.

     (a) For the purposes of this section, the term community health centers refers to federally

qualified health centers and rural health centers.

     (b) To support the ability of community health centers to provide high-quality medical,

behavioral, and dental care to patients, the executive office of health and human services

(“executive office”) may adopt and implement an alternative payment methodology (APM) for

determining a Medicaid per-visit reimbursement for community health centers that is compliant

with the prospective payment system (PPS) provided for in the Medicare, Medicaid, and SCHIP

Benefits Improvement and Protection Act of 2000. The following principles are to ensure that the

APM PPS rate determination methodology is part of the executive office overall value purchasing

approach. For community health centers that do not agree to the principles of reimbursement that

reflect the APM PPS, EOHHS shall reimburse such community health centers at the federal PPS

rate, as required per section 1902(bb)(3) of the Social Security Act, 42 U.S.C. § 1396a(bb)(3). For

community health centers that are reimbursed at the federal PPS rate, subsections (d) through (f)

of this section apply.

     (c) The APM PPS rate determination methodology will (i) Fairly recognize the reasonable

costs of providing services. Recognized reasonable costs will be those appropriate for the

organization, management, and direct provision of services and (ii) Provide assurances to the

executive office that services are provided in an effective and efficient manner, consistent with

industry standards. Except for demonstrated cause and at the discretion of the executive office, the

maximum reimbursement rate for a service (e.g., medical, dental, behavioral) provided by an

individual community health center shall not exceed equal the lesser of the actual cost or one

hundred twenty-five percent (125%) of the median rate for all community health centers within

Rhode Island. Actual cost shall be based on a Medicaid cost report.

     (d) Community health centers will cooperate fully and timely with reporting requirements

established by the executive office.

     (e) Reimbursement rates established through this methodology shall be incorporated into

the PPS reconciliation for services provided to Medicaid-eligible persons who are enrolled in a

health plan on the date of service. Monthly payments by the executive office related to PPS for

persons enrolled in a health plan shall be made directly to the community health centers.

     (f) Reimbursement rates established through this methodology shall be incorporated into

the actuarially certified capitation rates paid to a health plan. The health plan shall be responsible

for paying the full amount of the reimbursement rate to the community health center for each

service eligible for reimbursement under the Medicare, Medicaid, and SCHIP Benefits

Improvement and Protection Act of 2000. If the health plan has an alternative payment arrangement

with the community health center the health plan may establish a PPS reconciliation process for

eligible services and make monthly payments related to PPS for persons enrolled in the health plan

on the date of service. The executive office will review, at least annually, the Medicaid

reimbursement rates and reconciliation methodology used by the health plans for community health

centers to ensure payments to each are made in compliance with the Medicare, Medicaid, and

SCHIP Benefits Improvement and Protection Act of 2000.

     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HUMAN SERVICES -- MEDICAL ASSISTANCE

***

     This act would require reimbursement for medical, dental, and behavioral health services

provided at community health care centers to equal the lesser of the actual cost, based on Medicaid

reports, or one hundred twenty-five percent (125%) of the median rate for all community health

centers within Rhode Island.

     This act would take effect upon passage.

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