2025 -- S 0488

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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 -- RHODE ISLAND MEDICAID ELIGIBILITY

DETERMINATION ACT

     Introduced By: Senators Bell, Ujifusa, Thompson, Quezada, Ciccone, Mack, Kallman,
Burke, Euer, and Valverde

     Date Introduced: February 26, 2025

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

     SECTION 1. Title 40 of the General Laws entitled "HUMAN SERVICES" is hereby

amended by adding thereto the following chapter:

CHAPTER 23

RHODE ISLAND MEDICAID ELIGIBILITY DETERMINATION ACT

     40-23-1. Short title.

     This chapter shall be known and may be cited as the "Rhode Island Medicaid Eligibility

Determination Act."

     40-23-2. Definitions.

     For the purposes of this chapter, the following words and terms have the following

meanings:

     (1) “Decision to terminate” shall mean the entire process of deciding to remove an

individual from enrollment in Medicaid or request information from an individual when the failure

to respond within a set timeframe will remove the individual from enrollment in Medicaid.

     (2) “Private entity data” means any data purchased from private entities or involving wage,

address, or other eligibility-related data collected by a private entity, such as data reported by

employers to a private entity.

     (3) "Public assistance reporting information system" or "PARIS" means a federal-state

partnership that facilitates the sharing of data between states to identify individuals who may be

receiving benefits in multiple states.

     (4) “Public data sources” means any data collected, maintained, or controlled by a state or

federal government entity or agency, including, but not limited to, SWICA, PARIS, and other state-

administered databases.

     (5) "State wage information collection agency date" or "SWICA data" means the data from

the Rhode Island department of labor and training that collects wage and employment data for

unemployment insurance purposes and provides data on individuals’ earnings.

     (6) “Terminate” shall mean to make a decision to terminate.

     (7) “Termination” shall mean a removal from Medicaid enrollment as a result of a decision

to terminate.

     (8) “Termination decision” shall mean a decision of whether or not to terminate, including

decisions to not terminate. It shall include a decision to request information from an individual

when the failure to respond within a set timeframe will remove the individual from enrollment in

Medicaid. In such a case, the decision to remove an individual who has not responded to such a

request from enrollment in Medicaid shall not count as an additional termination decision, but a

decision of whether or not to proceed with removing the individual from enrollment in Medicaid

after they do respond in any manner shall count as an additional termination decision, even if the

response is deemed insufficient.

     40-23-3. Eligibility determination based on state data only.

     (a) Eligibility criteria. The eligibility for Medicaid benefits in Rhode Island shall be

determined exclusively by the use of the following state-controlled data sources:

     (1) SWICA data including, but not limited to, wage, employment, and earnings

information.

     (2) PARIS data, including information about applicants who may be receiving benefits

from other states.

     (3) Other state-maintained databases as determined by the Rhode Island executive office

of health and human services.

     (b) Prohibition on private entity data. No private entity data may be used for any part of

the Medicaid eligibility determination process, including post-eligibility verification. Any

termination where private entity data was utilized for any part of the decision to terminate shall not

be valid.

     (c) Retroactive reinstatement. Any individuals terminated from Medicaid utilizing private

entity data prior to the effective date of this act shall be retroactively reinstated within ten (10) days

of the effective date of this act, unless the executive office of health and human services determines

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that the decision to terminate was correct using only state data sources within the ten (10) days. If

the decision to terminate is determined to be correct, terminated individuals shall have a right to

appeal the termination to the executive office of health and human services and/or the superior

court and shall receive written notice of their rights. The executive office of health and human

services shall not impose a time limit on the right of appeal.

     (d) Ban on automated terminations. No termination from Medicaid shall be valid unless

the decision to terminate was made by a human being employed by the executive office of health

and human services or the department of human services. No terminations from Medicaid shall be

valid if, on the day when the decision to terminate was made, the employee making the decision to

terminate made more than fifty (50) termination decisions. No termination from Medicaid shall be

valid if the decision to terminate was made by a computer program. If the decision to terminate was

recommended by a computer program, the burden of proof shall fall on the state to demonstrate

that the employee certifying the termination made a good faith effort to independently review the

case.

     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 -- RHODE ISLAND MEDICAID ELIGIBILITY

DETERMINATION ACT

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     This bill would establish that Medicaid eligibility in Rhode Island can only be determined

using state-controlled data, prohibit private entity data in eligibility decisions, and ensure

terminations are made by human employees rather than automated systems. It would also mandate

retroactive reinstatement for improperly terminated individuals

     This act would take effect upon passage.

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