Rhode Island 2023 Regular Session

Rhode Island Senate Bill S0572 Compare Versions

Only one version of the bill is available at this time.

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5	5	2023 -- S 0572
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7	7	LC001777
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9	9	S TATE OF RHODE IS LAND
10	10	IN GENERAL ASSEMBLY
11	11	JANUARY SESSION, A.D. 2023
12	12	____________
13	13
14	14	A N A C T
15	15	RELATING TO HEALTH AND SAFETY -- COMPREHENSIVE HEALTH INSURANCE
16	16	PROGRAM
17	17	Introduced By: Senators Bell, Ujifusa, Kallman, Ciccone, and Lauria
18	18	Date Introduced: March 07, 2023
19	19	Referred To: Senate Health & Human Services
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21	21
22	22	It is enacted by the General Assembly as follows:
23	23	SECTION 1. Title 23 of the General Laws entitled "HEALTH AND SAFETY" is hereby 1
24	24	amended by adding thereto the following chapter: 2
25	25	CHAPTER 99 3
26	26	THE RHODE ISLAND COMPREHENSIVE HEALTH INSURANCE PROGRAM 4
27	27	23-99-1. Legislative findings. 5
28	28	(1) Health care is a human right, not a commodity available only to those who can afford 6
29	29	it; 7
30	30	(2) Although the federal Affordable Care Act (ACA) allowed states to offer more people 8
31	31	taxpayer subsidized private health insurance, the ACA has not provided universal, comprehensive, 9
32	32	affordable coverage for all Rhode Islanders: 10
33	33	(i) In 2019, about four and three-tenths percent (4.3%) of Rhode Islanders had no health 11
34	34	insurance, causing about forty-three (43) (1 per 1,000 uninsured) unnecessary deaths each year; 12
35	35	(ii) An estimated forty-five percent (45%) of Rhode Islanders are under-insured (e.g., not 13
36	36	seeking health care because of high deductibles and co-pays); 14
37	37	(3) COVID-19 exacerbated and highlighted problems with the status quo health insurance 15
38	38	system including: 16
39	39	(i) Coverage is too easily lost when health insurance is tied to jobs - between February and 17
40	40	May, 2020, about twenty-one thousand (21,000) more Rhode Islanders lost their jobs and their 18
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42	42
43	43	LC001777 - Page 2 of 96
44	44	health insurance; 1
45	45	(ii) Systemic racism is reinforced - Black and Hispanic/Latinx Rhode Islanders, are more 2
46	46	likely to be uninsured or underinsured, have suffered the highest rates of COVID-19 mortality and 3
47	47	morbidity; 4
48	48	(iii) The fear of out-of-pocket costs for uninsured and underinsured puts everyone at risk 5
49	49	because they avoid testing and treatment; 6
50	50	(4) In 2016, sixty million (60,000,000) people separated from their job at some point during 7
51	51	the year (i.e., about forty-two percent (42%) of the American workforce) and although this act may 8
52	52	cause some job loss, on balance, single payer would increase employment in Rhode Island by nearly 9
53	53	three percent (3%); 10
54	54	(5) The existing US health insurance system has failed to control the cost of health care 11
55	55	and to provide universal access to health care in a system which is widely accepted to waste thirty 12
56	56	percent (30%) of its revenues on activities that do not improve the health of Americans; 13
57	57	(6) Every industrialized nation in the world, except the United States, offers universal 14
58	58	health care to its citizens and enjoys better health outcomes for less than two thirds (2/3) to one-15
59	59	half (1/2) the cost; 16
60	60	(7) Health care is rationed under our current multi-payer system, despite the fact that Rhode 17
61	61	Island patients, businesses and taxpayers already pay enough to have comprehensive and universal 18
62	62	health insurance under a single-payer system; 19
63	63	(8) About one-third (1/3) of every "health care" dollar spent in the U.S. is wasted on 20
64	64	unnecessary administrative costs and excessive pharmaceutical company profits due to laws 21
65	65	preventing Medicare from negotiating prices and private health insurance companies lacking 22
66	66	adequate market share to effectively negotiate prices; 23
67	67	(9) Private health insurance companies are incentivized to let the cost of health care rise 24
68	68	because higher costs require health insurance companies to charge higher health insurance 25
69	69	premiums, increasing companies' revenue and stock price; 26
70	70	(10) The health care marketplace is not an efficient market and because it represents only 27
71	71	eighteen percent (18%) of the US domestic market, significantly restricts economic growth and 28
72	72	thus the financial well-being of every American, including every Rhode Islander; 29
73	73	(11) Rhode Islanders cannot afford to keep the current multi-payer health insurance system: 30
74	74	(i) Between 1991 and 2014, health care spending in Rhode Island per person rose by over 31
75	75	two hundred fifty percent (250%) rising much faster than income and greatly reducing disposable 32
76	76	income; 33
77	77	(ii) It is estimated that by 2025, the cost of health insurance for an average family of four 34
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81	81	(4) will equal about one-half (1/2) of their annual income; 1
82	82	(iii) In the U.S., about two-thirds (2/3) of personal bankruptcies are medical cost-related 2
83	83	and of these, about three-fourths (3/4) had health insurance at the onset of their medical problems. 3
84	84	In no other industrialized country do people worry about going bankrupt over medical costs; 4
85	85	(12) Rhode Island private businesses bear most of the costs of employee health insurance 5
86	86	coverage and spend significant time and money choosing from a confusing array of increasingly 6
87	87	expensive plans which do not provide comprehensive coverage; 7
88	88	(13) Rhode Island employees and retirees lose significant wages and pensions as they are 8
89	89	forced to pay higher amounts of health insurance and health care costs; 9
90	90	(14) Rhode Island's hospitals are under increasing financial distress i.e., closing, sold to 10
91	91	out-of-state entities, attempting mergers largely due to health insurance reimbursement problems 11
92	92	that other nations do not face and are fixed by a single-payer system; 12
93	93	(15) The state and its municipalities face enormous other post-employment benefits 13
94	94	(OPEB) unfunded liabilities due mostly to health insurance costs; 14
95	95	(16) An improved Medicare-for-all style single-payer program would, based on the 15
96	96	performance of existing Medicare, eliminate fifty percent (50%) of the administrative waste in the 16
97	97	current system of private insurance before other savings achieved through meaningful negotiation 17
98	98	of prices and other savings are considered; 18
99	99	(17) The high costs of medical care could be lowered significantly if the state could 19
100	100	negotiate on behalf of all its residents for bulk purchasing, as well as gain access to usage and price 20
101	101	information currently kept confidential by private health insurers as "proprietary information;" 21
102	102	(18) Single payer health care would establish a true "free market" system where doctors 22
103	103	compete for patients rather than health insurance companies dictating which patients are able to see 23
104	104	which doctors and setting reimbursement rates; 24
105	105	(19) Health care providers would spend significantly less time with administrative work 25
106	106	caused by multiple health insurance company requirements and barriers to care delivery and would 26
107	107	spend significantly less for overhead costs because of streamlined billing; 27
108	108	(20) Rhode Island must act because there are currently no effective state or federal laws 28
109	109	that can provide universal coverage and adequately control rising premiums, co-pays, deductibles 29
110	110	and medical costs, or prevent private insurance companies from continuing to limit available 30
111	111	providers and coverage; 31
112	112	(21) In 1962, Canada's successful single-payer program began in the province of 32
113	113	Saskatchewan (with approximately the same population as Rhode Island) and became a national 33
114	114	program within ten (10) years; and 34
115	115
116	116
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118	118	(22) The proposed Rhode Island single payer program was studied by Professor Gerald 1
119	119	Friedman at UMass Amherst in 2015 and he concluded that: 2
120	120	"Single-payer in Rhode Island will finance medical care with substantial savings compared 3
121	121	with the existing multi-payer system of public and private insurers and would improve access to 4
122	122	health care by extending coverage to the four percent (4%) of Rhode Island residents still without 5
123	123	insurance under the Affordable Care Act and expanding coverage for the growing number with 6
124	124	inadequate health care coverage. Single-payer would improve the economic health of Rhode Island 7
125	125	by: increasing real disposable income for most residents; reducing the burden of health care on 8
126	126	businesses and promoting increased employment; and shifting the costs of health care away from 9
127	127	working and middle-class residents." 10
128	128	23-99-2. Legislative purpose. 11
129	129	It is the intent of the general assembly that this chapter establish a universal, 12
130	130	comprehensive, affordable single-payer health care insurance program that will help control health 13
131	131	care costs which shall be referred to as, "the Rhode Island comprehensive health insurance 14
132	132	program" (RICHIP). The program will be paid for by consolidating government and private 15
133	133	payments to multiple insurance carriers into a more economical and efficient improved Medicare- 16
134	134	for-all style single-payer program and substituting lower progressive taxes for higher health 17
135	135	insurance premiums, co-pays, deductibles and costs in excess of caps. This program will save 18
136	136	Rhode Islanders from the current overly expensive, inefficient and unsustainable multi-payer health 19
137	137	insurance system that unnecessarily prevents access to medically necessary health care. The 20
138	138	program will be established after the standard of care funded by Medicaid has been raised to a 21
139	139	Medicare standard. 22
140	140	23-99-3. Definitions. 23
141	141	As used in this chapter: 24
142	142	(1) "Affordable Care Act" or "ACA" means the Federal Patient Protection and Affordable 25
143	143	Care Act (Pub. L. 111-148), as amended by the Federal Health Care and Education Reconciliation 26
144	144	Act of 2010 (Pub. L. 111-152), and any amendments to, or regulations or guidance issued under, 27
145	145	those acts. 28
146	146	(2) "Carrier" means either a private health insurer authorized to sell health insurance in 29
147	147	Rhode Island or a health care service plan, i.e., any person who undertakes to arrange for the 30
148	148	provision of health care services to subscribers or enrollees, or to pay for or to reimburse any part 31
149	149	of the cost for those services, in return for a prepaid or periodic charge paid by or on behalf of the 32
150	150	subscribers or enrollees, or any person, whether located within or outside of this state, who solicits 33
151	151	or contracts with a subscriber or enrollee in this state to pay for or reimburse any part of the cost 34
152	152
153	153
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155	155	of, or who undertakes to arrange or arranges for, the provision of health care services that are to be 1
156	156	provided, wholly or in part, in a foreign country in return for a prepaid or periodic charge paid by 2
157	157	or on behalf of the subscriber or enrollee. 3
158	158	(3) "Dependent" has the same definition as set forth in federal tax law (26 U.S.C. § 152). 4
159	159	(4) "Emergency and urgently needed services" has the same definition as set forth in the 5
160	160	federal Medicare law (42 CFR 422.113). 6
161	161	(5) "Federally matched public health program" means the state's Medicaid program under 7
162	162	Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.) and the state's Children's Health 8
163	163	Insurance Program (CHIP) under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa et 9
164	164	seq.). 10
165	165	(6) "For-profit provider" means any health care professional or health care institution that 11
166	166	provides payments, profits or dividends to investors or owners who do not directly provide health 12
167	167	care. 13
168	168	(7) "Medicaid" or "medical assistance" means a program that is one of the following: 14
169	169	(i) The state's Medicaid program under Title XIX of the Social Security Act (42 U.S.C. 15
170	170	Sec. 1396 et seq.); or 16
171	171	(ii) The state's Children's Health Insurance Program under Title XXI of the Social Security 17
172	172	Act (42 U.S.C. Sec. 1397aa et seq.). 18
173	173	(8) "Medically necessary" means medical, surgical or other services or goods (including 19
174	174	prescription drugs) required for the prevention, diagnosis, cure, or treatment of a health-related 20
175	175	condition including any such services that are necessary to prevent a detrimental change in either 21
176	176	medical or mental health status. Medically necessary services shall be provided in a cost-effective 22
177	177	and appropriate setting and shall not be provided solely for the convenience of the patient or service 23
178	178	provider. "Medically necessary" does not include services or goods that are primarily for cosmetic 24
179	179	purposes; and does not include services or goods that are experimental, unless approved pursuant 25
180	180	to § 23-99-6(b). 26
181	181	(9) "Medicare" means Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) 27
182	182	and the programs thereunder. 28
183	183	(10) "Qualified health care provider" means any individual who meets requirements set 29
184	184	forth in § 23-99-7(a)(1). 30
185	185	(11) "Qualified Rhode Island resident" means any individual who is a "resident" as defined 31
186	186	by §§ 44-30-5(a)(1) and (a)(2) or a dependent of that resident. 32
187	187	(12) "Rhode Island comprehensive health insurance program" or ("RICHIP") means the 33
188	188	affordable, comprehensive and effective health insurance program as set forth in this chapter. 34
189	189
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192	192	(13) "RICHIP participant" means a qualified Rhode Island resident who is enrolled in 1
193	193	RICHIP (and not disenrolled or disqualified) at the time they seek health care. 2
194	194	23-99-4. Rhode Island health insurance program. 3
195	195	(a) Organization. This chapter creates the Rhode Island comprehensive health insurance 4
196	196	program (RICHIP), as an independent state government agency. 5
197	197	(b) Director. A director shall be appointed by the governor, with the advice and consent of 6
198	198	the senate, to lead RICHIP and serve a term of four (4) years, subject to oversight by an executive 7
199	199	board. The director shall be compensated in accordance with the job title and job classification 8
200	200	established by the division of human resources and approved by the general assembly. The duties 9
201	201	of the director shall include: 10
202	202	(1) Employ staff and authorize reasonable expenditures, as necessary, from the RICHIP 11
203	203	trust fund, to pay program expenses and to administer the program, including creation and oversight 12
204	204	of RICHIP budgets; 13
205	205	(2) Oversee management of the RICHIP trust fund set forth in § 23-99-12(a) to ensure the 14
206	206	operational well-being and fiscal solvency of the program, including ensuring that all available 15
207	207	funds from all appropriate sources are collected and placed into the trust fund; 16
208	208	(3) Take any actions necessary and proper to implement the provisions of this chapter; 17
209	209	(4) Implement standardized claims and reporting procedures; 18
210	210	(5) Provide for timely payments to participating providers through a structure that is well 19
211	211	organized and that eliminates unnecessary administrative costs, i.e., coordinate with the state 20
212	212	comptroller to facilitate billing from and payments to providers using the state's computerized 21
213	213	financial system, the Rhode Island financial and accounting network system (RIFANS); 22
214	214	(6) Coordinate with federal health care programs, including Medicare and Medicaid, to 23
215	215	obtain necessary waivers and streamline federal funding and reimbursement; 24
216	216	(7) Monitor billing and reimbursements to detect inappropriate behavior by providers and 25
217	217	patients and create prohibitions and penalties regarding bad faith or criminal RICHIP participation, 26
218	218	and procedures by which they will be enforced; 27
219	219	(8) Support the development of an integrated health care database for health care planning 28
220	220	and quality assurance and ensure the legally required confidentiality of all health records it 29
221	221	contains; 30
222	222	(9) Determine eligibility for RICHIP and establish procedures for enrollment, 31
223	223	disenrollment and disqualification from RICHIP, as well as procedures for handling complaints 32
224	224	and appeals from affected individuals, as set forth in § 29-99-5; 33
225	225	(10) Create RICHIP expenditure, status, and assessment reports, including, but not limited 34
226	226
227	227
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229	229	to, annual reports with the following: 1
230	230	(i) Performance of the program; 2
231	231	(ii) Fiscal condition of the program; 3
232	232	(iii) Recommendations for statutory changes; 4
233	233	(iv) Receipt of payments from the federal government; 5
234	234	(v) Whether current year goals and priorities were met; and 6
235	235	(vi) Future goals and priorities; 7
236	236	(11) Review RICHIP collections and disbursements on at least a quarterly basis and 8
237	237	recommend adjustments needed to achieve budgetary targets and permit adequate access to care; 9
238	238	(12) Develop procedures for accommodating: 10
239	239	(i) Employer retiree health benefits for people who have been members of RICHIP but go 11
240	240	to live as retirees out of the state; 12
241	241	(ii) Employer retiree health benefits for people who earned or accrued those benefits while 13
242	242	residing in the state prior to the implementation of RICHIP and live as retirees out of the state; and 14
243	243	(iii) RICHIP coverage of health care services currently covered under the workers' 15
244	244	compensation system, including whether and how to continue funding for those services under that 16
245	245	system and whether and how to incorporate an element of experience rating; and 17
246	246	(13) No later than two (2) years after the effective date of this chapter, develop a proposal, 18
247	247	consistent with the principles of this chapter, for provision and funding by the program of long- 19
248	248	term care coverage. 20
249	249	(c) Board. There shall be a RICHIP board composed of nine (9) members serving terms of 21
250	250	four (4) years. Members shall be appointed by the governor with advice and consent of the senate. 22
251	251	Members of the board shall have no pecuniary interest in any health insurance company or any 23
252	252	business subject to regulation of the board and cannot have previously worked for a health 24
253	253	insurance company. The duties of the board shall include: 25
254	254	(1) Annually establish a RICHIP benefits package for participants, including a formulary 26
255	255	and a list of other medically necessary goods, as well as a procedure for handling complaints and 27
256	256	appeals relating to the benefits package, pursuant to § 23-99-6. 28
257	257	(2) Establish RICHIP provider reimbursement and a procedure for handling provider 29
258	258	complaints and appeals as set forth in § 23-99-9; 30
259	259	(3) Review budget proposals from providers pursuant to § 23-99-11(b); and 31
260	260	(4) The board shall be subject to chapter 46 of title 42 ("open meetings"). 32
261	261	23-99-5. Coverage. 33
262	262	(a) All qualified Rhode Island residents may participate in RICHIP. The director shall 34
263	263
264	264
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266	266	establish procedures to determine eligibility, enrollment, disenrollment and disqualification, 1
267	267	including criteria and procedures by which RICHIP can: 2
268	268	(1) Identify, automatically enroll, and provide a RICHIP card to qualified Rhode Island 3
269	269	residents; 4
270	270	(2) Process applications from individuals seeking to obtain RICHIP coverage for 5
271	271	dependents after the implementation date; 6
272	272	(3) Ensure eligible residents are knowledgeable and aware of their rights to health care; 7
273	273	(4) Determine whether an individual should be disenrolled (e.g., for leaving the state); 8
274	274	(5) Determine whether an individual should be disqualified (e.g., for fraudulent receipt of 9
275	275	benefits or reimbursements); 10
276	276	(6) Determine appropriate actions that should be taken with respect to individuals who are 11
277	277	disenrolled or disqualified (including civil and criminal penalties); and 12
278	278	(7) Permit individuals to request review and appeal decisions to disenroll or disqualify 13
279	279	them. 14
280	280	(b) Medicare and Medicaid eligible coverage under RICHIP shall be as follows: 15
281	281	(1) If all necessary federal waivers are obtained, qualified Rhode Island residents eligible 16
282	282	for federal Medicare ("Medicare eligible residents") shall continue to pay required fees to the 17
283	283	federal government. RICHIP shall establish procedures to ensure that Medicare eligible residents 18
284	284	shall have such amounts deducted from what they owe to RICHIP under § 23-99-12(h). RICHIP 19
285	285	shall become the equivalent of qualifying coverage under Medicare part D and Medicare advantage 20
286	286	programs, and as such shall be the vendor for coverage to RICHIP participants. RICHIP shall 21
287	287	provide Medicare eligible residents benefits equal to those available to all other RICHIP 22
288	288	participants and equal to or greater than those available through the federal Medicare program. To 23
289	289	streamline the process, RICHIP shall seek to receive federal reimbursements for services and goods 24
290	290	to Medicare eligible residents and administer all Medicare funds. 25
291	291	(2) If all necessary federal waivers are obtained, RICHIP shall become the state's sole 26
292	292	Medicaid provider. RICHIP shall create procedures to enroll all qualified Rhode Island residents 27
293	293	eligible for Medicaid ("Medicaid eligible residents") in the federal Medicaid program to ensure a 28
294	294	maximum amount of federal Medicaid funds go to the RICHIP trust fund. RICHIP shall provide 29
295	295	benefits to Medicaid eligible residents equal to those available to all other RICHIP participants. 30
296	296	(3) If all necessary federal waivers are not granted from the Medicaid or Medicare 31
297	297	programs operated under Title XVIII or XIX of the Social Security Act, the Medicaid or Medicare 32
298	298	program for which a waiver is not granted shall act as the primary insurer for those eligible for such 33
299	299	coverage, and RICHIP shall serve as the secondary or supplemental plan of health insurance 34
300	300
301	301
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303	303	coverage. Until such time as a waiver is granted, the plan shall not pay for services for persons 1
304	304	otherwise eligible for the same health care benefits under the Medicaid or Medicare program. The 2
305	305	director shall establish procedures for determining amounts owed by Medicare and Medicaid 3
306	306	eligible residents for supplemental RICHIP coverage and the extent of such coverage. 4
307	307	(4) The director may require Rhode Island residents to provide information necessary to 5
308	308	determine whether the resident is eligible for a federally matched public health program or for 6
309	309	Medicare, or any program or benefit under Medicare. 7
310	310	(5) As a condition of eligibility or continued eligibility for health care services under 8
311	311	RICHIP, a qualified Rhode Island resident who is eligible for benefits under Medicare shall enroll 9
312	312	in Medicare, including Parts A, B, and D. 10
313	313	(c) Veterans. RICHIP shall serve as the secondary or supplemental plan of health insurance 11
314	314	coverage for military veterans. The director shall establish procedures for determining amounts 12
315	315	owed by military veterans who are qualified residents for such supplemental RICHIP coverage and 13
316	316	the extent of such coverage. 14
317	317	(d) This chapter does not create any employment benefit, nor require, prohibit, or limit the 15
318	318	providing of any employment benefit. 16
319	319	(e) This chapter does not affect or limit collective action or collective bargaining on the 17
320	320	part of a health care provider with their employer or any other lawful collective action or collective 18
321	321	bargaining. 19
322	322	23-99-6. Benefits. 20
323	323	(a) This chapter shall provide insurance coverage for services and goods (including 21
324	324	prescription drugs) deemed medically necessary by a qualified health care provider and that is 22
325	325	currently covered under: 23
326	326	(1) Services and goods currently covered by the federal Medicare program (Social Security 24
327	327	Act title XVIII) parts A, B and D; 25
328	328	(2) Services and goods covered by Medicaid as of January 1, 2024; 26
329	329	(3) Services and goods currently covered by the state's Children's Health Insurance 27
330	330	Program; 28
331	331	(4) Essential health benefits mandated by the Affordable Care Act; and 29
332	332	(5) Services and goods within the following categories: 30
333	333	(i) Primary and preventive care; 31
334	334	(ii) Approved dietary and nutritional therapies; 32
335	335	(iii) Inpatient care; 33
336	336	(iv) Outpatient care; 34
337	337
338	338
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340	340	(v) Emergency and urgently needed care; 1
341	341	(vi) Prescription drugs and medical devices; 2
342	342	(vii) Laboratory and diagnostic services; 3
343	343	(viii) Palliative care; 4
344	344	(ix) Mental health services; 5
345	345	(x) Oral health, including dental services, periodontics, oral surgery, and endodontics; 6
346	346	(xi) Substance abuse treatment services; 7
347	347	(xii) Physical therapy and chiropractic services; 8
348	348	(xiii) Vision care and vision correction; 9
349	349	(xiv) Hearing services, including coverage of hearing aids; 10
350	350	(xv) Podiatric care; 11
351	351	(xvi) Comprehensive family planning, reproductive, maternity, and newborn care; 12
352	352	(xvii) Short-term rehabilitative services and devices; 13
353	353	(xviii) Durable medical equipment; 14
354	354	(xix) Gender affirming health care; and 15
355	355	(xx) Diagnostic and routine medical testing. 16
356	356	(b) Additional coverage. The director shall create a procedure that may permit additional 17
357	357	medically necessary goods and services beyond that provided by federal laws cited herein and 18
358	358	within the areas set forth in § 23-99-5, if the coverage is for services and goods deemed medically 19
359	359	necessary based on credible scientific evidence published in peer-reviewed medical literature 20
360	360	generally recognized by the relevant medical community, physician specialty society 21
361	361	recommendations, and the views of physicians practicing in relevant clinical areas and any other 22
362	362	relevant factors. The director shall create procedures for handling complaints and appeals 23
363	363	concerning the benefits package. 24
364	364	(c) Restrictions shall not apply. In order for RICHIP participants to be able to receive 25
365	365	medically necessary goods and services, this chapter shall override any state law that restricts the 26
366	366	provision or use of state funds for any medically necessary goods or services, including those 27
367	367	related to family planning and reproductive health care. 28
368	368	(d) Medically necessary goods: 29
369	369	(1) Prescription drug formulary: 30
370	370	(i) In general. The director shall establish a prescription drug formulary system, to be 31
371	371	approved by the board, and encourage best-practices in prescribing and discourage the use of 32
372	372	ineffective, dangerous, or excessively costly medications when better alternatives are available. 33
373	373	(ii) Promotion of generics. The formulary under this subsection shall promote the use of 34
374	374
375	375
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377	377	generic medications to the greatest extent possible. 1
378	378	(iii) Formulary updates and petition rights. The formulary under this subsection shall be 2
379	379	updated frequently and the director shall create a procedure for patients and providers to make 3
380	380	requests and appeal denials to add new pharmaceuticals or to remove ineffective or dangerous 4
381	381	medications from the formulary. 5
382	382	(iv) Use of off-formulary medications. The director shall promulgate rules regarding the 6
383	383	use of off-formulary medications which allow for patient access but do not compromise the 7
384	384	formulary. 8
385	385	(v) Approved devices and equipment. The director shall present a list of medically 9
386	386	necessary devices and equipment that shall be covered by RICHIP, subject to final approval by the 10
387	387	board. 11
388	388	(vi) Bulk purchasing. The director shall seek and implement ways to obtain goods at the 12
389	389	lowest possible cost, including bulk purchasing agreements. 13
390	390	23-99-7. Providers. 14
391	391	(a) Rhode Island providers. 15
392	392	(1) Licensing. Participating providers shall meet state licensing requirements in order to 16
393	393	participate in RICHIP. No provider whose license is under suspension or has been revoked shall 17
394	394	participate in the program. 18
395	395	(2) Participation. All providers may participate in RICHIP by providing items on the 19
396	396	RICHIP benefits list for which they are licensed. Providers may elect either to participate fully, or 20
397	397	not at all, in the program. 21
398	398	(3) For-profit providers. For-profit providers may continue to offer services and goods in 22
399	399	Rhode Island, but are prohibited from charging patients more than RICHIP reimbursement rates 23
400	400	for covered services and goods and shall notify qualified Rhode Island residents when the services 24
401	401	and goods they offer will not be reimbursed fully under RICHIP. 25
402	402	(b) Out-of-state providers. Except for emergency and urgently needed service, as set forth 26
403	403	in § 23-99-7(d), RICHIP shall not pay for health care services obtained outside of Rhode Island 27
404	404	unless the following requirements are met: 28
405	405	(1) The out-of-state provider agrees to accept the RICHIP rate for out-of-state providers; 29
406	406	and 30
407	407	(2) The services are medically necessary care. 31
408	408	(c) Out-of-state provider reimbursement. The program shall pay out-of-state health care 32
409	409	providers at a rate equal to the average rate paid by commercial insurers or Medicare for the services 33
410	410	rendered, whichever is higher. 34
411	411
412	412
413	413	LC001777 - Page 12 of 96
414	414	(d) Out-of-state residents. 1
415	415	(1) In general. Rhode Island providers who provide any services to individuals who are not 2
416	416	RICHIP participants shall not be reimbursed by RICHIP and shall seek reimbursement from those 3
417	417	individuals or other sources. 4
418	418	(2) Emergency care exception. Nothing in this chapter shall prevent any individual from 5
419	419	receiving or any provider from providing emergency health care services and goods in Rhode 6
420	420	Island. The director shall adopt rules to provide reimbursement; however, the rules shall reasonably 7
421	421	limit reimbursement to protect the fiscal integrity of RICHIP. The director shall implement 8
422	422	procedures to secure reimbursement from any appropriate third-party funding source or from the 9
423	423	individual to whom the emergency services were rendered. 10
424	424	23-99-8. Cross border employees. 11
425	425	(a) State residents employed out-of-state. If an individual is employed out-of-state by an 12
426	426	employer that is subject to Rhode Island state law, the employer and employee shall be required to 13
427	427	pay the payroll taxes as to that employee as if the employment were in the state. If an individual is 14
428	428	employed out-of-state by an employer that is not subject to Rhode Island state law, the employee 15
429	429	health coverage provided by the out-of-state employer to a resident working out-of-state shall serve 16
430	430	as the employee's primary plan of health coverage, and RICHIP shall serve as the employee's 17
431	431	secondary plan of health coverage. The director shall establish procedures for determining amounts 18
432	432	owed by residents employed out-of-state for such supplemental secondary RICHIP coverage and 19
433	433	the extent of such coverage. 20
434	434	(b) Out-of-state residents employed in the state. The payroll tax set forth in § 23-99-12(i) 21
435	435	shall apply to any out-of-state resident who is employed or self-employed in the state. However, 22
436	436	such out-of-state residents shall be able to take a credit for amounts they spend on health benefits 23
437	437	for themselves that would otherwise be covered by RICHIP if the individual were a RICHIP 24
438	438	participant. The out-of-state resident's employer shall be able to take a credit against such payroll 25
439	439	taxes regardless of the form of the health benefit (e.g., health insurance, a self-insured plan, direct 26
440	440	services, or reimbursement for services), to ensure that the revenue proposal does not relate to 27
441	441	employment benefits in violation of the Federal Employee Retirement Income Security Act 28
442	442	("ERISA") law. For non-employment-based spending by individuals, the credit shall be available 29
443	443	for and limited to spending for health coverage (not out-of-pocket health spending). The credit shall 30
444	444	be available without regard to how little is spent or how sparse the benefit. The credit may only be 31
445	445	taken against the payroll taxes set forth in § 23-99-12(i). Any excess amount may not be applied to 32
446	446	other tax liability. For employment-based health benefits, the credit shall be distributed between 33
447	447	the employer and employee in the same proportion as the spending by each for the benefit. The 34
448	448
449	449
450	450	LC001777 - Page 13 of 96
451	451	employer and employee may each apply their respective portion of the credit to their respective 1
452	452	portion of the payroll taxes set forth in § 23-99-12(i). If any provision of this clause or any 2
453	453	application of it shall be ruled to violate ERISA, the provision or the application of it shall be null 3
454	454	and void and the ruling shall not affect any other provision or application of this section or this 4
455	455	chapter. 5
456	456	23-99-9. Provider reimbursement. 6
457	457	(a) Rates for services and goods. RICHIP reimbursement rates to providers shall be 7
458	458	determined by the RICHIP board. These rates shall be equal to or greater than the federal Medicare 8
459	459	rates available to Rhode Island qualified residents that are in effect at the time services and goods 9
460	460	are provided. For outpatient behavioral health services, the minimum rate shall equal one hundred 10
461	461	fifty percent (150%) of federal Medicare rates. If the director determines that there are no such 11
462	462	federal Medicare reimbursement rates, the director shall set the minimum rate. The director shall 12
463	463	review the rates at least annually, recommend changes to the board, and establish procedures by 13
464	464	which complaints about reimbursement rates may be reviewed by the board. 14
465	465	(b) Billing and payments. Providers shall submit billing for services to RICHIP participants 15
466	466	in the form of electronic invoices entered into RIFANS, the state's computerized financial system. 16
467	467	The director shall coordinate the manner of processing and payment with the office of accounts and 17
468	468	control and the RIFANS support team within the division of information technology. Payments 18
469	469	shall be made by check or electronic funds transfer in accordance with terms and procedures 19
470	470	coordinated by the director and the office of accounts and control and consistent with the fiduciary 20
471	471	management of the RICHIP trust fund. 21
472	472	(c) Provider restrictions. In-state providers who accept any payment from RICHIP shall 22
473	473	not bill any patient for any covered benefit. In-state providers cannot use any of their operating 23
474	474	budgets for expansion, profit, excessive executive income, including bonuses, marketing, or major 24
475	475	capital purchases or leases. 25
476	476	23-99-10. Private insurance companies. 26
477	477	(a) Non-duplication. It is unlawful for a private health insurer to sell health insurance 27
478	478	coverage to qualified Rhode Island residents that duplicates the benefits provided under this 28
479	479	chapter. Nothing in this chapter shall be construed as prohibiting the sale of health insurance 29
480	480	coverage for any additional benefits not covered by this chapter, including additional benefits that 30
481	481	an employer may provide to employees or their dependents, or to former employees or their 31
482	482	dependents (e.g., multiemployer plans can continue to provide wrap-around coverage for any 32
483	483	benefits not provided by RICHIP). 33
484	484	(b) Displaced employees. Re-education and job placement of persons employed in Rhode 34
485	485
486	486
487	487	LC001777 - Page 14 of 96
488	488	Island-located enterprises who have lost their jobs as a result of this chapter shall be managed by 1
489	489	the Rhode Island department of labor and training or an appropriate federal retraining program. The 2
490	490	director may provide funds from RICHIP or funds otherwise appropriated for this purpose for 3
491	491	retraining and assisting job transition for individuals employed or previously employed in the fields 4
492	492	of health insurance, health care service plans, and other third-party payments for health care or 5
493	493	those individuals providing services to health care providers to deal with third-party payers for 6
494	494	health care, whose jobs may be or have been ended as a result of the implementation of the program, 7
495	495	consistent with applicable laws. 8
496	496	23-99-11. Budgeting. 9
497	497	(a) Operating budget. Annually, the director shall create an operating budget for the 10
498	498	program that includes the costs for all benefits set forth in § 23-99-5 and the costs for RICHIP 11
499	499	administration. The director shall determine appropriate reimbursement rates for benefits pursuant 12
500	500	to § 23-99-9(a). The operating budget shall be approved by the executive board prior to submission 13
501	501	to the governor and general assembly. 14
502	502	(b) Capital expenditures. The director shall work with representatives from state entities 15
503	503	involved with provider capital expenditures (e.g., the Rhode Island department of administration 16
504	504	office of capital projects, the Rhode Island health and educational building corporation, etc.), and 17
505	505	providers to help ensure that capital expenditures proposed by providers, including amounts to be 18
506	506	spent on construction and renovation of health facilities and major equipment purchases, will 19
507	507	address health care needs of RICHIP participants. To the extent that providers are seeking to use 20
508	508	RICHIP funds for capital expenditures, the director shall have the authority to approve or deny such 21
509	509	expenditures. 22
510	510	(c) Prohibition against co-mingling operations and capital improvement funds. It is 23
511	511	prohibited to use funds under this chapter that are earmarked: 24
512	512	(1) For operations for capital expenditures; or 25
513	513	(2) For capital expenditures for operations. 26
514	514	23-99-12. Financing. 27
515	515	(a) RICHIP trust fund. There shall be established a RICHIP trust fund into which funds 28
516	516	collected pursuant to this chapter are deposited and from which funds are distributed. All money 29
517	517	collected and received shall be used exclusively to finance RICHIP. The governor or general 30
518	518	assembly may provide funds to the RICHIP trust fund, but may not remove or borrow funds from 31
519	519	the RICHIP trust fund. 32
520	520	(b) Revenue proposal. After approval of the RICHIP executive board, the director shall 33
521	521	submit to the governor and the general assembly a revenue plan and, if required, legislation 34
522	522
523	523
524	524	LC001777 - Page 15 of 96
525	525	(referred to collectively in this section as the "revenue proposal") to provide the revenue necessary 1
526	526	to finance RICHIP. The initial revenue proposal shall be submitted once waiver negotiations have 2
527	527	proceeded to a level deemed sufficient by the director and annually, thereafter. The basic structure 3
528	528	of the initial revenue proposal will be based on a consideration of: 4
529	529	(1) Anticipated savings from a single payer program; 5
530	530	(2) Government funds available for health care; 6
531	531	(3) Private funds available for health care; and 7
532	532	(4) Replacing current regressive health insurance payments made to multiple health 8
533	533	insurance carriers with progressive contributions to a single payer (RICHIP) in order to make health 9
534	534	care insurance affordable and remove unnecessary barriers to health care access. 10
535	535	Subsequent proposals shall adjust the RICHIP contributions, based on projections from the 11
536	536	total RICHIP costs in the previous year, and shall include a five (5) year plan for adjusting RICHIP 12
537	537	contributions to best meet the goals set forth in this section and § 23-99-2. 13
538	538	(c) Anticipated savings. It is anticipated that RICHIP will lower health care costs by: 14
539	539	(1) Eliminating payments to private health insurance carriers; 15
540	540	(2) Reducing paperwork and administrative expenses for both providers and payers created 16
541	541	by the marketing, sales, eligibility checks, network contract management, issues associated 17
542	542	multiple benefit packages, and other administrative waste associated with the current multi-payer 18
543	543	private health insurance system; 19
544	544	(3) Allowing the planning and delivery of a public health strategy for the entire population 20
545	545	of Rhode Island; 21
546	546	(4) Improving access to preventive health care; and 22
547	547	(5) Negotiating on behalf of the state for bulk purchasing of medical supplies and 23
548	548	pharmaceuticals. 24
549	549	(d) Federal funds. The executive office of health and human services, in collaboration with 25
550	550	the director, the board and the Medicaid office, shall seek and obtain waivers and other approvals 26
551	551	relating to Medicaid, the Children's Health Insurance Program, Medicare, federal tax exemptions 27
552	552	for health care, the ACA, and any other relevant federal programs in order that: 28
553	553	(1) Federal funds and other subsidies for health care that would otherwise be paid to the 29
554	554	state and its residents and health care providers, would be paid by the federal government to the 30
555	555	state and deposited into the RICHIP trust fund; 31
556	556	(2) Programs would be waived and such funding from federal programs in Rhode Island 32
557	557	would be replaced or merged into RICHIP in order that it can operate as a single payer program; 33
558	558	(3) Maximum federal funding for health care is sought even if any necessary waivers or 34
559	559
560	560
561	561	LC001777 - Page 16 of 96
562	562	approvals are not obtained and multiple sources of funding with RICHIP trust fund monies are 1
563	563	pooled, in order that RICHIP can act as much as possible like a single payer program to maximize 2
564	564	benefits to Rhode Islanders; and 3
565	565	(4) Federal financial participation in the programs that are incorporated into RICHIP are 4
566	566	not jeopardized. 5
567	567	(e) State funds. State funds that would otherwise be appropriated to any governmental 6
568	568	agency, office, program, instrumentality, or institution for services and benefits covered under 7
569	569	RICHIP shall be directed into the RICHIP trust fund. Payments to the fund pursuant to this section 8
570	570	shall be in an amount equal to the money appropriated for those purposes in the fiscal year 9
571	571	beginning immediately preceding the effective date of this chapter. 10
572	572	(f) Private funds. Private grants (e.g., from nonprofit corporations) and other funds 11
573	573	specifically ear-marked for health care (e.g., from litigation against tobacco companies, opioid 12
574	574	manufacturers, etc.), shall also be put into the RICHIP trust fund. 13
575	575	(g) Assignments from RICHIP participants. Receipt of health care services under the plan 14
576	576	shall be deemed an assignment by the RICHIP participant of any right to payment for services from 15
577	577	a policy of insurance, a health benefit plan or other source. The other source of health care benefits 16
578	578	shall pay to the fund all amounts it is obligated to pay to, or on behalf of, the RICHIP participant 17
579	579	for covered health care services. The director may commence any action necessary to recover the 18
580	580	amounts due. 19
581	581	(h) Replacing current health insurance payments with progressive contributions. Instead of 20
582	582	making health insurance payments to multiple carriers (i.e., for premiums, co-pays deductibles, and 21
583	583	costs in excess of caps) for limited coverage, individuals and entities subject to Rhode Island 22
584	584	taxation pursuant to § 44-30-1 shall pay progressive contributions to the RICHIP trust fund 23
585	585	(referred to collectively in this section as the "RICHIP contributions") for comprehensive coverage. 24
586	586	These RICHIP contributions shall be set and adjusted over time to an appropriate level to: 25
587	587	(1) Cover the actual cost of the program; 26
588	588	(2) Ensure that higher brackets of income subject to specified taxes shall be assessed at a 27
589	589	higher marginal rate than lower brackets; and 28
590	590	(3) Protect the economic welfare of small businesses, low-income earners and working 29
591	591	families through tax credits or exemptions. 30
592	592	(i) Contributions based on earned income. The amounts currently paid by employers and 31
593	593	employees for health insurance shall initially be replaced by a ten percent (10%) payroll tax, based 32
594	594	on the projected average payroll of employees over three (3) previous calendar years. The employer 33
595	595	shall pay eighty percent (80%) and the employee shall pay twenty percent (20%) of this payroll 34
596	596
597	597
598	598	LC001777 - Page 17 of 96
599	599	tax, except that an employer may agree to pay all or part of the employee's share. Self- employed 1
600	600	individuals shall initially pay one-hundred percent (100%) of the payroll tax. The ten percent (10%) 2
601	601	initial rate will be adjusted by the director in order that higher brackets of income subject to these 3
602	602	taxes shall be assessed at a higher marginal rate than lower brackets and in order that small 4
603	603	businesses and lower income earners receive a credit or exemption. 5
604	604	(j) Contributions based on unearned income. There shall be a progressive contribution 6
605	605	based on unearned income, i.e., capital gains, dividends, interest, profits, and rents. Initially, the 7
606	606	unearned income RICHIP contributions shall be equal to ten percent (10%) of such unearned 8
607	607	income. The ten percent (10%) initial rate may be adjusted by the director to allow for a graduated 9
608	608	progressive exemption or credit for individuals with lower unearned income levels. 10
609	609	23-99-13. Implementation. 11
610	610	(a) State laws and regulations. 12
611	611	(1) In general. The director shall work with the executive board and receive such assistance 13
612	612	as may be necessary from other state agencies and entities to examine state laws and regulations 14
613	613	and to make recommendations necessary to conform such laws and regulations to properly 15
614	614	implement the RICHIP program. The director shall report recommendations to the governor and 16
615	615	the general assembly. 17
616	616	(2) Anti-trust laws. The intent of this chapter is to exempt activities provided for under this 18
617	617	chapter from state antitrust laws and to provide immunity from federal antitrust laws through the 19
618	618	state action doctrine. 20
619	619	(b) The director shall complete an implementation plan to provide health care coverage for 21
620	620	qualified residents in accordance with this chapter within twelve (12) months of its effective date. 22
621	621	(c) The executive office of health and human services, in collaboration with the director, 23
622	622	the board, and the Medicaid director, will have the initial responsibility of negotiating the waivers. 24
623	623	(d) Severability. If any provision or application of this chapter shall be held to be invalid, 25
624	624	or to violate or be inconsistent with any applicable federal law or regulation, that shall not affect 26
625	625	other provisions or applications of this chapter which can be given effect without that provision or 27
626	626	application; and to that end, the provisions and applications of this chapter are severable. 28
627	627	SECTION 2. Chapter 22-11 of the General Laws entitled "Joint Committee on Legislative 29
628	628	Services" is hereby amended by adding thereto the following section: 30
629	629	22-11-4.1. Employees needed to maximize federal Medicaid funding. 31
630	630	The joint committee on legislative services shall fund five (5) new FTEs for the senate 32
631	631	fiscal office and five (5) new FTEs for the house fiscal office exclusively devoted to finding ways 33
632	632	to maximize federal Medicaid funding, including compiling proposals for expanding eligibility to 34
633	633
634	634
635	635	LC001777 - Page 18 of 96
636	636	maximize the eligibility allowed by Centers for Medicare & Medicaid Services (CMS). 1
637	637	SECTION 3. Section 23-17-38.1 of the General Laws in Chapter 23-17 entitled "Licensing 2
638	638	of Healthcare Facilities" is hereby amended to read as follows: 3
639	639	23-17-38.1. Hospitals -- Licensing fee. 4
640	640	(a) There is imposed a hospital licensing fee for state fiscal year 2021 against each hospital 5
641	641	in the state. The hospital licensing fee is equal to five percent (5.0%) of the net patient-services 6
642	642	revenue of every hospital for the hospital’s first fiscal year ending on or after January 1, 2019, 7
643	643	except that the license fee for all hospitals located in Washington County, Rhode Island shall be 8
644	644	discounted by thirty-seven percent (37%). The discount for Washington County hospitals is subject 9
645	645	to approval by the Secretary of the U.S. Department of Health and Human Services of a state plan 10
646	646	amendment submitted by the executive office of health and human services for the purpose of 11
647	647	pursuing a waiver of the uniformity requirement for the hospital license fee. This licensing fee shall 12
648	648	be administered and collected by the tax administrator, division of taxation within the department 13
649	649	of revenue, and all the administration, collection, and other provisions of chapter 51 of title 44 shall 14
650	650	apply. Every hospital shall pay the licensing fee to the tax administrator on or before July 13, 2021, 15
651	651	and payments shall be made by electronic transfer of monies to the general treasurer and deposited 16
652	652	to the general fund. Every hospital shall, on or before June 15, 2020, make a return to the tax 17
653	653	administrator containing the correct computation of net patient-services revenue for the hospital 18
654	654	fiscal year ending September 30, 2019, and the licensing fee due upon that amount. All returns 19
655	655	shall be signed by the hospital’s authorized representative, subject to the pains and penalties of 20
656	656	perjury. 21
657	657	(b)(a) There is also imposed a hospital licensing fee for state fiscal year 2023 against each 22
658	658	hospital in the state. The hospital licensing fee is equal to five and forty-two hundredths percent 23
659	659	(5.42%) of the net patient-services revenue of every hospital for the hospital’s first fiscal year 24
660	660	ending on or after January 1, 2021, except that the license fee for all hospitals located in Washington 25
661	661	County, Rhode Island shall be discounted by thirty-seven percent (37%). The discount for 26
662	662	Washington County hospitals is subject to approval by the Secretary of the U.S. Department of 27
663	663	Health and Human Services of a state plan amendment submitted by the executive office of health 28
664	664	and human services for the purpose of pursuing a waiver of the uniformity requirement for the 29
665	665	hospital license fee. This licensing fee shall be administered and collected by the tax administrator, 30
666	666	division of taxation within the department of revenue, and all the administration, collection, and 31
667	667	other provisions of chapter 51 of title 44 shall apply. Every hospital shall pay the licensing fee to 32
668	668	the tax administrator on or before June 30, 2023, and payments shall be made by electronic transfer 33
669	669	of monies to the general treasurer and deposited to the general fund. Every hospital shall, on or 34
670	670
671	671
672	672	LC001777 - Page 19 of 96
673	673	before May 25, 2023, make a return to the tax administrator containing the correct computation of 1
674	674	net patient-services revenue for the hospital fiscal year ending September 30, 2021, and the 2
675	675	licensing fee due upon that amount. All returns shall be signed by the hospital’s authorized 3
676	676	representative, subject to the pains and penalties of perjury. 4
677	677	(c)(b) There is also imposed a hospital licensing fee for state fiscal year 2022 against each 5
678	678	hospital in the state. The hospital licensing fee is equal to five and seven hundred twenty-five 6
679	679	thousandths percent (5.725%) of the net patient-services revenue of every hospital for the hospital's 7
680	680	first fiscal year ending on or after January 1, 2020, except that the license fee for all hospitals 8
681	681	located in Washington County, Rhode Island shall be discounted by thirty-seven percent (37%). 9
682	682	The discount for Washington County hospitals is subject to approval by the Secretary of the U.S. 10
683	683	Department of Health and Human Services of a state plan amendment submitted by the executive 11
684	684	office of health and human services for the purpose of pursuing a waiver of the uniformity 12
685	685	requirement for the hospital license fee. This licensing fee shall be administered and collected by 13
686	686	the tax administrator, division of taxation within the department of revenue, and all the 14
687	687	administration, collection, and other provisions of Chapter 51 of title 44 shall apply. Every hospital 15
688	688	shall pay the licensing fee to the tax administrator on or before July 13, 2022, and payments shall 16
689	689	be made by electronic transfer of monies to the general treasurer and deposited to the general fund. 17
690	690	Every hospital shall, on or before June 15, 2022, make a return to the tax administrator containing 18
691	691	the correct computation of net patient-services revenue for the hospital fiscal year ending 19
692	692	September 30, 2020, and the licensing fee due upon that amount. All returns shall be signed by the 20
693	693	hospital's authorized representative, subject to the pains and penalties of perjury. 21
694	694	(c) There is also imposed a hospital licensing fee described in subsections d through g for 22
695	695	state fiscal year 2024 against net patient-services revenue of every non-government owned hospital 23
696	696	as defined herein for the hospital’s first fiscal year ending on or after January 1, 2022. The hospital 24
697	697	licensing fee shall have three (3) tiers with differing fees based on inpatient and outpatient net 25
698	698	patient-services revenue. The executive office of health and human services, in consultation with 26
699	699	the tax administrator, shall identify the hospitals in each tier, subject to the definitions in this 27
700	700	section, by July 15, 2023, and shall notify each hospital of its tier by August 1, 2023. 28
701	701	(d) Tier 1 is composed of hospitals that do not meet the description of either Tier 2 or Tier 29
702	702	3. 30
703	703	(1) The inpatient hospital licensing fee for Tier 1 is equal to thirteen and fifty-four 31
704	704	hundredths percent (13.54%) of the inpatient net patient-services revenue derived from inpatient 32
705	705	net patient-services revenue of every Tier 1 hospital. 33
706	706	(2) The outpatient hospital licensing fee for Tier 1 is equal to thirteen and seventy-three 34
707	707
708	708
709	709	LC001777 - Page 20 of 96
710	710	hundredths percent (13.73%) of the net patient-services revenue derived from outpatient net 1
711	711	patient-services revenue of every Tier 1 hospital. 2
712	712	(e) Tier 2 is composed of High Medicaid/Uninsured Cost Hospitals and Independent 3
713	713	Hospitals. 4
714	714	(1) The inpatient hospital licensing fee for Tier 2 is equal to two and seventy-one 5
715	715	hundredths (2.71%) of the inpatient net patient-services revenue derived from inpatient net patient 6
716	716	services revenue of every Tier 2 hospital. 7
717	717	(2) The outpatient hospital licensing fee for Tier 2 is equal to two and seven-five one 8
718	718	hundredths (2.75%) of the outpatient net patient-services revenue derived from outpatient net 9
719	719	patient-services revenue of every Tier 2 hospital. 10
720	720	(f) Tier 3 is composed of hospitals that are Medicare-designated Low Volume hospitals 11
721	721	and rehabilitative hospitals. 12
722	722	(1) The inpatient hospital licensing fee for Tier 3 is equal to one and thirty-five hundredths 13
723	723	(1.35%) of the inpatient net patient-services revenue derived from inpatient net patient-services 14
724	724	revenue of every Tier 3 hospital. 15
725	725	(2) The outpatient hospital licensing fee for Tier 3 is equal to one and thirty-seven 16
726	726	hundredths (1.37%) of the outpatient net patient-services revenue derived from outpatient net 17
727	727	patient-services revenue of every Tier 3 hospital. 18
728	728	(g) There is also imposed a hospital licensing fee for state fiscal year 2024 against state 19
729	729	government owned and operated hospitals in the state as defined therein. The hospital licensing fee 20
730	730	is equal to five and forty-two hundredths percent (5.42%) of the net patient-services revenue of 21
731	731	every hospital for the hospital’s first fiscal year ending on or after January 1, 2023. 22
732	732	(h) The hospital licensing fee described in subsections (c) through (g) is subject to U.S. 23
733	733	Department of Health and Human Services approval of a request to waive the requirement that 24
734	734	health care-related taxes be imposed uniformly as contained in 42 CFR 433.68(d). (i) This hospital 25
735	735	licensing fee shall be administered and collected by the tax administrator, division of taxation 26
736	736	within the department of revenue, and all the administration, collection, and other provisions of 27
737	737	chapter 51 of title 44 shall apply. Every hospital shall pay the licensing fee to the tax administrator 28
738	738	on a quarterly basis and fully before June 30, 2024, and payments shall be made by electronic 29
739	739	transfer of monies to the tax administrator and deposited to the general fund. Every hospital shall, 30
740	740	on or before August 1, 2023, make a return to the tax administrator containing the correct 31
741	741	computation of inpatient and outpatient net patient-services revenue for the hospital fiscal year 32
742	742	ending in 2022, and the licensing fee due upon that amount. All returns shall be signed by the 33
743	743	hospital’s authorized representative, subject to the pains and penalties of perjury. 34
744	744
745	745
746	746	LC001777 - Page 21 of 96
747	747	(d)(i) For purposes of this section the following words and phrases have the following 1
748	748	meanings: 2
749	749	(2)(1) "Gross patient-services revenue" means the gross revenue related to patient care 3
750	750	services. 4
751	751	(2) “High Medicaid/Uninsured cost hospital” means a hospital for which the hospital’s total 5
752	752	uncompensated care, as calculated pursuant to § 40-8.3-2(4), divided by the hospital’s total net 6
753	753	patient-services revenues, is equal to 6.0% or greater. 7
754	754	(1)(3) "Hospital" means the actual facilities and buildings in existence in Rhode Island, 8
755	755	licensed pursuant to § 23-17-1 et seq. on June 30, 2010, and thereafter any premises included on 9
756	756	that license, regardless of changes in licensure status pursuant to chapter 17.14 of title 23 (hospital 10
757	757	conversions) and § 23-17-6(b) (change in effective control), that provides short-term acute inpatient 11
758	758	and/or outpatient care to persons who require definitive diagnosis and treatment for injury, illness, 12
759	759	disabilities, or pregnancy. Notwithstanding the preceding language, the negotiated Medicaid 13
760	760	managed care payment rates for a court-approved purchaser that acquires a hospital through 14
761	761	receivership, special mastership, or other similar state insolvency proceedings (which court-15
762	762	approved purchaser is issued a hospital license after January 1, 2013) shall be based upon the newly 16
763	763	negotiated rates between the court-approved purchaser and the health plan, and such rates shall be 17
764	764	effective as of the date that the court-approved purchaser and the health plan execute the initial 18
765	765	agreement containing the newly negotiated rate. The rate-setting methodology for inpatient hospital 19
766	766	payments and outpatient hospital payments set forth in §§ 40-8-13.4(b) and 40-8-13.4(b)(2), 20
767	767	respectively, shall thereafter apply to negotiated increases for each annual twelve-month (12) 21
768	768	period as of July 1 following the completion of the first full year of the court-approved purchaser's 22
769	769	initial Medicaid managed care contract. 23
770	770	(4) “Independent hospitals” means a hospital not part of a multi-hospital system 24
771	771	(5) “Medicare-designated low volume hospital” means a hospital that qualifies under 42 25
772	772	32 CFR 412.101(b)(2) for additional Medicare payments to qualifying hospitals for the higher 26
773	773	incremental costs associated with a low volume of discharges. 27
774	774	(3)(6) "Net patient-services revenue" means the charges related to patient care services less 28
775	775	(i) Charges attributable to charity care; (ii) Bad debt expenses; and (iii) Contractual allowances. 29
776	776	(7) “Non-government owned hospitals” means a hospital not owned and operated by the 30
777	777	state. 31
778	778	(8) “Rehabilitative hospital” means rehabilitation hospital center licensed by the Rhode 32
779	779	Island department of health. 33
780	780	(9) “State-government owned and operated hospitals” means a hospital facility licensed by 34
781	781
782	782
783	783	LC001777 - Page 22 of 96
784	784	the Rhode Island department of health, owned and operated by the state of Rhode Island. 1
785	785	(e)(k) The tax administrator in consultation with the executive office of health and human 2
786	786	services shall make and promulgate any rules, regulations, and procedures not inconsistent with 3
787	787	state law and fiscal procedures that he or she deems necessary for the proper administration of this 4
788	788	section and to carry out the provisions, policy, and purposes of this section. 5
789	789	(f)(l) The licensing fee imposed by subsection (a) shall apply to hospitals as defined herein 6
790	790	that are duly licensed on July 1, 2020 2021, and shall be in addition to the inspection fee imposed 7
791	791	by § 23-17-38 and to any licensing fees previously imposed in accordance with this section. 8
792	792	(g)(m) The licensing fee imposed by subsection (b) shall apply to hospitals as defined 9
793	793	herein that are duly licensed on July 1, 2021 2022, and shall be in addition to the inspection fee 10
794	794	imposed by § 23-17-38 and to any licensing fees previously imposed in accordance with this 11
795	795	section. 12
796	796	(h)(n) The licensing fee fees imposed by subsection subsections (c) through (g) shall apply 13
797	797	to hospitals as defined herein that are duly licensed on July 1, 2022 2023, and shall be in addition 14
798	798	to the inspection fee imposed by § 23-17-38 and to any licensing fees previously imposed in 15
799	799	accordance with this section. 16
800	800	SECTION 4. Section 27-34.3-7 of the General Laws in Chapter 27-34.3 entitled "Rhode 17
801	801	Island Life and Health Insurance Guaranty Association Act" is hereby amended to read as follows: 18
802	802	27-34.3-7. Board of directors. 19
803	803	(a) The board of directors of the association shall consist of: 20
804	804	(1) Nine (9) members appointed by the governor with advice and consent of the senate; 21
805	805	Not less than five (5) nor more than nine (9) member insurers serving terms as established in the 22
806	806	plan of operation; and 23
807	807	(2) The commissioner or the commissioner's designee, who shall chair the board in a non-24
808	808	voting ex officio capacity. Only member insurers shall be eligible to vote. The members of the 25
809	809	board shall be selected by member insurers subject to the approval of the commissioner. The board 26
810	810	of directors, previously established under § 27-34.1-8 [Repealed], shall continue to operate in 27
811	811	accordance with the provision of this section. Vacancies on the board shall be filled for the 28
812	812	remaining period of the term by a majority vote of the remaining board members, subject to the 29
813	813	approval of the commissioner. 30
814	814	(b) In approving selections to the board, the commissioner shall consider, among other 31
815	815	things, whether all member insurers are fairly represented. 32
816	816	(c) Members of the board may be reimbursed from the assets of the association for expenses 33
817	817	incurred by them as members of the board of directors but members of the board shall not be 34
818	818
819	819
820	820	LC001777 - Page 23 of 96
821	821	compensated by the association for their services. 1
822	822	SECTION 5. Section 27-66-24 of the General Laws in Chapter 27-66 entitled "The Health 2
823	823	Insurance Conversions Act" is hereby amended to read as follows: 3
824	824	27-66-24. Exceptions -- Rehabilitation, liquidation or conservation. 4
825	825	No proposed conversion shall be subject to this chapter in In the event that the health 5
826	826	insurance corporation, health maintenance corporation, a nonprofit hospital service corporation, 6
827	827	nonprofit medical service corporation or affiliate or subsidiary of them, hereinafter "the insurer," 7
828	828	is subject to an order from the superior court directing the director to rehabilitate, liquidate or 8
829	829	conserve, as provided in §§ 27-19-28, 27-20-24, 27-41-18, or chapter 14.1, 14.2,14.3 or 14.4 of this 9
830	830	title., certain additional conditions shall apply to the insurer: 10
831	831	(1) The insolvency, financial condition, or default of the insurer at any time shall not permit 11
832	832	the insurer to fail to pay claims in a timely manner. 12
833	833	(2) Should the insurer fail to pay claims in a timely manner, those claims shall become a 13
834	834	temporary obligation of the state, who shall pay them in a timely manner. Should the state be 14
835	835	compelled to pay claims for this reason, the insurer shall owe the state a fine ten (10) times the 15
836	836	value of all claims paid. 16
837	837	(3) The insolvency, financial condition, or default of the insurer at any time shall not permit 17
838	838	the insurer to fail to pay state taxes on time. Should the insurer fail to pay taxes on time, the size of 18
839	839	the tax obligation owed shall increase by a factor of ten (10). 19
840	840	(4) The Medicaid office shall be guaranteed a right of first refusal to acquire the insurer 20
841	841	before alternate buyers are considered. Any obligations due to the state by the insurer shall be 21
842	842	counted towards the purchase price of the insurer. The Rhode Island life and health insurance 22
843	843	guaranty association, created pursuant to § 27-34.3-6, shall pay the costs of the acquisition, but all 23
844	844	ownership shares shall be held by the Medicaid office. 24
845	845	SECTION 6. Title 27 of the General Laws entitled "INSURANCE" is hereby amended by 25
846	846	adding thereto the following chapter: 26
847	847	CHAPTER 82 27
848	848	PRIOR AUTHORIZATION OF CERTAIN HEALTH INSURANCE POLICY CHANGES 28
849	849	27-82-1. Prior authorization of general assembly. 29
850	850	(a) Prior authorization of the general assembly shall be required for certain policy changes 30
851	851	by health insurers: 31
852	852	(1) Any change that increases the average amount charged annually to consumers on a per 32
853	853	beneficiary basis; 33
854	854	(2) Any change that in any way reduces any benefits offered to plan beneficiaries; 34
855	855
856	856
857	857	LC001777 - Page 24 of 96
858	858	(3) Any change that increases any premiums, deductibles, or copays; or 1
859	859	(4) Ceasing offering any plan a health insurer offers within the State of Rhode Island. 2
860	860	(b) No rate reviews pursuant to those utilized in § 27-18-54, § 27-19-30.1, § 27-20-25.2, § 3
861	861	27-41-27.2, and §42-62-13 shall be construed to exempt any health insurer from the prior 4
862	862	authorization requirements of this chapter. 5
863	863	SECTION 7. Section 28-57-5 of the General Laws in Chapter 28-57 entitled "Healthy and 6
864	864	Safe Families and Workplaces Act" is hereby amended to read as follows: 7
865	865	28-57-5. Accrual of paid sick and safe leave time. 8
866	866	(a) All employees employed by an employer of eighteen (18) or more employees in Rhode 9
867	867	Island shall accrue a minimum of one hour of paid sick and safe leave time for every thirty five 10
868	868	(35) hours worked up to a maximum of twenty-four (24) hours during the calendar year of 2018, 11
869	869	thirty-two (32) hours during calendar year 2019, and up to a maximum of forty (40) hours per year 12
870	870	during the calendar years 2023 and 2024 and up to a maximum of one hundred sixty (160) hours 13
871	871	per year thereafter, unless the employer chooses to provide a higher annual limit in both accrual 14
872	872	and use. In determining the number of employees who are employed by an employer for 15
873	873	compensation, all employees defined in § 28-57-3(7) shall be counted. 16
874	874	(b) Employees who are exempt from the overtime requirements under 29 U.S.C. § 17
875	875	213(a)(1) of the Federal Fair Labor Standards Act, 29 U.S.C. § 201 et seq., will be assumed to work 18
876	876	forty (40) hours in each work week for purposes of paid sick and safe leave time accrual unless 19
877	877	their normal work week is less than forty (40) hours, in which case paid sick and safe leave time 20
878	878	accrues based upon that normal work week. 21
879	879	(c) Paid sick and safe leave time as provided in this chapter shall begin to accrue at the 22
880	880	commencement of employment or pursuant to the law's effective date [July 1, 2018], whichever is 23
881	881	later. An employer may provide all paid sick and safe leave time that an employee is expected to 24
882	882	accrue in a year at the beginning of the year. 25
883	883	(d) An employer may require a waiting period for newly hired employees of up to ninety 26
884	884	(90) days. During this waiting period, an employee shall accrue earned sick time pursuant to this 27
885	885	section or the employer's policy, if exempt under § 28-57-4(b), but shall not be permitted to use the 28
886	886	earned sick time until after he or she has completed the waiting period. 29
887	887	(e) Paid sick and safe leave time shall be carried over to the following calendar year; 30
888	888	however, an employee's use of paid sick and safe leave time provided under this chapter in each 31
889	889	calendar year shall not exceed twenty-four (24) hours during calendar year 2018, and thirty-two 32
890	890	(32) hours during calendar year 2019, and forty (40) hours per year thereafter. Alternatively, in lieu 33
891	891	of carryover of unused earned paid sick and safe leave time from one year to the next, an employer 34
892	892
893	893
894	894	LC001777 - Page 25 of 96
895	895	may pay an employee for unused earned paid sick and safe leave time at the end of a year and 1
896	896	provide the employee with an amount of paid sick and safe leave that meets or exceeds the 2
897	897	requirements of this chapter that is available for the employee's immediate use at the beginning of 3
898	898	the subsequent year. 4
899	899	(f) Nothing in this chapter shall be construed as requiring financial or other reimbursement 5
900	900	to an employee from an employer upon the employee's termination, resignation, retirement, or other 6
901	901	separation from employment for accrued paid sick and safe leave time that has not been used. 7
902	902	(g) If an employee is transferred to a separate division, entity, or location within the state, 8
903	903	but remains employed by the same employer as defined in 29 C.F.R. § 791.2 of the Federal Fair 9
904	904	Labor Standards Act, 29 U.S.C. § 201 et seq., the employee is entitled to all paid sick and safe leave 10
905	905	time accrued at the prior division, entity, or location and is entitled to use all paid sick and safe 11
906	906	leave time as provided in this act. When there is a separation from employment and the employee 12
907	907	is rehired within one hundred thirty-five (135) days of separation by the same employer, previously 13
908	908	accrued paid sick and safe leave time that had not been used shall be reinstated. Further, the 14
909	909	employee shall be entitled to use accrued paid sick and safe leave time and accrue additional sick 15
910	910	and safe leave time at the re-commencement of employment. 16
911	911	(h) When a different employer succeeds or takes the place of an existing employer, all 17
912	912	employees of the original employer who remain employed by the successor employer within the 18
913	913	state are entitled to all earned paid sick and safe leave time they accrued when employed by the 19
914	914	original employer, and are entitled to use earned paid sick and safe leave time previously accrued. 20
915	915	(i) At its discretion, an employer may loan sick and safe leave time to an employee in 21
916	916	advance of accrual by such employee. 22
917	917	(j) Temporary employees shall be entitled to use accrued paid sick and safe leave time 23
918	918	beginning on the one hundred eightieth (180) calendar day following commencement of their 24
919	919	employment, unless otherwise permitted by the employer. On and after the one hundred eightieth 25
920	920	(180) calendar day of employment, employees may use paid sick and safe leave time as it is 26
921	921	accrued. During this waiting period, an employee shall accrue earned sick time pursuant to this 27
922	922	chapter, but shall not be permitted to use the earned sick time until after he or she has completed 28
923	923	the waiting period. 29
924	924	(k) Seasonal employees shall be entitled to use accrued paid sick and safe leave time 30
925	925	beginning on the one hundred fiftieth (150) calendar day following commencement of their 31
926	926	employment, unless otherwise permitted by the employer. On and after the one hundred fiftieth 32
927	927	(150) calendar day of employment, employees may use paid sick and safe leave time as it is 33
928	928	accrued. During this waiting period, an employee shall accrue earned sick time pursuant to this 34
929	929
930	930
931	931	LC001777 - Page 26 of 96
932	932	chapter, but shall not be permitted to use the earned sick time until after he or she has completed 1
933	933	the waiting period. 2
934	934	SECTION 8. Section 36-12-2.1 of the General Laws in Chapter 36-12 entitled "Insurance 3
935	935	Benefits" is hereby repealed. 4
936	936	36-12-2.1. Health insurance benefits -- Coverage for abortions excluded. 5
937	937	(a) The state of Rhode Island shall not include in any health insurance contracts, plans, or 6
938	938	policies covering employees, any provision which shall provide coverage for induced abortions 7
939	939	(except where the life of the mother would be endangered if the fetus were carried to term, or where 8
940	940	the pregnancy resulted from rape or incest). This section shall be applicable to all contracts, plans 9
941	941	or policies of: 10
942	942	(1) All health insurers subject to title 27; 11
943	943	(2) All group and blanket health insurers subject to title 27; 12
944	944	(3) All nonprofit hospital, medical, surgical, dental, and health service corporations; 13
945	945	(4) All health maintenance organizations; and 14
946	946	(5) Any provision of medical, hospital, surgical, and funeral benefits and of coverage 15
947	947	against accidental death or injury when the benefits or coverage are incidental to or part of other 16
948	948	insurance authorized by the statutes of this state. 17
949	949	(b) Provided, however, that the provisions of this section shall not apply to benefits 18
950	950	provided under existing collective bargaining agreements entered into prior to June 30, 1982. 19
951	951	(c) Nothing contained herein shall be construed to pertain to insurance coverage for 20
952	952	complications as the result of an abortion. 21
953	953	SECTION 9. Sections 40-8-2, 40-8-6, 40-8-10, 40-8-13, 40-8-13.4, 40-8-16, 40-8-19, 40-22
954	954	8-26 and 40-8-32 of the General Laws in Chapter 40-8 entitled "Medical Assistance" are hereby 23
955	955	amended to read as follows: 24
956	956	40-8-2. Definitions. 25
957	957	As used in this chapter, unless the context shall otherwise require: 26
958	958	(1) "Dental service" means and includes emergency care, X-rays for diagnoses, extractions, 27
959	959	palliative treatment, and the refitting and relining of existing dentures and prosthesis. 28
960	960	(2) "Department" means the department of human services. 29
961	961	(3) "Director" means the director of human services Medicaid director. 30
962	962	(4) "Drug" means and includes only drugs and biologicals prescribed by a licensed dentist 31
963	963	or physician as are either included in the United States pharmacopoeia, national formulary, or are 32
964	964	new and nonofficial drugs and remedies. 33
965	965	(5) "Inpatient" means a person admitted to and under treatment or care of a physician or 34
966	966
967	967
968	968	LC001777 - Page 27 of 96
969	969	surgeon in a hospital or nursing facility that meets standards of and complies with rules and 1
970	970	regulations promulgated by the director. 2
971	971	(6) "Inpatient hospital services" means the following items and services furnished to an 3
972	972	inpatient in a hospital other than a hospital, institution, or facility for tuberculosis or mental 4
973	973	diseases: 5
974	974	(i) Bed and board; 6
975	975	(ii) Nursing services and other related services as are customarily furnished by the hospital 7
976	976	for the care and treatment of inpatients and drugs, biologicals, supplies, appliances, and equipment 8
977	977	for use in the hospital, as are customarily furnished by the hospital for the care and treatment of 9
978	978	patients; 10
979	979	(iii) (A) Other diagnostic or therapeutic items or services, including, but not limited to, 11
980	980	pathology, radiology, and anesthesiology furnished by the hospital or by others under arrangements 12
981	981	made by the hospital, as are customarily furnished to inpatients either by the hospital or by others 13
982	982	under such arrangements, and services as are customarily provided to inpatients in the hospital by 14
983	983	an intern or resident-in-training under a teaching program having the approval of the Council on 15
984	984	Medical Education and Hospitals of the American Medical Association or of any other recognized 16
985	985	medical society approved by the director. 17
986	986	(B) The term "inpatient hospital services" shall be taken to include medical and surgical 18
987	987	services provided by the inpatient's physician, but shall not include the services of a private-duty 19
988	988	nurse or services in a hospital, institution, or facility maintained primarily for the treatment and 20
989	989	care of patients with tuberculosis or mental diseases. Provided, further, it shall be taken to include 21
990	990	only the following organ transplant operations: kidney, liver, cornea, pancreas, bone marrow, lung, 22
991	991	heart, and heart/lung, and other organ transplant operations as may be designated by the director 23
992	992	after consultation with medical advisory staff or medical consultants; and provided that any such 24
993	993	transplant operation is determined by the director or his or her designee to be medically necessary. 25
994	994	Prior written approval of the director, or his or her designee, shall be required for all covered organ 26
995	995	transplant operations. 27
996	996	(C) In determining medical necessity for organ transplant procedures, the state plan shall 28
997	997	adopt a case-by-case approach and shall focus on the medical indications and contra-indications in 29
998	998	each instance; the progressive nature of the disease; the existence of any alternative therapies; the 30
999	999	life-threatening nature of the disease; the general state of health of the patient apart from the 31
1000	1000	particular organ disease; and any other relevant facts and circumstances related to the applicant and 32
1001	1001	the particular transplant procedure. 33
1002	1002	(7) "Medicare equivalent rate" means the amount that would be paid for the relevant 34
1003	1003
1004	1004
1005	1005	LC001777 - Page 28 of 96
1006	1006	services as furnished by the relevant group of facilities under Medicare payment principles 1
1007	1007	delineated in subchapter B of 42 CFR Chapter IV. Should no direct Medicare rates be available for 2
1008	1008	the particular service and facility group, the Medicaid director will estimate the rate. Providers will 3
1009	1009	have standing to bring an action in superior court for a higher rate, but intermediary insurers such 4
1010	1010	as managed care entities shall have no standing to bring an action for a lower rate. 5
1011	1011	(7)(8) "Nursing services" means the following items and services furnished to an inpatient 6
1012	1012	in a nursing facility: 7
1013	1013	(i) Bed and board; 8
1014	1014	(ii) Nursing care and other related services as are customarily furnished to inpatients 9
1015	1015	admitted to the nursing facility, and drugs, biologicals, supplies, appliances, and equipment for use 10
1016	1016	in the facility, as are customarily furnished in the facility for the care and treatment of patients; 11
1017	1017	(iii) Other diagnostic or therapeutic items or services, legally furnished by the facility or 12
1018	1018	by others under arrangements made by the facility, as are customarily furnished to inpatients either 13
1019	1019	by the facility or by others under such arrangement; 14
1020	1020	(iv) Medical services provided in the facility by the inpatient's physician, or by an intern 15
1021	1021	or resident-in-training of a hospital with which the facility is affiliated or that is under the same 16
1022	1022	control, under a teaching program of the hospital approved as provided in subsection (6); and 17
1023	1023	(v) A personal-needs allowance of fifty dollars ($50.00) two hundred dollars ($200) per 18
1024	1024	month. 19
1025	1025	(8)(9) "Relative with whom the dependent child is living" means and includes the father, 20
1026	1026	mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, 21
1027	1027	uncle, aunt, first cousin, nephew, or niece of any dependent child who maintains a home for the 22
1028	1028	dependent child. 23
1029	1029	(9)(10) "Visiting nurse service" means part-time or intermittent nursing care provided by 24
1030	1030	or under the supervision of a registered professional nurse other than in a hospital or nursing home. 25
1031	1031	40-8-6. Review of application for benefits. 26
1032	1032	The director, or someone designated by him or her, shall review each application for 27
1033	1033	benefits filed in accordance with regulations, and shall make a determination of whether the 28
1034	1034	application will be honored and the extent of the benefits to be made available to the applicant, and 29
1035	1035	shall, within thirty (30) fifteen (15) days after the filing, notify the applicant, in writing, of the 30
1036	1036	determination. If the application is rejected, the notice to the applicant shall set forth therein the 31
1037	1037	reason therefor. The director may at any time reconsider any determination. 32
1038	1038	40-8-10. Recovery of benefits paid in error. 33
1039	1039	Any person, who through error or mistake of himself or herself or another, receives medical 34
1040	1040
1041	1041
1042	1042	LC001777 - Page 29 of 96
1043	1043	care benefits to which he or she is not entitled or with respect to which he or she was ineligible, 1
1044	1044	shall be required to reimburse the state for the benefits paid through error or mistake within the 2
1045	1045	previous three (3) years. 3
1046	1046	40-8-13. Rules, regulations, and fee schedules. 4
1047	1047	The director shall make and promulgate rules, regulations, and fee schedules not 5
1048	1048	inconsistent with state law and fiscal procedures as he or she deems necessary for the proper 6
1049	1049	administration of this chapter and to carry out the policy and purposes thereof, and to make the 7
1050	1050	department's plan conform to the provisions of the federal Social Security Act, 42 U.S.C. § 1396 8
1051	1051	et seq., and any rules or regulations promulgated pursuant thereto. Except where explicitly 9
1052	1052	authorized by this title, the director shall have no power to set any fee schedule below the Medicare 10
1053	1053	equivalent rate; provided, however, that the director shall be empowered to provide a lower rate 11
1054	1054	equal to the maximum rate where federal reimbursement can be obtained in the event that federal 12
1055	1055	reimbursement cannot be obtained for the Medicare equivalent rate. For outpatient behavioral 13
1056	1056	health services, the minimum fee schedule shall be set at one hundred fifty percent (150%) of the 14
1057	1057	Medicare equivalent rate. The director shall attempt to obtain federal reimbursement for billing 15
1058	1058	outpatient behavioral health services at one hundred fifty percent (150%) of the Medicare 16
1059	1059	equivalent rate, but the state shall bear the costs of this higher rate for outpatient behavioral health 17
1060	1060	services even if federal reimbursement cannot be obtained. Should federal financial participation 18
1061	1061	be impossible to obtain for outpatient behavioral health services rate of one hundred fifty percent 19
1062	1062	(150%) of the Medicare equivalent rate, the director shall impose a surtax on the tax imposed on 20
1063	1063	health insurers pursuant to chapter 17 of title 44 in the amount necessary to defray the costs of the 21
1064	1064	inability to obtain federal reimbursement for an outpatient behavioral health services rate of one 22
1065	1065	hundred fifty percent (150%) of the Medicare equivalent rate. 23
1066	1066	40-8-13.4. Rate methodology for payment for in-state and out-of-state hospital 24
1067	1067	services. 25
1068	1068	(a) The executive office of health and human services ("executive office") shall implement 26
1069	1069	a new methodology for payment for in-state and out-of-state hospital services in order to ensure 27
1070	1070	access to, and the provision of, high-quality and cost-effective hospital care to its eligible recipients. 28
1071	1071	(b) In order to improve efficiency and cost-effectiveness, the executive office shall: 29
1072	1072	(1) (i) With respect to inpatient services for persons in fee-for-service Medicaid, which is 30
1073	1073	non-managed care, implement a new payment methodology for inpatient services utilizing the 31
1074	1074	Diagnosis Related Groups (DRG) method of payment, which is, a patient-classification method 32
1075	1075	that provides a means of relating payment to the hospitals to the type of patients cared for by the 33
1076	1076	hospitals. It is understood that a payment method based on DRG may include cost outlier payments 34
1077	1077
1078	1078
1079	1079	LC001777 - Page 30 of 96
1080	1080	and other specific exceptions. The executive office will review the DRG-payment method and the 1
1081	1081	DRG base price annually, making adjustments as appropriate in consideration of such elements as 2
1082	1082	trends in hospital input costs; patterns in hospital coding; beneficiary access to care; and the Centers 3
1083	1083	for Medicare and Medicaid Services national CMS Prospective Payment System (IPPS) Hospital 4
1084	1084	Input Price index. For the twelve-month (12) period beginning July 1, 2015, the DRG base rate for 5
1085	1085	Medicaid fee-for-service inpatient hospital services shall not exceed ninety-seven and one-half 6
1086	1086	percent (97.5%) of the payment rates in effect as of July 1, 2014. Beginning July 1, 2019, the DRG 7
1087	1087	base rate for Medicaid fee-for-service inpatient hospital services shall be 107.2% of the payment 8
1088	1088	rates in effect as of July 1, 2018. Increases in the Medicaid fee-for-service DRG hospital payments 9
1089	1089	for the twelve-month (12) period beginning July 1, 2020, shall be based on the payment rates in 10
1090	1090	effect as of July 1 of the preceding fiscal year, and shall be the Centers for Medicare and Medicaid 11
1091	1091	Services national Prospective Payment System (IPPS) Hospital Input Price Index. Beginning July 12
1092	1092	1, 2023, payments for inpatient services in fee-for-service Medicaid shall cease utilizing the DRG 13
1093	1093	method of payment, and payments shall take place on a pure fee-for-services basis, unless a 14
1094	1094	provider shall elect to utilize the DRG payment methodology. DRG rates shall be set equal to ninety 15
1095	1095	percent (90%) of a reasonable estimate of the Medicare equivalent rate. Non-DRG rates shall be 16
1096	1096	set by the Medicaid director through regulation in order that the projected overall per capita 17
1097	1097	expenditures shall equal ninety-five percent (95%) of a reasonable estimate of the equivalent 18
1098	1098	overall per capital expenditures that would have been reached under the Medicare equivalent rate. 19
1099	1099	(ii) With respect to inpatient services, (A) It is required as of January 1, 2011, until 20
1100	1100	December 31, 2011, that the Medicaid managed care payment rates between each hospital and 21
1101	1101	health plan shall not exceed ninety and one-tenth percent (90.1%) of the rate in effect as of June 22
1102	1102	30, 2010. Increases in inpatient hospital payments for each annual twelve-month (12) period 23
1103	1103	beginning January 1, 2012, may not exceed the Centers for Medicare and Medicaid Services 24
1104	1104	national CMS Prospective Payment System (IPPS) Hospital Input Price index for the applicable 25
1105	1105	period; (B) Provided, however, for the twenty-four-month (24) period beginning July 1, 2013, the 26
1106	1106	Medicaid managed care payment rates between each hospital and health plan shall not exceed the 27
1107	1107	payment rates in effect as of January 1, 2013, and for the twelve-month (12) period beginning July 28
1108	1108	1, 2015, the Medicaid managed care payment inpatient rates between each hospital and health plan 29
1109	1109	shall not exceed ninety-seven and one-half percent (97.5%) of the payment rates in effect as of 30
1110	1110	January 1, 2013; (C) Increases in inpatient hospital payments for each annual twelve-month (12) 31
1111	1111	period beginning July 1, 2017, shall be the Centers for Medicare and Medicaid Services national 32
1112	1112	CMS Prospective Payment System (IPPS) Hospital Input Price Index, less Productivity 33
1113	1113	Adjustment, for the applicable period and shall be paid to each hospital retroactively to July 1; (D) 34
1114	1114
1115	1115
1116	1116	LC001777 - Page 31 of 96
1117	1117	Beginning July 1, 2019, the Medicaid managed care payment inpatient rates between each hospital 1
1118	1118	and health plan shall be 107.2% of the payment rates in effect as of January 1, 2019, and shall be 2
1119	1119	paid to each hospital retroactively to July 1; (E) Increases in inpatient hospital payments for each 3
1120	1120	annual twelve-month (12) period beginning July 1, 2020, shall be based on the payment rates in 4
1121	1121	effect as of January 1 of the preceding fiscal year, and shall be the Centers for Medicare and 5
1122	1122	Medicaid Services national CMS Prospective Payment System (IPPS) Hospital Input Price Index, 6
1123	1123	less Productivity Adjustment, for the applicable period and shall be paid to each hospital 7
1124	1124	retroactively to July 1; the executive office will develop an audit methodology and process to assure 8
1125	1125	that savings associated with the payment reductions will accrue directly to the Rhode Island 9
1126	1126	Medicaid program through reduced managed care plan payments and shall not be retained by the 10
1127	1127	managed care plans; (F) All hospitals licensed in Rhode Island shall accept such payment rates as 11
1128	1128	payment in full; and (G) For all such hospitals, compliance with the provisions of this section shall 12
1129	1129	be a condition of participation in the Rhode Island Medicaid program. Beginning July 1, 2023, 13
1130	1130	Medicaid managed care payment rates shall equal one hundred five percent (105%) of the fee-for-14
1131	1131	service rates set in subsection (b)(1)(i) of this section. 15
1132	1132	(2) With respect to outpatient services and notwithstanding any provisions of the law to the 16
1133	1133	contrary, for persons enrolled in fee-for-service Medicaid, the executive office will reimburse 17
1134	1134	hospitals for outpatient services using a rate methodology determined by the executive office and 18
1135	1135	in accordance with federal regulations. Fee-for-service outpatient rates shall align with Medicare 19
1136	1136	payments for similar services. Notwithstanding the above, there shall be no increase in the 20
1137	1137	Medicaid fee-for-service outpatient rates effective on July 1, 2013, July 1, 2014, or July 1, 2015. 21
1138	1138	For the twelve-month (12) period beginning July 1, 2015, Medicaid fee-for-service outpatient rates 22
1139	1139	shall not exceed ninety-seven and one-half percent (97.5%) of the rates in effect as of July 1, 2014. 23
1140	1140	Increases in the outpatient hospital payments for the twelve-month (12) period beginning July 1, 24
1141	1141	2016, may not exceed the CMS national Outpatient Prospective Payment System (OPPS) Hospital 25
1142	1142	Input Price Index. Beginning July 1, 2019, the Medicaid fee-for-service outpatient rates shall be 26
1143	1143	107.2% of the payment rates in effect as of July 1, 2018. Increases in the outpatient hospital 27
1144	1144	payments for the twelve-month (12) period beginning July 1, 2020, shall be based on the payment 28
1145	1145	rates in effect as of July 1 of the preceding fiscal year, and shall be the CMS national Outpatient 29
1146	1146	Prospective Payment System (OPPS) Hospital Input Price Index. With respect to the outpatient 30
1147	1147	rate, (i) It is required as of January 1, 2011, until December 31, 2011, that the Medicaid managed 31
1148	1148	care payment rates between each hospital and health plan shall not exceed one hundred percent 32
1149	1149	(100%) of the rate in effect as of June 30, 2010; (ii) Increases in hospital outpatient payments for 33
1150	1150	each annual twelve-month (12) period beginning January 1, 2012, until July 1, 2017, may not 34
1151	1151
1152	1152
1153	1153	LC001777 - Page 32 of 96
1154	1154	exceed the Centers for Medicare and Medicaid Services national CMS Outpatient Prospective 1
1155	1155	Payment System OPPS hospital price index for the applicable period; (iii) Provided, however, for 2
1156	1156	the twenty-four-month (24) period beginning July 1, 2013, the Medicaid managed care outpatient 3
1157	1157	payment rates between each hospital and health plan shall not exceed the payment rates in effect 4
1158	1158	as of January 1, 2013, and for the twelve-month (12) period beginning July 1, 2015, the Medicaid 5
1159	1159	managed care outpatient payment rates between each hospital and health plan shall not exceed 6
1160	1160	ninety-seven and one-half percent (97.5%) of the payment rates in effect as of January 1, 2013; (iv) 7
1161	1161	Increases in outpatient hospital payments for each annual twelve-month (12) period beginning July 8
1162	1162	1, 2017, shall be the Centers for Medicare and Medicaid Services national CMS OPPS Hospital 9
1163	1163	Input Price Index, less Productivity Adjustment, for the applicable period and shall be paid to each 10
1164	1164	hospital retroactively to July 1; (v) Beginning July 1, 2019, the Medicaid managed care outpatient 11
1165	1165	payment rates between each hospital and health plan shall be one hundred seven and two-tenths 12
1166	1166	percent (107.2%) of the payment rates in effect as of January 1, 2019 and shall be paid to each 13
1167	1167	hospital retroactively to July 1; (vi) Increases in outpatient hospital payments for each annual 14
1168	1168	twelve-month (12) period beginning July 1, 2020, shall be based on the payment rates in effect as 15
1169	1169	of January 1 of the preceding fiscal year, and shall be the Centers for Medicare and Medicaid 16
1170	1170	Services national CMS OPPS Hospital Input Price Index, less Productivity Adjustment, for the 17
1171	1171	applicable period and shall be paid to each hospital retroactively to July 1. Beginning July 1, 2023, 18
1172	1172	fee-for-service and managed care outpatient rates shall equal the Medicare equivalent rate. 19
1173	1173	(3) "Hospital," as used in this section, shall mean the actual facilities and buildings in 20
1174	1174	existence in Rhode Island, licensed pursuant to § 23-17-1 et seq. on June 30, 2010, and thereafter 21
1175	1175	any premises included on that license, regardless of changes in licensure status pursuant to chapter 22
1176	1176	17.14 of title 23 (hospital conversions) and § 23-17-6(b) (change in effective control), that provides 23
1177	1177	short-term, acute inpatient and/or outpatient care to persons who require definitive diagnosis and 24
1178	1178	treatment for injury, illness, disabilities, or pregnancy. Notwithstanding the preceding language, 25
1179	1179	the Medicaid managed care payment rates for a court-approved purchaser that acquires a hospital 26
1180	1180	through receivership, special mastership or other similar state insolvency proceedings (which court-27
1181	1181	approved purchaser is issued a hospital license after January 1, 2013), shall be based upon the new 28
1182	1182	rates between the court-approved purchaser and the health plan, and such rates shall be effective as 29
1183	1183	of the date that the court-approved purchaser and the health plan execute the initial agreement 30
1184	1184	containing the new rates. The rate-setting methodology for inpatient-hospital payments and 31
1185	1185	outpatient-hospital payments set forth in subsections (b)(1)(ii)(C) and (b)(2), respectively, shall 32
1186	1186	thereafter apply to increases for each annual twelve-month (12) period as of July 1 following the 33
1187	1187	completion of the first full year of the court-approved purchaser's initial Medicaid managed care 34
1188	1188
1189	1189
1190	1190	LC001777 - Page 33 of 96
1191	1191	contract. 1
1192	1192	(c) It is intended that payment utilizing the phasing out the DRG method shall reward 2
1193	1193	hospitals for providing the most efficient highest quality care, and provide the executive office the 3
1194	1194	opportunity to conduct value-based purchasing of inpatient care. 4
1195	1195	(d) The secretary of the executive office is hereby authorized to promulgate such rules and 5
1196	1196	regulations consistent with this chapter, and to establish fiscal procedures he or she deems 6
1197	1197	necessary, for the proper implementation and administration of this chapter in order to provide 7
1198	1198	payment to hospitals using the DRG-payment methodology. Furthermore, amendment of the Rhode 8
1199	1199	Island state plan for Medicaid, pursuant to Title XIX of the federal Social Security Act, 42 U.S.C. 9
1200	1200	§ 1396 et seq., is hereby authorized to provide for payment to hospitals for services provided to 10
1201	1201	eligible recipients in accordance with this chapter. 11
1202	1202	(e) The executive office shall comply with all public notice requirements necessary to 12
1203	1203	implement these rate changes. 13
1204	1204	(f) As a condition of participation in the DRG methodology for payment of hospital 14
1205	1205	services, every hospital shall submit year-end settlement reports to the executive office within one 15
1206	1206	year from the close of a hospital's fiscal year. Should a participating hospital fail to timely submit 16
1207	1207	a year-end settlement report as required by this section, the executive office shall withhold 17
1208	1208	financial-cycle payments due by any state agency with respect to this hospital by not more than ten 18
1209	1209	percent (10%) until the report is submitted. For hospital fiscal year 2010 and all subsequent fiscal 19
1210	1210	years, hospitals will not be required to submit year-end settlement reports on payments for 20
1211	1211	outpatient services. For hospital fiscal year 2011 and all subsequent fiscal years, hospitals will not 21
1212	1212	be required to submit year-end settlement reports on claims for hospital inpatient services. Further, 22
1213	1213	for hospital fiscal year 2010, hospital inpatient claims subject to settlement shall include only those 23
1214	1214	claims received between October 1, 2009, and June 30, 2010. 24
1215	1215	(g) The provisions of this section shall be effective upon implementation of the new 25
1216	1216	payment methodology set forth in this section and § 40-8-13.3, which shall in any event be no later 26
1217	1217	than March 30, 2010, at which time the provisions of §§ 40-8-13.2, 27-19-14, 27-19-15, and 27-27
1218	1218	19-16 shall be repealed in their entirety. 28
1219	1219	40-8-16. Notification of long-term care alternative. 29
1220	1220	(a) The department of human services, before authorizing care in a nursing home or 30
1221	1221	intermediate-care facility for a person who is eligible to receive benefits pursuant to Title XIX of 31
1222	1222	the federal Social Security Act, 42 U.S.C. § 1396 et seq., and who is being discharged from a 32
1223	1223	hospital to a nursing home, shall notify the person, in writing, of the provisions of the long-term-33
1224	1224	care alternative, a home- and a community-based program. 34
1225	1225
1226	1226
1227	1227	LC001777 - Page 34 of 96
1228	1228	(b) If a person, eligible to receive benefits pursuant to Title XIX of the federal Social 1
1229	1229	Security Act, requires services in a nursing home and desires to remain in his or her own home or 2
1230	1230	the home of a responsible relative or other adult, the person or his or her representative shall so 3
1231	1231	inform the department. 4
1232	1232	(c) The department shall not make payments pursuant to Title XIX of the federal Social 5
1233	1233	Security Act for benefits until written notification documenting the person's choice as to a nursing 6
1234	1234	home or home- and community-based services has been filed with the department. 7
1235	1235	40-8-19. Rates of payment to nursing facilities. 8
1236	1236	(a) Rate reform. 9
1237	1237	(1) The rates to be paid by the state to nursing facilities licensed pursuant to chapter 17 of 10
1238	1238	title 23, and certified to participate in Title XIX of the Social Security Act for services rendered to 11
1239	1239	Medicaid-eligible residents, shall be reasonable and adequate to meet the costs that must be 12
1240	1240	incurred by efficiently and economically operated facilities in accordance with 42 U.S.C. § 13
1241	1241	1396a(a)(13). The executive office of health and human services ("executive office") shall 14
1242	1242	promulgate or modify the principles of reimbursement for nursing facilities in effect as of July 1, 15
1243	1243	2011, to be consistent with the provisions of this section and Title XIX, 42 U.S.C. § 1396 et seq., 16
1244	1244	of the Social Security Act. 17
1245	1245	(2) The executive office shall review the current methodology for providing Medicaid 18
1246	1246	payments to nursing facilities, including other long-term-care services providers, and is authorized 19
1247	1247	to modify the principles of reimbursement to replace the current cost-based methodology rates with 20
1248	1248	rates based on a price-based methodology to be paid to all facilities with recognition of the acuity 21
1249	1249	of patients and the relative Medicaid occupancy, and to include the following elements to be 22
1250	1250	developed by the executive office: 23
1251	1251	(i) A direct-care rate adjusted for resident acuity; 24
1252	1252	(ii) An indirect-care rate comprised of a base per diem for all facilities; 25
1253	1253	(iii) A rearray of costs for all facilities every three (3) years beginning October, 2015, that 26
1254	1254	may or may not result in automatic per diem revisions; 27
1255	1255	(iv) Application of a fair-rental-value system; 28
1256	1256	(v) Application of a pass-through system; and 29
1257	1257	(vi) Adjustment of rates by the change in a recognized national nursing home inflation 30
1258	1258	index to be applied on October 1 of each year, beginning October 1, 2012. This adjustment will not 31
1259	1259	occur on October 1, 2013, October 1, 2014, or October 1, 2015, but will occur on April 1, 2015. 32
1260	1260	The adjustment of rates will also not occur on October 1, 2017, October 1, 2018, and October 1, 33
1261	1261	2019. Effective July 1, 2018, rates paid to nursing facilities from the rates approved by the Centers 34
1262	1262
1263	1263
1264	1264	LC001777 - Page 35 of 96
1265	1265	for Medicare and Medicaid Services and in effect on October 1, 2017, both fee-for-service and 1
1266	1266	managed care, will be increased by one and one-half percent (1.5%) and further increased by one 2
1267	1267	percent (1%) on October 1, 2018, and further increased by one percent (1%) on October 1, 2019. 3
1268	1268	The inflation index shall be applied without regard for the transition factors in subsections (b)(1) 4
1269	1269	and (b)(2). For purposes of October 1, 2016, adjustment only, any rate increase that results from 5
1270	1270	application of the inflation index to subsections (a)(2)(i) and (a)(2)(ii) shall be dedicated to increase 6
1271	1271	compensation for direct-care workers in the following manner: Not less than 85% of this aggregate 7
1272	1272	amount shall be expended to fund an increase in wages, benefits, or related employer costs of direct-8
1273	1273	care staff of nursing homes. For purposes of this section, direct-care staff shall include registered 9
1274	1274	nurses (RNs), licensed practical nurses (LPNs), certified nursing assistants (CNAs), certified 10
1275	1275	medical technicians, housekeeping staff, laundry staff, dietary staff, or other similar employees 11
1276	1276	providing direct-care services; provided, however, that this definition of direct-care staff shall not 12
1277	1277	include: (i) RNs and LPNs who are classified as "exempt employees" under the Federal Fair Labor 13
1278	1278	Standards Act (29 U.S.C. § 201 et seq.); or (ii) CNAs, certified medical technicians, RNs, or LPNs 14
1279	1279	who are contracted, or subcontracted, through a third-party vendor or staffing agency. By July 31, 15
1280	1280	2017, nursing facilities shall submit to the secretary, or designee, a certification that they have 16
1281	1281	complied with the provisions of this subsection (a)(2)(vi) with respect to the inflation index applied 17
1282	1282	on October 1, 2016. Any facility that does not comply with terms of such certification shall be 18
1283	1283	subjected to a clawback, paid by the nursing facility to the state, in the amount of increased 19
1284	1284	reimbursement subject to this provision that was not expended in compliance with that certification. 20
1285	1285	(b) Transition to full implementation of rate reform. For no less than four (4) years after 21
1286	1286	the initial application of the price-based methodology described in subsection (a)(2) to payment 22
1287	1287	rates, the executive office of health and human services shall implement a transition plan to 23
1288	1288	moderate the impact of the rate reform on individual nursing facilities. Said transition shall include 24
1289	1289	the following components: 25
1290	1290	(1) No nursing facility shall receive reimbursement for direct-care costs that is less than 26
1291	1291	the rate of reimbursement for direct-care costs received under the methodology in effect at the time 27
1292	1292	of passage of this act; for the year beginning October 1, 2017, the reimbursement for direct-care 28
1293	1293	costs under this provision will be phased out in twenty-five-percent (25%) increments each year 29
1294	1294	until October 1, 2021, when the reimbursement will no longer be in effect; and 30
1295	1295	(2) No facility shall lose or gain more than five dollars ($5.00) in its total, per diem rate the 31
1296	1296	first year of the transition. An adjustment to the per diem loss or gain may be phased out by twenty-32
1297	1297	five percent (25%) each year; except, however, for the years beginning October 1, 2015, there shall 33
1298	1298	be no adjustment to the per diem gain or loss, but the phase out shall resume thereafter; and 34
1299	1299
1300	1300
1301	1301	LC001777 - Page 36 of 96
1302	1302	(3) The transition plan and/or period may be modified upon full implementation of facility 1
1303	1303	per diem rate increases for quality of care-related measures. Said modifications shall be submitted 2
1304	1304	in a report to the general assembly at least six (6) months prior to implementation. 3
1305	1305	(4) Notwithstanding any law to the contrary, for the twelve-month (12) period beginning 4
1306	1306	July 1, 2015, Medicaid payment rates for nursing facilities established pursuant to this section shall 5
1307	1307	not exceed ninety-eight percent (98%) of the rates in effect on April 1, 2015. Consistent with the 6
1308	1308	other provisions of this chapter, nothing in this provision shall require the executive office to restore 7
1309	1309	the rates to those in effect on April 1, 2015, at the end of this twelve-month (12) period. 8
1310	1310	(c) Effective July 1, 2023, and for each subsequent year, the executive office of health and 9
1311	1311	human services is hereby authorized and directed to amend its regulations for reimbursement to 10
1312	1312	nursing facilities in order that each nursing facility in the State of Rhode Island shall receive a 11
1313	1313	quarterly adjustment payment each state fiscal year of an amount determined as follows: 12
1314	1314	(1) Determine the percent of the state's total Medicaid outpatient and emergency 13
1315	1315	department services (exclusive of physician services) provided by each nursing home during each 14
1316	1316	nursing facility's prior fiscal year; 15
1317	1317	(2) Determine the sum of all Medicaid payments to nursing facilities made for services 16
1318	1318	provided during each nursing facility's prior fiscal year; 17
1319	1319	(3) Multiply the sum of all Medicaid payments as determined in subsection (c)(2) of this 18
1320	1320	section by a percentage defined as the total identified upper payment limit for all nursing facilities 19
1321	1321	divided by the sum of all Medicaid payments as determined in subsection (c)(2) of this section; and 20
1322	1322	then multiply that result by each nursing facility's percentage of the state's total Medicaid services 21
1323	1323	as determined in subsection (c)(1) of this section to obtain the total adjustment for each nursing 22
1324	1324	facility to be paid each year; and 23
1325	1325	(4) Pay each nursing facility on or before July 20, October 20, January 20, and April 20 24
1326	1326	one quarter (1/4) of its total adjustment as determined in subsection (c)(3) of this section. 25
1327	1327	40-8-26. Community health centers. 26
1328	1328	(a) For the purposes of this section, the term community health centers refers to federally 27
1329	1329	qualified health centers and rural health centers. 28
1330	1330	(b) To support the ability of community health centers to provide high-quality medical care 29
1331	1331	to patients, the executive office of health and human services ("executive office") may adopt and 30
1332	1332	implement an alternative payment methodology (APM) for determining a Medicaid per-visit 31
1333	1333	reimbursement for community health centers that is compliant with the prospective payment system 32
1334	1334	(PPS) provided for in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection 33
1335	1335	Act of 2000. The following principles are to ensure that the APM PPS rate determination 34
1336	1336
1337	1337
1338	1338	LC001777 - Page 37 of 96
1339	1339	methodology is part of the executive office overall value purchasing approach. For community 1
1340	1340	health centers that do not agree to the principles of reimbursement that reflect the APM PPS, 2
1341	1341	EOHHS shall reimburse such community health centers at the federal PPS rate, as required per 3
1342	1342	section 1902(bb)(3) of the Social Security Act, 42 U.S.C. § 1396a(bb)(3). For community health 4
1343	1343	centers that are reimbursed at the federal PPS rate, subsections (d) through (f) of this section apply. 5
1344	1344	(c) The APM PPS rate determination methodology will (i) Fairly recognize the reasonable 6
1345	1345	costs of providing services. Recognized reasonable costs will be those appropriate for the 7
1346	1346	organization, management, and direct provision of services and (ii) Provide assurances to the 8
1347	1347	executive office that services are provided in an effective and efficient manner, consistent with 9
1348	1348	industry standards. Except for demonstrated cause and at the discretion of the executive office, the 10
1349	1349	maximum reimbursement rate for a service (e.g., medical, dental) provided by an individual 11
1350	1350	community health center shall not exceed one hundred twenty-five percent (125%) of the median 12
1351	1351	rate for all community health centers within Rhode Island. not only bill the community health center 13
1352	1352	on a fee-for-service basis at ninety percent (90%) of the federal PPS rate but also make a series of 14
1353	1353	quality incentive payments if the community health center meets certain quality incentives. Quality 15
1354	1354	incentive payments shall be set at a percentage of the aggregate monthly billing that would be 16
1355	1355	reached under the traditional federal PPS methodology. The quality incentive payments shall be as 17
1356	1356	follows: 18
1357	1357	(1) Ten percent (10%) for meeting benchmarks set by the Medicaid director for screening 19
1358	1358	patients for Medicaid eligibility or having added one-tenth percent (0.1%) of its monthly patients 20
1359	1359	to the Medicaid rolls. 21
1360	1360	(2) Five percent (5%) for enrolling at least five percent (5%) of patients who identified as 22
1361	1361	tobacco smokers in smoking cessation programs. 23
1362	1362	(3) Ten percent (10%) for meeting benchmarks set by the director of human services for 24
1363	1363	screening patients for supplemental nutrition assistance program eligibility or having added one-25
1364	1364	tenth percent (0.1%) of its monthly patients to the supplemental nutrition assistance program rolls. 26
1365	1365	(4) Ten percent (10%) for ensuring that no more than one percent (1%) of patients are ever 27
1366	1366	not offered an appointment within a month if they request one. 28
1367	1367	(5) Up to fifteen percent (15%) for meeting benchmarks set by the Medicaid director for 29
1368	1368	the improvement of air quality in patients' homes through directly funding interventions such as: 30
1369	1369	air quality inspections, the installation of air filters, the installation of ventilation, and the 31
1370	1370	replacement of gas stoves with electric stoves. 32
1371	1371	(6) Up to fifteen percent (15%) for meeting benchmarks set by the Medicaid director for 33
1372	1372	the removal or mitigation of environmental toxins in patients' homes through the direct funding of 34
1373	1373
1374	1374
1375	1375	LC001777 - Page 38 of 96
1376	1376	removal or mitigation of environmental toxins. These toxins shall include, but shall not be limited 1
1377	1377	to, lead, radon, asbestos, and carbon monoxide. 2
1378	1378	(d) Community health centers will cooperate fully and timely with reporting requirements 3
1379	1379	established by the executive office. 4
1380	1380	(e) Reimbursement rates established through this methodology shall be incorporated into 5
1381	1381	the PPS reconciliation for services provided to Medicaid-eligible persons who are enrolled in a 6
1382	1382	health plan on the date of service. Monthly payments by the executive office related to PPS for 7
1383	1383	persons enrolled in a health plan shall be made directly to the community health centers. 8
1384	1384	(f) Reimbursement rates established through this the APM methodology shall not be 9
1385	1385	incorporated into the actuarially certified capitation rates paid to a health plan. The health plan shall 10
1386	1386	be responsible for paying the full amount of the reimbursement rate to the community health center 11
1387	1387	for each service eligible for reimbursement under the Medicare, Medicaid, and SCHIP Benefits 12
1388	1388	Improvement and Protection Act of 2000. If the health plan has an alternative payment arrangement 13
1389	1389	with the community health center opts to utilize the APM methodology, the health plan shall bear 14
1390	1390	the full upside and downside risk of decreased or increased costs from the APM methodology may 15
1391	1391	establish a PPS reconciliation process for eligible services and make monthly payments related to 16
1392	1392	PPS for persons enrolled in the health plan on the date of service. The executive office will review, 17
1393	1393	at least annually, the Medicaid reimbursement rates and reconciliation methodology used by the 18
1394	1394	health plans for community health centers to ensure payments to each are made in compliance with 19
1395	1395	the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000. 20
1396	1396	40-8-32. Support for certain patients of nursing facilities. 21
1397	1397	(a) Definitions. For purposes of this section: 22
1398	1398	(1) "Applied income" shall mean the amount of income a Medicaid beneficiary is required 23
1399	1399	to contribute to the cost of his or her care. 24
1400	1400	(2) "Authorized individual" shall mean a person who has authority over the income of a 25
1401	1401	patient of a nursing facility, such as a person who has been given or has otherwise obtained 26
1402	1402	authority over a patient's bank account; has been named as or has rights as a joint account holder; 27
1403	1403	or is a fiduciary as defined below. 28
1404	1404	(3) "Costs of care" shall mean the costs of providing care to a patient of a nursing facility, 29
1405	1405	including nursing care, personal care, meals, transportation, and any other costs, charges, and 30
1406	1406	expenses incurred by a nursing facility in providing care to a patient. Costs of care shall not exceed 31
1407	1407	the customary rate the nursing facility charges to a patient who pays for his or her care directly 32
1408	1408	rather than through a governmental or other third-party payor. 33
1409	1409	(4) "Fiduciary" shall mean a person to whom power or property has been formally entrusted 34
1410	1410
1411	1411
1412	1412	LC001777 - Page 39 of 96
1413	1413	for the benefit of another, such as an attorney-in-fact, legal guardian, trustee, or representative 1
1414	1414	payee. 2
1415	1415	(5) "Nursing facility" shall mean a nursing facility licensed under chapter 17 of title 23, 3
1416	1416	that is a participating provider in the Rhode Island Medicaid program. 4
1417	1417	(6) "Penalty period" means the period of Medicaid ineligibility imposed pursuant to 42 5
1418	1418	U.S.C. § 1396p(c), as amended from time to time, on a person whose assets have been transferred 6
1419	1419	for less than fair market value. 7
1420	1420	(7) "Uncompensated care" — Care and services provided by a nursing facility to a 8
1421	1421	Medicaid applicant without receiving compensation therefore from Medicaid, Medicare, the 9
1422	1422	Medicaid applicant, or other source. The acceptance of any payment representing actual or 10
1423	1423	estimated applied income shall not disqualify the care and services provided from qualifying as 11
1424	1424	uncompensated care. 12
1425	1425	(b) Penalty period resulting from transfer. Any transfer or assignment of assets resulting in 13
1426	1426	the establishment or imposition of a penalty period shall create a debt that shall be due and owing 14
1427	1427	to a nursing facility for the unpaid costs of care provided during the penalty period to a patient of 15
1428	1428	that facility who has been subject to the penalty period. The amount of the debt established shall 16
1429	1429	not exceed the fair market value of the transferred assets at the time of transfer that are the subject 17
1430	1430	of the penalty period. A nursing facility may bring an action to collect a debt for the unpaid costs 18
1431	1431	of care given to a patient who has been subject to a penalty period, against either the transferor or 19
1432	1432	the transferee, or both. The provisions of this section shall not affect other rights or remedies of the 20
1433	1433	parties. 21
1434	1434	(c) Applied income. A nursing facility may provide written notice to a patient who is a 22
1435	1435	Medicaid recipient and any authorized individual of that patient: 23
1436	1436	(1) Of the amount of applied income due; 24
1437	1437	(2) Of the recipient's legal obligation to pay the applied income to the nursing facility; and 25
1438	1438	(3) That the recipient's failure to pay applied income due to a nursing facility not later than 26
1439	1439	thirty (30) days after receiving notice from the nursing facility may result in a court action to 27
1440	1440	recover the amount of applied income due. 28
1441	1441	A nursing facility that is owed applied income may, in addition to any other remedies 29
1442	1442	authorized under law, bring a claim to recover the applied income against a patient and any 30
1443	1443	authorized individual. If a court of competent jurisdiction determines, based upon clear and 31
1444	1444	convincing evidence, that a defendant willfully failed to pay or withheld applied income due and 32
1445	1445	owing to a nursing facility for more than thirty (30) days after receiving notice pursuant to 33
1446	1446	subsection (c), the court may award the amount of the debt owed, court costs, and reasonable 34
1447	1447
1448	1448
1449	1449	LC001777 - Page 40 of 96
1450	1450	attorney's fees to the nursing facility. 1
1451	1451	(d) Effects. Nothing contained in this section shall prohibit or otherwise diminish any other 2
1452	1452	causes of action possessed by any such nursing facility. The death of the person receiving nursing 3
1453	1453	facility care shall not nullify or otherwise affect the liability of the person or persons charged with 4
1454	1454	the costs of care rendered or the applied income amount as referenced in this section. 5
1455	1455	SECTION 10. Sections 40-8-3.1, 40-8-9.1, 40-8-13.5, 40-8-15, 40-8-19.2 and 40-8-27 of 6
1456	1456	the General Laws in Chapter 40-8 entitled "Medical Assistance" are hereby repealed. 7
1457	1457	40-8-3.1. Life estate in property -- Retained powers. 8
1458	1458	When an applicant or recipient of Medicaid owns a life estate in property that is his or her 9
1459	1459	principal place of residence with the reserved power and authority, during his or her lifetime, to 10
1460	1460	sell, convey, mortgage, or otherwise dispose of the real property without the consent or joinder by 11
1461	1461	the holder(s) of the remainder interest, the principal place of residence shall not be regarded as an 12
1462	1462	excluded resource for the purpose of Medicaid eligibility, unless the applicant or recipient 13
1463	1463	individually, or through his or her guardian, conservator, or attorney in fact, conveys all outstanding 14
1464	1464	remainder interest to him or herself. 15
1465	1465	An applicant or recipient who, by a deed created, executed and recorded on or before June 16
1466	1466	30, 2014, has reserved a life estate in property that is his or her principal place of residence with 17
1467	1467	the reserved power and authority, during his or her lifetime, to sell, convey, mortgage, or otherwise 18
1468	1468	dispose of the real property without the consent or joinder by the holder(s) of the remainder interest, 19
1469	1469	shall not be ineligible for Medicaid on the basis of the deed, regardless of whether the transferee of 20
1470	1470	the remainder interest is a person or persons, trust, or entity. 21
1471	1471	40-8-9.1. Notice. 22
1472	1472	Whenever an individual who is receiving medical assistance under this chapter transfers 23
1473	1473	an interest in real or personal property, the individual shall notify the executive office of health and 24
1474	1474	human services within ten (10) days of the transfer. The notice shall be sent to the individual's local 25
1475	1475	office and the legal office of the executive office of health and human services and include, at a 26
1476	1476	minimum, the individual's name, social security number or, if different, the executive office of 27
1477	1477	health and human services identification number, the date of transfer, and the dollar value, if any, 28
1478	1478	paid or received by the individual who received benefits under this chapter. In the event an 29
1479	1479	individual fails to provide notice required by this section to the executive office of health and human 30
1480	1480	services and in the event an individual has received medical assistance, any individual and/or entity, 31
1481	1481	who knew or should have known that the individual failed to provide the notice and who receives 32
1482	1482	any distribution of value as a result of the transfer, shall be liable to the executive office of health 33
1483	1483	and human services to the extent of the value of the transfer. Moreover, any such individual shall 34
1484	1484
1485	1485
1486	1486	LC001777 - Page 41 of 96
1487	1487	be subject to the provisions of § 40-6-15 and any remedy provided by applicable state and federal 1
1488	1488	laws and rules and regulations. Failure to comply with the notice requirements set forth in the 2
1489	1489	section shall not affect the marketability of title to real estate transferred while the transferor is 3
1490	1490	receiving medical assistance. 4
1491	1491	40-8-13.5. Hospital Incentive Program (HIP). 5
1492	1492	The secretary of the executive office of health and human services is authorized to seek the 6
1493	1493	federal authorities required to implement a hospital incentive program (HIP). The HIP shall provide 7
1494	1494	the participating licensed hospitals the ability to obtain certain payments for achieving performance 8
1495	1495	goals established by the secretary. HIP payments shall commence no earlier than July 1, 2016. 9
1496	1496	40-8-15. Lien on deceased recipient's estate for assistance. 10
1497	1497	(a)(1) Upon the death of a recipient of Medicaid under Title XIX of the federal Social 11
1498	1498	Security Act (42 U.S.C. § 1396 et seq. and referred to hereinafter as the "Act"), the total sum for 12
1499	1499	Medicaid benefits so paid on behalf of a beneficiary who was fifty-five (55) years of age or older 13
1500	1500	at the time of receipt shall be and constitute a lien upon the estate, as defined in subsection (a)(2), 14
1501	1501	of the beneficiary in favor of the executive office of health and human services ("executive office"). 15
1502	1502	The lien shall not be effective and shall not attach as against the estate of a beneficiary who is 16
1503	1503	survived by a spouse, or a child who is under the age of twenty-one (21), or a child who is blind or 17
1504	1504	permanently and totally disabled as defined in Title XVI of the federal Social Security Act, 42 18
1505	1505	U.S.C. § 1381 et seq. The lien shall attach against property of a beneficiary, which is included or 19
1506	1506	includable in the decedent's probate estate, regardless of whether or not a probate proceeding has 20
1507	1507	been commenced in the probate court by the executive office or by any other party. Provided, 21
1508	1508	however, that such lien shall only attach and shall only be effective against the beneficiary's real 22
1509	1509	property included or includable in the beneficiary's probate estate if such lien is recorded in the 23
1510	1510	land evidence records and is in accordance with subsection (e). Decedents who have received 24
1511	1511	Medicaid benefits are subject to the assignment and subrogation provisions of §§ 40-6-9 and 40-6-25
1512	1512	10. 26
1513	1513	(2) For purposes of this section, the term "estate" with respect to a deceased individual 27
1514	1514	shall include all real and personal property and other assets included or includable within the 28
1515	1515	individual's probate estate. 29
1516	1516	(b) The executive office is authorized to promulgate regulations to implement the terms, 30
1517	1517	intent, and purpose of this section and to require the legal representative(s) and/or the heirs-at-law 31
1518	1518	of the decedent to provide reasonable written notice to the executive office of the death of a 32
1519	1519	beneficiary of Medicaid benefits who was fifty-five (55) years of age or older at the date of death, 33
1520	1520	and to provide a statement identifying the decedent's property and the names and addresses of all 34
1521	1521
1522	1522
1523	1523	LC001777 - Page 42 of 96
1524	1524	persons entitled to take any share or interest of the estate as legatees or distributees thereof. 1
1525	1525	(c) The amount of reimbursement for Medicaid benefits imposed under this section shall 2
1526	1526	also become a debt to the state from the person or entity liable for the payment thereof. 3
1527	1527	(d) Upon payment of the amount of reimbursement for Medicaid benefits imposed by this 4
1528	1528	section, the secretary of the executive office, or his or her designee, shall issue a written discharge 5
1529	1529	of lien. 6
1530	1530	(e) Provided, however, that no lien created under this section shall attach nor become 7
1531	1531	effective upon any real property unless and until a statement of claim is recorded naming the 8
1532	1532	debtor/owner of record of the property as of the date and time of recording of the statement of 9
1533	1533	claim, and describing the real property by a description containing all of the following: (1) Tax 10
1534	1534	assessor's plat and lot; and (2) Street address. The statement of claim shall be recorded in the records 11
1535	1535	of land evidence in the town or city where the real property is situated. Notice of the lien shall be 12
1536	1536	sent to the duly appointed executor or administrator, the decedent's legal representative, if known, 13
1537	1537	or to the decedent's next of kin or heirs at law as stated in the decedent's last application for 14
1538	1538	Medicaid benefits. 15
1539	1539	(f) The executive office shall establish procedures, in accordance with the standards 16
1540	1540	specified by the Secretary, United States Department of Health and Human Services, under which 17
1541	1541	the executive office shall waive, in whole or in part, the lien and reimbursement established by this 18
1542	1542	section if the lien and reimbursement would cause an undue hardship, as determined by the 19
1543	1543	executive office, on the basis of the criteria established by the secretary in accordance with 42 20
1544	1544	U.S.C. § 1396p(b)(3). 21
1545	1545	(g) Upon the filing of a petition for admission to probate of a decedent's will or for 22
1546	1546	administration of a decedent's estate, when the decedent was fifty-five (55) years or older at the 23
1547	1547	time of death, a copy of the petition and a copy of the death certificate shall be sent to the executive 24
1548	1548	office. Within thirty (30) days of a request by the executive office, an executor or administrator 25
1549	1549	shall complete and send to the executive office a form prescribed by that office and shall provide 26
1550	1550	such additional information as the office may require. In the event a petitioner fails to send a copy 27
1551	1551	of the petition and a copy of the death certificate to the executive office and a decedent has received 28
1552	1552	Medicaid benefits for which the executive office is authorized to recover, no distribution and/or 29
1553	1553	payments, including administration fees, shall be disbursed. Any person and/or entity that receives 30
1554	1554	a distribution of assets from the decedent's estate shall be liable to the executive office to the extent 31
1555	1555	of such distribution. 32
1556	1556	(h) Compliance with the provisions of this section shall be consistent with the requirements 33
1557	1557	set forth in § 33-11-5 and the requirements of the affidavit of notice set forth in § 33-11-5.2. Nothing 34
1558	1558
1559	1559
1560	1560	LC001777 - Page 43 of 96
1561	1561	in these sections shall limit the executive office from recovery, to the extent of the distribution, in 1
1562	1562	accordance with all state and federal laws. 2
1563	1563	(i) To ensure the financial integrity of the Medicaid eligibility determination, benefit 3
1564	1564	renewal, and estate recovery processes in this and related sections, the secretary of health and 4
1565	1565	human services is authorized and directed to, by no later than August 1, 2018: (1) Implement an 5
1566	1566	automated asset verification system, as mandated by § 1940 of the Act, that uses electronic data 6
1567	1567	sources to verify the ownership and value of countable resources held in financial institutions and 7
1568	1568	any real property for applicants and beneficiaries subject to resource and asset tests pursuant to the 8
1569	1569	Act in § 1902(e)(14)(D); (2) Apply the provisions required under §§ 1902(a)(18) and 1917(c) of 9
1570	1570	the Act pertaining to the disposition of assets for less than fair market value by applicants and 10
1571	1571	beneficiaries for Medicaid long-term services and supports and their spouses, without regard to 11
1572	1572	whether they are subject to or exempted from resources and asset tests as mandated by federal 12
1573	1573	guidance; and (3) Pursue any state plan or waiver amendments from the United States Centers for 13
1574	1574	Medicare and Medicaid Services and promulgate such rules, regulations, and procedures he or she 14
1575	1575	deems necessary to carry out the requirements set forth herein and ensure the state plan and 15
1576	1576	Medicaid policy conform and comply with applicable provisions of Title XIX. 16
1577	1577	40-8-19.2. Nursing Facility Incentive Program (HIP). 17
1578	1578	The secretary of the executive office of health and human services is authorized to seek the 18
1579	1579	federal authority required to implement a nursing facility incentive program (NFIP). The NFIP 19
1580	1580	shall provide the participating licensed nursing facilities the ability to obtain certain payments for 20
1581	1581	achieving performance goals established by the secretary. NFIP payments shall commence no 21
1582	1582	earlier than July 1, 2016. 22
1583	1583	40-8-27. Cooperation by providers. 23
1584	1584	Medicaid providers who employ individuals applying for benefits under any chapter of this 24
1585	1585	title shall comply in a timely manner with requests made by the department for any documents 25
1586	1586	describing employer-sponsored health insurance coverage or benefits the provider offers that are 26
1587	1587	necessary to determine eligibility for the state's premium assistance program pursuant to § 40-8.4-27
1588	1588	12. Documents requested by the department may include, but are not limited to, certificates of 28
1589	1589	coverage or a summary of benefits and employee obligations. Upon receiving notification that the 29
1590	1590	department has determined that the employee is eligible for premium assistance under § 40-8.4-12, 30
1591	1591	the provider shall accept the enrollment of the employee and his or her family in the employer-31
1592	1592	based health insurance plan without regard to any seasonal enrollment restrictions, including open-32
1593	1593	enrollment restrictions, and/or the impact on the employee's wages. Additionally, the Medicaid 33
1594	1594	provider employing such persons shall not offer "pay in lieu of benefits." Providers who do not 34
1595	1595
1596	1596
1597	1597	LC001777 - Page 44 of 96
1598	1598	comply with the provisions set forth in this section shall be subject to suspension as a participating 1
1599	1599	Medicaid provider. 2
1600	1600	SECTION 11. Sections 40-8.4-4, 40-8.4-5, 40-8.4-10, 40-8.4-12, 40-8.4-15 and 40-8.4-19 3
1601	1601	of the General Laws in Chapter 40-8.4 entitled "Health Care for Families" are hereby amended to 4
1602	1602	read as follows: 5
1603	1603	40-8.4-4. Eligibility. 6
1604	1604	(a) Medical assistance for families. There is hereby established a category of medical 7
1605	1605	assistance eligibility pursuant to § 1931 of Title XIX of the Social Security Act, 42 U.S.C. § 1396u-8
1606	1606	1, for families whose income and resources are no greater than the standards in effect in the aid to 9
1607	1607	families with dependent children program on July 16, 1996, or such increased standards as the 10
1608	1608	department may determine. The executive office of health and human services is directed to amend 11
1609	1609	the medical assistance Title XIX state plan and to submit to the United States Department of Health 12
1610	1610	and Human Services an amendment to the RIte Care waiver project to provide for medical 13
1611	1611	assistance coverage to families under this chapter in the same amount, scope, and duration as 14
1612	1612	coverage provided to comparable groups under the waiver. The department is further authorized 15
1613	1613	and directed to submit amendments and/or requests for waivers to the Title XXI state plan as may 16
1614	1614	be necessary to maximize federal contribution for provision of medical assistance coverage 17
1615	1615	provided pursuant to this chapter, including providing medical coverage as a "qualified state" in 18
1616	1616	accordance with Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. Implementation 19
1617	1617	of expanded coverage under this chapter shall not be delayed pending federal review of any Title 20
1618	1618	XXI amendment or waiver. 21
1619	1619	(b) Income. The secretary of the executive office of health and human services is 22
1620	1620	authorized and directed to amend the medical assistance Title XIX state plan or RIte Care waiver 23
1621	1621	to provide medical assistance coverage through expanded income disregards or other methodology 24
1622	1622	for parents or relative caretakers whose income levels are below one hundred thirty-three percent 25
1623	1623	(133%) of the federal poverty level. 26
1624	1624	(c) Health care coverage provided under this section shall also be provided without regard 27
1625	1625	to availability of federal financial participation to a noncitizen family member who is a resident of 28
1626	1626	Rhode Island, and who is otherwise eligible for such assistance. The department is further 29
1627	1627	authorized to promulgate any regulations necessary, and in accord with title XIX [42 U.S.C. § 1396 30
1628	1628	et seq.] and title XXI [42 U.S.C. § 1397 et seq.] of the Social Security Act as necessary in order to 31
1629	1629	implement the state plan amendment. The executive office of health and human services is directed 32
1630	1630	to ensure that federal financial participation is assessed to the maximum extent allowable to provide 33
1631	1631	coverage pursuant to this section, at least every two (2) years, and that state-only funds will be used 34
1632	1632
1633	1633
1634	1634	LC001777 - Page 45 of 96
1635	1635	only if federal financial participation is not available. 1
1636	1636	40-8.4-5. Managed care. 2
1637	1637	The delivery and financing of the healthcare services provided under this chapter shall may 3
1638	1638	be provided through a system of managed care. A managed care system integrates an efficient 4
1639	1639	financing mechanism with quality service delivery; provides a "medical home" to ensure 5
1640	1640	appropriate care and deter unnecessary and inappropriate care; and places emphasis on preventive 6
1641	1641	and primary health care. Beginning July 1, 2027, all payments shall be provided directly by the 7
1642	1642	state without an intermediate payment to a managed care entity or other form of health insurance 8
1643	1643	company. Beginning July 1, 2023, no new contracts may be entered into between the Medicaid 9
1644	1644	office and an intermediate payor such as a managed care entity or other form of health insurance 10
1645	1645	company for the payment of health care services pursuant to this chapter. 11
1646	1646	40-8.4-10. Regulations. 12
1647	1647	(a) The department of human services Medicaid director is authorized to promulgate any 13
1648	1648	regulations necessary to implement this chapter. 14
1649	1649	(b) When promulgating any rule or regulation necessary to implement this chapter, or any 15
1650	1650	rule or regulation related to RIte Care, the department Medicaid director shall send the notice 16
1651	1651	referred to in § 42-35-3 and a true copy of the rule referred to in § 42-35-4 of the Rhode Island 17
1652	1652	administrative procedures act to each of the co-chairpersons of the permanent joint committee on 18
1653	1653	health care oversight established by § 40-8.4-14. 19
1654	1654	40-8.4-12. RIte Share health insurance premium assistance program. 20
1655	1655	(a) Basic RIte Share health insurance premium assistance program. Under the terms of 21
1656	1656	Section 1906 of Title XIX of the U.S. Social Security Act, 42 U.S.C. § 1396e, states are permitted 22
1657	1657	to pay a Medicaid-eligible person's share of the costs for enrolling in employer-sponsored health 23
1658	1658	insurance (ESI) coverage if it is cost-effective to do so. Pursuant to the general assembly's direction 24
1659	1659	in the Rhode Island health reform act of 2000, the Medicaid agency requested and obtained federal 25
1660	1660	approval under § 1916, 42 U.S.C. § 1396o, to establish the RIte Share premium assistance program 26
1661	1661	to subsidize the costs of enrolling Medicaid-eligible persons and families in employer-sponsored 27
1662	1662	health insurance plans that have been approved as meeting certain cost and coverage requirements. 28
1663	1663	The Medicaid agency also obtained, at the general assembly's direction, federal authority to require 29
1664	1664	any such persons with access to ESI coverage to enroll as a condition of retaining eligibility 30
1665	1665	providing that doing so meets the criteria established in Title XIX for obtaining federal matching 31
1666	1666	funds. 32
1667	1667	(b) Definitions. For the purposes of this section, the following definitions apply: 33
1668	1668	(1) "Cost-effective" means that the portion of the ESI that the state would subsidize, as 34
1669	1669
1670	1670
1671	1671	LC001777 - Page 46 of 96
1672	1672	well as wrap-around costs, would on average cost less to the state than enrolling that same 1
1673	1673	person/family in a managed-care delivery system. 2
1674	1674	(2) "Cost sharing" means any co-payments, deductibles, or co-insurance associated with 3
1675	1675	ESI. 4
1676	1676	(3) "Employee premium" means the monthly premium share a person or family is required 5
1677	1677	to pay to the employer to obtain and maintain ESI coverage. 6
1678	1678	(4) "Employer-sponsored insurance" or "ESI" means health insurance or a group health 7
1679	1679	plan offered to employees by an employer. This includes plans purchased by small employers 8
1680	1680	through the state health insurance marketplace, healthsource, RI (HSRI). 9
1681	1681	(5) "Policy holder" means the person in the household with access to ESI, typically the 10
1682	1682	employee. 11
1683	1683	(6) "RIte Share-approved employer-sponsored insurance (ESI)" means an employer-12
1684	1684	sponsored health insurance plan that meets the coverage and cost-effectiveness criteria for RIte 13
1685	1685	Share. 14
1686	1686	(7) "RIte Share buy-in" means the monthly amount an Medicaid-ineligible policy holder 15
1687	1687	must pay toward RIte Share-approved ESI that covers the Medicaid-eligible children, young adults, 16
1688	1688	or spouses with access to the ESI. The buy-in only applies in instances when household income is 17
1689	1689	above one hundred fifty percent (150%) of the FPL. 18
1690	1690	(8) "RIte Share premium assistance program" means the Rhode Island Medicaid premium 19
1691	1691	assistance program in which the State pays the eligible Medicaid member's share of the cost of 20
1692	1692	enrolling in a RIte Share-approved ESI plan. This allows the state to share the cost of the health 21
1693	1693	insurance coverage with the employer. 22
1694	1694	(9) "RIte Share unit" means the entity within the executive office of health and human 23
1695	1695	services (EOHHS) responsible for assessing the cost-effectiveness of ESI, contacting employers 24
1696	1696	about ESI as appropriate, initiating the RIte Share enrollment and disenrollment process, handling 25
1697	1697	member communications, and managing the overall operations of the RIte Share program. 26
1698	1698	(10) "Third-party liability (TPL)" means other health insurance coverage. This insurance 27
1699	1699	is in addition to Medicaid and is usually provided through an employer. Since Medicaid is always 28
1700	1700	the payer of last resort, the TPL is always the primary coverage. 29
1701	1701	(11) "Wrap-around services or coverage" means any healthcare services not included in 30
1702	1702	the ESI plan that would have been covered had the Medicaid member been enrolled in a RIte Care 31
1703	1703	or Rhody Health Partners plan. Coverage of deductibles and co-insurance is included in the wrap. 32
1704	1704	Co-payments to providers are not covered as part of the wrap-around coverage. 33
1705	1705	(c) RIte Share populations. Medicaid beneficiaries subject to eligible for RIte Share 34
1706	1706
1707	1707
1708	1708	LC001777 - Page 47 of 96
1709	1709	include: children, families, parent and caretakers eligible for Medicaid or the children's health 1
1710	1710	insurance program (CHIP) under this chapter or chapter 12.3 of title 42; and adults between the 2
1711	1711	ages of nineteen (19) and sixty-four (64) who are eligible under chapter 8.12 of this title, not 3
1712	1712	receiving or eligible to receive Medicare, and are enrolled in managed care delivery systems. The 4
1713	1713	following conditions apply: 5
1714	1714	(1) The income of Medicaid beneficiaries shall affect whether and in what manner they 6
1715	1715	must may participate in RIte Share as follows: 7
1716	1716	(i) Income at or below one hundred fifty percent (150%) of FPL — Persons and families 8
1717	1717	determined to have household income at or below one hundred fifty percent (150%) of the federal 9
1718	1718	poverty level (FPL) guidelines based on the modified adjusted gross income (MAGI) standard or 10
1719	1719	other standard approved by the secretary are required to participate in RIte Share if a Medicaid-11
1720	1720	eligible adult or parent/caretaker has access to cost-effective ESI. Enrolling in ESI through RIte 12
1721	1721	Share shall be a condition of maintaining Medicaid health coverage for any eligible adult with 13
1722	1722	access to such coverage. 14
1723	1723	(ii) Income above one hundred fifty percent (150%) of FPL and policy holder is not 15
1724	1724	Medicaid-eligible — Premium assistance is available when the household includes Medicaid-16
1725	1725	eligible members, but the ESI policy holder (typically a parent/caretaker, or spouse) is not eligible 17
1726	1726	for Medicaid. Premium assistance for parents/caretakers and other household members who are not 18
1727	1727	Medicaid-eligible may be provided in circumstances when enrollment of the Medicaid-eligible 19
1728	1728	family members in the approved ESI plan is contingent upon enrollment of the ineligible policy 20
1729	1729	holder and the executive office of health and human services (executive office) determines, based 21
1730	1730	on a methodology adopted for such purposes, that it is cost-effective to provide premium assistance 22
1731	1731	for family or spousal coverage. 23
1732	1732	(d) RIte Share enrollment not condition of eligibility. RIte Share enrollment shall be 24
1733	1733	purely voluntary and shall never be a condition of eligibility for Medicaid. For Medicaid 25
1734	1734	beneficiaries over the age of nineteen (19), enrollment in RIte Share shall be a condition of 26
1735	1735	eligibility except as exempted below and by regulations promulgated by the executive office. 27
1736	1736	(1) Medicaid-eligible children and young adults up to age nineteen (19) shall not be 28
1737	1737	required to enroll in a parent/caretaker relative's ESI as a condition of maintaining Medicaid 29
1738	1738	eligibility if the person with access to RIte Share-approved ESI does not enroll as required. These 30
1739	1739	Medicaid-eligible children and young adults shall remain eligible for Medicaid and shall be 31
1740	1740	enrolled in a RIte Care plan. 32
1741	1741	(2) There shall be a limited six-month (6) exemption from the mandatory enrollment 33
1742	1742	requirement for persons participating in the RI works program pursuant to chapter 5.2 of this title. 34
1743	1743
1744	1744
1745	1745	LC001777 - Page 48 of 96
1746	1746	(e) Approval of health insurance plans for premium assistance. The executive office of 1
1747	1747	health and human services shall adopt regulations providing for the approval of employer-based 2
1748	1748	health insurance plans for premium assistance and shall approve employer-based health insurance 3
1749	1749	plans based on these regulations. In order for an employer-based health insurance plan to gain 4
1750	1750	approval, the executive office must determine that the benefits offered by the employer-based 5
1751	1751	health insurance plan are substantially similar in amount, scope, and duration to the benefits 6
1752	1752	provided to Medicaid-eligible persons enrolled in a Medicaid managed care plan, when the plan is 7
1753	1753	evaluated in conjunction with available supplemental benefits provided by the office. The office 8
1754	1754	shall obtain and make available to persons otherwise eligible for Medicaid identified in this section 9
1755	1755	as supplemental benefits those benefits not reasonably available under employer-based health 10
1756	1756	insurance plans that are required for Medicaid beneficiaries by state law or federal law or 11
1757	1757	regulation. Once it has been determined by the Medicaid agency that the ESI offered by a particular 12
1758	1758	employer is RIte Share-approved, all Medicaid members with access to that employer's plan are 13
1759	1759	required to participate in RIte Share. Failure to meet the mandatory enrollment requirement shall 14
1760	1760	result in the termination of the Medicaid eligibility of the policy holder and other Medicaid 15
1761	1761	members nineteen (19) or older in the household who could be covered under the ESI until the 16
1762	1762	policy holder complies with the RIte Share enrollment procedures established by the executive 17
1763	1763	office. 18
1764	1764	(f) Premium assistance. The executive office shall provide premium assistance by paying 19
1765	1765	all or a portion of the employee's cost for covering the eligible person and/or his or her family under 20
1766	1766	such a RIte Share-approved ESI plan subject to the buy-in provisions in this section. 21
1767	1767	(g) Buy-in. Persons who can afford it shall share in the cost. — The executive office is 22
1768	1768	authorized and directed to apply for and obtain any necessary state plan and/or waiver amendments 23
1769	1769	from the Secretary of the United States Department of Health and Human Services (DHHS) to 24
1770	1770	require that persons enrolled in a RIte Share-approved employer-based health plan who have 25
1771	1771	income equal to or greater than one hundred fifty percent (150%) of the FPL to buy-in to pay a 26
1772	1772	share of the costs based on the ability to pay, provided that the buy-in cost shall not exceed five 27
1773	1773	percent (5%) of the person's annual income. The executive office shall implement the buy-in by 28
1774	1774	regulation, and shall consider co-payments, premium shares, or other reasonable means to do so. 29
1775	1775	(h) Maximization of federal contribution. The executive office of health and human 30
1776	1776	services is authorized and directed to apply for and obtain federal approvals and waivers necessary 31
1777	1777	to maximize the federal contribution for provision of medical assistance coverage under this 32
1778	1778	section, including the authorization to amend the Title XXI state plan and to obtain any waivers 33
1779	1779	necessary to reduce barriers to provide premium assistance to recipients as provided for in Title 34
1780	1780
1781	1781
1782	1782	LC001777 - Page 49 of 96
1783	1783	XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. 1
1784	1784	(i) Implementation by regulation. The executive office of health and human services is 2
1785	1785	authorized and directed to adopt regulations to ensure the establishment and implementation of the 3
1786	1786	premium assistance program in accordance with the intent and purpose of this section, the 4
1787	1787	requirements of Title XIX, Title XXI, and any approved federal waivers. 5
1788	1788	(j) Outreach and reporting. The executive office of health and human services shall develop 6
1789	1789	a plan to identify Medicaid-eligible individuals who have access to employer-sponsored insurance 7
1790	1790	and increase the use of RIte Share benefits. Beginning October 1, 2019, the executive office shall 8
1791	1791	submit the plan to be included as part of the reporting requirements under § 35-17-1. Starting 9
1792	1792	January 1, 2020, the executive office of health and human services shall include the number of 10
1793	1793	Medicaid recipients with access to employer-sponsored insurance, the number of plans that did not 11
1794	1794	meet the cost-effectiveness criteria for RIte Share, and enrollment in the premium assistance 12
1795	1795	program as part of the reporting requirements under § 35-17-1. 13
1796	1796	(k) Employer-sponsored insurance. The executive office of health and human services shall 14
1797	1797	dedicate staff and resources to reporting monthly as part of the requirements under § 35-17-1 which 15
1798	1798	employer-sponsored insurance plans meet the cost-effectiveness criteria for RIte Share. 16
1799	1799	Information in the report shall be used for screening for Medicaid enrollment to encourage Rite 17
1800	1800	Share participation. By October 1, 2021, the report shall include any employers with 300 or more 18
1801	1801	employees. By January 1, 2022, the report shall include employers with 100 or more employees. 19
1802	1802	The January report shall also be provided to the chairperson of the house finance committee; the 20
1803	1803	chairperson of the senate finance committee; the house fiscal advisor; the senate fiscal advisor; and 21
1804	1804	the state budget officer. 22
1805	1805	40-8.4-15. Advisory commission on health care. 23
1806	1806	(a) There is hereby established an advisory commission to be known as the "advisory 24
1807	1807	commission on health care" to advise the director of the department of human services on all 25
1808	1808	matters relating to the RIte Care and RIte Share programs, and other matters concerning access for 26
1809	1809	all Rhode Islanders to quality health care in the most affordable, economical manner. The director 27
1810	1810	of the department of human services shall serve ex officio as chairperson. The director shall appoint 28
1811	1811	the eighteen (18) members: 29
1812	1812	(1) Three (3) of whom shall represent the healthcare providers; 30
1813	1813	(2) Three (3) of whom shall represent the members of the public with significant health 31
1814	1814	care conditions healthcare insurers; 32
1815	1815	(3) Three (3) of whom shall represent healthcare consumers or consumer organizations; 33
1816	1816	(4) Two (2) of whom shall represent organized labor; 34
1817	1817
1818	1818
1819	1819	LC001777 - Page 50 of 96
1820	1820	(5) One of whom shall be the health care advocate in the office of the attorney general; 1
1821	1821	(6) Three (3) of whom shall represent employers; and 2
1822	1822	(7) Three (3) of whom shall be other members of the public. 3
1823	1823	(b) The commission may study all aspects of the provisions of the RIte Care and RIte Share 4
1824	1824	programs involving purchasers of health care, including employers, consumers, and the state, health 5
1825	1825	insurers, providers of health care, and healthcare facilities, and all matters related to the interaction 6
1826	1826	among these groups, including methods to achieve more effective and timely resolution of disputes, 7
1827	1827	better communication, speedier, more reliable and less-costly administrative processes, claims, 8
1828	1828	payments, and other reimbursement matters, and the application of new processes or technologies 9
1829	1829	to such issues. 10
1830	1830	(c) Members of the commission shall be appointed in the month of July, each to hold office 11
1831	1831	until the last day of June in the second year of his or her appointment or until his or her successor 12
1832	1832	is appointed by the director. 13
1833	1833	(d) The commission shall meet at least quarterly, and the initial meeting of the commission 14
1834	1834	shall take place on or before September 15, 2000. The commission may meet more frequently than 15
1835	1835	quarterly at the call of the chair or at the call of any three (3) members of the commission. 16
1836	1836	(e) Members of the permanent joint committee on health care oversight established 17
1837	1837	pursuant to § 40-8.4-14 shall be notified of each meeting of the commission and shall be invited to 18
1838	1838	participate. 19
1839	1839	40-8.4-19. Managed healthcare delivery systems for families.Cost sharing. 20
1840	1840	(a) Notwithstanding any other provision of state law, the delivery and financing of the 21
1841	1841	healthcare services provided under this chapter shall be provided through a system of managed 22
1842	1842	care. "Managed care" is defined as systems that: integrate an efficient financing mechanism with 23
1843	1843	quality service delivery; provide a "medical home" to ensure appropriate care and deter unnecessary 24
1844	1844	services; and place emphasis on preventive and primary care. 25
1845	1845	(b) Enrollment in managed care health delivery systems is mandatory for individua ls 26
1846	1846	eligible for medical assistance under this chapter. This includes children in substitute care, children 27
1847	1847	receiving medical assistance through an adoption subsidy, and children eligible for medical 28
1848	1848	assistance based on their disability. Beneficiaries with third-party medical coverage or insurance 29
1849	1849	may be exempt from mandatory managed care in accordance with rules and regulations 30
1850	1850	promulgated by the department of human services for such purposes. 31
1851	1851	(c) Individuals who can afford to contribute shall share in the cost. The department of 32
1852	1852	human services is authorized and directed to apply for and obtain any necessary waivers and/or 33
1853	1853	state plan amendments from the Secretary of the United States Department of Health and Human 34
1854	1854
1855	1855
1856	1856	LC001777 - Page 51 of 96
1857	1857	Services, including, but not limited to, a waiver of the appropriate sections of Title XIX, 42 U.S.C. 1
1858	1858	§ 1396 et seq., to require that beneficiaries eligible under this chapter or chapter 12.3 of title 42, 2
1859	1859	with incomes equal to or greater than one hundred fifty percent (150%) of the federal poverty level, 3
1860	1860	pay a share of the costs of health coverage based on the ability to pay. The department of human 4
1861	1861	services shall implement this cost-sharing obligation by regulation, and shall consider co-payments, 5
1862	1862	premium shares, or other reasonable means to do so in accordance with approved provisions of 6
1863	1863	appropriate waivers and/or state plan amendments approved by the Secretary of the United States 7
1864	1864	Department of Health and Human Services. 8
1865	1865	SECTION 12. Section 40-8.4-13 of the General Laws in Chapter 40-8.4 entitled "Health 9
1866	1866	Care for Families" is hereby repealed in its entirety. 10
1867	1867	40-8.4-13. Utilization of available employer-based health insurance. 11
1868	1868	To the extent permitted under Titles XIX and XXI of the Social Security Act, 42 U.S.C. § 12
1869	1869	1396 et seq. and 42 U.S.C. § 1397aa et seq., or by waiver from the Secretary of the United States 13
1870	1870	Department of Health and Human Services, the department of human services shall adopt 14
1871	1871	regulations to restrict eligibility for RIte Care under this chapter and/or chapter 12.3 of title 42, or 15
1872	1872	the RIte Share program under § 40-8.4-12, for certain periods of time for certain individuals or 16
1873	1873	families who have access to, or have refused or terminated employer-based health insurance and 17
1874	1874	for certain periods of time for certain individuals but not including children whose employer has 18
1875	1875	terminated their employer-based health insurance. The department is authorized and directed to 19
1876	1876	amend the medical assistance Title XIX and XXI state plans, and/or to seek and obtain appropriate 20
1877	1877	federal approvals or waivers to implement this section. 21
1878	1878	SECTION 13. Sections 40-8.5-1 and 40-8.5-1.1 of the General Laws in Chapter 40-8.5 22
1879	1879	entitled "Health Care for Elderly and Disabled Residents Act" are hereby amended to read as 23
1880	1880	follows: 24
1881	1881	40-8.5-1. Categorically needy medical assistance coverage. 25
1882	1882	The department of human services is hereby authorized and directed to amend its Title XIX 26
1883	1883	state plan to provide for categorically needy medical assistance coverage as permitted pursuant to 27
1884	1884	Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., as amended, to individuals who are 28
1885	1885	sixty-five (65) years or older or are disabled, as determined under § 1614(a)(3) of the Social 29
1886	1886	Security Act, 42 U.S.C. § 1382c(a)(3), as amended, whose income does not exceed one hundred 30
1887	1887	percent (100%) one hundred thirty-three percent (133%) of the federal poverty level (as revised 31
1888	1888	annually) applicable to the individual's family size, and whose resources do not exceed four 32
1889	1889	thousand dollars ($4,000) per individual, or six thousand dollars ($6,000) per couple. The 33
1890	1890	department shall provide medical assistance coverage to such elderly or disabled persons in the 34
1891	1891
1892	1892
1893	1893	LC001777 - Page 52 of 96
1894	1894	same amount, duration, and scope as provided to other categorically needy persons under the state's 1
1895	1895	Title XIX state plan. 2
1896	1896	40-8.5-1.1. Managed health care delivery systems. 3
1897	1897	(a) The delivery and financing of the health care services provided under this chapter may 4
1898	1898	be provided through a system of managed care. Beginning July 1, 2027, all payments shall be 5
1899	1899	provided directly by the state without an intermediate payment to a managed care entity or other 6
1900	1900	form of health insurance company. Beginning July 1, 2023, no new contracts may be entered into 7
1901	1901	between the Medicaid office and an intermediate payor such as a managed care entity or other form 8
1902	1902	of health insurance company for the payment of health care services pursuant to this chapter. To 9
1903	1903	ensure that all medical assistance beneficiaries, including the elderly and all individuals with 10
1904	1904	disabilities, have access to quality and affordable health care, the executive office of health and 11
1905	1905	human services ("executive office") is authorized to implement mandatory managed-care health 12
1906	1906	systems. 13
1907	1907	(b) "Managed care" is defined as systems that: integrate an efficient financing mechanism 14
1908	1908	with quality service delivery; provide a "medical home" to ensure appropriate care and deter 15
1909	1909	unnecessary services; and place emphasis on preventive and primary care. For purposes of this 16
1910	1910	section, managed care systems may also be defined to include a primary care case-management 17
1911	1911	model, community health teams, and/or other such arrangements that meet standards established 18
1912	1912	by the executive office and serve the purposes of this section. Managed care systems may also 19
1913	1913	include services and supports that optimize the health and independence of beneficiaries who are 20
1914	1914	determined to need Medicaid-funded long-term care under chapter 8.10 of this title or to be at risk 21
1915	1915	for the care under applicable federal state plan or waiver authorities and the rules and regulations 22
1916	1916	promulgated by the executive office. Any Medicaid beneficiaries who have third-party medical 23
1917	1917	coverage or insurance may be provided such services through an entity certified by, or in a 24
1918	1918	contractual arrangement with, the executive office or, as deemed appropriate, exempt from 25
1919	1919	mandatory managed care in accordance with rules and regulations promulgated by the executive 26
1920	1920	office. 27
1921	1921	(c) In accordance with § 42-12.4-7, the executive office is authorized to obtain any approval 28
1922	1922	through waiver(s), category II or III changes, and/or state-plan amendments, from the Secretary of 29
1923	1923	the United States Department of Health and Human Services, that are necessary to implement 30
1924	1924	mandatory, managed healthcare delivery systems for all Medicaid beneficiaries. The waiver(s), 31
1925	1925	category II or III changes, and/or state-plan amendments shall include the authorization to extend 32
1926	1926	managed care to cover long-term-care services and supports. Authorization shall also include, as 33
1927	1927	deemed appropriate, exempting certain beneficiaries with third-party medical coverage or 34
1928	1928
1929	1929
1930	1930	LC001777 - Page 53 of 96
1931	1931	insurance from mandatory managed care in accordance with rules and regulations promulgated by 1
1932	1932	the executive office. 2
1933	1933	(d)(b) To ensure the delivery of timely and appropriate services to persons who become 3
1934	1934	eligible for Medicaid by virtue of their eligibility for a United States Social Security Administration 4
1935	1935	program, the executive office is authorized to seek any and all data-sharing agreements or other 5
1936	1936	agreements with the Social Security Administration as may be necessary to receive timely and 6
1937	1937	accurate diagnostic data and clinical assessments. This information shall be used exclusively for 7
1938	1938	the purpose of service planning, and shall be held and exchanged in accordance with all applicable 8
1939	1939	state and federal medical record confidentiality laws and regulations. 9
1940	1940	SECTION 14. Sections 40-8.12-2 and 40-8.12-3 of the General Laws in Chapter 40-8.12 10
1941	1941	entitled "Health Care for Adults" are hereby amended to read as follows: 11
1942	1942	40-8.12-2. Eligibility. 12
1943	1943	(a) Medicaid coverage for nonpregnant adults without children. There is hereby 13
1944	1944	established, effective January 1, 2014, a category of Medicaid eligibility pursuant to Title XIX of 14
1945	1945	the Social Security Act, as amended by the U.S. Patient Protection and Affordable Care Act (ACA) 15
1946	1946	of 2010, 42 U.S.C. § 1396u-1, for adults ages nineteen (19) to sixty-four (64) who do not have 16
1947	1947	dependent children and do not qualify for Medicaid under Rhode Island general laws applying to 17
1948	1948	families with children and adults who are blind, aged, or living with a disability. The executive 18
1949	1949	office of health and human services is directed to make any amendments to the Medicaid state plan 19
1950	1950	and waiver authorities established under Title XIX necessary to implement this expansion in 20
1951	1951	eligibility and ensure the maximum federal contribution for health insurance coverage provided 21
1952	1952	pursuant to this chapter. 22
1953	1953	(b) Income. The secretary of the executive office of health and human services is 23
1954	1954	authorized and directed to amend the Medicaid Title XIX state plan and, as deemed necessary, any 24
1955	1955	waiver authority to effectuate this expansion of coverage to any Rhode Islander who qualifies for 25
1956	1956	Medicaid eligibility under this chapter with income at or below one hundred and thirty-three 26
1957	1957	percent (133%) of the federal poverty level, based on modified adjusted-gross income. 27
1958	1958	(c) Delivery system. The executive office of health and human services is authorized and 28
1959	1959	directed to apply for and obtain any waiver authorities necessary to provide persons eligible under 29
1960	1960	this chapter with managed, coordinated healthcare coverage consistent with the principles set forth 30
1961	1961	in chapter 12.4 of title 42, pertaining to a healthcare home. Beginning July 1, 2027, all payments 31
1962	1962	shall be provided directly by the state without an intermediate payment to a managed care entity or 32
1963	1963	other form of health insurance company. Beginning July 1, 2023, no new contracts may be entered 33
1964	1964	into between the Medicaid office and an intermediate payor such as a managed care entity or other 34
1965	1965
1966	1966
1967	1967	LC001777 - Page 54 of 96
1968	1968	form of health insurance company for the payment of health care services pursuant to this chapter. 1
1969	1969	40-8.12-3. Premium assistance program. 2
1970	1970	(a) The executive office of health and human services is directed to amend its rules and 3
1971	1971	regulations to implement a premium assistance program for adults with dependent children, 4
1972	1972	enrolled in the state's health-benefits exchange, whose annual income and resources meet the 5
1973	1973	guidelines established in § 40-8.4-4 in effect on December 1, 2013. The premium assistance will 6
1974	1974	pay one-half of the cost of a commercial plan that a parent may incur after subtracting the cost-7
1975	1975	sharing requirement under § 40-8.4-4 as of December 31, 2013, and any applicable federal tax 8
1976	1976	credits available. The office is also directed to amend the 1115 waiver demonstration extension and 9
1977	1977	the medical assistance Title XIX state plan for this program if it is determined that it is eligible for 10
1978	1978	funding pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. 11
1979	1979	(b) The executive office of health and human services shall require any individual receiving 12
1980	1980	benefits under a state-funded, healthcare assistance program to apply for any health insurance for 13
1981	1981	which he or she is eligible, including health insurance available through the health benefits 14
1982	1982	exchange. Nothing shall preclude the state from using funds appropriated for Affordable Care Act 15
1983	1983	transition expenses to reduce the impact on an individual who has been transitioned from a state 16
1984	1984	program to a health insurance plan available through the health benefits exchange. It shall not be 17
1985	1985	deemed cost-effective for the state if it would result in a loss of benefits or an increase in the cost 18
1986	1986	of healthcare services for the person above an amount deemed de minimus as determined by state 19
1987	1987	regulation. 20
1988	1988	SECTION 15. Chapter 44-8.13 of the General Law entitled "Long-Term Managed Care 21
1989	1989	Arrangements" is hereby repealed in its entirety. 22
1990	1990	40-8.13-1. Definitions. 23
1991	1991	For purposes of this section the following terms shall have the meanings indicated: 24
1992	1992	(1) "Beneficiary" means an individual who is eligible for medical assistance under the 25
1993	1993	Rhode Island Medicaid state plan established in accordance with 42 U.S.C. § 1396, and includes 26
1994	1994	individuals who are additionally eligible for benefits under the Medicare program (42 U.S.C. § 27
1995	1995	1395 et seq.) or other health plan. 28
1996	1996	(2) "Duals demonstration project" means a demonstration project established pursuant to 29
1997	1997	the financial alignment demonstration established under section 2602 of the Patient Protection and 30
1998	1998	Affordable Care Act (Pub. L. No. 111-148) [42 U.S.C. § 1315b], involving a three-way contract 31
1999	1999	between Rhode Island, the federal Centers for Medicare and Medicaid Services ("CMS"), and 32
2000	2000	qualified health plans, and covering healthcare services provided to beneficiaries. 33
2001	2001	(3) "EOHHS" means the Rhode Island executive office of health and human services. 34
2002	2002
2003	2003
2004	2004	LC001777 - Page 55 of 96
2005	2005	(4) "EOHHS level-of-care tool" refers to a set of criteria established by EOHHS and used 1
2006	2006	in January, 2014 to determine the long-term-care needs of a beneficiary as well as the appropriate 2
2007	2007	setting for delivery of that care. 3
2008	2008	(5) "Long-term-care services and supports" means a spectrum of services covered by the 4
2009	2009	Rhode Island Medicaid program and/or the Medicare program, that are required by individuals with 5
2010	2010	functional impairments and/or chronic illness, and includes skilled or custodial nursing facility 6
2011	2011	care, as well as various home- and community-based services. 7
2012	2012	(6) "Managed care organization" means any health plan, health-maintenance organization, 8
2013	2013	managed care plan, or other person or entity that enters into a contract with the state under which 9
2014	2014	it is granted the authority to arrange for the provision of, and/or payment for, long-term-care 10
2015	2015	supports and services to eligible beneficiaries under a managed long-term-care arrangement. 11
2016	2016	(7) "Managed long-term-care arrangement" means any arrangement under which a 12
2017	2017	managed care organization is granted some or all of the responsibility for providing and/or paying 13
2018	2018	for long-term-care services and supports that would otherwise be provided or paid under the Rhode 14
2019	2019	Island Medicaid program. The term includes, but is not limited to, a duals demonstration project, 15
2020	2020	and/or phase I and phase II of the integrated care initiative established by the executive office of 16
2021	2021	health and human services. 17
2022	2022	(8) "Plan of care" means a care plan established by a nursing facility in accordance with 18
2023	2023	state and federal regulations and that identifies specific care and services provided to a beneficiary. 19
2024	2024	40-8.13-2. Beneficiary choice. 20
2025	2025	Any managed long-term-care arrangement shall offer beneficiaries the option to decline 21
2026	2026	participation and remain in traditional Medicaid and, if a duals demonstration project, traditional 22
2027	2027	Medicare. Beneficiaries must be provided with sufficient information to make an informed choice 23
2028	2028	regarding enrollment, including: 24
2029	2029	(1) Any changes in the beneficiary's payment or other financial obligations with respect to 25
2030	2030	long-term-care services and supports as a result of enrollment; 26
2031	2031	(2) Any changes in the nature of the long-term-care services and supports available to the 27
2032	2032	beneficiary as a result of enrollment, including specific descriptions of new services that will be 28
2033	2033	available or existing services that will be curtailed or terminated; 29
2034	2034	(3) A contact person who can assist the beneficiary in making decisions about enrollment; 30
2035	2035	(4) Individualized information regarding whether the managed care organization's network 31
2036	2036	includes the healthcare providers with whom beneficiaries have established provider relationships. 32
2037	2037	Directing beneficiaries to a website identifying the plan's provider network shall not be sufficient 33
2038	2038	to satisfy this requirement; and 34
2039	2039
2040	2040
2041	2041	LC001777 - Page 56 of 96
2042	2042	(5) The deadline by which the beneficiary must make a choice regarding enrollment, and 1
2043	2043	the length of time a beneficiary must remain enrolled in a managed care organization before being 2
2044	2044	permitted to change plans or opt out of the arrangement. 3
2045	2045	40-8.13-3. Ombudsman process. 4
2046	2046	EOHHS shall designate an ombudsperson to advocate for beneficiaries enrolled in a 5
2047	2047	managed long-term-care arrangement. The ombudsperson shall advocate for beneficiaries through 6
2048	2048	complaint and appeal processes and ensure that necessary healthcare services are provided. At the 7
2049	2049	time of enrollment, a managed care organization must inform enrollees of the availability of the 8
2050	2050	ombudsperson, including contact information. 9
2051	2051	40-8.13-4. Provider/plan liaison. 10
2052	2052	EOHHS shall designate an individual, not employed by or otherwise under contract with a 11
2053	2053	participating managed care organization, who shall act as liaison between healthcare providers and 12
2054	2054	managed care organizations, for the purpose of facilitating communications and ensuring that issues 13
2055	2055	and concerns are promptly addressed. 14
2056	2056	40-8.13-5. Financial principles under managed care. 15
2057	2057	(a) To the extent that financial savings are a goal under any managed long-term-care 16
2058	2058	arrangement, it is the intent of the legislature to achieve savings through administrative efficiencies, 17
2059	2059	care coordination, improvements in care outcomes and in a way that encourages the highest quality 18
2060	2060	care for patients and maximizes value for the managed-care organization and the state. Therefore, 19
2061	2061	any managed long-term-care arrangement shall include a requirement that the managed care 20
2062	2062	organization reimburse providers for services in accordance with these principles. Notwithstanding 21
2063	2063	any law to the contrary, for the twelve-month (12) period beginning July 1, 2015, Medicaid 22
2064	2064	managed long-term-care payment rates to nursing facilities established pursuant to this section shall 23
2065	2065	not exceed ninety-eight percent (98.0%) of the rates in effect on April 1, 2015. 24
2066	2066	(1) For a duals demonstration project, the managed care organization: 25
2067	2067	(i) Shall not combine the rates of payment for post-acute skilled and rehabilitation care 26
2068	2068	provided by a nursing facility and long-term and chronic care provided by a nursing facility in order 27
2069	2069	to establish a single-payment rate for dual eligible beneficiaries requiring skilled nursing services; 28
2070	2070	(ii) Shall pay nursing facilities providing post-acute skilled and rehabilitation care or long-29
2071	2071	term and chronic care rates that reflect the different level of services and intensity required to 30
2072	2072	provide these services; and 31
2073	2073	(iii) For purposes of determining the appropriate rate for the type of care identified in 32
2074	2074	subsection (a)(1)(ii) of this section, the managed care organization shall pay no less than the rates 33
2075	2075	that would be paid for that care under traditional Medicare and Rhode Island Medicaid for these 34
2076	2076
2077	2077
2078	2078	LC001777 - Page 57 of 96
2079	2079	service types. The managed care organization shall not, however, be required to use the same 1
2080	2080	payment methodology. 2
2081	2081	The state shall not enter into any agreement with a managed care organization in connection 3
2082	2082	with a duals demonstration project unless that agreement conforms to this section, and any existing 4
2083	2083	such agreement shall be amended as necessary to conform to this subsection. 5
2084	2084	(2) For a managed long-term-care arrangement that is not a duals demonstration project, 6
2085	2085	the managed care organization shall reimburse providers in an amount not less than the amount that 7
2086	2086	would be paid for the same care by the executive office of health and human services under the 8
2087	2087	Medicaid program. The managed care organization shall not, however, be required to use the same 9
2088	2088	payment methodology as the executive office of health and human services. 10
2089	2089	(3) Notwithstanding any provisions of the general or public laws to the contrary, the 11
2090	2090	protections of subsections (a)(1) and (a)(2) of this section may be waived by a nursing facility in 12
2091	2091	the event it elects to accept a payment model developed jointly by the managed care organization 13
2092	2092	and skilled nursing facilities, that is intended to promote quality of care and cost-effectiveness, 14
2093	2093	including, but not limited to, bundled-payment initiatives, value-based purchasing arrangements, 15
2094	2094	gainsharing, and similar models. 16
2095	2095	(b) Notwithstanding any law to the contrary, for the twelve-month (12) period beginning 17
2096	2096	July 1, 2015, Medicaid managed long-term-care payment rates to nursing facilities established 18
2097	2097	pursuant to this section shall not exceed ninety-eight percent (98.0%) of the rates in effect on April 19
2098	2098	1, 2015. 20
2099	2099	40-8.13-6. Payment incentives. 21
2100	2100	In order to encourage quality improvement and promote appropriate utilization incentives 22
2101	2101	for providers in a managed long-term-care arrangement, a managed care organization may use 23
2102	2102	incentive or bonus payment programs that are in addition to the rates identified in § 40-8.13-5. 24
2103	2103	40-8.13-7. Willing provider. 25
2104	2104	A managed care organization must contract with and cover services furnished by any 26
2105	2105	nursing facility licensed under chapter 17 of title 23 and certified by CMS that provides Medicaid-27
2106	2106	covered nursing facility services pursuant to a provider agreement with the state, provided that the 28
2107	2107	nursing facility is not disqualified under the managed care organization's quality standards that are 29
2108	2108	applicable to all nursing facilities; and the nursing facility is willing to accept the reimbursement 30
2109	2109	rates described in § 40-8.13-5. 31
2110	2110	40-8.13-8. Level-of-care tool. 32
2111	2111	A managed long-term-care arrangement must require that all participating managed care 33
2112	2112	organizations use only the EOHHS level-of-care tool in determining coverage of long-term-care 34
2113	2113
2114	2114
2115	2115	LC001777 - Page 58 of 96
2116	2116	supports and services for beneficiaries. EOHHS may amend the level-of-care tool provided that 1
2117	2117	any changes are established in consultation with beneficiaries and providers of Medicaid-covered 2
2118	2118	long-term-care supports and services, and are based upon reasonable medical evidence or 3
2119	2119	consensus, in consideration of the specific needs of Rhode Island beneficiaries. Notwithstanding 4
2120	2120	any other provisions herein, however, in the case of a duals demonstration project, a managed care 5
2121	2121	organization may use a different level-of-care tool for determining coverage of services that would 6
2122	2122	otherwise be covered by Medicare, since the criteria established by EOHHS are directed towards 7
2123	2123	Medicaid-covered services; provided, that the level-of-care tool is based on reasonable medical 8
2124	2124	evidence or consensus in consideration of the specific needs of Rhode Island beneficiaries. 9
2125	2125	40-8.13-9. Case management/plan of care. 10
2126	2126	No managed care organization acting under a managed long-term-care arrangement may 11
2127	2127	require a provider to change a plan of care if the provider reasonably believes that such an action 12
2128	2128	would conflict with the provider's responsibility to develop an appropriate care plan under state and 13
2129	2129	federal regulations. 14
2130	2130	40-8.13-10. Care transitions. 15
2131	2131	In the event that a beneficiary: 16
2132	2132	(1) Has been determined to meet level-of-care requirements for nursing facility coverage 17
2133	2133	as of the date of his or her enrollment in a managed care organization; or 18
2134	2134	(2) Has been determined to meet level of care requirements for nursing facility coverage 19
2135	2135	by a managed care organization after enrollment; and there is a change in condition whereby the 20
2136	2136	managed care organization determines that the beneficiary no longer meets such level-of-care 21
2137	2137	requirements, the nursing facility shall promptly arrange for an appropriate and safe discharge (with 22
2138	2138	the assistance of the managed care organization if the facility requests it), and the managed care 23
2139	2139	organization shall continue to pay for the beneficiary's nursing facility care at the same rate until 24
2140	2140	the beneficiary is discharged. 25
2141	2141	40-8.13-11. Reporting requirements. 26
2142	2142	EOHHS shall report to the general assembly and shall make available to interested persons 27
2143	2143	a separate accounting of state expenditures for long-term-care supports and services under any 28
2144	2144	managed long-term-care arrangement, specifically and separately identifying expenditures for 29
2145	2145	home- and community-based services, assisted-living services, hospice services within nursing 30
2146	2146	facilities, hospice services outside of nursing facilities, and nursing facility services. Such reports 31
2147	2147	shall be made twice annually, six (6) months apart, beginning six (6) months following the 32
2148	2148	implementation of any managed long-term-care arrangement, and shall include a detailed report of 33
2149	2149	utilization of each service. In order to facilitate reporting, any managed long-term-care arrangement 34
2150	2150
2151	2151
2152	2152	LC001777 - Page 59 of 96
2153	2153	shall include a requirement that a participating managed care organization make timely reports of 1
2154	2154	the data necessary to compile the reports. 2
2155	2155	SECTION 16. Sections 42-7.2-10, 42-7.2-16 and 42-7.2-16.1 of the General Laws in 3
2156	2156	Chapter 42-7.2 entitled "Office of Health and Human Services" are hereby amended to read as 4
2157	2157	follows: 5
2158	2158	42-7.2-10. Appropriations and disbursements. 6
2159	2159	(a) The general assembly shall annually appropriate such sums as it may deem necessary 7
2160	2160	for the purpose of carrying out the provisions of this chapter. The state controller is hereby 8
2161	2161	authorized and directed to draw his or her orders upon the general treasurer for the payment of such 9
2162	2162	sum or sums, or so much thereof as may from time to time be required, upon receipt by him or her 10
2163	2163	of proper vouchers approved by the secretary of the executive office of health and human services, 11
2164	2164	or his or her designee. 12
2165	2165	(b) The general assembly shall, through the utilization of federal Medicaid reimbursement 13
2166	2166	for administrative costs, and additional funds, appropriate such funds as may be necessary to hire 14
2167	2167	additional personnel for the Medicaid office as follows: one hundred (100) outreach social workers 15
2168	2168	to encourage, assist and expedite individuals applying for Medicaid benefits; one hundred (100) 16
2169	2169	new programmers in order to build digital infrastructure for the Medicaid office; thirty (30) new 17
2170	2170	social workers and ten (10) new programmers to help increase spend down program utilization and 18
2171	2171	feasibility and examine possible legal changes necessary to increase spend down program 19
2172	2172	eligibility; and fifty (50) additional personnel for building administrative capacity. The Medicaid 20
2173	2173	office shall be exempt from any limitations placed on the number of full-time equivalent personnel 21
2174	2174	employed by the executive office of health and human services. 22
2175	2175	(b)(c) For the purpose of recording federal financial participation associated with 23
2176	2176	qualifying healthcare workforce development activities at the state's public institutions of higher 24
2177	2177	education, and pursuant to the Rhode Island designated state health programs (DSHP), as approved 25
2178	2178	by the Centers for Medicare & Medicaid Services (CMC) October 20, 2016, in the 11-W-00242/1 26
2179	2179	amendment to Rhode Island's section 1115 Demonstration Waiver, there is hereby established a 27
2180	2180	restricted-receipt account entitled "Health System Transformation Project" in the general fund of 28
2181	2181	the state and included in the budget of the office of health and human services. Due to the COVID-29
2182	2182	19 pandemic, the office of health and human services is forbidden from utilizing any funds within 30
2183	2183	the health system transformation project restricted receipts account for any imposition of downside 31
2184	2184	risk for providers. No payment models that impose downside risk or in any way deviate from fee-32
2185	2185	for-service shall be utilized for the Medicaid program without explicit authorization by the general 33
2186	2186	assembly. 34
2187	2187
2188	2188
2189	2189	LC001777 - Page 60 of 96
2190	2190	(c)(d) There are hereby created within the general fund of the state and housed within the 1
2191	2191	budget of the office of health and human services two restricted receipt accounts, respectively 2
2192	2192	entitled “HCBS Support-ARPA” and “HCBS Admin Support-ARPA”. Amounts deposited into 3
2193	2193	these accounts are equivalent to the general revenue savings generated by the enhanced federal 4
2194	2194	match received on eligible home and community-based services between April 1, 2021, and March 5
2195	2195	31, 2022, allowable under Section 9817 of the American Rescue Plan Act of 2021, Pub. L. No. 6
2196	2196	117-2. Funds deposited into the “HCBS Support-ARPA” account will be used to finance the state 7
2197	2197	share of newly eligible Medicaid expenditures by the office of health and human services and its 8
2198	2198	sister agencies, including the department of children, youth and families, the department of health, 9
2199	2199	and the department of behavioral healthcare, developmental disabilities and hospitals. Funds 10
2200	2200	deposited into the “HCBS Admin Support-ARPA” account will be used to finance the state share 11
2201	2201	of allowable administrative expenditures attendant to the implementation of these newly eligible 12
2202	2202	Medicaid expenditures. The accounts created under this subsection shall be exempt from the 13
2203	2203	indirect cost recovery provisions of § 35-4-27. 14
2204	2204	(d)(e) There is hereby created within the general fund of the state and housed within the 15
2205	2205	budget of the office of health and human services a restricted receipt account entitled “Rhode Island 16
2206	2206	Statewide Opioid Abatement Account” for the purpose of receiving and expending monies from 17
2207	2207	settlement agreements with opioid manufacturers, pharmaceutical distributors, pharmacies, or their 18
2208	2208	affiliates, as well as monies resulting from bankruptcy proceedings of the same entities. The 19
2209	2209	executive office of health and human services shall deposit any revenues from such sources that 20
2210	2210	are designated for opioid abatement purposes into the restricted receipt account. Funds from this 21
2211	2211	account shall only be used for forward-looking opioid abatement efforts as defined and limited by 22
2212	2212	any settlement agreements, state-city and town agreements, or court orders pertaining to the use of 23
2213	2213	such funds. By January 1 of each calendar year, the secretary of health and human services shall 24
2214	2214	report to the governor, the speaker of the house of representatives, the president of the senate, and 25
2215	2215	the attorney general on the expenditures that were funded using monies from the Rhode Island 26
2216	2216	statewide opioid abatement account and the amount of funds spent. The account created under this 27
2217	2217	subsection shall be exempt from the indirect cost recovery provisions of § 35-4-27. No 28
2218	2218	governmental entity has the authority to assert a claim against the entities with which the attorney 29
2219	2219	general has entered into settlement agreements concerning the manufacturing, marketing, 30
2220	2220	distributing, or selling of opioids that are the subject of the Rhode Island Memorandum of 31
2221	2221	Understanding Between the State and Cities and Towns Receiving Opioid Settlement Funds 32
2222	2222	executed by every city and town and the attorney general and wherein every city and town agreed 33
2223	2223	to release all such claims against these settling entities, and any amendment thereto. Governmental 34
2224	2224
2225	2225
2226	2226	LC001777 - Page 61 of 96
2227	2227	entity means any state or local governmental entity or sub-entity and includes, but is not limited to, 1
2228	2228	school districts, fire districts, and any other such districts. The claims that shall not be asserted are 2
2229	2229	the released claims, as that term is defined in the settlement agreements executed by the attorney 3
2230	2230	general, or, if not defined therein, the claims sought to be released in such settlement agreements. 4
2231	2231	42-7.2-16. Medicaid System Reform 2008 Medicaid System Reform. 5
2232	2232	(a) The executive office of health and human services, in conjunction with the department 6
2233	2233	of human services, the department of children, youth and families, the department of health and the 7
2234	2234	department of behavioral healthcare, developmental disabilities and hospitals, is authorized to 8
2235	2235	design options that further the reforms in Medicaid initiated in 2008 Medicaid reform to ensure that 9
2236	2236	the program: transitions to a Medicare level of care as a first step in the transition to a state-level 10
2237	2237	Medicare for All system; phases out the use of intermediary insurance companies such as managed 11
2238	2238	care entities; transitions to the management of health insurers acquired due to insolvency, smoothly 12
2239	2239	integrating publicly owned health insurers with the Medicaid system; utilizes payment models such 13
2240	2240	as fee-for-service that incentivize higher quality of care and more utilization of care; provides for 14
2241	2241	the financial health of Rhode Island health care providers; encourages fair wages and benefits for 15
2242	2242	Rhode Island's health care workforce; develops and builds out the Medicaid office's human capital, 16
2243	2243	technological infrastructure, expertise, and general ability to manage health care payments to 17
2244	2244	prepare for the transition to a single-payer Medicare-for-All system; and guides the transition of 18
2245	2245	the Rhode Island health care funding system to a state-level Medicare-for-All system. utilizes 19
2246	2246	competitive and value based purchasing to maximize the available service options, promotes 20
2247	2247	accountability and transparency, and encourages and rewards healthy outcomes, independence, and 21
2248	2248	responsible choices; promotes efficiencies and the coordination of services across all health and 22
2249	2249	human services agencies; and ensures the state will have a fiscally sound source of publicly-23
2250	2250	financed health care for Rhode Islanders in need. 24
2251	2251	(b) Principles and goals. In developing and implementing this system of reform, the 25
2252	2252	executive office of health and human services and the four (4) health and human services 26
2253	2253	departments shall pursue the following principles and goals: 27
2254	2254	(1) Empower consumers to make reasoned and cost-effective choices about their health by 28
2255	2255	providing them with the information and array of service options they need and offering rewards 29
2256	2256	for healthy decisions; 30
2257	2257	(2) Encourage personal responsibility by assuring the information available to beneficiaries 31
2258	2258	is easy to understand and accurate, provide that a fiscal intermediary is provided when necessary, 32
2259	2259	and adequate access to needed services; 33
2260	2260	(3) When appropriate, promote community-based care solutions by transitioning 34
2261	2261
2262	2262
2263	2263	LC001777 - Page 62 of 96
2264	2264	beneficiaries from institutional settings back into the community and by providing the needed 1
2265	2265	assistance and supports to beneficiaries requiring long-term care or residential services who wish 2
2266	2266	to remain, or are better served in the community; 3
2267	2267	(4) Enable consumers to receive individualized health care that is outcome-oriented, 4
2268	2268	focused on prevention, disease management, recovery and maintaining independence; 5
2269	2269	(5) Promote competition between healthcare providers to ensure best value purchasing, to 6
2270	2270	leverage resources and to create opportunities for improving service quality and performance; 7
2271	2271	(6) Redesign purchasing and payment methods to promote payment models such as fee-8
2272	2272	for-service that incentivize higher quality of care and more utilization of care and phase out the use 9
2273	2273	of payment models that shift risk to providers assure fiscal accountability and encourage and to 10
2274	2274	reward service quality and cost-effectiveness by tying reimbursements to evidence-based 11
2275	2275	performance measures and standards, including those related to patient satisfaction; and 12
2276	2276	(7) Continually improve technology to take advantage of recent innovations and advances 13
2277	2277	that help decision makers, consumers and providers to make informed and cost-effective decisions 14
2278	2278	regarding health care. 15
2279	2279	(c) The executive office of health and human services shall annually submit a report to the 16
2280	2280	governor and the general assembly describing the status of the administration and implementation 17
2281	2281	of the Medicaid Section 1115 demonstration waiver. 18
2282	2282	42-7.2-16.1. Reinventing Medicaid Act of 2015. 19
2283	2283	(a) Findings. The Rhode Island Medicaid program is an integral component of the state's 20
2284	2284	healthcare system that provides crucial services and supports to many Rhode Islanders. As the 21
2285	2285	program's reach has expanded, the costs of the program have continued to rise and the delivery of 22
2286	2286	care has become more fragmented and uncoordinated. Given the crucial role of the Medicaid 23
2287	2287	program to the state, it is of compelling importance that the state conduct a fundamental 24
2288	2288	restructuring of its Medicaid program that achieves measurable improvement in health outcomes 25
2289	2289	for the people and transforms the healthcare system to one that pays for the outcomes and quality 26
2290	2290	they deserve at a sustainable, predictable and affordable cost. The Reinventing Medicaid Act of 27
2291	2291	2015, as implemented in the budget for fiscal year two thousand sixteen (FY2016), involved drastic 28
2292	2292	cuts to the Medicaid program, along with policies that shifted risk to providers away from 29
2293	2293	intermediary insurers. Since the passage of that act, the finances of health care providers in Rhode 30
2294	2294	Island have deteriorated significantly, and it is therefore the duty of the general assembly to seek 31
2295	2295	corrective action to restore critical investments in the Medicaid system and redesign payment 32
2296	2296	models to remove risk from providers and concentrate risk in private insurance companies during 33
2297	2297	their phase-out period along the transition to Medicare-for-All. 34
2298	2298
2299	2299
2300	2300	LC001777 - Page 63 of 96
2301	2301	(b) The Working Group to Reinvent Medicaid, which was established to refine the 1
2302	2302	principles and goals of the Medicaid reforms begun in 2008, was directed to present to the general 2
2303	2303	assembly and the governor initiatives to improve the value, quality, and outcomes of the health care 3
2304	2304	funded by the Medicaid program. 4
2305	2305	SECTION 17. Chapter 42-12.1 of the General Laws entitled "Department of Behavioral 5
2306	2306	Healthcare, Developmental Disabilities, and Hospitals" is hereby amended by adding thereto the 6
2307	2307	following section: 7
2308	2308	42-12.1-11. The Rhode Island institute for mental disease. 8
2309	2309	(a) There is hereby established a state hospital for the care for Rhode Islanders in need of 9
2310	2310	hospital-level inpatient behavioral health care known as the Rhode Island institute for mental 10
2311	2311	disease. The Rhode Island institute for mental disease shall fall within the purview of the 11
2312	2312	department, and the chief executive officer, chief financial officer, and chief medical officer shall 12
2313	2313	be appointed by the governor with advice and consent of the senate. 13
2314	2314	(b) All forensic patients in the care of the Eleanor Slater Hospital shall be immediately 14
2315	2315	transferred to the Rhode Island institute for mental disease. 15
2316	2316	(c) The Reagan Building of the Eleanor Slater Hospital shall be immediately transferred to 16
2317	2317	the Rhode Island institute for mental disease. 17
2318	2318	(d) A section of the Zambarano Building of the Eleanor Slater Hospital shall be designated 18
2319	2319	by the department for the use of the Rhode Island institute for mental disease. 19
2320	2320	(e) In the event that the director determines that the patient mix at the Eleanor Slater 20
2321	2321	Hospital may be at risk of jeopardizing federal Medicaid reimbursement through the classification 21
2322	2322	of the Eleanor Slater Hospital as an institution for mental disease, the director shall be empowered 22
2323	2323	to administratively transfer inpatient behavioral health patients at Eleanor Slater Hospital to the 23
2324	2324	Rhode Island institute for mental disease. 24
2325	2325	(f) The Medicaid director is hereby directed to apply for a waiver to allow for Medicaid 25
2326	2326	reimbursement of some or all inpatient behavioral health patients at the Rhode Island institute for 26
2327	2327	mental disease. 27
2328	2328	SECTION 18. Sections 42-12.3-2, 42-12.3-3, 42-12.3-5, 42-12.3-7 and 42-12.3-9 of the 28
2329	2329	General Laws in Chapter 42-12.3 entitled "Health Care for Children and Pregnant Women" are 29
2330	2330	hereby amended to read as follows: 30
2331	2331	42-12.3-2. Purposes. 31
2332	2332	(a) It is the intent of the general assembly to assure access to the comprehensive health care 32
2333	2333	by providing health insurance to all Rhode Islanders who are uninsured; 33
2334	2334	Universal comprehensive coverage for all Rhode Islanders is a goal to be achieved over 34
2335	2335
2336	2336
2337	2337	LC001777 - Page 64 of 96
2338	2338	the course of several years; 1
2339	2339	The first step in providing comprehensive health coverage is to assure coverage for the 2
2340	2340	most vulnerable residents of the state; 3
2341	2341	Uninsured pregnant women and children under age eight (8) nineteen (19) are among the 4
2342	2342	most vulnerable residents of the state; and 5
2343	2343	The governor's health care advisory committee has provided advice and recommendations 6
2344	2344	in its report of January, 1993 to improve access to health care for pregnant women and children up 7
2345	2345	to age six (6); 8
2346	2346	The objectives to meet the goal of comprehensive health coverage are: 9
2347	2347	(1) Every child under age eight (8) nineteen (19) in Rhode Island will have a reliable source 10
2348	2348	of health coverage and health care; 11
2349	2349	(2) Every pregnant woman in Rhode Island will have early and comprehensive prenatal 12
2350	2350	and maternity care services; 13
2351	2351	(3) All low income families will have improved access to family planning and reproductive 14
2352	2352	services; and 15
2353	2353	(4) Every pregnant woman and child in Rhode Island will receive effective, preventive 16
2354	2354	primary care. 17
2355	2355	(b) To assure access to care and availability of services, the following principles will guide 18
2356	2356	the design of the health care act: 19
2357	2357	(1) There will be equal access to health care for children and pregnant women, regardless 20
2358	2358	of the type of coverage; 21
2359	2359	(2) There shall be an emphasis on primary and preventive care which will include a 22
2360	2360	"medical home" for every child; 23
2361	2361	(3) Current deficiencies in the fee for service delivery system will be addressed; 24
2362	2362	(4) In addition to accessibility of health care, provisions must be made to address language, 25
2363	2363	cultural and transportation barriers; 26
2364	2364	(5) Enrollment must be both timely and accomplished in a user friendly fashion; 27
2365	2365	(6) An adequate source of primary care providers should be developed; 28
2366	2366	(7) An enhanced set of services should be developed to support and address the needs of 29
2367	2367	families at risk. 30
2368	2368	42-12.3-3. Medical assistance expansion for pregnant women/RIte Start. 31
2369	2369	(a) The secretary of the executive office of health and human services is authorized to 32
2370	2370	amend its Title XIX state plan pursuant to Title XIX of the Social Security Act to provide Medicaid 33
2371	2371	coverage and to amend its Title XXI state plan pursuant to Title XXI of the Social Security Act to 34
2372	2372
2373	2373
2374	2374	LC001777 - Page 65 of 96
2375	2375	provide medical assistance coverage through expanded family income disregards for pregnant 1
2376	2376	women persons whose family income levels are between one hundred eighty-five percent (185%) 2
2377	2377	and two hundred fifty percent (250%) of the federal poverty level. The department is further 3
2378	2378	authorized to promulgate any regulations necessary and in accord with Title XIX [42 U.S.C. § 1396 4
2379	2379	et seq.] and Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act necessary in order to 5
2380	2380	implement said state plan amendment. The services provided shall be in accord with Title XIX [42 6
2381	2381	U.S.C. § 1396 et seq.] and Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act. 7
2382	2382	(b) The secretary of health and human services is authorized and directed to establish a 8
2383	2383	payor of last resort program to cover prenatal, delivery and postpartum care. The program shall 9
2384	2384	cover the cost of maternity care for any woman person who lacks health insurance coverage for 10
2385	2385	maternity care and who is not eligible for medical assistance under Title XIX [42 U.S.C. § 1396 et 11
2386	2386	seq.] and Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act including, but not limited 12
2387	2387	to, a noncitizen pregnant woman person lawfully admitted for permanent residence on or after 13
2388	2388	August 22, 1996, without regard to the availability of federal financial participation, provided such 14
2389	2389	pregnant woman person satisfies all other eligibility requirements. The secretary shall promulgate 15
2390	2390	regulations to implement this program. Such regulations shall include specific eligibility criteria; 16
2391	2391	the scope of services to be covered; procedures for administration and service delivery; referrals 17
2392	2392	for non-covered services; outreach; and public education. Excluded services under this subsection 18
2393	2393	will include, but not be limited to, induced abortion except in cases of rape or incest or to save the 19
2394	2394	life of the pregnant individual. 20
2395	2395	(c) The secretary of health and human services may enter into cooperative agreements with 21
2396	2396	the department of health and/or other state agencies to provide services to individuals eligible for 22
2397	2397	services under subsections (a) and (b) above. 23
2398	2398	(d) The following services shall be provided through the program: 24
2399	2399	(1) Ante-partum and postpartum care; 25
2400	2400	(2) Delivery; 26
2401	2401	(3) Cesarean section; 27
2402	2402	(4) Newborn hospital care; 28
2403	2403	(5) Inpatient transportation from one hospital to another when authorized by a medical 29
2404	2404	provider; and 30
2405	2405	(6) Prescription medications and laboratory tests. 31
2406	2406	(e) The secretary of health and human services shall provide enhanced services, as 32
2407	2407	appropriate, to pregnant women persons as defined in subsections (a) and (b), as well as to other 33
2408	2408	pregnant women persons eligible for medical assistance. These services shall include: care 34
2409	2409
2410	2410
2411	2411	LC001777 - Page 66 of 96
2412	2412	coordination; nutrition and social service counseling; high-risk obstetrical care; childbirth and 1
2413	2413	parenting preparation programs; smoking cessation programs; outpatient counseling for drug-2
2414	2414	alcohol use; interpreter services; mental health services; and home visitation. The provision of 3
2415	2415	enhanced services is subject to available appropriations. In the event that appropriations are not 4
2416	2416	adequate for the provision of these services, the executive office has the authority to limit the 5
2417	2417	amount, scope, and duration of these enhanced services. 6
2418	2418	(f) The executive office of health and human services shall provide for extended family 7
2419	2419	planning services for up to twenty-four (24) months postpartum. These services shall be available 8
2420	2420	to women persons who have been determined eligible for RIte Start or for medical assistance under 9
2421	2421	Title XIX [42 U.S.C. § 1396 et seq.] or Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security 10
2422	2422	Act. 11
2423	2423	(g) Effective October 1, 2022, individuals eligible for RIte Start pursuant to this section or 12
2424	2424	for medical assistance under Title XIX or Title XXI of the Social Security Act while pregnant 13
2425	2425	(including during a period of retroactive eligibility), are eligible for full Medicaid benefits through 14
2426	2426	the last day of the month in which their twelve-month (12) postpartum period ends. This benefit 15
2427	2427	will be provided to eligible Rhode Island residents without regard to the availability of federal 16
2428	2428	financial participation. The executive office of health and human services is directed to ensure that 17
2429	2429	federal financial participation is used to the maximum extent allowable to provide coverage 18
2430	2430	pursuant to this section, and that state-only funds will be used only if federal financial participation 19
2431	2431	is not available. 20
2432	2432	(h) Any person eligible for services under subsections (a) and (b) of this section, or 21
2433	2433	otherwise eligible for medical assistance under title XIX [42 U.S.C. § 1396 et seq.] and title XXI 22
2434	2434	[42 U.S.C. § 1397 et seq.] of the Social Security Act, shall also be entitled to services for any 23
2435	2435	termination of pregnancy permitted under § 23-4.13-2; provided, however, that no federal funds 24
2436	2436	shall be used to pay for such services, except as authorized under federal law. 25
2437	2437	42-12.3-5. Managed care. 26
2438	2438	The delivery and financing of the health care services provided pursuant to §§ 42-12.3-3 27
2439	2439	and 42-12.3-4 shall may be provided through a system of managed care. The delivery and financing 28
2440	2440	of the health care services provided under this chapter may be provided through a system of 29
2441	2441	managed care. Beginning July 1, 2027, all payments shall be provided directly by the state without 30
2442	2442	an intermediate payment to a managed care entity or other form of health insurance company. 31
2443	2443	Beginning July 1, 2023, no new contracts may be entered into between the Medicaid office and an 32
2444	2444	intermediate payor such as a managed care entity or other form of health insurance company for 33
2445	2445	the payment of health care services pursuant to this chapter. 34
2446	2446
2447	2447
2448	2448	LC001777 - Page 67 of 96
2449	2449	A managed care system integrates an efficient financing mechanism with quality service 1
2450	2450	delivery, provides a "medical home" to assure appropriate care and deter unnecessary and 2
2451	2451	inappropriate care, and places emphasis on preventive and primary health care. In developing a 3
2452	2452	managed care system the department of human services shall consider managed care models 4
2453	2453	recognized by the health care financing administration. The department of human services is hereby 5
2454	2454	authorized and directed to seek any necessary approvals or waivers from the U.S. Department of 6
2455	2455	Health and Human Services, Health Care Financing Administration, needed to assure that services 7
2456	2456	are provided through a mandatory managed care system. Certain health services may be provided 8
2457	2457	on an interim basis through a fee for service arrangement upon a finding that there are temporary 9
2458	2458	barriers to implementation of mandatory managed care for a particular population or particular 10
2459	2459	geographic area. Nothing in this section shall prohibit the department of human services from 11
2460	2460	providing enhanced services to medical assistance recipients within existing appropriations. 12
2461	2461	42-12.3-7. Financial contributions. 13
2462	2462	The department of human services may not require the payment of enrollment fees, sliding 14
2463	2463	fees, deductibles, co-payments, and/or other contributions based on ability to pay. These fees shall 15
2464	2464	be established by rules and regulations to be promulgated by the department of human services or 16
2465	2465	the department of health, as appropriate. 17
2466	2466	42-12.3-9. Insurance coverage -- Third party insurance. 18
2467	2467	(a) No payment will be made nor service provided in the RIte Start or RIte Track program 19
2468	2468	with respect to any health care that is covered or would be covered, by any employee welfare benefit 20
2469	2469	plan under which a woman or child is either covered or eligible to be covered either as an employee 21
2470	2470	or dependent, whether or not coverage under such plan is elected. 22
2471	2471	(b) A premium may be charged for participation in the RIte Track or RIte Start programs 23
2472	2472	for eligible individuals whose family incomes are in excess of two hundred fifty percent (250%) of 24
2473	2473	the federal poverty level and who have voluntarily terminated health care insurance within one year 25
2474	2474	of the date of application for benefits under this chapter. 26
2475	2475	(c)(b) Every family who is eligible to participate in the RIte Track program, who has an 27
2476	2476	additional child who because of age is not eligible for RIte Track, or whose child becomes ineligible 28
2477	2477	for RIte Track because of his or her age, may be offered by the managed care provider with whom 29
2478	2478	the family is enrolled, the opportunity to enroll such ineligible child or children in the same 30
2479	2479	managed care program on a self-pay basis at the same cost, charge or premium as is being charged 31
2480	2480	to the state under the provisions of this chapter for other covered children within the managed care 32
2481	2481	program. The family may also purchase a package of enhanced services at the same cost or charge 33
2482	2482	to the department. 34
2483	2483
2484	2484
2485	2485	LC001777 - Page 68 of 96
2486	2486	SECTION 19. Section 42-12.3-14 of the General Laws in Chapter 42-12.3 entitled "Health 1
2487	2487	Care for Children and Pregnant Women" is hereby repealed in its entirety. 2
2488	2488	42-12.3-14. Benefits and coverage -- Exclusion. 3
2489	2489	For as long as the United States Department of Health and Human Services, Health Care 4
2490	2490	Financing Administration Project No. 11-W-0004/1-01 entitled "RIte Care" remains in effect, any 5
2491	2491	health care services provided pursuant to this chapter shall be exempt from all mandatory benefits 6
2492	2492	and coverage as may otherwise be provided for in the general laws. 7
2493	2493	SECTION 20. Sections 42-14.5-2 and 42-14.5-3 of the General Laws in Chapter 42-14.5 8
2494	2494	entitled "The Rhode Island Health Care Reform Act of 2004 - Health Insurance Oversight" are 9
2495	2495	hereby amended to read as follows: 10
2496	2496	42-14.5-2. Purpose. 11
2497	2497	With respect to health insurance as defined in § 42-14-5, the health insurance commissioner 12
2498	2498	shall discharge the powers and duties of office to: 13
2499	2499	(1) Claw back excessive profits, reserves charges, and other monies that health insurers 14
2500	2500	may have accumulated against the public interest of the people of Rhode Island Guard the solvency 15
2501	2501	of health insurers; 16
2502	2502	(2) Protect the interests of consumers; 17
2503	2503	(3) Encourage fair treatment of health care providers; 18
2504	2504	(4) Encourage policies and developments that improve the quality and efficiency of health 19
2505	2505	care service delivery and outcomes; and 20
2506	2506	(5) View the health care system as a comprehensive entity and encourage and direct 21
2507	2507	insurers towards policies that advance the welfare of the public through overall efficiency, 22
2508	2508	improved health care quality, and appropriate access; and 23
2509	2509	(6) Facilitate the transformation of the health care payments system to a state-level 24
2510	2510	Medicare-for-All system. 25
2511	2511	42-14.5-3. Powers and duties. 26
2512	2512	The health insurance commissioner shall have the following powers and duties: 27
2513	2513	(a) To conduct quarterly public meetings throughout the state, separate and distinct from 28
2514	2514	rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 29
2515	2515	licensed to provide health insurance in the state; the effects of such rates, services, and operations 30
2516	2516	on consumers, medical care providers, patients, and the market environment in which the insurers 31
2517	2517	operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 32
2518	2518	than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 33
2519	2519	Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 34
2520	2520
2521	2521
2522	2522	LC001777 - Page 69 of 96
2523	2523	general, and the chambers of commerce. Public notice shall be posted on the department’s website 1
2524	2524	and given in the newspaper of general circulation, and to any entity in writing requesting notice. 2
2525	2525	(b) To make recommendations to the governor and the house of representatives and senate 3
2526	2526	finance committees regarding healthcare insurance and the regulations, rates, services, 4
2527	2527	administrative expenses, reserve requirements, and operations of insurers providing health 5
2528	2528	insurance in the state, and to prepare or comment on, upon the request of the governor or 6
2529	2529	chairpersons of the house or senate finance committees, draft legislation to improve the regulation 7
2530	2530	of health insurance. In making the recommendations, the commissioner shall recognize that it is 8
2531	2531	the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 9
2532	2532	of individual administrative expenditures as well as total administrative costs. The commissioner 10
2533	2533	shall make recommendations on the levels of reserves, including consideration of: targeted reserve 11
2534	2534	levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 12
2535	2535	reserves. 13
2536	2536	(c) To establish a consumer/business/labor/medical advisory council to obtain information 14
2537	2537	and present concerns of consumers, business, and medical providers affected by health insurance 15
2538	2538	decisions. The council shall develop proposals to allow the market for small business health 16
2539	2539	insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 17
2540	2540	the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 18
2541	2541	measures to inform small businesses of an insurance complaint process to ensure that small 19
2542	2542	businesses that experience rate increases in a given year may request and receive a formal review 20
2543	2543	by the department. The advisory council shall assess views of the health provider community 21
2544	2544	relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 22
2545	2545	insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 23
2546	2546	an annual report of findings and recommendations to the governor and the general assembly and 24
2547	2547	present its findings at hearings before the house and senate finance committees. The advisory 25
2548	2548	council is to be diverse in interests and shall include representatives of community consumer 26
2549	2549	organizations; small businesses, other than those involved in the sale of insurance products; and 27
2550	2550	hospital, medical, and other health provider organizations. Such representatives shall be nominated 28
2551	2551	by their respective organizations. The advisory council shall be co-chaired by the health insurance 29
2552	2552	commissioner and a community consumer organization or small business member to be elected by 30
2553	2553	the full advisory council. 31
2554	2554	(d) To establish and provide guidance and assistance to a subcommittee (“the professional-32
2555	2555	provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 33
2556	2556	composed of healthcare providers and Rhode Island licensed health plans. This subcommittee The 34
2557	2557
2558	2558
2559	2559	LC001777 - Page 70 of 96
2560	2560	health insurance commissioner shall include provide in its an annual report and presentation before 1
2561	2561	the house and senate finance committees the following information: 2
2562	2562	(1) A method whereby health plans shall disclose to contracted providers the fee schedules 3
2563	2563	used to provide payment to those providers for services rendered to covered patients; 4
2564	2564	(2) A standardized provider application and credentials verification process, for the 5
2565	2565	purpose of verifying professional qualifications of participating healthcare providers; 6
2566	2566	(3) The uniform health plan claim form utilized by participating providers; 7
2567	2567	(4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 8
2568	2568	hospital or medical-service corporations, as defined by chapters 19 and 20 of title 27, to make 9
2569	2569	facility-specific data and other medical service-specific data available in reasonably consistent 10
2570	2570	formats to patients regarding quality and costs. This information would help consumers make 11
2571	2571	informed choices regarding the facilities and clinicians or physician practices at which to seek care. 12
2572	2572	Among the items considered would be the unique health services and other public goods provided 13
2573	2573	by facilities and clinicians or physician practices in establishing the most appropriate cost 14
2574	2574	comparisons; 15
2575	2575	(5) All activities related to contractual disclosure to participating providers of the 16
2576	2576	mechanisms for resolving health plan/provider disputes; 17
2577	2577	(6) The uniform process being utilized for confirming, in real time, patient insurance 18
2578	2578	enrollment status, benefits coverage, including co-pays and deductibles; 19
2579	2579	(7) Information related to temporary credentialing of providers seeking to participate in the 20
2580	2580	plan’s network and the impact of the activity on health plan accreditation; 21
2581	2581	(8) The feasibility of regular contract renegotiations between plans and the providers in 22
2582	2582	their networks; and 23
2583	2583	(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 24
2584	2584	(e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). 25
2585	2585	(f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 26
2586	2586	fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 27
2587	2587	(g) To analyze the impact of changing the rating guidelines and/or merging the individual 28
2588	2588	health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 29
2589	2589	insurance market, as defined in chapter 50 of title 27, in accordance with the following: 30
2590	2590	(1) The analysis shall forecast the likely rate increases required to effect the changes 31
2591	2591	recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 32
2592	2592	health insurance market over the next five (5) years, based on the current rating structure and 33
2593	2593	current products. 34
2594	2594
2595	2595
2596	2596	LC001777 - Page 71 of 96
2597	2597	(2) The analysis shall include examining the impact of merging the individual and small-1
2598	2598	employer markets on premiums charged to individuals and small-employer groups. 2
2599	2599	(3) The analysis shall include examining the impact on rates in each of the individual and 3
2600	2600	small-employer health insurance markets and the number of insureds in the context of possible 4
2601	2601	changes to the rating guidelines used for small-employer groups, including: community rating 5
2602	2602	principles; expanding small-employer rate bonds beyond the current range; increasing the employer 6
2603	2603	group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 7
2604	2604	(4) The analysis shall include examining the adequacy of current statutory and regulatory 8
2605	2605	oversight of the rating process and factors employed by the participants in the proposed, new 9
2606	2606	merged market. 10
2607	2607	(5) The analysis shall include assessment of possible reinsurance mechanisms and/or 11
2608	2608	federal high-risk pool structures and funding to support the health insurance market in Rhode Island 12
2609	2609	by reducing the risk of adverse selection and the incremental insurance premiums charged for this 13
2610	2610	risk, and/or by making health insurance affordable for a selected at-risk population. 14
2611	2611	(6) The health insurance commissioner shall work with an insurance market merger task 15
2612	2612	force to assist with the analysis. The task force shall be chaired by the health insurance 16
2613	2613	commissioner and shall include, but not be limited to, representatives of the general assembly, the 17
2614	2614	business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 18
2615	2615	the individual market in Rhode Island, health insurance brokers, and members of the general public. 19
2616	2616	(7) For the purposes of conducting this analysis, the commissioner may contract with an 20
2617	2617	outside organization with expertise in fiscal analysis of the private insurance market. In conducting 21
2618	2618	its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 22
2619	2619	data shall be subject to state and federal laws and regulations governing confidentiality of health 23
2620	2620	care and proprietary information. 24
2621	2621	(8) The task force shall meet as necessary and include its findings in the annual report, and 25
2622	2622	the commissioner shall include the information in the annual presentation before the house and 26
2623	2623	senate finance committees. 27
2624	2624	(h) To establish and convene a workgroup representing healthcare providers and health 28
2625	2625	insurers for the purpose of coordinating the development of processes, guidelines, and standards to 29
2626	2626	streamline healthcare administration that are to be adopted by payors and providers of healthcare 30
2627	2627	services operating in the state. This workgroup shall include representatives with expertise who 31
2628	2628	would contribute to the streamlining of healthcare administration and who are selected from 32
2629	2629	hospitals, physician practices, community behavioral health organizations, each health insurer 33
2630	2630	labor union representing health care workers, and other affected entities. The workgroup shall also 34
2631	2631
2632	2632
2633	2633	LC001777 - Page 72 of 96
2634	2634	include at least one designee each from the Rhode Island Medical Society, Rhode Island Council 1
2635	2635	of Community Mental Health Organizations, the Rhode Island Health Center Association, and the 2
2636	2636	Hospital Association of Rhode Island. The workgroup shall consider and make recommendations 3
2637	2637	for: 4
2638	2638	(1) Establishing a consistent standard for electronic eligibility and coverage verification. 5
2639	2639	Such standard shall: 6
2640	2640	(i) Include standards for eligibility inquiry and response and, wherever possible, be 7
2641	2641	consistent with the standards adopted by nationally recognized organizations, such as the Centers 8
2642	2642	for Medicare and Medicaid Services; 9
2643	2643	(ii) Enable providers and payors to exchange eligibility requests and responses on a system-10
2644	2644	to-system basis or using a payor-supported web browser; 11
2645	2645	(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 12
2646	2646	coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 13
2647	2647	requirements for specific services at the specific time of the inquiry; current deductible amounts; 14
2648	2648	accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 15
2649	2649	other information required for the provider to collect the patient’s portion of the bill; 16
2650	2650	(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 17
2651	2651	and benefits information; 18
2652	2652	(v) Recommend a standard or common process to protect all providers from the costs of 19
2653	2653	services to patients who are ineligible for insurance coverage in circumstances where a payor 20
2654	2654	provides eligibility verification based on best information available to the payor at the date of the 21
2655	2655	request of eligibility. 22
2656	2656	(2) Developing implementation guidelines and promoting adoption of the guidelines for: 23
2657	2657	(i) The use of the National Correct Coding Initiative code-edit policy by payors and 24
2658	2658	providers in the state; 25
2659	2659	(ii) Publishing any variations from codes and mutually exclusive codes by payors in a 26
2660	2660	manner that makes for simple retrieval and implementation by providers; 27
2661	2661	(iii) Use of Health Insurance Portability and Accountability Act standard group codes, 28
2662	2662	reason codes, and remark codes by payors in electronic remittances sent to providers; 29
2663	2663	(iv) The processing of corrections to claims by providers and payors. 30
2664	2664	(v) A standard payor-denial review process for providers when they request a 31
2665	2665	reconsideration of a denial of a claim that results from differences in clinical edits where no single, 32
2666	2666	common-standards body or process exists and multiple conflicting sources are in use by payors and 33
2667	2667	providers. 34
2668	2668
2669	2669
2670	2670	LC001777 - Page 73 of 96
2671	2671	(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 1
2672	2672	payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 2
2673	2673	detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 3
2674	2674	disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 4
2675	2675	the application of such edits and that the provider have access to the payor’s review and appeal 5
2676	2676	process to challenge the payor’s adjudication decision. 6
2677	2677	(vii) Nothing in this subsection shall be construed to modify the rights or obligations of 7
2678	2678	payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 8
2679	2679	prosecution under applicable law of potentially fraudulent billing activities. 9
2680	2680	(3) Developing and promoting widespread adoption by payors and providers of guidelines 10
2681	2681	to: 11
2682	2682	(i) Ensure payors do not automatically deny claims for services when extenuating 12
2683	2683	circumstances make it impossible for the provider to obtain a preauthorization before services are 13
2684	2684	performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 14
2685	2685	(ii) Require payors to use common and consistent processes and time frames when 15
2686	2686	responding to provider requests for medical management approvals. Whenever possible, such time 16
2687	2687	frames shall be consistent with those established by leading national organizations and be based 17
2688	2688	upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 18
2689	2689	management includes prior authorization of services, preauthorization of services, precertification 19
2690	2690	of services, post-service review, medical-necessity review, and benefits advisory; 20
2691	2691	(iii) Develop, maintain, and promote widespread adoption of a single, common website 21
2692	2692	where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 22
2693	2693	requirements; 23
2694	2694	(iv) Establish guidelines for payors to develop and maintain a website that providers can 24
2695	2695	use to request a preauthorization, including a prospective clinical necessity review; receive an 25
2696	2696	authorization number; and transmit an admission notification. 26
2697	2697	(4) To provide a report to the house and senate, on or before January 1, 2017, with 27
2698	2698	recommendations for establishing guidelines and regulations for systems that give patients 28
2699	2699	electronic access to their claims information, particularly to information regarding their obligations 29
2700	2700	to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 30
2701	2701	(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 31
2702	2702	thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 32
2703	2703	committee on health and human services, and the house committee on corporations, with: (1) 33
2704	2704	Information on the availability in the commercial market of coverage for anti-cancer medication 34
2705	2705
2706	2706
2707	2707	LC001777 - Page 74 of 96
2708	2708	options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 1
2709	2709	options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 2
2710	2710	utilization and cost-sharing expense. 3
2711	2711	(j) To monitor the adequacy of each health plan’s compliance with the provisions of the 4
2712	2712	federal Mental Health Parity Act, including a review of related claims processing and 5
2713	2713	reimbursement procedures. Findings, recommendations, and assessments shall be made available 6
2714	2714	to the public. 7
2715	2715	(k) To monitor the prevent by regulation transition from fee-for-service and toward global 8
2716	2716	and other alternative payment methodologies for the payment for healthcare services that the health 9
2717	2717	insurance commissioner shall deem against the interest of public health. The health insurance 10
2718	2718	commissioner shall have no power to impose, encourage, or in any way incentivize any rate caps, 11
2719	2719	global budgets, episode-based payments, or capitation structures in the payment models utilized in 12
2720	2720	contracts between health insurers and providers. Alternative payment methodologies should be 13
2721	2721	assessed for their likelihood to promote damage access to affordable health insurance care, health 14
2722	2722	outcomes, and performance. 15
2723	2723	(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 16
2724	2724	payment variation, including findings and recommendations, subject to available resources. 17
2725	2725	(m) Notwithstanding any provision of the general or public laws or regulation to the 18
2726	2726	contrary, provide a report with findings and recommendations to the president of the senate and the 19
2727	2727	speaker of the house, on or before April 1, 2014, including, but not limited to, the following 20
2728	2728	information: 21
2729	2729	(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 22
2730	2730	27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-23
2731	2731	18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 24
2732	2732	insurance for fully insured employers, subject to available resources; 25
2733	2733	(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 26
2734	2734	the existing standards of care and/or delivery of services in the healthcare system; 27
2735	2735	(3) A state-by-state comparison of health insurance mandates and the extent to which 28
2736	2736	Rhode Island mandates exceed other states benefits; and 29
2737	2737	(4) Recommendations for amendments to existing mandated benefits based on the findings 30
2738	2738	in (m)(1), (m)(2), and (m)(3) above. 31
2739	2739	(n) On or before July 1, 2014, the office of the health insurance commissioner, in 32
2740	2740	collaboration with the director of health and lieutenant governor’s office, shall submit a report to 33
2741	2741	the general assembly and the governor to inform the design of accountable care organizations 34
2742	2742
2743	2743
2744	2744	LC001777 - Page 75 of 96
2745	2745	(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-1
2746	2746	based payment arrangements, that shall include, but not be limited to: 2
2747	2747	(1) Utilization review; 3
2748	2748	(2) Contracting; and 4
2749	2749	(3) Licensing and regulation. 5
2750	2750	(o) On or before February 3, 2015, the office of the health insurance commissioner shall 6
2751	2751	submit a report to the general assembly and the governor that describes, analyzes, and proposes 7
2752	2752	recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 8
2753	2753	to patients with mental health and substance use disorders. 9
2754	2754	(p) To work to ensure the health insurance coverage of behavioral health care under the 10
2755	2755	same terms and conditions as other health care, and to integrate behavioral health parity 11
2756	2756	requirements into the office of the health insurance commissioner insurance oversight and health 12
2757	2757	care transformation efforts. 13
2758	2758	(q) To work with other state agencies to seek delivery system improvements that enhance 14
2759	2759	access to a continuum of mental health and substance use disorder treatment in the state; and 15
2760	2760	integrate that treatment with primary and other medical care to the fullest extent possible. 16
2761	2761	(r) To direct insurers toward policies and practices that address the behavioral health needs 17
2762	2762	of the public and greater integration of physical and behavioral healthcare delivery. 18
2763	2763	(s) The office of the health insurance commissioner shall conduct an analysis of the impact 19
2764	2764	of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 20
2765	2765	submit a report of its findings to the general assembly on or before June 1, 2023. 21
2766	2766	(t) To undertake the analyses, reports, and studies contained in this section: 22
2767	2767	(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 23
2768	2768	and competent firm or firms to undertake the following analyses, reports, and studies: 24
2769	2769	(i) The firm shall undertake a comprehensive review of all social and human service 25
2770	2770	programs having a contract with or licensed by the state or any subdivision of the department of 26
2771	2771	children, youth and families (DCYF), the department of behavioral healthcare, developmental 27
2772	2772	disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 28
2773	2773	health (DOH), and Medicaid for the purposes of: 29
2774	2774	(A) Establishing a baseline of the eligibility factors for receiving services; 30
2775	2775	(B) Establishing a baseline of the service offering through each agency for those 31
2776	2776	determined eligible; 32
2777	2777	(C) Establishing a baseline understanding of reimbursement rates for all social and human 33
2778	2778	service programs including rates currently being paid, the date of the last increase, and a proposed 34
2779	2779
2780	2780
2781	2781	LC001777 - Page 76 of 96
2782	2782	model that the state may use to conduct future studies and analyses; 1
2783	2783	(D) Ensuring accurate and adequate reimbursement to social and human service providers 2
2784	2784	that facilitate the availability of high-quality services to individuals receiving home and 3
2785	2785	community-based long-term services and supports provided by social and human service providers; 4
2786	2786	(E) Ensuring the general assembly is provided accurate financial projections on social and 5
2787	2787	human service program costs, demand for services, and workforce needs to ensure access to entitled 6
2788	2788	beneficiaries and services; 7
2789	2789	(F) Establishing a baseline and determining the relationship between state government and 8
2790	2790	the provider network including functions, responsibilities, and duties; 9
2791	2791	(G) Determining a set of measures and accountability standards to be used by EOHHS and 10
2792	2792	the general assembly to measure the outcomes of the provision of services including budgetary 11
2793	2793	reporting requirements, transparency portals, and other methods; and 12
2794	2794	(H) Reporting the findings of human services analyses and reports to the speaker of the 13
2795	2795	house, senate president, chairs of the house and senate finance committees, chairs of the house and 14
2796	2796	senate health and human services committees, and the governor. 15
2797	2797	(2) The analyses, reports, and studies required pursuant to this section shall be 16
2798	2798	accomplished and published as follows and shall provide: 17
2799	2799	(i) An assessment and detailed reporting on all social and human service program rates to 18
2800	2800	be completed by January 1, 2023, including rates currently being paid and the date of the last 19
2801	2801	increase; 20
2802	2802	(ii) An assessment and detailed reporting on eligibility standards and processes of all 21
2803	2803	mandatory and discretionary social and human service programs to be completed by January 1, 22
2804	2804	2023; 23
2805	2805	(iii) An assessment and detailed reporting on utilization trends from the period of January 24
2806	2806	1, 2017, through December 31, 2021, for social and human service programs to be completed by 25
2807	2807	January 1, 2023; 26
2808	2808	(iv) An assessment and detailed reporting on the structure of the state government as it 27
2809	2809	relates to the provision of services by social and human service providers including eligibility and 28
2810	2810	functions of the provider network to be completed by January 1, 2023; 29
2811	2811	(v) An assessment and detailed reporting on accountability standards for services for social 30
2812	2812	and human service programs to be completed by January 1, 2023; 31
2813	2813	(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 32
2814	2814	and unlicensed personnel requirements for established rates for social and human service programs 33
2815	2815	pursuant to a contract or established fee schedule; 34
2816	2816
2817	2817
2818	2818	LC001777 - Page 77 of 96
2819	2819	(vii) An assessment and reporting on access to social and human service programs, to 1
2820	2820	include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 2
2821	2821	(viii) An assessment and reporting of national and regional Medicaid rates in comparison 3
2822	2822	to Rhode Island social and human service provider rates by April 1, 2023; 4
2823	2823	(ix) An assessment and reporting on usual and customary rates paid by private insurers and 5
2824	2824	private pay for similar social and human service providers, both nationally and regionally, by April 6
2825	2825	1, 2023; and 7
2826	2826	(x) Completion of the development of an assessment and review process that includes the 8
2827	2827	following components: eligibility; scope of services; relationship of social and human service 9
2828	2828	provider and the state; national and regional rate comparisons and accountability standards that 10
2829	2829	result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 11
2830	2830	and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 12
2831	2831	requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 13
2832	2832	1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 14
2833	2833	results and findings of this process shall be transparent, and public meetings shall be conducted to 15
2834	2834	allow providers, recipients, and other interested parties an opportunity to ask questions and provide 16
2835	2835	comment beginning in September 2023 and biennially thereafter. 17
2836	2836	(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 18
2837	2837	insurance commissioner shall consult with the Executive Office of Health and Human Services. 19
2838	2838	(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 20
2839	2839	include the corresponding components of the assessment and review (i.e., eligibility; scope of 21
2840	2840	services; relationship of social and human service provider and the state; and national and regional 22
2841	2841	rate comparisons and accountability standards including any changes or substantive issues between 23
2842	2842	biennial reviews) including the recommended rates from the most recent assessment and review 24
2843	2843	with their annual budget submission to the office of management and budget and provide a detailed 25
2844	2844	explanation and impact statement if any rate variances exist between submitted recommended 26
2845	2845	budget and the corresponding recommended rate from the most recent assessment and review 27
2846	2846	process starting October 1, 2023, and biennially thereafter. 28
2847	2847	(v) The general assembly shall appropriate adequate funding as it deems necessary to 29
2848	2848	undertake the analyses, reports, and studies contained in this section relating to the powers and 30
2849	2849	duties of the office of the health insurance commissioner. 31
2850	2850	(w) To approve or deny any compensation of employees of health insurers subject to the 32
2851	2851	laws of the State of Rhode Island in excess of one million dollars ($1,000,000) per employee. 33
2852	2852	(x) To approve or deny any dividends or stock buybacks of health insurers subject to the 34
2853	2853
2854	2854
2855	2855	LC001777 - Page 78 of 96
2856	2856	laws of the State of Rhode Island. 1
2857	2857	SECTION 20. Section 44-17-1 of the General Laws in Chapter 44-17 entitled "Taxation of 2
2858	2858	Insurance Companies" is hereby amended to read as follows: 3
2859	2859	44-17-1. Companies required to file -- Payment of tax -- Retaliatory rates. 4
2860	2860	(a) Every domestic, foreign, or alien insurance company, mutual association, organization, 5
2861	2861	or other insurer, including any health maintenance organization as defined in § 27-41-2, any 6
2862	2862	medical malpractice insurance joint underwriters association as defined in § 42-14.1-1, any 7
2863	2863	nonprofit dental service corporation as defined in § 27-20.1-2 and any nonprofit hospital or medical 8
2864	2864	service corporation as defined in chapters 19 and 20 of title 27, except companies mentioned in § 9
2865	2865	44-17-6 and organizations defined in § 27-25-1, transacting business in this state, shall, on or before 10
2866	2866	April 15 in each year, file with the tax administrator, in the form that he or she may prescribe, a 11
2867	2867	return under oath or affirmation signed by a duly authorized officer or agent of the company, 12
2868	2868	containing information that may be deemed necessary for the determination of the tax imposed by 13
2869	2869	this chapter, and shall at the same time pay an annual tax to the tax administrator of two percent 14
2870	2870	(2%) three percent (3%) of the gross premiums on contracts of insurance, except for ocean marine 15
2871	2871	insurance as referred to in § 44-17-6, covering property and risks within the state, written during 16
2872	2872	the calendar year ending December 31st next preceding. 17
2873	2873	(b) Qualifying insurers for purposes of this section means every domestic, foreign, or alien 18
2874	2874	insurance company, mutual association, organization, or other insurer and excludes: 19
2875	2875	(1) Health maintenance organizations, as defined in § 27-41-2; 20
2876	2876	(2) Nonprofit dental service corporations, as defined in § 27-20.1-2; and 21
2877	2877	(3) Nonprofit hospital or medical service corporations, as defined in §§ 27-19-1 and 27-22
2878	2878	20-1. 23
2879	2879	(c) For tax years 2018 and thereafter, the rate of taxation may be reduced as set forth below 24
2880	2880	and, if so reduced, shall be fully applicable to qualifying insurers instead of the two percent (2%) 25
2881	2881	rate listed in subsection (a). In the case of foreign or alien companies, except as provided in § 27-26
2882	2882	2-17(d), the tax shall not be less in amount than is imposed by the laws of the state or country under 27
2883	2883	which the companies are organized upon like companies incorporated in this state or upon its 28
2884	2884	agents, if doing business to the same extent in the state or country. The tax rate shall not be reduced 29
2885	2885	for gross premiums written on contracts of health insurance as defined in § 42-14-5(c) but shall 30
2886	2886	remain at two percent (2%) three percent (3%) or the appropriate retaliatory tax rate, whichever is 31
2887	2887	higher. 32
2888	2888	(d) For qualifying insurers, the premium tax rate may be decreased based upon Rhode 33
2889	2889	Island jobs added by the industry as detailed below: 34
2890	2890
2891	2891
2892	2892	LC001777 - Page 79 of 96
2893	2893	(1) A committee shall be established for the purpose of implementing tax rates using the 1
2894	2894	framework established herein. The committee shall be comprised of the following persons or their 2
2895	2895	designees: the secretary of commerce, the director of the department of business regulation, the 3
2896	2896	director of the department of revenue, and the director of the office of management and budget. No 4
2897	2897	rule may be issued pursuant to this section without the prior, unanimous approval of the committee; 5
2898	2898	(2) On the timetable listed below, the committee shall determine whether qualifying 6
2899	2899	insurers have added new qualifying jobs in this state in the preceding calendar year. A qualifying 7
2900	2900	job for purposes of this section is any employee with total annual wages equal to or greater than 8
2901	2901	forty percent (40%) of the average annual wages of the Rhode Island insurance industry, as 9
2902	2902	published by the annual employment and wages report of the Rhode Island department of labor and 10
2903	2903	training, in NAICS code 5241; 11
2904	2904	(3) If the committee determines that there has been a sufficient net increase in qualifying 12
2905	2905	jobs in the preceding calendar year(s) to offset a material reduction in the premium tax, it shall 13
2906	2906	calculate a reduced premium tax rate. Such rate shall be determined via a method selected by the 14
2907	2907	committee and designed such that the estimated personal income tax generated by the increase in 15
2908	2908	qualifying jobs is at least one hundred and twenty-five percent (125%) of the anticipated reduction 16
2909	2909	in premium tax receipts resulting from the new rate. For purposes of this calculation, the committee 17
2910	2910	may consider personal income tax withholdings or receipts, but in no event may the committee 18
2911	2911	include for the purposes of determining revenue neutrality income taxes that are subject to 19
2912	2912	segregation pursuant to § 44-48.3-8(f) or that are otherwise available to the general fund; 20
2913	2913	(4) Any reduced rate established pursuant to this section must be established in a 21
2914	2914	rulemaking proceeding pursuant to chapter 35 of title 42, subject to the following conditions: 22
2915	2915	(i) Any net increase in qualifying jobs and the resultant premium tax reduction and revenue 23
2916	2916	impact shall be determined in any rulemaking proceeding conducted under this section and shall 24
2917	2917	be set forth in a report included in the rulemaking record, which report shall also include a 25
2918	2918	description of the data sources and calculation methods used. The first such report shall also include 26
2919	2919	a calculation of the baseline level of employment of qualifying insurers for the calendar year 2015; 27
2920	2920	and 28
2921	2921	(ii) Notwithstanding any provision of the law to the contrary, no rule changing the tax rate 29
2922	2922	shall take effect until one hundred and twenty (120) days after notice of the rate change is provided 30
2923	2923	to the speaker of the house, the president of the senate, the house and senate fiscal advisors, and 31
2924	2924	the auditor general, which notice shall include the report required under the preceding provision. 32
2925	2925	(5) For each of the first three (3) rulemaking proceedings required under this section, the 33
2926	2926	tax rate may remain unchanged or be decreased consistent with the requirements of this section, 34
2927	2927
2928	2928
2929	2929	LC001777 - Page 80 of 96
2930	2930	but may not be increased. These first three (3) rulemaking proceedings shall be conducted by the 1
2931	2931	division of taxation and occur in the following manner: 2
2932	2932	(i) The first rulemaking proceeding shall take place in calendar year 2017. This proceeding 3
2933	2933	shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the requirements 4
2934	2934	of this section, which rate shall take effect in 2018, and (B) A method for calculating the number 5
2935	2935	of jobs at qualifying insurers; 6
2936	2936	(ii) The second rulemaking proceeding shall take place in calendar year 2018. This 7
2937	2937	proceeding shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the 8
2938	2938	requirements of this section, which rate shall take effect in 2019, and (B) The changes, if any, to 9
2939	2939	the method for calculating the number of jobs at qualifying insurers; and 10
2940	2940	(iii) The third rulemaking proceeding shall take place in calendar year 2019. This 11
2941	2941	proceeding shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the 12
2942	2942	requirements of this section, which rate shall take effect in 2020, and (B) The changes, if any, to 13
2943	2943	the method for calculating the number of jobs at qualifying insurers. 14
2944	2944	(6) The tax rate established in the regulation following regulatory proceedings that take 15
2945	2945	place in 2019 shall remain in effect through and including 2023. In calendar year 2023, the 16
2946	2946	department of business regulation will conduct a rulemaking proceeding and issue a rule that sets 17
2947	2947	forth: (A) A new premium tax rate, if allowed under the requirements of this section, which rate 18
2948	2948	shall take effect in 2024, and (B) The changes, if any, to the method for calculating the number of 19
2949	2949	jobs at qualifying insurers. A rule issued by the department of business regulation may decrease 20
2950	2950	the tax rate if the requirements for a rate reduction contained in this section are met, or it may 21
2951	2951	increase the tax rate to the extent necessary to achieve the overall revenue level sought when the 22
2952	2952	then-existing tax rate was established. Any rate established shall be no lower than one percent (1%) 23
2953	2953	and no higher than two percent (2%). This proceeding shall be repeated every three (3) calendar 24
2954	2954	years thereafter, however, the base for determination of job increases or decreases shall remain the 25
2955	2955	number of jobs existing during calendar year 2022; 26
2956	2956	(7) No reduction in the premium tax rate pursuant to this section shall be allowed absent a 27
2957	2957	determination that qualifying insurers have added in this state at least three hundred fifty (350) 28
2958	2958	new, full-time, qualifying jobs above the baseline level of employment of qualifying insurers for 29
2959	2959	the calendar year 2015; 30
2960	2960	(8) Notwithstanding any provision of this section to the contrary, the premium tax rate shall 31
2961	2961	never be set lower than one percent (1%); 32
2962	2962	(9) The division of taxation may adopt implementation guidelines, directives, criteria, rules 33
2963	2963	and regulations pursuant to chapter 35 of title 42 as are necessary to implement this section; and 34
2964	2964
2965	2965
2966	2966	LC001777 - Page 81 of 96
2967	2967	(10) The calculation of revenue impacts under this section is at the sole discretion of the 1
2968	2968	committee established under subsection (d)(1). Notwithstanding any provision of law to the 2
2969	2969	contrary, any administrative action or rule setting a tax rate pursuant to this section or failing or 3
2970	2970	declining to alter a tax rate pursuant to this section shall not be subject to judicial review under 4
2971	2971	chapter 35 of title 42. 5
2972	2972	(d) The department of revenue shall calculate the impacts of changes made to Medicaid 6
2973	2973	taking effect in fiscal year two thousand twenty three (FY2023) on state funds, excluding increased 7
2974	2974	federal reimbursements, hereinafter the "FY23 Medicaid adjustment." Should the Medicaid 8
2975	2975	adjustment exceed the revenue impact of raising the gross premiums tax rate from two percent (2%) 9
2976	2976	to three percent (3%), hereinafter the "insurance premium tax rate adjustment revenue bonus" 10
2977	2977	surtax shall be imposed on gross premiums written on contracts of health insurance as defined in § 11
2978	2978	42-14-5(c) at the rate that shall raise aggregate revenue equal to the Medicaid adjustment minus 12
2979	2979	the insurance premium tax rate adjustment revenue bonus. 13
2980	2980	SECTION 21. Section 44-51-3 of the General Laws in Chapter 44-51 entitled "Nursing 14
2981	2981	Facility Provider Assessment Act" is hereby amended to read as follows: 15
2982	2982	44-51-3. Imposition of assessment -- Nursing facilities. 16
2983	2983	(a) For purposes of this section, a "nursing facility" means a person or governmental unit 17
2984	2984	licensed in accordance with chapter 17 of title 23 to establish, maintain, and operate a nursing 18
2985	2985	facility. 19
2986	2986	(b) An assessment is imposed upon the gross patient revenue received by every nursing 20
2987	2987	facility in each month beginning January 1, 2008, at a rate of five and one-half percent (5.5%) six 21
2988	2988	percent (6%) for services provided on or after January 1, 2008. Every provider shall pay the 22
2989	2989	monthly assessment no later than the twenty-fifth (25th) day of each month following the month of 23
2990	2990	receipt of gross patient revenue. 24
2991	2991	(c) The assessment imposed by this section shall be repealed on the effective date of the 25
2992	2992	repeal or a restricted amendment of those provisions of the Medicaid Voluntary Contribution and 26
2993	2993	Provider-Specific Tax Amendments of 1991 (P.L. 102-234) that permit federal financial 27
2994	2994	participation to match state funds generated by taxes. 28
2995	2995	(d) If, after applying the applicable federal law and/or rules, regulations, or standards 29
2996	2996	relating to health care providers, the tax administrator determines that the assessment rate 30
2997	2997	established in subsection (b) of this section exceeds the maximum rate of assessment that federal 31
2998	2998	law will allow without reduction in federal financial participation, then the tax administrator is 32
2999	2999	directed to reduce the assessment to a rate equal to the maximum rate which the federal law will 33
3000	3000	allow without reduction in federal participation. Provided, however, that the authority of the tax 34
3001	3001
3002	3002
3003	3003	LC001777 - Page 82 of 96
3004	3004	administrator to lower the assessment rate established in subsection (b) of this section shall be 1
3005	3005	limited solely to such determination. 2
3006	3006	(e) In order that the tax administrator may properly carry out his/her responsibilities under 3
3007	3007	this section, the director of the department of human services shall notify the tax administrator of 4
3008	3008	any damages in federal law and/or any rules, regulations, or standards which affect any rates for 5
3009	3009	health care provider assessments. 6
3010	3010	SECTION 22. Title 44 of the General Laws entitled "TAXATION" is hereby amended by 7
3011	3011	adding thereto the following chapter: 8
3012	3012	CHAPTER 71 9
3013	3013	PRIVATE HEALTH CARE PROVIDERS ASSESSMENT ACT 10
3014	3014	44-71-1. Short title. 11
3015	3015	This chapter shall be known and may be cited as the "Private Health Care Providers 12
3016	3016	Assessment Act." 13
3017	3017	44-71-2. Definitions. 14
3018	3018	Except where the context otherwise requires, the following words and phrases as used in 15
3019	3019	this chapter shall have the following meaning: 16
3020	3020	(1) "Administrator" means the tax administrator. 17
3021	3021	(2) "Assessment" means the assessment imposed upon gross patient revenue pursuant to 18
3022	3022	this chapter. 19
3023	3023	(3) "Eligible provider" means a privately operated health care facility, which is eligible for 20
3024	3024	taxation up to six percent (6%) of gross patient revenue pursuant to 42 CFR 433.68. Nursing 21
3025	3025	facilities taxed pursuant to § 44-51-3 and hospital facilities taxed pursuant to § 23-17-38.1 shall not 22
3026	3026	be considered providers subject to taxation under this chapter. 23
3027	3027	(4) "Gross patient revenue" means the gross amount received on a cash basis by the 24
3028	3028	provider from all patient care services. Charitable contributions, donated goods and services, fund 25
3029	3029	raising proceeds, endowment support, income from meals on wheels, income from investments, 26
3030	3030	and other nonpatient revenues defined by the tax administrator upon the recommendation of the 27
3031	3031	department of human services shall not be considered as "gross patient revenue". 28
3032	3032	(5) "Person" means any individual, corporation, company, association, partnership, joint 29
3033	3033	stock association, and the legal successor thereof. 30
3034	3034	44-71-3. Imposition of assessment. 31
3035	3035	(a) An assessment is imposed upon the gross patient revenue received by every eligible 32
3036	3036	provider in each month beginning July 1, 2023, at a rate of six percent (6%) for services provided 33
3037	3037	on or after July 1, 2023. Every eligible provider shall pay the monthly assessment no later than the 34
3038	3038
3039	3039
3040	3040	LC001777 - Page 83 of 96
3041	3041	twenty-fifth day of each month following the month of receipt of gross patient revenue. 1
3042	3042	(b) The assessment rate established in subsection (a) of this section shall be reduced by the 2
3043	3043	effective rate of any tax subject to the six percent (6%) limit established pursuant to 42 CFR 433.68 3
3044	3044	imposed on the eligible provider in other chapters of the general laws in order that the total 4
3045	3045	aggregate tax shall be at a rate of six percent (6%). 5
3046	3046	(c) If, after applying the applicable federal law and/or rules, regulations, or standards 6
3047	3047	relating to health care providers, the tax administrator determines that the assessment rate 7
3048	3048	established in subsection (a) of this section exceeds the maximum rate of assessment that federal 8
3049	3049	law will allow without reduction in federal financial participation, then the tax administrator is 9
3050	3050	directed to reduce the assessment to a rate equal to the maximum rate which the federal law will 10
3051	3051	allow without reduction in federal participation. Provided, however, that the authority of the tax 11
3052	3052	administrator to lower the assessment rate established in subsection (a) of this section shall be 12
3053	3053	limited solely to such determination. In order that the tax administrator may properly carry out 13
3054	3054	his/her responsibilities under this section, the director of the department of human services shall 14
3055	3055	notify the tax administrator of any changes in federal law and/or any rules, regulations, or standards 15
3056	3056	which affect any rates for health care provider assessments. 16
3057	3057	44-71-4. Returns. 17
3058	3058	(a) Every eligible provider shall on or before the twenty-fifth day of the month following 18
3059	3059	the month of receipt of gross patient revenue make a return to the tax administrator. 19
3060	3060	(b) The tax administrator shall adopt rules, pursuant to this chapter, relative to the form of 20
3061	3061	the return and the data which it must contain for the correct computation of gross patient revenue 21
3062	3062	and the assessment upon that amount. All returns shall be signed by the eligible provider or by its 22
3063	3063	authorized representative, subject to the pains and penalties of perjury. If a return shows an 23
3064	3064	overpayment of the assessment due, the tax administrator shall refund or credit the overpayment to 24
3065	3065	the eligible provider. 25
3066	3066	(c) For good cause, the tax administrator may extend the time within which an eligible 26
3067	3067	provider is required to file a return, and if the return is filed during the period of extension, no 27
3068	3068	penalty or late filing charge may be imposed for failure to file the return at the time required by this 28
3069	3069	chapter, but the provider may be liable for interest as prescribed in this chapter. Failure to file the 29
3070	3070	return during the period for the extension shall void the extension. 30
3071	3071	44-71-5. Set-off for delinquent assessments. 31
3072	3072	If an eligible provider shall fail to pay an assessment within thirty (30) days of its due date, 32
3073	3073	the tax administrator may request any agency of state government making payments to the eligible 33
3074	3074	provider to set off the amount of the delinquency against any payment due the provider from the 34
3075	3075
3076	3076
3077	3077	LC001777 - Page 84 of 96
3078	3078	agency of state government and remit the sum to the tax administrator. Upon receipt of the set off 1
3079	3079	request from the tax administrator, any agency of state government is authorized and empowered 2
3080	3080	to set off the amount of the delinquency against any payment or amounts due the eligible provider. 3
3081	3081	The amount of set-off shall be credited against the assessment due from the eligible provider. 4
3082	3082	44-71-6. Assessment on available information -- Interest on delinquencies -- Penalties 5
3083	3083	-- Collection powers. 6
3084	3084	If any eligible provider shall fail to file a return within the time required by this chapter, or 7
3085	3085	shall file an insufficient or incorrect return, or shall not pay the assessment imposed by this chapter 8
3086	3086	when it is due, the tax administrator shall assess upon the information as may be available, which 9
3087	3087	shall be payable upon demand and shall bear interest at the annual rate provided by § 44-1-7 from 10
3088	3088	the date when the assessment should have been paid. If any part of the assessment made is due to 11
3089	3089	negligence or intentional disregard of the provisions of this chapter, a penalty of ten percent (10%) 12
3090	3090	of the amount of the determination shall be added to the assessment. The tax administrator shall 13
3091	3091	collect the assessment with interest in the same manner and with the same powers as are prescribed 14
3092	3092	for collection of taxes in this title. 15
3093	3093	44-71-7. Claims for refund -- Hearing upon denial. 16
3094	3094	(a) Any eligible provider subject to the provisions of this chapter may file a claim for refund 17
3095	3095	with the tax administrator at any time within two (2) years after the assessment has been paid. If 18
3096	3096	the tax administrator shall determine that the assessment has been overpaid, he or she shall make a 19
3097	3097	refund with interest from the date of overpayment. 20
3098	3098	(b) Any eligible provider whose claim for refund has been denied may, within thirty (30) 21
3099	3099	days from the date of the mailing by the tax administrator of the notice of the decision, request a 22
3100	3100	hearing and the tax administrator shall, as soon as practicable, set a time and place for the hearing 23
3101	3101	and shall notify the eligible provider. 24
3102	3102	44-71-8. Hearing by administrator on application. 25
3103	3103	Any eligible provider aggrieved by the action of the tax administrator in determining the 26
3104	3104	amount of any assessment or penalty imposed under the provisions of this chapter may apply to the 27
3105	3105	tax administrator, in writing, within thirty (30) days after the notice of the action is mailed to it, for 28
3106	3106	a hearing relative to the assessment or penalty. The tax administrator shall fix a time and place for 29
3107	3107	the hearing and shall notify the provider. Upon the hearing, the tax administrator shall correct 30
3108	3108	manifest errors, if any, disclosed at the hearing and assess and collect the amount lawfully due 31
3109	3109	together with any penalty or interest. 32
3110	3110	44-71-9. Appeals. 33
3111	3111	Appeals from administrative orders or decisions made pursuant to any provisions of this 34
3112	3112
3113	3113
3114	3114	LC001777 - Page 85 of 96
3115	3115	chapter shall be to the sixth division district court pursuant to §§ 8-8-24 through 8-8-29. The eligible 1
3116	3116	provider's right to appeal under this section shall be expressly made conditional upon prepayment 2
3117	3117	of all assessments, interest, and penalties unless the provider moves for and is granted an exemption 3
3118	3118	from the prepayment requirement pursuant to § 8-8-26. If the court, after appeal, holds that the 4
3119	3119	eligible provider is entitled to a refund, the eligible provider shall also be paid interest on the amount 5
3120	3120	at the rate provided in § 44-1-7.1. 6
3121	3121	44-71-10. Eligible provider records. 7
3122	3122	Every eligible provider shall: 8
3123	3123	(1) Keep records as may be necessary to determine the amount of its liability under this 9
3124	3124	chapter. 10
3125	3125	(2) Preserve those records for the period of three (3) years following the date of filing of 11
3126	3126	any return required by this chapter, or until any litigation or prosecution under this chapter is finally 12
3127	3127	determined. 13
3128	3128	(3) Make those records available for inspection by the tax administrator or the 14
3129	3129	administrator's authorized agents, upon demand, at reasonable times during regular business hours. 15
3130	3130	44-71-11. Method of payment and deposit of assessment. 16
3131	3131	(a) The payments required by this chapter may be made by electronic transfer of monies to 17
3132	3132	the general treasurer and deposited to the general fund. 18
3133	3133	(b) The general treasurer is authorized to establish an account or accounts and to take all 19
3134	3134	steps necessary to facilitate the electronic transfer of monies. The general treasurer shall provide 20
3135	3135	the tax administrator with a record of any monies transferred and deposited. 21
3136	3136	44-71-12. Rules and regulations. 22
3137	3137	The tax administrator shall make and promulgate rules, regulations, and procedures not 23
3138	3138	inconsistent with state law and fiscal procedures as the tax administrator deems necessary for the 24
3139	3139	proper administration of this chapter and to implement the provisions, policy, and purposes of this 25
3140	3140	chapter. 26
3141	3141	44-71-13. Release of assessment information. 27
3142	3142	Notwithstanding any other provisions of the general laws, the tax administrator shall not 28
3143	3143	be prohibited from providing assessment information to the director of the department of human 29
3144	3144	services or his or her designee, with respect to the assessment imposed by this chapter; provided 30
3145	3145	that, the director of human services and the director's agents and employees may use or disclose 31
3146	3146	that information only for purposes directly connected with the administration of the duties and 32
3147	3147	programs of the department of human services. 33
3148	3148	44-71-14. Severability. 34
3149	3149
3150	3150
3151	3151	LC001777 - Page 86 of 96
3152	3152	If any provision of this chapter or the application of this chapter to any person or 1
3153	3153	circumstances is held invalid, that invalidity shall not affect other provisions or applications of the 2
3154	3154	chapter which can be given effect without the invalid provision or application, and to this end the 3
3155	3155	provisions of this chapter are declared to be severable. 4
3156	3156	SECTION 23. Relating to Capital Development Programs - Statewide Referendum. 5
3157	3157	Section 1. Proposition to be submitted to the people. -- At the general election to be held 6
3158	3158	on the Tuesday next after the first Monday in November, 2024, there shall be submitted to the 7
3159	3159	people of the State of Rhode Island, for their approval or rejection, the following proposition: 8
3160	3160	"Shall the action of the general assembly, by an act passed at the January 2023 session, 9
3161	3161	authorizing the issuance of a bond, refunding bond, and/or temporary note of the State of Rhode 10
3162	3162	Island for the local capital projects and in the total amount with respect to the projects listed below 11
3163	3163	be approved, and the issuance of a bond, refunding bond, and/or temporary note authorized in 12
3164	3164	accordance with the provisions of said act? 13
3165	3165	Funding 14
3166	3166	The bond, refunding bond and/or temporary note shall be allocated to the Medicaid office 15
3167	3167	for oversight of the funds. 16
3168	3168	Project 17
3169	3169	(1) Group homes, assisted living facilities, and recovery beds $300,000,000 18
3170	3170	Approval of this question will allow the State of Rhode Island to issue general obligation 19
3171	3171	bonds, refunding bonds, and/or temporary notes in an amount not to exceed three hundred million 20
3172	3172	dollars ($300,000,000) for expansion of and investment in Rhode Island Community Living and 21
3173	3173	Supports. One hundred million dollars ($100,000,000) shall be allocated for investment in and 22
3174	3174	expansion of state group homes operated by Rhode Island Community Living and Supports. One 23
3175	3175	hundred million dollars ($100,000,000) shall be allocated for the construction of assisted living-24
3176	3176	level care facilities for people with mental illnesses and developmental disabilities operated by 25
3177	3177	Rhode Island Community Living and Supports for persons who are eligible for Medicaid. One 26
3178	3178	hundred million dollars ($100,000,000) shall be allocated for the construction of inpatient recovery 27
3179	3179	facilities operated by Rhode Island Community Living and Supports for persons who are eligible 28
3180	3180	for Medicaid and suffering from substance abuse issues in need of inpatient recovery services. 29
3181	3181	None of these funds may be allocated to private facilities. 30
3182	3182	(2) Hospital facilities expansion $50,000,000 31
3183	3183	Approval of this question will allow the State of Rhode Island to issue general obligation 32
3184	3184	bonds, refunding bonds, and/or temporary notes in an amount not to exceed fifty million dollars 33
3185	3185	($50,000,000) for the improvement of state operated hospital facilities. 34
3186	3186
3187	3187
3188	3188	LC001777 - Page 87 of 96
3189	3189	(3) University of Rhode Island Medical School $500,000,000 1
3190	3190	Approval of this question will allow the State of Rhode Island to issue a general obligation 2
3191	3191	bond, refunding bond, and/or temporary note in an amount not to exceed five hundred million 3
3192	3192	dollars ($500,000,000) for the construction of a medical school at the University of Rhode Island. 4
3193	3193	The Medicaid office shall work with the University of Rhode Island Medical School to establish a 5
3194	3194	reasonable annual contribution to fund the debt service on this bond from tuition revenue. While 6
3195	3195	these contributions shall continue until the entire debt service costs are paid, the Medicaid office 7
3196	3196	may allow for an amortization schedule that lasts for up to fifty (50) years." 8
3197	3197	Section 2. Ballot labels and applicability of general election laws. -- The secretary of state 9
3198	3198	shall prepare and deliver to the state board of elections ballot labels for each of the projects provided 10
3199	3199	for in Section 1 hereof with the designations "approve" or "reject" provided next to the description 11
3200	3200	of each such project to enable voters to approve or reject each such proposition. The general 12
3201	3201	election laws, so far as consistent herewith, shall apply to this proposition. 13
3202	3202	Section 3. Approval of projects by people. -- If a majority of the people voting on the 14
3203	3203	proposition in Section 1 hereof shall vote to approve any project stated therein, said project shall 15
3204	3204	be deemed to be approved by the people. The authority to issue bonds, refunding bonds and/or 16
3205	3205	temporary notes of the state shall be limited to the aggregate amount for all such projects as set 17
3206	3206	forth in the proposition, which have been approved by the people. 18
3207	3207	Section 4. Bonds for capital development program. -- The general treasurer is hereby 19
3208	3208	authorized and empowered, with the approval of the governor, and in accordance with the 20
3209	3209	provisions of this act to issue capital development bonds in serial form, in the name of and on behalf 21
3210	3210	of the State of Rhode Island, in amounts as may be specified by the governor in an aggregate 22
3211	3211	principal amount not to exceed the total amount for all projects approved by the people and 23
3212	3212	designated as "capital development loan of 2024 bonds." Provided, however, that the aggregate 24
3213	3213	principal amount of such capital development bonds and of any temporary notes outstanding at any 25
3214	3214	one time issued in anticipation thereof pursuant to Section 7 hereof shall not exceed the total amount 26
3215	3215	for all such projects approved by the people. All provisions in this act relating to "bonds" shall also 27
3216	3216	be deemed to apply to "refunding bonds." 28
3217	3217	Capital development bonds issued under this act shall be in denominations of one thousand 29
3218	3218	dollars ($1,000) each, or multiples thereof, and shall be payable in any coin or currency of the 30
3219	3219	United States which at the time of payment shall be legal tender for public and private debts. 31
3220	3220	These capital development bonds shall bear such date or dates, mature at specified time or 32
3221	3221	times, but not mature beyond the end of the twentieth state fiscal year following the fiscal year in 33
3222	3222	which they are issued; bear interest payable semi-annually at a specified rate or different or varying 34
3223	3223
3224	3224
3225	3225	LC001777 - Page 88 of 96
3226	3226	rates; be payable at designated time or times at specified place or places; be subject to express terms 1
3227	3227	of redemption or recall, with or without premium; be in a form, with or without interest coupons 2
3228	3228	attached; carry such registration, conversion, reconversion, transfer, debt retirement, acceleration 3
3229	3229	and other provisions as may be fixed by the general treasurer, with the approval of the governor, 4
3230	3230	upon each issue of such capital development bonds at the time of each issue. Whenever the 5
3231	3231	governor shall approve the issuance of such capital development bonds, the governor's approval 6
3232	3232	shall be certified to the secretary of state; the bonds shall be signed by the general treasurer and 7
3233	3233	countersigned by the secretary of state and shall bear the seal of the state. The signature approval 8
3234	3234	of the governor shall be endorsed on each bond. 9
3235	3235	Section 5. Refunding bonds for 2024 capital development program. -- The general treasurer 10
3236	3236	is hereby authorized and empowered, with the approval of the governor, and in accordance with 11
3237	3237	the provisions of this act, to issue bonds to refund the 2024 capital development program bonds, in 12
3238	3238	the name of and on behalf of the state, in amounts as may be specified by the governor in an 13
3239	3239	aggregate principal amount not to exceed the total amount approved by the people, to be designated 14
3240	3240	as "capital development program loan of 2024 refunding bonds" (hereinafter "refunding bonds"). 15
3241	3241	The general treasurer with the approval of the governor shall fix the terms and form of any 16
3242	3242	refunding bonds issued under this act in the same manner as the capital development bonds issued 17
3243	3243	under this act, except that the refunding bonds may not mature more than twenty (20) years from 18
3244	3244	the date of original issue of the capital development bonds being refunded. The proceeds of the 19
3245	3245	refunding bonds, exclusive of any premium and accrual interest and net the underwriters' cost, and 20
3246	3246	cost of bond insurance, shall, upon their receipt, be paid by the general treasurer immediately to 21
3247	3247	the paying agent for the capital development bonds which are to be called and prepaid. The paying 22
3248	3248	agent shall hold the refunding bond proceeds in trust until they are applied to prepay the capital 23
3249	3249	development bonds. While the proceeds are held in trust, the proceeds may be invested for the 24
3250	3250	benefit of the state in obligations of the United States of America or the State of Rhode Island. 25
3251	3251	If the general treasurer shall deposit with the paying agent for the capital development 26
3252	3252	bonds the proceeds of the refunding bonds, or proceeds from other sources, amounts that, when 27
3253	3253	invested in obligations of the United States or the State of Rhode Island, are sufficient to pay all 28
3254	3254	principal, interest, and premium, if any, on the capital development bonds until these bonds are 29
3255	3255	called for prepayment, then such capital development bonds shall not be considered debts of the 30
3256	3256	State of Rhode Island for any purpose starting from the date of deposit of such monies with the 31
3257	3257	paying agent. The refunding bonds shall continue to be a debt of the state until paid. 32
3258	3258	The term "bond" shall include "note," and the term "refunding bonds" shall include 33
3259	3259	"refunding notes" when used in this act. 34
3260	3260
3261	3261
3262	3262	LC001777 - Page 89 of 96
3263	3263	Section 6. Proceeds of capital development program. -- The general treasurer is directed to 1
3264	3264	deposit the proceeds from the sale of capital development bonds issued under this act, exclusive of 2
3265	3265	premiums and accrued interest and net the underwriters' cost, and cost of bond insurance, in one or 3
3266	3266	more of the depositories in which the funds of the state may be lawfully kept in special accounts 4
3267	3267	(hereinafter cumulatively referred to as "such capital development bond fund") appropriately 5
3268	3268	designated for each of the projects set forth in Section 1 hereof which shall have been approved by 6
3269	3269	the people to be used for the purpose of paying the cost of all such projects so approved. 7
3270	3270	All monies in the capital development bond fund shall be expended for the purposes 8
3271	3271	specified in the proposition provided for in Section 1 hereof under the direction and supervision of 9
3272	3272	the director of administration (hereinafter referred to as "director"). The director, or designee, shall 10
3273	3273	be vested with all power and authority necessary or incidental to the purposes of this act, including, 11
3274	3274	but not limited to, the following authority: 12
3275	3275	(1) To acquire land or other real property or any interest, estate, or right therein as may be 13
3276	3276	necessary or advantageous to accomplish the purposes of this act; 14
3277	3277	(2) To direct payment for the preparation of any reports, plans and specifications, and 15
3278	3278	relocation expenses and other costs such as for furnishings, equipment designing, inspecting, and 16
3279	3279	engineering, required in connection with the implementation of any projects set forth in Section 1 17
3280	3280	hereof; 18
3281	3281	(3) To direct payment for the costs of construction, rehabilitation, enlargement, provision 19
3282	3282	of service utilities, and razing of facilities, and other improvements to land in connection with the 20
3283	3283	implementation of any projects set forth in Section 1 hereof; and 21
3284	3284	(4) To direct payment for the cost of equipment, supplies, devices, materials, and labor for 22
3285	3285	repair, renovation, or conversion of systems and structures as necessary for the 2023 capital 23
3286	3286	development program bonds or notes hereunder from the proceeds thereof. No funds shall be 24
3287	3287	expended in excess of the amount of the capital development bond fund designated for each project 25
3288	3288	authorized in Section 1 hereof. 26
3289	3289	Section 7. Sale of bonds and notes. --Any bonds or notes issued under the authority of this 27
3290	3290	act shall be sold at not less than the principal amount thereof, in such mode and on such terms and 28
3291	3291	conditions as the general treasurer, with the approval of the governor, shall deem to be in the best 29
3292	3292	interests of the state. 30
3293	3293	Any bonds or notes issued under the provisions of this act and coupons on any capital 31
3294	3294	development bonds, if properly executed by the manual or electronic signatures of officers of the 32
3295	3295	state in office on the date of execution, shall be valid and binding according. to their tenor, 33
3296	3296	notwithstanding that before the delivery thereof and payment therefor, any or all such officers shall 34
3297	3297
3298	3298
3299	3299	LC001777 - Page 90 of 96
3300	3300	for any reason have ceased to hold office. 1
3301	3301	Section 8. Bonds and notes to be tax exempt and general obligations of the state. -- All 2
3302	3302	bonds and notes issued under the authority of this act shall be exempt from taxation in the state and 3
3303	3303	shall be general obligations of the state, and the full faith and credit of the state is hereby pledged 4
3304	3304	for the due payment of the principal and interest on each of such bonds and notes as the same shall 5
3305	3305	become due. 6
3306	3306	Section 9. Investment of monies in fund. -- All monies in the capital development fund not 7
3307	3307	immediately required for payment pursuant to the provisions of this act may be invested by the 8
3308	3308	investment commission, as established by chapter 10 of title 35, entitled "state investment 9
3309	3309	commission," pursuant to the provisions of such chapter; provided, however, that the securities in 10
3310	3310	which the capital development fund is invested shall remain a part of the capital development fund 11
3311	3311	until exchanged for other securities; and provided further, that the income from investments of the 12
3312	3312	capital development fund shall become a part of the general fund of the state and shall be applied 13
3313	3313	to the payment of debt service charges of the state, unless directed by federal law or regulation to 14
3314	3314	be used for some other purpose, or to the extent necessary, to rebate to the United States treasury 15
3315	3315	any income from investments (including gains from the disposition of investments) of proceeds of 16
3316	3316	bonds or notes to the extent deemed necessary to exempt (in whole or in part) the interest paid on 17
3317	3317	such bonds or notes from federal income taxation. 18
3318	3318	Section 10. Appropriation. -- To the extent the debt service on these bonds is not otherwise 19
3319	3319	provided, a sum sufficient to pay the interest and principal due each year on bonds and notes 20
3320	3320	hereunder is hereby annually appropriated out of any money in the treasury not otherwise 21
3321	3321	appropriated. 22
3322	3322	Section 11. Advances from general fund. -- The general treasurer is authorized, with the 23
3323	3323	approval of the director and the governor, in anticipation of the issuance of bonds or notes under 24
3324	3324	the authority of this act, to advance to the capital development bond fund for the purposes specified 25
3325	3325	in Section 1 hereof, any funds of the state not specifically held for any particular purpose; provided, 26
3326	3326	however, that all advances made to the capital development bond fund shall be returned to the 27
3327	3327	general fund from the capital development bond fund forthwith upon the receipt by the capital 28
3328	3328	development fund of proceeds resulting from the issue of bonds or notes to the extent of such 29
3329	3329	advances. 30
3330	3330	Section 12. Federal assistance and private funds. -- In carrying out this act, the director, or 31
3331	3331	designee, is authorized on behalf of the state, with the approval of the governor, to apply for and 32
3332	3332	accept any federal assistance which may become available for the purpose of this act, whether in 33
3333	3333	the form of a loan or grant or otherwise, to accept the provision of any federal legislation therefor, 34
3334	3334
3335	3335
3336	3336	LC001777 - Page 91 of 96
3337	3337	to enter into, act and carry out contracts in connection therewith, to act as agent for the federal 1
3338	3338	government in connection therewith, or to designate a subordinate so to act. Where federal 2
3339	3339	assistance is made available, the project shall be carried out in accordance with applicable federal 3
3340	3340	law, the rules and regulations thereunder and the contract or contracts providing for federal 4
3341	3341	assistance, notwithstanding any contrary provisions of state law. Subject to the foregoing, any 5
3342	3342	federal funds received for the purposes of this act shall be deposited in the capital development 6
3343	3343	bond fund and expended as a part thereof. The director or designee may also utilize any private 7
3344	3344	funds that may be made available for the purposes of this act. 8
3345	3345	Section 13. Effective Date. -- Sections 1, 2, 3, 11, 12 and 13 of this act shall take effect 9
3346	3346	upon passage. The remaining sections of this act shall take effect when and if the state board of 10
3347	3347	elections shall certify to the secretary of state that a majority of the qualified electors voting on the 11
3348	3348	proposition contained in Section 1 hereof have indicated their approval of all or any projects 12
3349	3349	thereunder. 13
3350	3350	SECTION 24. Rhode Island Medicaid Reform Act of 2008 Joint Resolution. 14
3351	3351	WHEREAS, The General Assembly enacted chapter 12.4 of title 42 entitled "The Rhode 15
3352	3352	Island Medicaid Reform Act of 2008"; and 16
3353	3353	WHEREAS, A legislative enactment is required pursuant to Rhode Island General Laws 17
3354	3354	chapter 12.4 of title 42; and 18
3355	3355	WHEREAS, Rhode Island General Laws § 42-7.2-5(3)(i) provides that the Secretary of the 19
3356	3356	Executive Office of Health and Human Services ("Executive Office") is responsible for the review 20
3357	3357	and coordination of any Medicaid section 1115 demonstration waiver requests and renewals as well 21
3358	3358	as any initiatives and proposals requiring amendments to the Medicaid state plan or category II or 22
3359	3359	III changes as described in the demonstration, "with potential to affect the scope, amount, or 23
3360	3360	duration of publicly-funded health care services, provider payments or reimbursements, or access 24
3361	3361	to or the availability of benefits and services provided by Rhode Island general and public laws"; 25
3362	3362	and 26
3363	3363	WHEREAS, In pursuit of a more cost-effective consumer choice system of care that is 27
3364	3364	fiscally sound and sustainable, the Secretary requests legislative approval of the following 28
3365	3365	proposals to amend the demonstration; and 29
3366	3366	WHEREAS, Implementation of adjustments may require amendments to Rhode Island's 30
3367	3367	Medicaid state plan and/or section 1115 waiver under the terms and conditions of the 31
3368	3368	demonstration. Further, adoption of new or amended rules, regulations and procedures may also be 32
3369	3369	required: 33
3370	3370	(a) Section 1115 Demonstration Waiver – Extension Request. The Executive Office 34
3371	3371
3372	3372
3373	3373	LC001777 - Page 92 of 96
3374	3374	proposes to seek approval from the federal Centers for Medicare and Medicaid Services ("CMS") 1
3375	3375	to extend the Medicaid section 1115 demonstration waiver as authorized in Rhode Island General 2
3376	3376	Laws Chapter 12.4 of Title 42. In the Medicaid section 1115 demonstration waiver extension 3
3377	3377	request due to CMS by December 31, 2023 in addition to maintaining existing Medicaid section 4
3378	3378	1115 demonstration waiver authorities, the Executive Office proposes to seek additional federal 5
3379	3379	authorities including, but not limited to, promoting choice and community integration. 6
3380	3380	(b) Raising Hospital Licensing Fee. The Secretary of the Executive Office is authorized to 7
3381	3381	pursue and implement any waiver amendments, state plan amendments, and/or changes to the 8
3382	3382	applicable department’s rules, regulations and procedures required to implement a hospital 9
3383	3383	licensing rate, including but not limited to, a three-tiered hospital licensing rate for non-government 10
3384	3384	owned hospitals and one rate for government-owned and operated hospitals. 11
3385	3385	(c) Raising Nursing Facility Personal Needs Allowance. The Executive Office proposes 12
3386	3386	raising the personal needs allowance for nursing facility residents to two hundred dollars ($200). 13
3387	3387	(d) Medicare Equivalent Rate. The Executive Office proposes raising all Medicaid rates, 14
3388	3388	except for hospital rates, nursing home rates, dental rates, and outpatient behavioral health rates to 15
3389	3389	equal the Medicare equivalent rate. Specific to early intervention services, a fifty dollars ($50.00) 16
3390	3390	per member per month payment shall be established in addition to these rates, and a floor of a fifty 17
3391	3391	percent (50%) rate increase shall be established within the calculation of the Medicare equivalent 18
3392	3392	rate. 19
3393	3393	(e) Setting Outpatient Behavioral Healthcare Rates at one hundred fifty percent (150%) of 20
3394	3394	Medicare Equivalent Rates. The Executive Office proposes to set outpatient behavioral health rates 21
3395	3395	at one hundred fifty percent (150%) of the Medicare equivalent rate. The Executive Office will 22
3396	3396	maximize federal financial participation if and when available, though state-only funds will be used 23
3397	3397	if federal financial participation is not available. 24
3398	3398	(f) Establishing a Nursing Facility Upper Payment Limit Payment. The Executive Office 25
3399	3399	proposes to establish an upper payment limit payment for nursing facilities. 26
3400	3400	(g) FQHC APM Modernization. The Executive Office proposes certain modifications to 27
3401	3401	modernize and standardize the alternative payment methodology option for federally qualified 28
3402	3402	health centers. 29
3403	3403	(h) Hospital Payment Modernization. The Executive Office proposes certain changes to 30
3404	3404	hospital payment rates to modernize payment methodologies to encourage utilization and quality. 31
3405	3405	Inpatient FFS DRG rates will be set at ninety percent (90%) of the Medicare equivalent rate, 32
3406	3406	inpatient non-DRG FFS rates will be established at ninety-five percent (95%) of the Medicare 33
3407	3407	equivalent rate, inpatient managed care rates will be set at one hundred five percent (105%) of FFS 34
3408	3408
3409	3409
3410	3410	LC001777 - Page 93 of 96
3411	3411	rates, and outpatient rates will be set at one hundred percent (100%) of Medicare rates. 1
3412	3412	(i) RIteShare Freedom of Choice. The Executive Office proposes to make employee 2
3413	3413	participation in the RIteShare program voluntary. 3
3414	3414	(j) Elderly and Disabled Eligibility Expansion. The Executive Office proposes expanding 4
3415	3415	Medicaid eligibility for elderly and disabled residents to one hundred thirty-three percent (133%) 5
3416	3416	of the federal poverty level. 6
3417	3417	(k) Payments Streamlining. The Executive Office proposes a multifaceted initiative to 7
3418	3418	begin the phase-out of intermediary payers such as managed care entities, streamlining payments 8
3419	3419	and reducing wasteful expenditures on intermediary payers. 9
3420	3420	(l) Medicaid Office Expansion. The Executive Office proposes an expansion of Medicaid 10
3421	3421	office staffing to improve administrative capacities. 11
3422	3422	(m) COVID-19 Adjustments to Health System Transformation Project. The Executive 12
3423	3423	Office proposes to eliminate the imposition of downside risk as part of the Health System 13
3424	3424	Transformation Project to protect the solvency of providers in light of the COVID-19 pandemic. 14
3425	3425	(n) Rhode Island Institute for Mental Disease. The Executive Office proposes to construct 15
3426	3426	a new Institution for Mental Disease (IMD) to serve vulnerable Rhode Island residents. The 16
3427	3427	Executive Office seeks a waiver of the IMD exclusion rule similar to that granted to Vermont to 17
3428	3428	allow federal Medicaid reimbursement. 18
3429	3429	(o) Raising Nursing Facility Assessment Rate. The Executive Office proposes to raise the 19
3430	3430	nursing facility assessment rate to six percent (6%). 20
3431	3431	(p) Universal Provider Assessment. Consistent with overall goals of transitioning all 21
3432	3432	services to a model where rates are at the Medicare equivalent rate, the Executive Office proposes 22
3433	3433	to extend the existing nursing facility assessment model to cover all providers eligible for taxation 23
3434	3434	under federal regulations to help defray the costs of the state component. 24
3435	3435	(q) Dental Optimization. The Executive Office proposes to make an array of changes to 25
3436	3436	dental benefits offered under Medicaid. Rates will be the rates utilized in § 27-18-54; § 27-19-30.1; 26
3437	3437	§ 27-20-25.2; and § 27-41-27.2; billing will be extended to teledentistry services, Silver 27
3438	3438	Diamine Fluoride (code D1354), and denture billing (codes D5130, D5140, D5221, D5222, D5213, 28
3439	3439	and D5214); the mobile dentistry encounter rate will be raised to the FQHC rate; and a fifty percent 29
3440	3440	(50%) payment shall be established for undeliverable dentures. 30
3441	3441	(t) Commencement of Inpatient Substance Use Disorder Recovery Bed Federal Billing. 31
3442	3442	The Executive Office proposes to utilize the IMD waiver authority granted in 2019 to begin federal 32
3443	3443	reimbursement billing for inpatient substance use disorder recovery beds, a service that will also 33
3444	3444	see a rate increase pursuant to subsection (d). The Executive Office also proposes a general 34
3445	3445
3446	3446
3447	3447	LC001777 - Page 94 of 96
3448	3448	obligation bond referendum to fund the necessary capital expenditures associated with the 1
3449	3449	expansion of RICLAS to inpatient substance use disorder recovery services. 2
3450	3450	(u) Coverage of Abortion Services. The Executive Office proposes to end the exclusion of 3
3451	3451	abortion care from covered Medicaid services. The Executive Office will maximize federal 4
3452	3452	financial participation if and when available, though state-only funds will be used if federal 5
3453	3453	financial participation is not available. 6
3454	3454	(v) Transition to State-Level Medicare for All. The Executive Office proposes to begin the 7
3455	3455	process of negotiating the necessary waivers for a transition to a state-level Medicare for All health 8
3456	3456	care payments system for Rhode Island. These waivers shall include the combining of all federal 9
3457	3457	health care funding streams into the system financing including, but not limited to, Medicaid, 10
3458	3458	Medicare, federal health care tax exemptions, and exchange subsides established pursuant to the 11
3459	3459	U.S. Patient Protection and Affordable Care Act of 2010. The Executive Office plans to begin the 12
3460	3460	transition process after the completion of the raising of the Medicaid system to a Medicare standard 13
3461	3461	of care and the associated stabilization of the Rhode Island health care workforce and provider 14
3462	3462	network; provided, however, that the Executive Office, understanding the complexity of the 15
3463	3463	proposed waiver application, reserves the right to begin the waiver negotiation process before the 16
3464	3464	transition of Medicaid to a Medicare standard is complete. The Executive Office shall only proceed 17
3465	3465	with the waiver and transition should waiver conditions be favorable to the state as a whole, in the 18
3466	3466	judgment of the Executive Office. In the event that a full waiver cannot be complete, and health 19
3467	3467	insurers have been acquired by the Medicaid Office due to insolvency and the Medicaid Office's 20
3468	3468	goal of payer system stabilization, the Executive Office is empowered to seek limited waivers for 21
3469	3469	the streamlining and integration of acquired health insurers with the Medicaid system. The 22
3470	3470	Executive Office shall submit the final approved waiver and transition plan to the general assembly 23
3471	3471	for final approval. 24
3472	3472	(w) Federal Financing Opportunities. The Executive Office proposes to review Medicaid 25
3473	3473	requirements and opportunities under the U.S. Patient Protection and Affordable Care Act of 2010 26
3474	3474	(PPACA) and various other recently enacted federal laws and pursue any changes in the Rhode 27
3475	3475	Island Medicaid program that promote service quality, access and cost-effectiveness that may 28
3476	3476	warrant a Medicaid state plan amendment or amendment under the terms and conditions of Rhode 29
3477	3477	Island's section 1115 waiver, its successor, or any extension thereof. Any such actions by the 30
3478	3478	Executive Office shall not have an adverse impact on beneficiaries. 31
3479	3479	Now, therefore, be it: 32
3480	3480	RESOLVED, That the General Assembly hereby approves the proposals stated above in 33
3481	3481	the recitals; and be it further; 34
3482	3482
3483	3483
3484	3484	LC001777 - Page 95 of 96
3485	3485	RESOLVED, That the Secretary of the Executive Office of Health and Human Services is 1
3486	3486	authorized to pursue and implement any waiver amendments, state plan amendments, and/or 2
3487	3487	changes to the applicable department's rules, regulations and procedures approved herein and as 3
3488	3488	authorized by chapter 12.4 of title 42; and be it further; 4
3489	3489	RESOLVED, That this Joint Resolution shall take effect upon passage. 5
3490	3490	SECTION 25. This act shall take effect upon passage; however, the RICHIP program shall 6
3491	3491	not come into operation until the necessary waivers are obtained, and the final financing proposal 7
3492	3492	is approved by the general assembly. 8
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3494	3494	LC001777
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3496	3496
3497	3497
3498	3498	LC001777 - Page 96 of 96
3499	3499	EXPLANATION
3500	3500	BY THE LEGISLATIVE COUNCIL
3501	3501	OF
3502	3502	A N A C T
3503	3503	RELATING TO HEALTH AND SAFETY -- COMPREHENSIVE HEALTH INSURANCE
3504	3504	PROGRAM
3505	3505	***
3506	3506	This act would establish a universal, comprehensive, affordable single-payer health care 1
3507	3507	insurance program and help control health care costs, which would be referred to as, "the Rhode 2
3508	3508	Island Comprehensive Health Insurance Program" (RICHIP). The program would be paid for by 3
3509	3509	consolidating government and private payments to multiple insurance carriers into a more 4
3510	3510	economical and efficient improved Medicare-for-all style single-payer program and substituting 5
3511	3511	lower progressive taxes for higher health insurance premiums, co-pays, deductibles and costs due 6
3512	3512	to caps. This program would save Rhode Islanders from the current overly expensive, inefficient 7
3513	3513	and unsustainable multi-payer health insurance system that unnecessarily prevents access to 8
3514	3514	medically necessary health care. 9
3515	3515	This act would take effect upon passage; however, the RICHIP program would not come 10
3516	3516	into operation until the necessary waivers are obtained, and the final financing proposal is approved 11
3517	3517	by the general assembly. 12
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3519	3519	LC001777
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3521	3521