2025 -- H 5773
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LC001838
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S T A T E O F R H O D E I S L A N D
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2025
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A N A C T
RELATING TO HUMAN SERVICES -- MEDICAL ASSISTANCE LONG-TERM CARE
SERVICE AND FINANCE REFORM
Introduced By: Representatives Baginski, and Casimiro
Date Introduced: February 26, 2025
Referred To: House Finance
It is enacted by the General Assembly as follows:
SECTION 1. Section 40-8.9-9 of the General Laws in Chapter 40-8.9 entitled "Medical 1
Assistance — Long-Term Care Service and Finance Reform" is hereby amended to read as follows: 2
40-8.9-9. Long-term-care rebalancing system reform goal. 3
(a) Notwithstanding any other provision of state law, the executive office of health and 4
human services is authorized and directed to apply for, and obtain, any necessary waiver(s), waiver 5
amendment(s), and/or state-plan amendments from the Secretary of the United States Department 6
of Health and Human Services, and to promulgate rules necessary to adopt an affirmative plan of 7
program design and implementation that addresses the goal of allocating a minimum of fifty percent 8
(50%) of Medicaid long-term-care funding for persons aged sixty-five (65) and over and adults 9
with disabilities, in addition to services for persons with developmental disabilities, to home- and 10
community-based care; provided, further, the executive office shall report annually as part of its 11
budget submission, the percentage distribution between institutional care and home- and 12
community-based care by population and shall report current and projected waiting lists for long-13
term-care and home- and community-based care services. The executive office is further authorized 14
and directed to prioritize investments in home- and community-based care and to maintain the 15
integrity and financial viability of all current long-term-care services while pursuing this goal. 16
(b) The reformed long-term-care system rebalancing goal is person-centered and 17
encourages individual self-determination, family involvement, interagency collaboration, and 18
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individual choice through the provision of highly specialized and individually tailored home-based 1
services. Additionally, individuals with severe behavioral, physical, or developmental disabilities 2
must have the opportunity to live safe and healthful lives through access to a wide range of 3
supportive services in an array of community-based settings, regardless of the complexity of their 4
medical condition, the severity of their disability, or the challenges of their behavior. Delivery of 5
services and supports in less-costly and less-restrictive community settings will enable children, 6
adolescents, and adults to be able to curtail, delay, or avoid lengthy stays in long-term-care 7
institutions, such as behavioral health residential-treatment facilities, long-term-care hospitals, 8
intermediate-care facilities, and/or skilled nursing facilities. 9
(c) Pursuant to federal authority procured under § 42-7.2-16, the executive office of health 10
and human services is directed and authorized to adopt a tiered set of criteria to be used to determine 11
eligibility for services. The criteria shall be developed in collaboration with the state’s health and 12
human services departments and, to the extent feasible, any consumer group, advisory board, or 13
other entity designated for these purposes, and shall encompass eligibility determinations for long-14
term-care services in nursing facilities, hospitals, and intermediate-care facilities for persons with 15
intellectual disabilities, as well as home- and community-based alternatives, and shall provide a 16
common standard of income eligibility for both institutional and home- and community-based care. 17
The executive office is authorized to adopt clinical and/or functional criteria for admission to a 18
nursing facility, hospital, or intermediate-care facility for persons with intellectual disabilities that 19
are more stringent than those employed for access to home- and community-based services. The 20
executive office is also authorized to promulgate rules that define the frequency of re-assessments 21
for services provided for under this section. Levels of care may be applied in accordance with the 22
following: 23
(1) The executive office shall continue to apply the level-of-care criteria in effect on April 24
1, 2021, for any recipient determined eligible for and receiving Medicaid-funded long-term services 25
and supports in a nursing facility, hospital, or intermediate-care facility for persons with intellectual 26
disabilities on or before that date, unless: 27
(i) The recipient transitions to home- and community-based services because he or she 28
would no longer meet the level-of-care criteria in effect on April 1, 2021; or 29
(ii) The recipient chooses home- and community-based services over the nursing facility, 30
hospital, or intermediate-care facility for persons with intellectual disabilities. For the purposes of 31
this section, a failed community placement, as defined in regulations promulgated by the executive 32
office, shall be considered a condition of clinical eligibility for the highest level of care. The 33
executive office shall confer with the long-term-care ombudsperson with respect to the 34
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determination of a failed placement under the ombudsperson’s jurisdiction. Should any Medicaid 1
recipient eligible for a nursing facility, hospital, or intermediate-care facility for persons with 2
intellectual disabilities as of April 1, 2021, receive a determination of a failed community 3
placement, the recipient shall have access to the highest level of care; furthermore, a recipient who 4
has experienced a failed community placement shall be transitioned back into his or her former 5
nursing home, hospital, or intermediate-care facility for persons with intellectual disabilities 6
whenever possible. Additionally, residents shall only be moved from a nursing home, hospital, or 7
intermediate-care facility for persons with intellectual disabilities in a manner consistent with 8
applicable state and federal laws. 9
(2) Any Medicaid recipient eligible for the highest level of care who voluntarily leaves a 10
nursing home, hospital, or intermediate-care facility for persons with intellectual disabilities shall 11
not be subject to any wait list for home- and community-based services. 12
(3) No nursing home, hospital, or intermediate-care facility for persons with intellectual 13
disabilities shall be denied payment for services rendered to a Medicaid recipient on the grounds 14
that the recipient does not meet level-of-care criteria unless and until the executive office has: 15
(i) Performed an individual assessment of the recipient at issue and provided written notice 16
to the nursing home, hospital, or intermediate-care facility for persons with intellectual disabilities 17
that the recipient does not meet level-of-care criteria; and 18
(ii) The recipient has either appealed that level-of-care determination and been 19
unsuccessful, or any appeal period available to the recipient regarding that level-of-care 20
determination has expired. 21
(d) The executive office is further authorized to consolidate all home- and community-22
based services currently provided pursuant to 42 U.S.C. § 1396n into a single system of home- and 23
community-based services that include options for consumer direction and shared living. 24
(1) Shared living for older adults and adults with disabilities shall provide individuals with 25
the option to receive care from family caregivers, including caregivers who unrelated and related, 26
regardless of other activities (i.e. health care proxy, power of attorney, social security representative 27
payee) performed by the qualified caregiver on the individual’s behalf. Notwithstanding any 28
general or public law to the contrary, the executive office of health and human services shall not 29
implement any limitations on who can be an eligible caregiver through shared living that are more 30
restrictive than the standards that were in effect on January 1, 2025. 31
(2) The resulting single home- and community-based services system shall replace and 32
supersede all 42 U.S.C. § 1396n programs when fully implemented. Notwithstanding the foregoing, 33
the resulting single program home- and community-based services system shall include the 34
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continued funding of assisted-living services at any assisted-living facility financed by the Rhode 1
Island housing and mortgage finance corporation prior to January 1, 2006, and shall be in 2
accordance with chapter 66.8 of title 42 as long as assisted-living services are a covered Medicaid 3
benefit. 4
(e) The executive office is authorized to promulgate rules that permit certain optional 5
services including, but not limited to, homemaker services, home modifications, respite, and 6
physical therapy evaluations to be offered to persons at risk for Medicaid-funded long-term care 7
subject to availability of state-appropriated funding for these purposes. 8
(f) To promote the expansion of home- and community-based service capacity, the 9
executive office is authorized to pursue payment methodology reforms that increase access to 10
homemaker, personal care (home health aide), assisted living, adult supportive-care homes, and 11
adult day services, as follows: 12
(1) Development of revised or new Medicaid certification standards that increase access to 13
service specialization and scheduling accommodations by using payment strategies designed to 14
achieve specific quality and health outcomes. 15
(2) Development of Medicaid certification standards for state-authorized providers of adult 16
day services, excluding providers of services authorized under § 40.1-24-1(3), assisted living, and 17
adult supportive care (as defined under chapter 17.24 of title 23) that establish for each, an acuity-18
based, tiered service and payment methodology tied to: licensure authority; level of beneficiary 19
needs; the scope of services and supports provided; and specific quality and outcome measures. 20
The standards for adult day services for persons eligible for Medicaid-funded long-term 21
services may differ from those who do not meet the clinical/functional criteria set forth in § 40-22
8.10-3. 23
(3) As the state’s Medicaid program seeks to assist more beneficiaries requiring long-term 24
services and supports in home- and community-based settings, the demand for home-care workers 25
has increased, and wages for these workers has not kept pace with neighboring states, leading to 26
high turnover and vacancy rates in the state’s home-care industry, the executive office shall institute 27
a one-time increase in the base-payment rates for FY 2019, as described below, for home-care 28
service providers to promote increased access to and an adequate supply of highly trained home-29
healthcare professionals, in amount to be determined by the appropriations process, for the purpose 30
of raising wages for personal care attendants and home health aides to be implemented by such 31
providers. 32
(i) A prospective base adjustment, effective not later than July 1, 2018, of ten percent (10%) 33
of the current base rate for home-care providers, home nursing care providers, and hospice 34
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providers contracted with the executive office of health and human services and its subordinate 1
agencies to deliver Medicaid fee-for-service personal care attendant services. 2
(ii) A prospective base adjustment, effective not later than July 1, 2018, of twenty percent 3
(20%) of the current base rate for home-care providers, home nursing care providers, and hospice 4
providers contracted with the executive office of health and human services and its subordinate 5
agencies to deliver Medicaid fee-for-service skilled nursing and therapeutic services and hospice 6
care. 7
(iii) Effective upon passage of this section, hospice provider reimbursement, exclusively 8
for room and board expenses for individuals residing in a skilled nursing facility, shall revert to the 9
rate methodology in effect on June 30, 2018, and these room and board expenses shall be exempted 10
from any and all annual rate increases to hospice providers as provided for in this section. 11
(iv) On the first of July in each year, beginning on July 1, 2019, the executive office of 12
health and human services will initiate an annual inflation increase to the base rate for home-care 13
providers, home nursing care providers, and hospice providers contracted with the executive office 14
and its subordinate agencies to deliver Medicaid fee-for-service personal care attendant services, 15
skilled nursing and therapeutic services and hospice care. The base rate increase shall be a 16
percentage amount equal to the New England Consumer Price Index card as determined by the 17
United States Department of Labor for medical care and for compliance with all federal and state 18
laws, regulations, and rules, and all national accreditation program requirements. 19
(g) As the state’s Medicaid program seeks to assist more beneficiaries requiring long-term 20
services and supports in home- and community-based settings, the demand for home-care workers 21
has increased, and wages for these workers has not kept pace with neighboring states, leading to 22
high turnover and vacancy rates in the state’s home-care industry. To promote increased access to 23
and an adequate supply of direct-care workers, the executive office shall institute a payment 24
methodology change, in Medicaid fee-for-service and managed care, for FY 2022, that shall be 25
passed through directly to the direct-care workers’ wages who are employed by home nursing care 26
and home-care providers licensed by the Rhode Island department of health, as described below: 27
(1) Effective July 1, 2021, increase the existing shift differential modifier by $0.19 per 28
fifteen (15) minutes for personal care and combined personal care/homemaker. 29
(i) Employers must pass on one hundred percent (100%) of the shift differential modifier 30
increase per fifteen-minute (15) unit of service to the CNAs who rendered such services. This 31
compensation shall be provided in addition to the rate of compensation that the employee was 32
receiving as of June 30, 2021. For an employee hired after June 30, 2021, the agency shall use not 33
less than the lowest compensation paid to an employee of similar functions and duties as of June 34
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30, 2021, as the base compensation to which the increase is applied. 1
(ii) Employers must provide to EOHHS an annual compliance statement showing wages 2
as of June 30, 2021, amounts received from the increases outlined herein, and compliance with this 3
section by July 1, 2022. EOHHS may adopt any additional necessary regulations and processes to 4
oversee this subsection. 5
(2) Effective January 1, 2022, establish a new behavioral healthcare enhancement of $0.39 6
per fifteen (15) minutes for personal care, combined personal care/homemaker, and homemaker 7
only for providers who have at least thirty percent (30%) of their direct-care workers (which 8
includes certified nursing assistants (CNA) and homemakers) certified in behavioral healthcare 9
training. 10
(i) Employers must pass on one hundred percent (100%) of the behavioral healthcare 11
enhancement per fifteen (15) minute unit of service rendered by only those CNAs and homemakers 12
who have completed the thirty (30) hour behavioral health certificate training program offered by 13
Rhode Island College, or a training program that is prospectively determined to be compliant per 14
EOHHS, to those CNAs and homemakers. This compensation shall be provided in addition to the 15
rate of compensation that the employee was receiving as of December 31, 2021. For an employee 16
hired after December 31, 2021, the agency shall use not less than the lowest compensation paid to 17
an employee of similar functions and duties as of December 31, 2021, as the base compensation to 18
which the increase is applied. 19
(ii) By January 1, 2023, employers must provide to EOHHS an annual compliance 20
statement showing wages as of December 31, 2021, amounts received from the increases outlined 21
herein, and compliance with this section, including which behavioral healthcare training programs 22
were utilized. EOHHS may adopt any additional necessary regulations and processes to oversee 23
this subsection. 24
(h) The executive office shall implement a long-term-care-options counseling program to 25
provide individuals, or their representatives, or both, with long-term-care consultations that shall 26
include, at a minimum, information about: long-term-care options, sources, and methods of both 27
public and private payment for long-term-care services and an assessment of an individual’s 28
functional capabilities and opportunities for maximizing independence. Each individual admitted 29
to, or seeking admission to, a long-term-care facility, regardless of the payment source, shall be 30
informed by the facility of the availability of the long-term-care-options counseling program and 31
shall be provided with long-term-care-options consultation if they so request. Each individual who 32
applies for Medicaid long-term-care services shall be provided with a long-term-care consultation. 33
(i) The executive office shall implement, no later than January 1, 2024, a statewide network 34
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and rate methodology for conflict-free case management for individuals receiving Medicaid-funded 1
home and community-based services. The executive office shall coordinate implementation with 2
the state’s health and human services departments and divisions authorized to deliver Medicaid-3
funded home and community-based service programs, including the department of behavioral 4
healthcare, developmental disabilities and hospitals; the department of human services; and the 5
office of healthy aging. It is in the best interest of the Rhode Islanders eligible to receive Medicaid 6
home and community-based services under this chapter, title 40.1, title 42, or any other general 7
laws to provide equitable access to conflict-free case management that shall include person-8
centered planning, service arranging, and quality monitoring in the amount, duration, and scope 9
required by federal law and regulations. It is necessary to ensure that there is a robust network of 10
qualified conflict-free case management entities with the capacity to serve all participants on a 11
statewide basis and in a manner that promotes choice, self-reliance, and community integration. 12
The executive office, as the designated single state Medicaid authority and agency responsible for 13
coordinating policy and planning for health and human services under § 42-7.2-1 et seq., is directed 14
to establish a statewide conflict-free case management network under the management of the 15
executive office and to seek any Medicaid waivers, state plan amendments, and changes in rules, 16
regulations, and procedures that may be necessary to ensure that recipients of Medicaid home and 17
community-based services have access to conflict-free case management in a timely manner and in 18
accordance with the federal requirements that must be met to preserve financial participation. 19
(j) The executive office is also authorized, subject to availability of appropriation of 20
funding, and federal, Medicaid-matching funds, to pay for certain services and supports necessary 21
to transition or divert beneficiaries from institutional or restrictive settings and optimize their health 22
and safety when receiving care in a home or the community. The secretary is authorized to obtain 23
any state plan or waiver authorities required to maximize the federal funds available to support 24
expanded access to home- and community-transition and stabilization services; provided, however, 25
payments shall not exceed an annual or per-person amount. 26
(k) To ensure persons with long-term-care needs who remain living at home have adequate 27
resources to deal with housing maintenance and unanticipated housing-related costs, the secretary 28
is authorized to develop higher resource eligibility limits for persons or obtain any state plan or 29
waiver authorities necessary to change the financial eligibility criteria for long-term services and 30
supports to enable beneficiaries receiving home and community waiver services to have the 31
resources to continue living in their own homes or rental units or other home-based settings. 32
(l) The executive office shall implement, no later than January 1, 2016, the following home- 33
and community-based service and payment reforms: 34
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(1) [Deleted by P.L. 2021, ch. 162, art. 12, § 6.] 1
(2) Adult day services level of need criteria and acuity-based, tiered-payment 2
methodology; and 3
(3) Payment reforms that encourage home- and community-based providers to provide the 4
specialized services and accommodations beneficiaries need to avoid or delay institutional care. 5
(m) The secretary is authorized to seek any Medicaid section 1115 waiver or state-plan 6
amendments and take any administrative actions necessary to ensure timely adoption of any new 7
or amended rules, regulations, policies, or procedures and any system enhancements or changes, 8
for which appropriations have been authorized, that are necessary to facilitate implementation of 9
the requirements of this section by the dates established. The secretary shall reserve the discretion 10
to exercise the authority established under §§ 42-7.2-5(6)(v) and 42-7.2-6.1, in consultation with 11
the governor, to meet the legislative directives established herein. 12
SECTION 2. This act shall take effect upon passage. 13
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EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO HUMAN SERVICES -- MEDICAL ASSISTANCE LONG-TERM CARE
SERVICE AND FINANCE REFORM
***
This act would provide that shared living for older adults and adults with disabilities allow 1
individuals to receive care from family caregivers, related or unrelated, regardless of whether they 2
are performing other activities, such as a power of attorney, health care proxy, or social security 3
representative payee for those individuals. 4
This act would take effect upon passage. 5
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