Rhode Island 2025 Regular Session

Rhode Island House Bill H5989 Compare Versions

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

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5	5	2025 -- H 5989
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7	7	LC002101
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9	9	S T A T E O F R H O D E I S L A N D
10	10	IN GENERAL ASSEMBLY
11	11	JANUARY SESSION, A.D. 2025
12	12	____________
13	13
14	14	A N A C T
15	15	RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND
16	16	HEALTHCARE REFORM AC T OF 2004 -- HEALTH INSURANCE OVERSIGHT
17	17	Introduced By: Representative Matthew S. Dawson
18	18	Date Introduced: February 28, 2025
19	19	Referred To: House Finance
20	20
21	21
22	22	It is enacted by the General Assembly as follows:
23	23	SECTION 1. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The 1
24	24	Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" is hereby amended 2
25	25	to read as follows: 3
26	26	42-14.5-3. Powers and duties. 4
27	27	The health insurance commissioner shall have the following powers and duties: 5
28	28	(a) To conduct quarterly public meetings throughout the state, separate and distinct from 6
29	29	rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 7
30	30	licensed to provide health insurance in the state; the effects of such rates, services, and operations 8
31	31	on consumers, medical care providers, patients, and the market environment in which the insurers 9
32	32	operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 10
33	33	than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 11
34	34	Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 12
35	35	general, and the chambers of commerce. Public notice shall be posted on the department’s website 13
36	36	and given in the newspaper of general circulation, and to any entity in writing requesting notice. 14
37	37	(b) To make recommendations to the governor and the house of representatives and senate 15
38	38	finance committees regarding healthcare insurance and the regulations, rates, services, 16
39	39	administrative expenses, reserve requirements, and operations of insurers providing health 17
40	40	insurance in the state, and to prepare or comment on, upon the request of the governor or 18
41	41
42	42
43	43	LC002101 - Page 2 of 13
44	44	chairpersons of the house or senate finance committees, draft legislation to improve the regulation 1
45	45	of health insurance. In making the recommendations, the commissioner shall recognize that it is 2
46	46	the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 3
47	47	of individual administrative expenditures as well as total administrative costs. The commissioner 4
48	48	shall make recommendations on the levels of reserves, including consideration of: targeted reserve 5
49	49	levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 6
50	50	reserves. 7
51	51	(c) To establish a consumer/business/labor/medical advisory council to obtain information 8
52	52	and present concerns of consumers, business, and medical providers affected by health insurance 9
53	53	decisions. The council shall develop proposals to allow the market for small business health 10
54	54	insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 11
55	55	the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 12
56	56	measures to inform small businesses of an insurance complaint process to ensure that small 13
57	57	businesses that experience rate increases in a given year may request and receive a formal review 14
58	58	by the department. The advisory council shall assess views of the health provider community 15
59	59	relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 16
60	60	insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 17
61	61	an annual report of findings and recommendations to the governor and the general assembly and 18
62	62	present its findings at hearings before the house and senate finance committees. The advisory 19
63	63	council is to be diverse in interests and shall include representatives of community consumer 20
64	64	organizations; small businesses, other than those involved in the sale of insurance products; and 21
65	65	hospital, medical, and other health provider organizations. Such representatives shall be nominated 22
66	66	by their respective organizations. The advisory council shall be co-chaired by the health insurance 23
67	67	commissioner and a community consumer organization or small business member to be elected by 24
68	68	the full advisory council. 25
69	69	(d) To establish and provide guidance and assistance to a subcommittee (“the professional-26
70	70	provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 27
71	71	composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall 28
72	72	include in its annual report and presentation before the house and senate finance committees the 29
73	73	following information: 30
74	74	(1) A method whereby health plans shall disclose to contracted providers the fee schedules 31
75	75	used to provide payment to those providers for services rendered to covered patients; 32
76	76	(2) A standardized provider application and credentials verification process, for the 33
77	77	purpose of verifying professional qualifications of participating healthcare providers; 34
78	78
79	79
80	80	LC002101 - Page 3 of 13
81	81	(3) The uniform health plan claim form utilized by participating providers; 1
82	82	(4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 2
83	83	hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make 3
84	84	facility-specific data and other medical service-specific data available in reasonably consistent 4
85	85	formats to patients regarding quality and costs. This information would help consumers make 5
86	86	informed choices regarding the facilities and clinicians or physician practices at which to seek care. 6
87	87	Among the items considered would be the unique health services and other public goods provided 7
88	88	by facilities and clinicians or physician practices in establishing the most appropriate cost 8
89	89	comparisons; 9
90	90	(5) All activities related to contractual disclosure to participating providers of the 10
91	91	mechanisms for resolving health plan/provider disputes; 11
92	92	(6) The uniform process being utilized for confirming, in real time, patient insurance 12
93	93	enrollment status, benefits coverage, including copays and deductibles; 13
94	94	(7) Information related to temporary credentialing of providers seeking to participate in the 14
95	95	plan’s network and the impact of the activity on health plan accreditation; 15
96	96	(8) The feasibility of regular contract renegotiations between plans and the providers in 16
97	97	their networks; and 17
98	98	(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 18
99	99	(e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). 19
100	100	(f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 20
101	101	fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 21
102	102	(g) To analyze the impact of changing the rating guidelines and/or merging the individual 22
103	103	health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 23
104	104	insurance market, as defined in chapter 50 of title 27, in accordance with the following: 24
105	105	(1) The analysis shall forecast the likely rate increases required to effect the changes 25
106	106	recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 26
107	107	health insurance market over the next five (5) years, based on the current rating structure and 27
108	108	current products. 28
109	109	(2) The analysis shall include examining the impact of merging the individual and small-29
110	110	employer markets on premiums charged to individuals and small-employer groups. 30
111	111	(3) The analysis shall include examining the impact on rates in each of the individual and 31
112	112	small-employer health insurance markets and the number of insureds in the context of possible 32
113	113	changes to the rating guidelines used for small-employer groups, including: community rating 33
114	114	principles; expanding small-employer rate bonds beyond the current range; increasing the employer 34
115	115
116	116
117	117	LC002101 - Page 4 of 13
118	118	group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 1
119	119	(4) The analysis shall include examining the adequacy of current statutory and regulatory 2
120	120	oversight of the rating process and factors employed by the participants in the proposed, new 3
121	121	merged market. 4
122	122	(5) The analysis shall include assessment of possible reinsurance mechanisms and/or 5
123	123	federal high-risk pool structures and funding to support the health insurance market in Rhode Island 6
124	124	by reducing the risk of adverse selection and the incremental insurance premiums charged for this 7
125	125	risk, and/or by making health insurance affordable for a selected at-risk population. 8
126	126	(6) The health insurance commissioner shall work with an insurance market merger task 9
127	127	force to assist with the analysis. The task force shall be chaired by the health insurance 10
128	128	commissioner and shall include, but not be limited to, representatives of the general assembly, the 11
129	129	business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 12
130	130	the individual market in Rhode Island, health insurance brokers, and members of the general public. 13
131	131	(7) For the purposes of conducting this analysis, the commissioner may contract with an 14
132	132	outside organization with expertise in fiscal analysis of the private insurance market. In conducting 15
133	133	its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 16
134	134	data shall be subject to state and federal laws and regulations governing confidentiality of health 17
135	135	care and proprietary information. 18
136	136	(8) The task force shall meet as necessary and include its findings in the annual report, and 19
137	137	the commissioner shall include the information in the annual presentation before the house and 20
138	138	senate finance committees. 21
139	139	(h) To establish and convene a workgroup representing healthcare providers and health 22
140	140	insurers for the purpose of coordinating the development of processes, guidelines, and standards to 23
141	141	streamline healthcare administration that are to be adopted by payors and providers of healthcare 24
142	142	services operating in the state. This workgroup shall include representatives with expertise who 25
143	143	would contribute to the streamlining of healthcare administration and who are selected from 26
144	144	hospitals, physician practices, community behavioral health organizations, each health insurer, and 27
145	145	other affected entities. The workgroup shall also include at least one designee each from the Rhode 28
146	146	Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the 29
147	147	Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year 30
148	148	that the workgroup meets and submits recommendations to the office of the health insurance 31
149	149	commissioner, the office of the health insurance commissioner shall submit such recommendations 32
150	150	to the health and human services committees of the Rhode Island house of representatives and the 33
151	151	Rhode Island senate prior to the implementation of any such recommendations and subsequently 34
152	152
153	153
154	154	LC002101 - Page 5 of 13
155	155	shall submit a report to the general assembly by June 30, 2024. The report shall include the 1
156	156	recommendations the commissioner may implement, with supporting rationale. The workgroup 2
157	157	shall consider and make recommendations for: 3
158	158	(1) Establishing a consistent standard for electronic eligibility and coverage verification. 4
159	159	Such standard shall: 5
160	160	(i) Include standards for eligibility inquiry and response and, wherever possible, be 6
161	161	consistent with the standards adopted by nationally recognized organizations, such as the Centers 7
162	162	for Medicare & Medicaid Services; 8
163	163	(ii) Enable providers and payors to exchange eligibility requests and responses on a system-9
164	164	to-system basis or using a payor-supported web browser; 10
165	165	(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 11
166	166	coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 12
167	167	requirements for specific services at the specific time of the inquiry; current deductible amounts; 13
168	168	accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 14
169	169	other information required for the provider to collect the patient’s portion of the bill; 15
170	170	(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 16
171	171	and benefits information; 17
172	172	(v) Recommend a standard or common process to protect all providers from the costs of 18
173	173	services to patients who are ineligible for insurance coverage in circumstances where a payor 19
174	174	provides eligibility verification based on best information available to the payor at the date of the 20
175	175	request of eligibility. 21
176	176	(2) Developing implementation guidelines and promoting adoption of the guidelines for: 22
177	177	(i) The use of the National Correct Coding Initiative code-edit policy by payors and 23
178	178	providers in the state; 24
179	179	(ii) Publishing any variations from codes and mutually exclusive codes by payors in a 25
180	180	manner that makes for simple retrieval and implementation by providers; 26
181	181	(iii) Use of Health Insurance Portability and Accountability Act standard group codes, 27
182	182	reason codes, and remark codes by payors in electronic remittances sent to providers; 28
183	183	(iv) Uniformity in the processing of claims by payors; and the processing of corrections to 29
184	184	claims by providers and payors; 30
185	185	(v) A standard payor-denial review process for providers when they request a 31
186	186	reconsideration of a denial of a claim that results from differences in clinical edits where no single, 32
187	187	common-standards body or process exists and multiple conflicting sources are in use by payors and 33
188	188	providers. 34
189	189
190	190
191	191	LC002101 - Page 6 of 13
192	192	(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 1
193	193	payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 2
194	194	detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 3
195	195	disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 4
196	196	the application of such edits and that the provider have access to the payor’s review and appeal 5
197	197	process to challenge the payor’s adjudication decision. 6
198	198	(vii) Nothing in this subsection shall be construed to modify the rights or obligations of 7
199	199	payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 8
200	200	prosecution under applicable law of potentially fraudulent billing activities. 9
201	201	(3) Developing and promoting widespread adoption by payors and providers of guidelines 10
202	202	to: 11
203	203	(i) Ensure payors do not automatically deny claims for services when extenuating 12
204	204	circumstances make it impossible for the provider to obtain a preauthorization before services are 13
205	205	performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 14
206	206	(ii) Require payors to use common and consistent processes and time frames when 15
207	207	responding to provider requests for medical management approvals. Whenever possible, such time 16
208	208	frames shall be consistent with those established by leading national organizations and be based 17
209	209	upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 18
210	210	management includes prior authorization of services, preauthorization of services, precertification 19
211	211	of services, post-service review, medical-necessity review, and benefits advisory; 20
212	212	(iii) Develop, maintain, and promote widespread adoption of a single, common website 21
213	213	where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 22
214	214	requirements; 23
215	215	(iv) Establish guidelines for payors to develop and maintain a website that providers can 24
216	216	use to request a preauthorization, including a prospective clinical necessity review; receive an 25
217	217	authorization number; and transmit an admission notification; 26
218	218	(v) Develop and implement the use of programs that implement selective prior 27
219	219	authorization requirements, based on stratification of healthcare providers’ performance and 28
220	220	adherence to evidence-based medicine with the input of contracted healthcare providers and/or 29
221	221	provider organizations. Such criteria shall be transparent and easily accessible to contracted 30
222	222	providers. Such selective prior authorization programs shall be available when healthcare providers 31
223	223	participate directly with the insurer in risk-based payment contracts and may be available to 32
224	224	providers who do not participate in risk-based contracts; 33
225	225	(vi) Require the review of medical services, including behavioral health services, and 34
226	226
227	227
228	228	LC002101 - Page 7 of 13
229	229	prescription drugs, subject to prior authorization on at least an annual basis, with the input of 1
230	230	contracted healthcare providers and/or provider organizations. Any changes to the list of medical 2
231	231	services, including behavioral health services, and prescription drugs requiring prior authorization, 3
232	232	shall be shared via provider-accessible websites; 4
233	233	(vii) Improve communication channels between health plans, healthcare providers, and 5
234	234	patients by: 6
235	235	(A) Requiring transparency and easy accessibility of prior authorization requirements, 7
236	236	criteria, rationale, and program changes to contracted healthcare providers and patients/health plan 8
237	237	enrollees which may be satisfied by posting to provider-accessible and member-accessible 9
238	238	websites; and 10
239	239	(B) Supporting: 11
240	240	(I) Timely submission by healthcare providers of the complete information necessary to 12
241	241	make a prior authorization determination, as early in the process as possible; and 13
242	242	(II) Timely notification of prior authorization determinations by health plans to impacted 14
243	243	health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, 15
244	244	and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 16
245	245	provider-accessible websites or similar electronic portals or services; 17
246	246	(viii) Increase and strengthen continuity of patient care by: 18
247	247	(A) Defining protections for continuity of care during a transition period for patients 19
248	248	undergoing an active course of treatment, when there is a formulary or treatment coverage change 20
249	249	or change of health plan that may disrupt their current course of treatment and when the treating 21
250	250	physician determines that a transition may place the patient at risk; and for prescription medication 22
251	251	by allowing a grace period of coverage to allow consideration of referred health plan options or 23
252	252	establishment of medical necessity of the current course of treatment; 24
253	253	(B) Requiring continuity of care for medical services, including behavioral health services, 25
254	254	and prescription medications for patients on appropriate, chronic, stable therapy through 26
255	255	minimizing repetitive prior authorization requirements; and which for prescription medication shall 27
256	256	be allowed only on an annual review, with exception for labeled limitation, to establish continued 28
257	257	benefit of treatment; and 29
258	258	(C) Requiring communication between healthcare providers, health plans, and patients to 30
259	259	facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 31
260	260	by posting to provider-accessible websites or similar electronic portals or services; 32
261	261	(D) Continuity of care for formulary or drug coverage shall distinguish between FDA 33
262	262	designated interchangeable products and proprietary or marketed versions of a medication; 34
263	263
264	264
265	265	LC002101 - Page 8 of 13
266	266	(ix) Encourage healthcare providers and/or provider organizations and health plans to 1
267	267	accelerate use of electronic prior authorization technology, including adoption of national standards 2
268	268	where applicable; and 3
269	269	(x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 4
270	270	workgroup meeting may be conducted in part or whole through electronic methods. 5
271	271	(4) To provide a report to the house and senate, on or before January 1, 2017, with 6
272	272	recommendations for establishing guidelines and regulations for systems that give patients 7
273	273	electronic access to their claims information, particularly to information regarding their obligations 8
274	274	to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 9
275	275	(5) No provision of this subsection (h) shall preclude the ongoing work of the office of 10
276	276	health insurance commissioner’s administrative simplification task force, which includes meetings 11
277	277	with key stakeholders in order to improve, and provide recommendations regarding, the prior 12
278	278	authorization process. 13
279	279	(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 14
280	280	thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 15
281	281	committee on health and human services, and the house committee on corporations, with: (1) 16
282	282	Information on the availability in the commercial market of coverage for anti-cancer medication 17
283	283	options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 18
284	284	options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 19
285	285	utilization and cost-sharing expense. 20
286	286	(j) To monitor the adequacy of each health plan’s compliance with the provisions of the 21
287	287	federal Mental Health Parity Act, including a review of related claims processing and 22
288	288	reimbursement procedures. Findings, recommendations, and assessments shall be made available 23
289	289	to the public. 24
290	290	(k) To monitor the transition from fee-for-service and toward global and other alternative 25
291	291	payment methodologies for the payment for healthcare services. Alternative payment 26
292	292	methodologies should be assessed for their likelihood to promote access to affordable health 27
293	293	insurance, health outcomes, and performance. 28
294	294	(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 29
295	295	payment variation, including findings and recommendations, subject to available resources. 30
296	296	(m) Notwithstanding any provision of the general or public laws or regulation to the 31
297	297	contrary, provide a report with findings and recommendations to the president of the senate and the 32
298	298	speaker of the house, on or before April 1, 2014, including, but not limited to, the following 33
299	299	information: 34
300	300
301	301
302	302	LC002101 - Page 9 of 13
303	303	(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 1
304	304	27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-2
305	305	18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 3
306	306	insurance for fully insured employers, subject to available resources; 4
307	307	(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 5
308	308	the existing standards of care and/or delivery of services in the healthcare system; 6
309	309	(3) A state-by-state comparison of health insurance mandates and the extent to which 7
310	310	Rhode Island mandates exceed other states benefits; and 8
311	311	(4) Recommendations for amendments to existing mandated benefits based on the findings 9
312	312	in (m)(1), (m)(2), and (m)(3) above. 10
313	313	(n) On or before July 1, 2014, the office of the health insurance commissioner, in 11
314	314	collaboration with the director of health and lieutenant governor’s office, shall submit a report to 12
315	315	the general assembly and the governor to inform the design of accountable care organizations 13
316	316	(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-14
317	317	based payment arrangements, that shall include, but not be limited to: 15
318	318	(1) Utilization review; 16
319	319	(2) Contracting; and 17
320	320	(3) Licensing and regulation. 18
321	321	(o) On or before February 3, 2015, the office of the health insurance commissioner shall 19
322	322	submit a report to the general assembly and the governor that describes, analyzes, and proposes 20
323	323	recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 21
324	324	to patients with mental health and substance use disorders. 22
325	325	(p) To work to ensure the health insurance coverage of behavioral health care under the 23
326	326	same terms and conditions as other health care, and to integrate behavioral health parity 24
327	327	requirements into the office of the health insurance commissioner insurance oversight and 25
328	328	healthcare transformation efforts. 26
329	329	(q) To work with other state agencies to seek delivery system improvements that enhance 27
330	330	access to a continuum of mental health and substance use disorder treatment in the state; and 28
331	331	integrate that treatment with primary and other medical care to the fullest extent possible. 29
332	332	(r) To direct insurers toward policies and practices that address the behavioral health needs 30
333	333	of the public and greater integration of physical and behavioral healthcare delivery. 31
334	334	(s) The office of the health insurance commissioner shall conduct an analysis of the impact 32
335	335	of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 33
336	336	submit a report of its findings to the general assembly on or before June 1, 2023. 34
337	337
338	338
339	339	LC002101 - Page 10 of 13
340	340	(t) To undertake the analyses, reports, and studies contained in this section: 1
341	341	(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 2
342	342	and competent firm or firms to undertake the following analyses, reports, and studies: 3
343	343	(i) The firm shall undertake a comprehensive review of all social and human service 4
344	344	programs having a contract with or licensed by the state or any subdivision of the department of 5
345	345	children, youth and families (DCYF), the department of behavioral healthcare, developmental 6
346	346	disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 7
347	347	health (DOH), and Medicaid for the purposes of: 8
348	348	(A) Establishing a baseline of the eligibility factors for receiving services; 9
349	349	(B) Establishing a baseline of the service offering through each agency for those 10
350	350	determined eligible; 11
351	351	(C) Establishing a baseline understanding of reimbursement rates for all social and human 12
352	352	service programs including rates currently being paid, the date of the last increase, and a proposed 13
353	353	model that the state may use to conduct future studies and analyses; 14
354	354	(D) Ensuring accurate and adequate reimbursement to social and human service providers 15
355	355	that facilitate the availability of high-quality services to individuals receiving home and 16
356	356	community-based long-term services and supports provided by social and human service providers; 17
357	357	(E) Ensuring the general assembly is provided accurate financial projections on social and 18
358	358	human service program costs, demand for services, and workforce needs to ensure access to entitled 19
359	359	beneficiaries and services; 20
360	360	(F) Establishing a baseline and determining the relationship between state government and 21
361	361	the provider network including functions, responsibilities, and duties; 22
362	362	(G) Determining a set of measures and accountability standards to be used by EOHHS and 23
363	363	the general assembly to measure the outcomes of the provision of services including budgetary 24
364	364	reporting requirements, transparency portals, and other methods; and 25
365	365	(H) Reporting the findings of human services analyses and reports to the speaker of the 26
366	366	house, senate president, chairs of the house and senate finance committees, chairs of the house and 27
367	367	senate health and human services committees, and the governor. 28
368	368	(2) The analyses, reports, and studies required pursuant to this section shall be 29
369	369	accomplished and published as follows and shall provide: 30
370	370	(i) An assessment and detailed reporting on all social and human service program rates to 31
371	371	be completed by January 1, 2023, including rates currently being paid and the date of the last 32
372	372	increase; 33
373	373	(ii) An assessment and detailed reporting on eligibility standards and processes of all 34
374	374
375	375
376	376	LC002101 - Page 11 of 13
377	377	mandatory and discretionary social and human service programs to be completed by January 1, 1
378	378	2023; 2
379	379	(iii) An assessment and detailed reporting on utilization trends from the period of January 3
380	380	1, 2017, through December 31, 2021, for social and human service programs to be completed by 4
381	381	January 1, 2023; 5
382	382	(iv) An assessment and detailed reporting on the structure of the state government as it 6
383	383	relates to the provision of services by social and human service providers including eligibility and 7
384	384	functions of the provider network to be completed by January 1, 2023; 8
385	385	(v) An assessment and detailed reporting on accountability standards for services for social 9
386	386	and human service programs to be completed by January 1, 2023; 10
387	387	(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 11
388	388	and unlicensed personnel requirements for established rates for social and human service programs 12
389	389	pursuant to a contract or established fee schedule; 13
390	390	(vii) An assessment and reporting on access to social and human service programs, to 14
391	391	include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 15
392	392	(viii) An assessment and reporting of national and regional Medicaid rates in comparison 16
393	393	to Rhode Island social and human service provider rates by April 1, 2023; 17
394	394	(ix) An assessment and reporting on usual and customary rates paid by private insurers and 18
395	395	private pay for similar social and human service providers, both nationally and regionally, by April 19
396	396	1, 2023; and 20
397	397	(x) Completion of the development of an assessment and review process that includes the 21
398	398	following components: eligibility; scope of services; relationship of social and human service 22
399	399	provider and the state; national and regional rate comparisons and accountability standards that 23
400	400	result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 24
401	401	and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 25
402	402	requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 26
403	403	1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 27
404	404	results and findings of this process shall be transparent, and public meetings shall be conducted to 28
405	405	allow providers, recipients, and other interested parties an opportunity to ask questions and provide 29
406	406	comment beginning in September 2023 and biennially thereafter. 30
407	407	(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 31
408	408	insurance commissioner shall consult with the Executive Office of Health and Human Services. 32
409	409	(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 33
410	410	include the corresponding components of the assessment and review (i.e., eligibility; scope of 34
411	411
412	412
413	413	LC002101 - Page 12 of 13
414	414	services; relationship of social and human service provider and the state; and national and regional 1
415	415	rate comparisons and accountability standards including any changes or substantive issues between 2
416	416	biennial reviews) including the recommended rates from the most recent assessment and review 3
417	417	with their annual budget submission to the office of management and budget and provide a detailed 4
418	418	explanation and impact statement if any rate variances exist between submitted recommended 5
419	419	budget and the corresponding recommended rate from the most recent assessment and review 6
420	420	process starting October 1, 2023, and biennially thereafter. 7
421	421	(v) The general assembly shall appropriate adequate funding as it deems necessary to 8
422	422	undertake the analyses, reports, and studies contained in this section relating to the powers and 9
423	423	duties of the office of the health insurance commissioner. The general assembly shall appropriate 10
424	424	adequate funding such that provider reimbursement rates for intellectual and developmental 11
425	425	disabilities shall be increased by two and three-tenths percent (2.3%) commencing on October 1, 12
426	426	2025; the two and three-tenths percent (2.3%) increase shall be prorated relative to any increase or 13
427	427	decrease recommended and/or enacted via the rate review process outlined in subsection (t) of this 14
428	428	section, for FY 2026. If the state’s overall Medicaid budget declines by more than twenty percent 15
429	429	(20%) from FY2025 to FY2026, the increase shall be suspended. 16
430	430	SECTION 2. This act shall take effect upon passage. 17
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432	432	LC002101
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434	434
435	435
436	436	LC002101 - Page 13 of 13
437	437	EXPLANATION
438	438	BY THE LEGISLATIVE COUNCIL
439	439	OF
440	440	A N A C T
441	441	RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND
442	442	HEALTHCARE REFORM AC T OF 2004 -- HEALTH INSURANCE OVERSIGHT
443	443	***
444	444	This act would provide for a two and three-tenths percent (2.3%) increase of provider 1
445	445	reimbursement rates for intellectual and developmental disabilities commencing October 1, 2025; 2
446	446	provided that the state’s overall Medicaid budget does not decline by more than twenty percent 3
447	447	(20%) from FY2025 to FY2026. 4
448	448	This act would take effect upon passage. 5
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450	450	LC002101
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