Rhode Island 2025 Regular Session

Rhode Island Senate Bill S0121 Compare Versions

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

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5	5	2025 -- S 0121
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7	7	LC000190
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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 HEALTH
16	16	CARE REFORM ACT OF 2004 -- HEALTH INSURANCE OVERSIGHT
17	17	Introduced By: Senators Ujifusa, Murray, Lawson, Tikoian, Euer, Bell, Mack, DiMario,
18	18	and Vargas
19	19	Date Introduced: January 31, 2025
20	20	Referred To: Senate Health & Human Services
21	21
22	22
23	23	It is enacted by the General Assembly as follows:
24	24	SECTION 1. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The 1
25	25	Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" is hereby amended 2
26	26	to read as follows: 3
27	27	42-14.5-3. Powers and duties. 4
28	28	The health insurance commissioner shall have the following powers and duties: 5
29	29	(a) To conduct quarterly public meetings throughout the state, separate and distinct from 6
30	30	rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 7
31	31	licensed to provide health insurance in the state; the effects of such rates, services, and operations 8
32	32	on consumers, medical care providers, patients, and the market environment in which the insurers 9
33	33	operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 10
34	34	than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 11
35	35	Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 12
36	36	general, and the chambers of commerce. Public notice shall be posted on the department’s website 13
37	37	and given in the newspaper of general circulation, and to any entity in writing requesting notice. 14
38	38	(b) To make recommendations to the governor and the house of representatives and senate 15
39	39	finance committees regarding healthcare insurance and the regulations, rates, services, 16
40	40	administrative expenses, reserve requirements, and operations of insurers providing health 17
41	41	insurance in the state, and to prepare or comment on, upon the request of the governor or 18
42	42
43	43
44	44	LC000190 - Page 2 of 13
45	45	chairpersons of the house or senate finance committees, draft legislation to improve the regulation 1
46	46	of health insurance. In making the recommendations, the commissioner shall recognize that it is 2
47	47	the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 3
48	48	of individual administrative expenditures as well as total administrative costs. The commissioner 4
49	49	shall make recommendations on the levels of reserves, including consideration of: targeted reserve 5
50	50	levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 6
51	51	reserves. 7
52	52	(c) To establish a consumer/business/labor/medical advisory council to obtain information 8
53	53	and present concerns of consumers, business, and medical providers affected by health insurance 9
54	54	decisions. The council shall develop proposals to allow the market for small business health 10
55	55	insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 11
56	56	the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 12
57	57	measures to inform small businesses of an insurance complaint process to ensure that small 13
58	58	businesses that experience rate increases in a given year may request and receive a formal review 14
59	59	by the department. The advisory council shall assess views of the health provider community 15
60	60	relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 16
61	61	insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 17
62	62	an annual report of findings and recommendations to the governor and the general assembly and 18
63	63	present its findings at hearings before the house and senate finance committees. The advisory 19
64	64	council is to be diverse in interests and shall include representatives of community consumer 20
65	65	organizations; small businesses, other than those involved in the sale of insurance products; and 21
66	66	hospital, medical, and other health provider organizations. Such representatives shall be nominated 22
67	67	by their respective organizations. The advisory council shall be co-chaired by the health insurance 23
68	68	commissioner and a community consumer organization or small business member to be elected by 24
69	69	the full advisory council. 25
70	70	(d) To establish and provide guidance and assistance to a subcommittee (“the professional-26
71	71	provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 27
72	72	composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall 28
73	73	include in its annual report and presentation before the house and senate finance committees the 29
74	74	following information: 30
75	75	(1) A method whereby health plans shall disclose to contracted providers the fee schedules 31
76	76	used to provide payment to those providers for services rendered to covered patients; 32
77	77	(2) A standardized provider application and credentials verification process, for the 33
78	78	purpose of verifying professional qualifications of participating healthcare providers; 34
79	79
80	80
81	81	LC000190 - Page 3 of 13
82	82	(3) The uniform health plan claim form utilized by participating providers; 1
83	83	(4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 2
84	84	hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make 3
85	85	facility-specific data and other medical service-specific data available in reasonably consistent 4
86	86	formats to patients regarding quality and costs. This information would help consumers make 5
87	87	informed choices regarding the facilities and clinicians or physician practices at which to seek care. 6
88	88	Among the items considered would be the unique health services and other public goods provided 7
89	89	by facilities and clinicians or physician practices in establishing the most appropriate cost 8
90	90	comparisons; 9
91	91	(5) All activities related to contractual disclosure to participating providers of the 10
92	92	mechanisms for resolving health plan/provider disputes; 11
93	93	(6) The uniform process being utilized for confirming, in real time, patient insurance 12
94	94	enrollment status, benefits coverage, including copays and deductibles; 13
95	95	(7) Information related to temporary credentialing of providers seeking to participate in the 14
96	96	plan’s network and the impact of the activity on health plan accreditation; 15
97	97	(8) The feasibility of regular contract renegotiations between plans and the providers in 16
98	98	their networks; and 17
99	99	(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 18
100	100	(e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). 19
101	101	(f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 20
102	102	fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 21
103	103	(g) To analyze the impact of changing the rating guidelines and/or merging the individual 22
104	104	health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 23
105	105	insurance market, as defined in chapter 50 of title 27, in accordance with the following: 24
106	106	(1) The analysis shall forecast the likely rate increases required to effect the changes 25
107	107	recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 26
108	108	health insurance market over the next five (5) years, based on the current rating structure and 27
109	109	current products. 28
110	110	(2) The analysis shall include examining the impact of merging the individual and small-29
111	111	employer markets on premiums charged to individuals and small-employer groups. 30
112	112	(3) The analysis shall include examining the impact on rates in each of the individual and 31
113	113	small-employer health insurance markets and the number of insureds in the context of possible 32
114	114	changes to the rating guidelines used for small-employer groups, including: community rating 33
115	115	principles; expanding small-employer rate bonds beyond the current range; increasing the employer 34
116	116
117	117
118	118	LC000190 - Page 4 of 13
119	119	group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 1
120	120	(4) The analysis shall include examining the adequacy of current statutory and regulatory 2
121	121	oversight of the rating process and factors employed by the participants in the proposed, new 3
122	122	merged market. 4
123	123	(5) The analysis shall include assessment of possible reinsurance mechanisms and/or 5
124	124	federal high-risk pool structures and funding to support the health insurance market in Rhode Island 6
125	125	by reducing the risk of adverse selection and the incremental insurance premiums charged for this 7
126	126	risk, and/or by making health insurance affordable for a selected at-risk population. 8
127	127	(6) The health insurance commissioner shall work with an insurance market merger task 9
128	128	force to assist with the analysis. The task force shall be chaired by the health insurance 10
129	129	commissioner and shall include, but not be limited to, representatives of the general assembly, the 11
130	130	business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 12
131	131	the individual market in Rhode Island, health insurance brokers, and members of the general public. 13
132	132	(7) For the purposes of conducting this analysis, the commissioner may contract with an 14
133	133	outside organization with expertise in fiscal analysis of the private insurance market. In conducting 15
134	134	its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 16
135	135	data shall be subject to state and federal laws and regulations governing confidentiality of health 17
136	136	care and proprietary information. 18
137	137	(8) The task force shall meet as necessary and include its findings in the annual report, and 19
138	138	the commissioner shall include the information in the annual presentation before the house and 20
139	139	senate finance committees. 21
140	140	(h) To establish and convene a workgroup representing healthcare providers and health 22
141	141	insurers for the purpose of coordinating the development of processes, guidelines, and standards to 23
142	142	streamline healthcare administration that are to be adopted by payors and providers of healthcare 24
143	143	services operating in the state. This workgroup shall include representatives with expertise who 25
144	144	would contribute to the streamlining of healthcare administration and who are selected from 26
145	145	hospitals, physician practices, community behavioral health organizations, each health insurer, and 27
146	146	other affected entities. The workgroup shall also include at least one designee each from the Rhode 28
147	147	Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the 29
148	148	Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year 30
149	149	that the workgroup meets and submits recommendations to the office of the health insurance 31
150	150	commissioner, the office of the health insurance commissioner shall submit such recommendations 32
151	151	to the health and human services committees of the Rhode Island house of representatives and the 33
152	152	Rhode Island senate prior to the implementation of any such recommendations and subsequently 34
153	153
154	154
155	155	LC000190 - Page 5 of 13
156	156	shall submit a report to the general assembly by June 30, 2024, and a report that focuses on 1
157	157	prescription drug prior authorizations, by January 1, 2026. The report shall include the 2
158	158	recommendations the commissioner may implement, with supporting rationale. Workgroup 3
159	159	members shall comply with the commissioner’s requests for information and documents within 4
160	160	timelines set by the commissioner, who has authority to take enforcement actions necessary to 5
161	161	implement this section. The workgroup shall consider and make recommendations for: 6
162	162	(1) Establishing a consistent standard for electronic eligibility and coverage verification. 7
163	163	Such standard shall: 8
164	164	(i) Include standards for eligibility inquiry and response and, wherever possible, be 9
165	165	consistent with the standards adopted by nationally recognized organizations, such as the Centers 10
166	166	for Medicare & Medicaid Services; 11
167	167	(ii) Enable providers and payors to exchange eligibility requests and responses on a system-12
168	168	to-system basis or using a payor-supported web browser; 13
169	169	(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 14
170	170	coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 15
171	171	requirements for specific services at the specific time of the inquiry; current deductible amounts; 16
172	172	accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 17
173	173	other information required for the provider to collect the patient’s portion of the bill; 18
174	174	(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 19
175	175	and benefits information; 20
176	176	(v) Recommend a standard or common process to protect all providers from the costs of 21
177	177	services to patients who are ineligible for insurance coverage in circumstances where a payor 22
178	178	provides eligibility verification based on best information available to the payor at the date of the 23
179	179	request of eligibility. 24
180	180	(2) Developing implementation guidelines and promoting adoption of the guidelines for: 25
181	181	(i) The use of the National Correct Coding Initiative code-edit policy by payors and 26
182	182	providers in the state; 27
183	183	(ii) Publishing any variations from codes and mutually exclusive codes by payors in a 28
184	184	manner that makes for simple retrieval and implementation by providers; 29
185	185	(iii) Use of Health Insurance Portability and Accountability Act standard group codes, 30
186	186	reason codes, and remark codes by payors in electronic remittances sent to providers; 31
187	187	(iv) Uniformity in the processing of claims by payors; and the processing of corrections to 32
188	188	claims by providers and payors; 33
189	189	(v) A standard payor-denial review process for providers when they request a 34
190	190
191	191
192	192	LC000190 - Page 6 of 13
193	193	reconsideration of a denial of a claim that results from differences in clinical edits where no single, 1
194	194	common-standards body or process exists and multiple conflicting sources are in use by payors and 2
195	195	providers. 3
196	196	(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 4
197	197	payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 5
198	198	detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 6
199	199	disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 7
200	200	the application of such edits and that the provider have access to the payor’s review and appeal 8
201	201	process to challenge the payor’s adjudication decision. 9
202	202	(vii) Nothing in this subsection shall be construed to modify the rights or obligations of 10
203	203	payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 11
204	204	prosecution under applicable law of potentially fraudulent billing activities. 12
205	205	(3) Developing and promoting widespread adoption by payors and providers of guidelines 13
206	206	to: 14
207	207	(i) Ensure payors do not automatically deny claims for services when extenuating 15
208	208	circumstances make it impossible for the provider to obtain a preauthorization before services are 16
209	209	performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 17
210	210	(ii) Require payors to use common and consistent processes and time frames when 18
211	211	responding to provider requests for medical management approvals. Whenever possible, such time 19
212	212	frames shall be consistent with those established by leading national organizations and be based 20
213	213	upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 21
214	214	management includes prior authorization of services, preauthorization of services, precertification 22
215	215	of services, post-service review, medical-necessity review, and benefits advisory; 23
216	216	(iii) Develop, maintain, and promote widespread adoption of a single, common website 24
217	217	where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 25
218	218	requirements; 26
219	219	(iv) Establish guidelines for payors to develop and maintain a website that providers can 27
220	220	use to request a preauthorization, including a prospective clinical necessity review; receive an 28
221	221	authorization number; and transmit an admission notification; 29
222	222	(v) Develop and implement the use of programs that implement selective prior 30
223	223	authorization requirements, based on stratification of healthcare providers’ performance and 31
224	224	adherence to evidence-based medicine with the input of contracted healthcare providers and/or 32
225	225	provider organizations. Such criteria shall be transparent and easily accessible to contracted 33
226	226	providers. Such selective prior authorization programs shall be available when healthcare providers 34
227	227
228	228
229	229	LC000190 - Page 7 of 13
230	230	participate directly with the insurer in risk-based payment contracts and may be available to 1
231	231	providers who do not participate in risk-based contracts; 2
232	232	(vi) Require the review of medical services, including behavioral health services, and 3
233	233	prescription drugs, subject to prior authorization on at least an annual basis, with the input of 4
234	234	contracted healthcare providers and/or provider organizations. Any changes to the list of medical 5
235	235	services, including behavioral health services, and prescription drugs requiring prior authorization, 6
236	236	shall be shared via provider-accessible websites; 7
237	237	(vii) Improve communication channels between health plans, healthcare providers, and 8
238	238	patients by: 9
239	239	(A) Requiring transparency and easy accessibility of prior authorization requirements, 10
240	240	criteria, rationale, and program changes to contracted healthcare providers and patients/health plan 11
241	241	enrollees which may be satisfied by posting to provider-accessible and member-accessible 12
242	242	websites; and 13
243	243	(B) Supporting: 14
244	244	(I) Timely submission by healthcare providers of the complete information necessary to 15
245	245	make a prior authorization determination, as early in the process as possible; and 16
246	246	(II) Timely notification of prior authorization determinations by health plans to impacted 17
247	247	health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, 18
248	248	and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 19
249	249	provider-accessible websites or similar electronic portals or services; 20
250	250	(viii) Increase and strengthen continuity of patient care by: 21
251	251	(A) Defining protections for continuity of care during a transition period for patients 22
252	252	undergoing an active course of treatment, when there is a formulary or treatment coverage change 23
253	253	or change of health plan that may disrupt their current course of treatment and when the treating 24
254	254	physician determines that a transition may place the patient at risk; and for prescription medication 25
255	255	by allowing a grace period of coverage to allow consideration of referred health plan options or 26
256	256	establishment of medical necessity of the current course of treatment; 27
257	257	(B) Requiring continuity of care for medical services, including behavioral health services, 28
258	258	and prescription medications for patients on appropriate, chronic, stable therapy through 29
259	259	minimizing repetitive prior authorization requirements; and which for prescription medication shall 30
260	260	be allowed only on an annual review, with exception for labeled limitation, to establish continued 31
261	261	benefit of treatment; and 32
262	262	(C) Requiring communication between healthcare providers, health plans, and patients to 33
263	263	facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 34
264	264
265	265
266	266	LC000190 - Page 8 of 13
267	267	by posting to provider-accessible websites or similar electronic portals or services; 1
268	268	(D) Continuity of care for formulary or drug coverage shall distinguish between FDA 2
269	269	designated interchangeable products and proprietary or marketed versions of a medication; 3
270	270	(ix) Encourage healthcare providers and/or provider organizations and health plans to 4
271	271	accelerate use of electronic prior authorization technology, including adoption of national standards 5
272	272	where applicable; and 6
273	273	(x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 7
274	274	workgroup meeting may be conducted in part or whole through electronic methods. 8
275	275	(4) To provide a report to the house and senate, on or before January 1, 2017, with 9
276	276	recommendations for establishing guidelines and regulations for systems that give patients 10
277	277	electronic access to their claims information, particularly to information regarding their obligations 11
278	278	to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 12
279	279	(5) No provision of this subsection (h) shall preclude the ongoing work of the office of 13
280	280	health insurance commissioner’s administrative simplification task force, which includes meetings 14
281	281	with key stakeholders in order to improve, and provide recommendations regarding, the prior 15
282	282	authorization process. 16
283	283	(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 17
284	284	thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 18
285	285	committee on health and human services, and the house committee on corporations, with: (1) 19
286	286	Information on the availability in the commercial market of coverage for anti-cancer medication 20
287	287	options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 21
288	288	options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 22
289	289	utilization and cost-sharing expense. 23
290	290	(j) To monitor the adequacy of each health plan’s compliance with the provisions of the 24
291	291	federal Mental Health Parity Act, including a review of related claims processing and 25
292	292	reimbursement procedures. Findings, recommendations, and assessments shall be made available 26
293	293	to the public. 27
294	294	(k) To monitor the transition from fee-for-service and toward global and other alternative 28
295	295	payment methodologies for the payment for healthcare services. Alternative payment 29
296	296	methodologies should be assessed for their likelihood to promote access to affordable health 30
297	297	insurance, health outcomes, and performance. 31
298	298	(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 32
299	299	payment variation, including findings and recommendations, subject to available resources. 33
300	300	(m) Notwithstanding any provision of the general or public laws or regulation to the 34
301	301
302	302
303	303	LC000190 - Page 9 of 13
304	304	contrary, provide a report with findings and recommendations to the president of the senate and the 1
305	305	speaker of the house, on or before April 1, 2014, including, but not limited to, the following 2
306	306	information: 3
307	307	(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 4
308	308	27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-5
309	309	18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 6
310	310	insurance for fully insured employers, subject to available resources; 7
311	311	(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 8
312	312	the existing standards of care and/or delivery of services in the healthcare system; 9
313	313	(3) A state-by-state comparison of health insurance mandates and the extent to which 10
314	314	Rhode Island mandates exceed other states benefits; and 11
315	315	(4) Recommendations for amendments to existing mandated benefits based on the findings 12
316	316	in (m)(1), (m)(2), and (m)(3) above. 13
317	317	(n) On or before July 1, 2014, the office of the health insurance commissioner, in 14
318	318	collaboration with the director of health and lieutenant governor’s office, shall submit a report to 15
319	319	the general assembly and the governor to inform the design of accountable care organizations 16
320	320	(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-17
321	321	based payment arrangements, that shall include, but not be limited to: 18
322	322	(1) Utilization review; 19
323	323	(2) Contracting; and 20
324	324	(3) Licensing and regulation. 21
325	325	(o) On or before February 3, 2015, the office of the health insurance commissioner shall 22
326	326	submit a report to the general assembly and the governor that describes, analyzes, and proposes 23
327	327	recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 24
328	328	to patients with mental health and substance use disorders. 25
329	329	(p) To work to ensure the health insurance coverage of behavioral health care under the 26
330	330	same terms and conditions as other health care, and to integrate behavioral health parity 27
331	331	requirements into the office of the health insurance commissioner insurance oversight and 28
332	332	healthcare transformation efforts. 29
333	333	(q) To work with other state agencies to seek delivery system improvements that enhance 30
334	334	access to a continuum of mental health and substance use disorder treatment in the state; and 31
335	335	integrate that treatment with primary and other medical care to the fullest extent possible. 32
336	336	(r) To direct insurers toward policies and practices that address the behavioral health needs 33
337	337	of the public and greater integration of physical and behavioral healthcare delivery. 34
338	338
339	339
340	340	LC000190 - Page 10 of 13
341	341	(s) The office of the health insurance commissioner shall conduct an analysis of the impact 1
342	342	of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 2
343	343	submit a report of its findings to the general assembly on or before June 1, 2023. 3
344	344	(t) To undertake the analyses, reports, and studies contained in this section: 4
345	345	(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 5
346	346	and competent firm or firms to undertake the following analyses, reports, and studies: 6
347	347	(i) The firm shall undertake a comprehensive review of all social and human service 7
348	348	programs having a contract with or licensed by the state or any subdivision of the department of 8
349	349	children, youth and families (DCYF), the department of behavioral healthcare, developmental 9
350	350	disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 10
351	351	health (DOH), and Medicaid for the purposes of: 11
352	352	(A) Establishing a baseline of the eligibility factors for receiving services; 12
353	353	(B) Establishing a baseline of the service offering through each agency for those 13
354	354	determined eligible; 14
355	355	(C) Establishing a baseline understanding of reimbursement rates for all social and human 15
356	356	service programs including rates currently being paid, the date of the last increase, and a proposed 16
357	357	model that the state may use to conduct future studies and analyses; 17
358	358	(D) Ensuring accurate and adequate reimbursement to social and human service providers 18
359	359	that facilitate the availability of high-quality services to individuals receiving home and 19
360	360	community-based long-term services and supports provided by social and human service providers; 20
361	361	(E) Ensuring the general assembly is provided accurate financial projections on social and 21
362	362	human service program costs, demand for services, and workforce needs to ensure access to entitled 22
363	363	beneficiaries and services; 23
364	364	(F) Establishing a baseline and determining the relationship between state government and 24
365	365	the provider network including functions, responsibilities, and duties; 25
366	366	(G) Determining a set of measures and accountability standards to be used by EOHHS and 26
367	367	the general assembly to measure the outcomes of the provision of services including budgetary 27
368	368	reporting requirements, transparency portals, and other methods; and 28
369	369	(H) Reporting the findings of human services analyses and reports to the speaker of the 29
370	370	house, senate president, chairs of the house and senate finance committees, chairs of the house and 30
371	371	senate health and human services committees, and the governor. 31
372	372	(2) The analyses, reports, and studies required pursuant to this section shall be 32
373	373	accomplished and published as follows and shall provide: 33
374	374	(i) An assessment and detailed reporting on all social and human service program rates to 34
375	375
376	376
377	377	LC000190 - Page 11 of 13
378	378	be completed by January 1, 2023, including rates currently being paid and the date of the last 1
379	379	increase; 2
380	380	(ii) An assessment and detailed reporting on eligibility standards and processes of all 3
381	381	mandatory and discretionary social and human service programs to be completed by January 1, 4
382	382	2023; 5
383	383	(iii) An assessment and detailed reporting on utilization trends from the period of January 6
384	384	1, 2017, through December 31, 2021, for social and human service programs to be completed by 7
385	385	January 1, 2023; 8
386	386	(iv) An assessment and detailed reporting on the structure of the state government as it 9
387	387	relates to the provision of services by social and human service providers including eligibility and 10
388	388	functions of the provider network to be completed by January 1, 2023; 11
389	389	(v) An assessment and detailed reporting on accountability standards for services for social 12
390	390	and human service programs to be completed by January 1, 2023; 13
391	391	(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 14
392	392	and unlicensed personnel requirements for established rates for social and human service programs 15
393	393	pursuant to a contract or established fee schedule; 16
394	394	(vii) An assessment and reporting on access to social and human service programs, to 17
395	395	include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 18
396	396	(viii) An assessment and reporting of national and regional Medicaid rates in comparison 19
397	397	to Rhode Island social and human service provider rates by April 1, 2023; 20
398	398	(ix) An assessment and reporting on usual and customary rates paid by private insurers and 21
399	399	private pay for similar social and human service providers, both nationally and regionally, by April 22
400	400	1, 2023; and 23
401	401	(x) Completion of the development of an assessment and review process that includes the 24
402	402	following components: eligibility; scope of services; relationship of social and human service 25
403	403	provider and the state; national and regional rate comparisons and accountability standards that 26
404	404	result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 27
405	405	and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 28
406	406	requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 29
407	407	1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 30
408	408	results and findings of this process shall be transparent, and public meetings shall be conducted to 31
409	409	allow providers, recipients, and other interested parties an opportunity to ask questions and provide 32
410	410	comment beginning in September 2023 and biennially thereafter. 33
411	411	(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 34
412	412
413	413
414	414	LC000190 - Page 12 of 13
415	415	insurance commissioner shall consult with the Executive Office of Health and Human Services. 1
416	416	(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 2
417	417	include the corresponding components of the assessment and review (i.e., eligibility; scope of 3
418	418	services; relationship of social and human service provider and the state; and national and regional 4
419	419	rate comparisons and accountability standards including any changes or substantive issues between 5
420	420	biennial reviews) including the recommended rates from the most recent assessment and review 6
421	421	with their annual budget submission to the office of management and budget and provide a detailed 7
422	422	explanation and impact statement if any rate variances exist between submitted recommended 8
423	423	budget and the corresponding recommended rate from the most recent assessment and review 9
424	424	process starting October 1, 2023, and biennially thereafter. 10
425	425	(v) The general assembly shall appropriate adequate funding as it deems necessary to 11
426	426	undertake the analyses, reports, and studies contained in this section relating to the powers and 12
427	427	duties of the office of the health insurance commissioner. 13
428	428	SECTION 2. This act shall take effect upon passage. 14
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430	430	LC000190
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432	432
433	433
434	434	LC000190 - Page 13 of 13
435	435	EXPLANATION
436	436	BY THE LEGISLATIVE COUNCIL
437	437	OF
438	438	A N A C T
439	439	RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND HEALTH
440	440	CARE REFORM ACT OF 2004 -- HEALTH INSURANCE OVERSIGHT
441	441	***
442	442	This act would require a report to be produced that focuses on prescription drug prior 1
443	443	authorizations by January 1, 2026. 2
444	444	This act would take effect upon passage. 3
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446	446	LC000190
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448	448