2025 -- S 0346
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LC000271
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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
____________
A N A C T
RELATING TO HEALTH AND SAFETY -- THE RHODE ISLAND COMPREH ENSIVE
HEALTH INSURANCE PRO GRAM
Introduced By: Senators Bell, Ujifusa, Murray, Valverde, Lawson, DiMario, Mack, Euer,
Quezada, and Kallman
Date Introduced: February 21, 2025
Referred To: Senate Health & Human Services
It is enacted by the General Assembly as follows:
SECTION 1. Title 23 of the General Laws entitled "HEALTH AND SAFETY" is hereby 1
amended by adding thereto the following chapter: 2
CHAPTER 104 3
THE RHODE ISLAND COMPREHENSIVE HEALTH INSURANCE PROGRAM 4
23-104-1. Legislative findings. 5
(1) Health care is a human right, not a commodity available only to those who can afford 6
it; 7
(2) Although the federal Affordable Care Act (ACA) allowed states to offer more people 8
taxpayer subsidized private health insurance, the ACA has not provided universal, comprehensive, 9
affordable coverage for all Rhode Islanders: 10
(i) In 2019, about four and three-tenths percent (4.3%) of Rhode Islanders had no health 11
insurance, causing about forty-three (43) (1 per 1,000 uninsured) unnecessary deaths each year; 12
(ii) An estimated forty-five percent (45%) of Rhode Islanders are under-insured (e.g., not 13
seeking health care because of high deductibles and co-pays); 14
(3) COVID-19 exacerbated and highlighted problems with the status quo health insurance 15
system including: 16
(i) Coverage is too easily lost when health insurance is tied to jobs - between February and 17
May, 2020, about twenty-one thousand (21,000) more Rhode Islanders lost their jobs and their 18
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health insurance; 1
(ii) Systemic racism is reinforced - Black and Hispanic/Latinx Rhode Islanders, are more 2
likely to be uninsured or underinsured, have suffered the highest rates of COVID-19 mortality and 3
morbidity; 4
(iii) The fear of out-of-pocket costs for uninsured and underinsured puts everyone at risk 5
because they avoid testing and treatment; 6
(4) In 2016, sixty million (60,000,000) people separated from their job at some point during 7
the year (i.e., about forty-two percent (42%) of the American workforce) and although this act may 8
cause some job loss, on balance, single payer would increase employment in Rhode Island by nearly 9
three percent (3%); 10
(5) The existing US health insurance system has failed to control the cost of health care 11
and to provide universal access to health care in a system which is widely accepted to waste thirty 12
percent (30%) of its revenues on activities that do not improve the health of Americans; 13
(6) Every industrialized nation in the world, except the United States, offers universal 14
health care to its citizens and enjoys better health outcomes for less than two thirds (2/3) to one-15
half (1/2) the cost; 16
(7) Health care is rationed under our current multi-payer system, despite the fact that Rhode 17
Island patients, businesses and taxpayers already pay enough to have comprehensive and universal 18
health insurance under a single-payer system; 19
(8) About one-third (1/3) of every "healthcare" dollar spent in the U.S. is wasted on 20
unnecessary administrative costs and excessive pharmaceutical company profits due to laws 21
preventing Medicare from negotiating prices and private health insurance companies lacking 22
adequate market share to effectively negotiate prices; 23
(9) Private health insurance companies are incentivized to let the cost of health care rise 24
because higher costs require health insurance companies to charge higher health insurance 25
premiums, increasing companies' revenue and stock price; 26
(10) The healthcare marketplace is not an efficient market and because it represents only 27
eighteen percent (18%) of the US domestic market, significantly restricts economic growth and 28
thus the financial well-being of every American, including every Rhode Islander; 29
(11) Rhode Islanders cannot afford to keep the current multi-payer health insurance system: 30
(i) Between 1991 and 2014, healthcare spending in Rhode Island per person rose by over 31
two hundred fifty percent (250%) rising much faster than income and greatly reducing disposable 32
income; 33
(ii) It is estimated that by 2025, the cost of health insurance for an average family of four 34
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(4) will equal about one-half (1/2) of their annual income; 1
(iii) In the U.S., about two-thirds (2/3) of personal bankruptcies are medical cost-related 2
and of these, about three-fourths (3/4) had health insurance at the onset of their medical problems. 3
In no other industrialized country do people worry about going bankrupt over medical costs; 4
(12) Rhode Island private businesses bear most of the costs of employee health insurance 5
coverage and spend significant time and money choosing from a confusing array of increasingly 6
expensive plans which do not provide comprehensive coverage; 7
(13) Rhode Island employees and retirees lose significant wages and pensions as they are 8
forced to pay higher amounts of health insurance and healthcare costs; 9
(14) Rhode Island's hospitals are under increasing financial distress i.e., closing, sold to 10
out-of-state entities, attempting mergers largely due to health insurance reimbursement problems 11
that other nations do not face and are fixed by a single-payer system; 12
(15) The state and its municipalities face enormous other post-employment benefits 13
(OPEB) unfunded liabilities due mostly to health insurance costs; 14
(16) An improved Medicare-for-all style single-payer program would, based on the 15
performance of existing Medicare, eliminate fifty percent (50%) of the administrative waste in the 16
current system of private insurance before other savings achieved through meaningful negotiation 17
of prices and other savings are considered; 18
(17) The high costs of medical care could be lowered significantly if the state could 19
negotiate on behalf of all its residents for bulk purchasing, as well as gain access to usage and price 20
information currently kept confidential by private health insurers as "proprietary information;" 21
(18) Single payer health care would establish a true "free market" system where doctors 22
compete for patients rather than health insurance companies dictating which patients are able to see 23
which doctors and setting reimbursement rates; 24
(19) Healthcare providers would spend significantly less time with administrative work 25
caused by multiple health insurance company requirements and barriers to care delivery and would 26
spend significantly less for overhead costs because of streamlined billing; 27
(20) Rhode Island must act because there are currently no effective state or federal laws 28
that can provide universal coverage and adequately control rising premiums, co-pays, deductibles 29
and medical costs, or prevent private insurance companies from continuing to limit available 30
providers and coverage; 31
(21) In 1962, Canada's successful single-payer program began in the province of 32
Saskatchewan (with approximately the same population as Rhode Island) and became a national 33
program within ten (10) years; and 34
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(22) The proposed Rhode Island single payer program was studied by Professor Gerald 1
Friedman at UMass Amherst in 2015 and he concluded that: 2
"Single-payer in Rhode Island will finance medical care with substantial savings compared 3
with the existing multi-payer system of public and private insurers and would improve access to 4
health care by extending coverage to the four percent (4%) of Rhode Island residents still without 5
insurance under the Affordable Care Act and expanding coverage for the growing number with 6
inadequate healthcare coverage. Single-payer would improve the economic health of Rhode Island 7
by: increasing real disposable income for most residents; reducing the burden of health care on 8
businesses and promoting increased employment; and shifting the costs of health care away from 9
working and middle-class residents." 10
23-104-2. Legislative purpose. 11
It is the intent of the general assembly that this chapter establish a universal, 12
comprehensive, affordable single-payer healthcare insurance program that will help control 13
healthcare costs which shall be referred to as, "the Rhode Island comprehensive health insurance 14
program" (RICHIP). The program will be paid for by consolidating government and private 15
payments to multiple insurance carriers into a more economical and efficient improved Medicare- 16
for-all style single-payer program and substituting lower progressive taxes for higher health 17
insurance premiums, co-pays, deductibles and costs in excess of caps. This program will save 18
Rhode Islanders from the current overly expensive, inefficient and unsustainable multi-payer health 19
insurance system that unnecessarily prevents access to medically necessary health care. The 20
program will be established after the standard of care funded by Medicaid has been raised to a 21
Medicare standard. 22
23-104-3. Definitions. 23
As used in this chapter: 24
(1) "Affordable Care Act" or "ACA" means the Federal Patient Protection and Affordable 25
Care Act (Pub. L. 111-148), as amended by the Federal Health Care and Education Reconciliation 26
Act of 2010 (Pub. L. 111-152), and any amendments to, or regulations or guidance issued under, 27
those acts. 28
(2) "Carrier" means either a private health insurer authorized to sell health insurance in 29
Rhode Island or a healthcare service plan, i.e., any person who undertakes to arrange for the 30
provision of healthcare services to subscribers or enrollees, or to pay for or to reimburse any part 31
of the cost for those services, in return for a prepaid or periodic charge paid by or on behalf of the 32
subscribers or enrollees, or any person, whether located within or outside of this state, who solicits 33
or contracts with a subscriber or enrollee in this state to pay for or reimburse any part of the cost 34
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of, or who undertakes to arrange or arranges for, the provision of healthcare services that are to be 1
provided, wholly or in part, in a foreign country in return for a prepaid or periodic charge paid by 2
or on behalf of the subscriber or enrollee. 3
(3) "Dependent" has the same definition as set forth in federal tax law (26 U.S.C. § 152). 4
(4) "Emergency and urgently needed services" has the same definition as set forth in the 5
federal Medicare law (42 CFR 422.113). 6
(5) "Federally matched public health program" means the state's Medicaid program under 7
Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.) and the state's Children's Health 8
Insurance Program (CHIP) under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa et 9
seq.). 10
(6) "For-profit provider" means any healthcare professional or healthcare institution that 11
provides payments, profits or dividends to investors or owners who do not directly provide health 12
care. 13
(7) "Health insurance" means any entity subject to the insurance laws and regulations of 14
this state, or subject to the jurisdiction of the health insurance commissioner, that contracts or offers 15
to contract, to provide and/or insuring health services on a prepaid basis, including, but not limited 16
to, policies of accident and sickness insurance, as defined by chapter 18 of title 27, nonprofit 17
hospital service corporation as defined by chapter 19 of title 27, and nonprofit medical service 18
corporation as defined in chapter 20 of title 27, a health maintenance organizations, as defined in 19
chapter 41 of title 27 and also includes a nonprofit dental service corporation, as defined in chapter 20
20.1 of title 27, all nonprofit optometric service corporations, as defined in chapter 20.2 of title 27, 21
a domestic insurance company subject to chapter 1 of title 27 that offers or provides health 22
insurance coverage in the state, and a foreign insurance company, subject to chapter 2 of title 27, 23
all pharmacy benefit managers (PBMs) that contracts to administer or manage prescription drug 24
benefits, any plan preempted by ERISA, but subject to state control (specifically state government, 25
local government, and quasi-public agency ERISA plans). 26
(8) "Medicaid" or "medical assistance" means a program that is one of the following: 27
(i) The state's Medicaid program under Title XIX of the Social Security Act (42 U.S.C. 28
Sec. 1396 et seq.); or 29
(ii) The state's Children's Health Insurance Program under Title XXI of the Social Security 30
Act (42 U.S.C. Sec. 1397aa et seq.). 31
(9) "Medically necessary" means medical, surgical or other services or goods (including 32
prescription drugs) required for the prevention, diagnosis, cure, or treatment of a health-related 33
condition including any such services that are necessary to prevent a detrimental change in either 34
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medical or mental health status. Medically necessary services shall be provided in a cost-effective 1
and appropriate setting and shall not be provided solely for the convenience of the patient or service 2
provider. "Medically necessary" does not include services or goods that are primarily for cosmetic 3
purposes; and does not include services or goods that are experimental, unless approved pursuant 4
to § 23-104-6(b). 5
(10) "Medicare" means Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) 6
and the programs thereunder. 7
(11) "Qualified healthcare provider" means any individual who meets requirements set 8
forth in § 23-104-7(a)(1). 9
(12) "Qualified Rhode Island resident" means any individual who is a "resident" as defined 10
by §§ 44-30-5(a)(1) and (a)(2) or a dependent of that resident. 11
(13) "Rhode Island comprehensive health insurance program" or ("RICHIP") means the 12
affordable, comprehensive and effective health insurance program as set forth in this chapter. 13
(14) "RICHIP participant" means a qualified Rhode Island resident who is enrolled in 14
RICHIP (and not disenrolled or disqualified) at the time they seek health care. 15
23-104-4. Rhode Island health insurance program. 16
(a) Organization. This chapter creates the Rhode Island comprehensive health insurance 17
program (RICHIP), as an independent state government agency. 18
(b) Director. A director shall be appointed by the governor, with the advice and consent of 19
the senate, to lead RICHIP and serve a term of four (4) years, subject to oversight by an executive 20
board. The director shall be compensated in accordance with the job title and job classification 21
established by the division of human resources and approved by the general assembly. The duties 22
of the director shall include: 23
(1) Employ staff and authorize reasonable expenditures, as necessary, from the RICHIP 24
trust fund, to pay program expenses and to administer the program, including creation and oversight 25
of RICHIP budgets; 26
(2) Oversee management of the RICHIP trust fund set forth in § 23-104-12(a) to ensure the 27
operational well-being and fiscal solvency of the program, including ensuring that all available 28
funds from all appropriate sources are collected and placed into the trust fund; 29
(3) Take any actions necessary and proper to implement the provisions of this chapter; 30
(4) Implement standardized claims and reporting procedures; 31
(5) Provide for timely payments to participating providers through a structure that is well 32
organized and that eliminates unnecessary administrative costs, i.e., coordinate with the state 33
comptroller to facilitate billing from and payments to providers using the state's computerized 34
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financial system, the Rhode Island financial and accounting network system (RIFANS); 1
(6) Coordinate with federal healthcare programs, including Medicare and Medicaid, to 2
obtain necessary waivers and streamline federal funding and reimbursement; 3
(7) Monitor billing and reimbursements to detect inappropriate behavior by providers and 4
patients and create prohibitions and penalties regarding bad faith or criminal RICHIP participation, 5
and procedures by which they will be enforced; 6
(8) Support the development of an integrated healthcare database for healthcare planning 7
and quality assurance and ensure the legally required confidentiality of all health records it 8
contains; 9
(9) Determine eligibility for RICHIP and establish procedures for enrollment, 10
disenrollment and disqualification from RICHIP, as well as procedures for handling complaints 11
and appeals from affected individuals, as set forth in § 29-104-5; 12
(10) Create RICHIP expenditure, status, and assessment reports, including, but not limited 13
to, annual reports with the following: 14
(i) Performance of the program; 15
(ii) Fiscal condition of the program; 16
(iii) Recommendations for statutory changes; 17
(iv) Receipt of payments from the federal government; 18
(v) Whether current year goals and priorities were met; and 19
(vi) Future goals and priorities; 20
(11) Review RICHIP collections and disbursements on at least a quarterly basis and 21
recommend adjustments needed to achieve budgetary targets and permit adequate access to care; 22
(12) Develop procedures for accommodating: 23
(i) Employer retiree health benefits for people who have been members of RICHIP but go 24
to live as retirees out of the state; 25
(ii) Employer retiree health benefits for people who earned or accrued those benefits while 26
residing in the state prior to the implementation of RICHIP and live as retirees out of the state; and 27
(iii) RICHIP coverage of healthcare services currently covered under the workers' 28
compensation system, including whether and how to continue funding for those services under that 29
system and whether and how to incorporate an element of experience rating; and 30
(13) No later than two (2) years after the effective date of this chapter, develop a proposal, 31
consistent with the principles of this chapter, for provision and funding by the program of long- 32
term care coverage. 33
(c) Board. There shall be a RICHIP board composed of nine (9) members serving terms of 34
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four (4) years. Members shall be appointed by the governor with advice and consent of the senate. 1
Members of the board shall have no pecuniary interest in any health insurance company or any 2
business subject to regulation of the board and cannot have previously worked for a health 3
insurance company. The duties of the board shall include: 4
(1) Annually establish a RICHIP benefits package for participants, including a formulary 5
and a list of other medically necessary goods, as well as a procedure for handling complaints and 6
appeals relating to the benefits package, pursuant to § 23-104-6. 7
(2) Establish RICHIP provider reimbursement and a procedure for handling provider 8
complaints and appeals as set forth in § 23-104-9; 9
(3) Review budget proposals from providers pursuant to § 23-104-11(b); and 10
(4) The board shall be subject to chapter 46 of title 42 ("open meetings"). 11
23-104-5. Coverage. 12
(a) All qualified Rhode Island residents may participate in RICHIP. The director shall 13
establish procedures to determine eligibility, enrollment, disenrollment and disqualification, 14
including criteria and procedures by which RICHIP can: 15
(1) Identify, automatically enroll, and provide a RICHIP card to qualified Rhode Island 16
residents; 17
(2) Process applications from individuals seeking to obtain RICHIP coverage for 18
dependents after the implementation date; 19
(3) Ensure eligible residents are knowledgeable and aware of their rights to health care; 20
(4) Determine whether an individual should be disenrolled (e.g., for leaving the state); 21
(5) Determine whether an individual should be disqualified (e.g., for fraudulent receipt of 22
benefits or reimbursements); 23
(6) Determine appropriate actions that should be taken with respect to individuals who are 24
disenrolled or disqualified (including civil and criminal penalties); and 25
(7) Permit individuals to request review and appeal decisions to disenroll or disqualify 26
them. 27
(b) Medicare and Medicaid eligible coverage under RICHIP shall be as follows: 28
(1) If all necessary federal waivers are obtained, qualified Rhode Island residents eligible 29
for federal Medicare ("Medicare eligible residents") shall continue to pay required fees to the 30
federal government. RICHIP shall establish procedures to ensure that Medicare eligible residents 31
shall have such amounts deducted from what they owe to RICHIP under § 23-104-12(h). RICHIP 32
shall become the equivalent of qualifying coverage under Medicare part D and Medicare advantage 33
programs, and as such shall be the vendor for coverage to RICHIP participants. RICHIP shall 34
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provide Medicare eligible residents benefits equal to those available to all other RICHIP 1
participants and equal to or greater than those available through the federal Medicare program. To 2
streamline the process, RICHIP shall seek to receive federal reimbursements for services and goods 3
to Medicare eligible residents and administer all Medicare funds. 4
(2) If all necessary federal waivers are obtained, RICHIP shall become the state's sole 5
Medicaid provider. RICHIP shall create procedures to enroll all qualified Rhode Island residents 6
eligible for Medicaid ("Medicaid eligible residents") in the federal Medicaid program to ensure a 7
maximum amount of federal Medicaid funds go to the RICHIP trust fund. RICHIP shall provide 8
benefits to Medicaid eligible residents equal to those available to all other RICHIP participants. 9
(3) If all necessary federal waivers are not granted from the Medicaid or Medicare 10
programs operated under Title XVIII or XIX of the Social Security Act, the Medicaid or Medicare 11
program for which a waiver is not granted shall act as the primary insurer for those eligible for such 12
coverage, and RICHIP shall serve as the secondary or supplemental plan of health insurance 13
coverage. Until such time as a waiver is granted, the plan shall not pay for services for persons 14
otherwise eligible for the same healthcare benefits under the Medicaid or Medicare program. The 15
director shall establish procedures for determining amounts owed by Medicare and Medicaid 16
eligible residents for supplemental RICHIP coverage and the extent of such coverage. 17
(4) The director may require Rhode Island residents to provide information necessary to 18
determine whether the resident is eligible for a federally matched public health program or for 19
Medicare, or any program or benefit under Medicare. 20
(5) As a condition of eligibility or continued eligibility for healthcare services under 21
RICHIP, a qualified Rhode Island resident who is eligible for benefits under Medicare shall enroll 22
in Medicare, including Parts A, B, and D. 23
(c) Veterans. RICHIP shall serve as the secondary or supplemental plan of health insurance 24
coverage for military veterans. The director shall establish procedures for determining amounts 25
owed by military veterans who are qualified residents for such supplemental RICHIP coverage and 26
the extent of such coverage. 27
(d) This chapter does not create any employment benefit, nor require, prohibit, or limit the 28
providing of any employment benefit. 29
(e) This chapter does not affect or limit collective action or collective bargaining on the 30
part of a healthcare provider with their employer or any other lawful collective action or collective 31
bargaining. 32
23-104-6. Benefits. 33
(a) This chapter shall provide insurance coverage for services and goods (including 34
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prescription drugs) deemed medically necessary by a qualified healthcare provider and that is 1
currently covered under: 2
(1) Services and goods currently covered by the federal Medicare program (Social Security 3
Act title XVIII) parts A, B and D; 4
(2) Services and goods covered by Medicaid as of January 1, 2026; 5
(3) Services and goods currently covered by the state's Children's Health Insurance 6
Program; 7
(4) Essential health benefits mandated by the Affordable Care Act; and 8
(5) Services and goods within the following categories: 9
(i) Primary and preventive care; 10
(ii) Approved dietary and nutritional therapies; 11
(iii) Inpatient care; 12
(iv) Outpatient care; 13
(v) Emergency and urgently needed care; 14
(vi) Prescription drugs and medical devices; 15
(vii) Laboratory and diagnostic services; 16
(viii) Palliative care; 17
(ix) Mental health services; 18
(x) Oral health, including dental services, periodontics, oral surgery, and endodontics; 19
(xi) Substance abuse treatment services; 20
(xii) Physical therapy and chiropractic services; 21
(xiii) Vision care and vision correction; 22
(xiv) Hearing services, including coverage of hearing aids; 23
(xv) Podiatric care; 24
(xvi) Comprehensive family planning, reproductive, maternity, and newborn care; 25
(xvii) Short-term rehabilitative services and devices; 26
(xviii) Durable medical equipment; 27
(xix) Gender affirming health care; and 28
(xx) Diagnostic and routine medical testing. 29
(b) Additional coverage. The director shall create a procedure that may permit additional 30
medically necessary goods and services beyond that provided by federal laws cited herein and 31
within the areas set forth in § 23-104-5, if the coverage is for services and goods deemed medically 32
necessary based on credible scientific evidence published in peer-reviewed medical literature 33
generally recognized by the relevant medical community, physician specialty society 34
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recommendations, and the views of physicians practicing in relevant clinical areas and any other 1
relevant factors. The director shall create procedures for handling complaints and appeals 2
concerning the benefits package. 3
(c) Restrictions shall not apply. In order for RICHIP participants to be able to receive 4
medically necessary goods and services, this chapter shall override any state law that restricts the 5
provision or use of state funds for any medically necessary goods or services, including those 6
related to family planning and reproductive healthcare. 7
(d) Medically necessary goods: 8
(1) Prescription drug formulary: 9
(i) In general. The director shall establish a prescription drug formulary system, to be 10
approved by the board, and encourage best-practices in prescribing and discourage the use of 11
ineffective, dangerous, or excessively costly medications when better alternatives are available. 12
(ii) Promotion of generics. The formulary under this subsection shall promote the use of 13
generic medications to the greatest extent possible. 14
(iii) Formulary updates and petition rights. The formulary under this subsection shall be 15
updated frequently and the director shall create a procedure for patients and providers to make 16
requests and appeal denials to add new pharmaceuticals or to remove ineffective or dangerous 17
medications from the formulary. 18
(iv) Use of off-formulary medications. The director shall promulgate rules regarding the 19
use of off-formulary medications which allow for patient access but do not compromise the 20
formulary. 21
(v) Approved devices and equipment. The director shall present a list of medically 22
necessary devices and equipment that shall be covered by RICHIP, subject to final approval by the 23
board. 24
(vi) Bulk purchasing. The director shall seek and implement ways to obtain goods at the 25
lowest possible cost, including bulk purchasing agreements. 26
23-104-7. Providers. 27
(a) Rhode Island providers. 28
(1) Licensing. Participating providers shall meet state licensing requirements in order to 29
participate in RICHIP. No provider whose license is under suspension or has been revoked shall 30
participate in the program. 31
(2) Participation. All providers may participate in RICHIP by providing items on the 32
RICHIP benefits list for which they are licensed. Providers may elect either to participate fully, or 33
not at all, in the program. 34
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(3) For-profit providers. For-profit providers may continue to offer services and goods in 1
Rhode Island, but are prohibited from charging patients more than RICHIP reimbursement rates 2
for covered services and goods and shall notify qualified Rhode Island residents when the services 3
and goods they offer will not be reimbursed fully under RICHIP. 4
(b) Out-of-state providers. Except for emergency and urgently needed service, as set forth 5
in § 23-104-7(d), RICHIP shall not pay for healthcare services obtained outside of Rhode Island 6
unless the following requirements are met: 7
(1) The out-of-state provider agrees to accept the RICHIP rate for out-of-state providers; 8
and 9
(2) The services are medically necessary care. 10
(c) Out-of-state provider reimbursement. The program shall pay out-of-state healthcare 11
providers at a rate equal to the average rate paid by commercial insurers or Medicare for the services 12
rendered, whichever is higher. 13
(d) Out-of-state residents. 14
(1) In general. Rhode Island providers who provide any services to individuals who are not 15
RICHIP participants shall not be reimbursed by RICHIP and shall seek reimbursement from those 16
individuals or other sources. 17
(2) Emergency care exception. Nothing in this chapter shall prevent any individual from 18
receiving or any provider from providing emergency healthcare services and goods in Rhode 19
Island. The director shall adopt rules to provide reimbursement; however, the rules shall reasonably 20
limit reimbursement to protect the fiscal integrity of RICHIP. The director shall implement 21
procedures to secure reimbursement from any appropriate third-party funding source or from the 22
individual to whom the emergency services were rendered. 23
23-104-8. Cross border employees. 24
(a) State residents employed out-of-state. If an individual is employed out-of-state by an 25
employer that is subject to Rhode Island state law, the employer and employee shall be required to 26
pay the payroll taxes as to that employee as if the employment were in the state. If an individual is 27
employed out-of-state by an employer that is not subject to Rhode Island state law, the employee 28
health coverage provided by the out-of-state employer to a resident working out-of-state shall serve 29
as the employee's primary plan of health coverage, and RICHIP shall serve as the employee's 30
secondary plan of health coverage. The director shall establish procedures for determining amounts 31
owed by residents employed out-of-state for such supplemental secondary RICHIP coverage and 32
the extent of such coverage. 33
(b) Out-of-state residents employed in the state. The payroll tax set forth in § 23-104-12(i) 34
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shall apply to any out-of-state resident who is employed or self-employed in the state. However, 1
such out-of-state residents shall be able to take a credit for amounts they spend on health benefits 2
for themselves that would otherwise be covered by RICHIP if the individual were a RICHIP 3
participant. The out-of-state resident's employer shall be able to take a credit against such payroll 4
taxes regardless of the form of the health benefit (e.g., health insurance, a self-insured plan, direct 5
services, or reimbursement for services), to ensure that the revenue proposal does not relate to 6
employment benefits in violation of the Federal Employee Retirement Income Security Act 7
("ERISA") law. For non-employment-based spending by individuals, the credit shall be available 8
for and limited to spending for health coverage (not out-of-pocket health spending). The credit shall 9
be available without regard to how little is spent or how sparse the benefit. The credit may only be 10
taken against the payroll taxes set forth in § 23-104-12(i). Any excess amount may not be applied 11
to other tax liability. For employment-based health benefits, the credit shall be distributed between 12
the employer and employee in the same proportion as the spending by each for the benefit. The 13
employer and employee may each apply their respective portion of the credit to their respective 14
portion of the payroll taxes set forth in § 23-104-12(i). If any provision of this clause or any 15
application of it shall be ruled to violate ERISA, the provision or the application of it shall be null 16
and void and the ruling shall not affect any other provision or application of this section or this 17
chapter. 18
23-104-9. Provider reimbursement. 19
(a) Rates for services and goods. RICHIP reimbursement rates to providers shall be 20
determined by the RICHIP board. These rates shall be equal to or greater than the federal Medicare 21
rates available to Rhode Island qualified residents that are in effect at the time services and goods 22
are provided. For outpatient behavioral health services, the minimum rate shall equal one hundred 23
fifty percent (150%) of federal Medicare rates. If the director determines that there are no such 24
federal Medicare reimbursement rates, the director shall set the minimum rate. The director shall 25
review the rates at least annually, recommend changes to the board, and establish procedures by 26
which complaints about reimbursement rates may be reviewed by the board. 27
(b) Billing and payments. Providers shall submit billing for services to RICHIP participants 28
in the form of electronic invoices entered into RIFANS, the state's computerized financial system. 29
The director shall coordinate the manner of processing and payment with the office of accounts and 30
control and the RIFANS support team within the division of information technology. Payments 31
shall be made by check or electronic funds transfer in accordance with terms and procedures 32
coordinated by the director and the office of accounts and control and consistent with the fiduciary 33
management of the RICHIP trust fund. 34
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(c) Provider restrictions. In-state providers who accept any payment from RICHIP shall 1
not bill any patient for any covered benefit. In-state providers cannot use any of their operating 2
budgets for expansion, profit, excessive executive income, including bonuses, marketing, or major 3
capital purchases or leases. 4
23-104-10. Private insurance companies. 5
(a) Non-duplication. It is unlawful for a private health insurer to sell health insurance 6
coverage to qualified Rhode Island residents that duplicates the benefits provided under this 7
chapter. Nothing in this chapter shall be construed as prohibiting the sale of health insurance 8
coverage for any additional benefits not covered by this chapter, including additional benefits that 9
an employer may provide to employees or their dependents, or to former employees or their 10
dependents (e.g., multiemployer plans can continue to provide wrap-around coverage for any 11
benefits not provided by RICHIP). 12
(b) Displaced employees. Re-education and job placement of persons employed in Rhode 13
Island-located enterprises who have lost their jobs as a result of this chapter shall be managed by 14
the Rhode Island department of labor and training or an appropriate federal retraining program. The 15
director may provide funds from RICHIP or funds otherwise appropriated for this purpose for 16
retraining and assisting job transition for individuals employed or previously employed in the fields 17
of health insurance, healthcare service plans, and other third-party payments for health care or those 18
individuals providing services to healthcare providers to deal with third-party payers for health 19
care, whose jobs may be or have been ended as a result of the implementation of the program, 20
consistent with applicable laws. 21
23-104-11. Budgeting. 22
(a) Operating budget. Annually, the director shall create an operating budget for the 23
program that includes the costs for all benefits set forth in § 23-104-5 and the costs for RICHIP 24
administration. The director shall determine appropriate reimbursement rates for benefits pursuant 25
to § 23-104-9(a). The operating budget shall be approved by the executive board prior to 26
submission to the governor and general assembly. 27
(b) Capital expenditures. The director shall work with representatives from state entities 28
involved with provider capital expenditures (e.g., the Rhode Island department of administration 29
office of capital projects, the Rhode Island health and educational building corporation, etc.), and 30
providers to help ensure that capital expenditures proposed by providers, including amounts to be 31
spent on construction and renovation of health facilities and major equipment purchases, will 32
address healthcare needs of RICHIP participants. To the extent that providers are seeking to use 33
RICHIP funds for capital expenditures, the director shall have the authority to approve or deny such 34
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expenditures. 1
(c) Prohibition against co-mingling operations and capital improvement funds. It is 2
prohibited to use funds under this chapter that are earmarked: 3
(1) For operations for capital expenditures; or 4
(2) For capital expenditures for operations. 5
23-104-12. Financing. 6
(a) RICHIP trust fund. There shall be established a RICHIP trust fund into which funds 7
collected pursuant to this chapter are deposited and from which funds are distributed. All money 8
collected and received shall be used exclusively to finance RICHIP. The governor or general 9
assembly may provide funds to the RICHIP trust fund, but may not remove or borrow funds from 10
the RICHIP trust fund. 11
(b) Revenue proposal. After approval of the RICHIP executive board, the director shall 12
submit to the governor and the general assembly a revenue plan and, if required, legislation 13
(referred to collectively in this section as the "revenue proposal") to provide the revenue necessary 14
to finance RICHIP. The initial revenue proposal shall be submitted once waiver negotiations have 15
proceeded to a level deemed sufficient by the director and annually, thereafter. The basic structure 16
of the initial revenue proposal will be based on a consideration of: 17
(1) Anticipated savings from a single payer program; 18
(2) Government funds available for health care; 19
(3) Private funds available for health care; and 20
(4) Replacing current regressive health insurance payments made to multiple health 21
insurance carriers with progressive contributions to a single payer (RICHIP) in order to make 22
healthcare insurance affordable and remove unnecessary barriers to healthcare access. 23
Subsequent proposals shall adjust the RICHIP contributions, based on projections from the 24
total RICHIP costs in the previous year, and shall include a five (5) year plan for adjusting RICHIP 25
contributions to best meet the goals set forth in this section and § 23-104-2. 26
(c) Anticipated savings. It is anticipated that RICHIP will lower healthcare costs by: 27
(1) Eliminating payments to private health insurance carriers; 28
(2) Reducing paperwork and administrative expenses for both providers and payers created 29
by the marketing, sales, eligibility checks, network contract management, issues associated 30
multiple benefit packages, and other administrative waste associated with the current multi-payer 31
private health insurance system; 32
(3) Allowing the planning and delivery of a public health strategy for the entire population 33
of Rhode Island; 34
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(4) Improving access to preventive healthcare; and 1
(5) Negotiating on behalf of the state for bulk purchasing of medical supplies and 2
pharmaceuticals. 3
(d) Federal funds. The executive office of health and human services, in collaboration with 4
the director, the board and the Medicaid office, shall seek and obtain waivers and other approvals 5
relating to Medicaid, the Children's Health Insurance Program, Medicare, federal tax exemptions 6
for health care, the ACA, and any other relevant federal programs in order that: 7
(1) Federal funds and other subsidies for health care that would otherwise be paid to the 8
state and its residents and healthcare providers, would be paid by the federal government to the 9
state and deposited into the RICHIP trust fund; 10
(2) Programs would be waived and such funding from federal programs in Rhode Island 11
would be replaced or merged into RICHIP in order that it can operate as a single payer program; 12
(3) Maximum federal funding for health care is sought even if any necessary waivers or 13
approvals are not obtained and multiple sources of funding with RICHIP trust fund monies are 14
pooled, in order that RICHIP can act as much as possible like a single payer program to maximize 15
benefits to Rhode Islanders; and 16
(4) Federal financial participation in the programs that are incorporated into RICHIP are 17
not jeopardized. 18
(e) State funds. State funds that would otherwise be appropriated to any governmental 19
agency, office, program, instrumentality, or institution for services and benefits covered under 20
RICHIP shall be directed into the RICHIP trust fund. Payments to the fund pursuant to this section 21
shall be in an amount equal to the money appropriated for those purposes in the fiscal year 22
beginning immediately preceding the effective date of this chapter. 23
(f) Private funds. Private grants (e.g., from nonprofit corporations) and other funds 24
specifically ear-marked for health care (e.g., from litigation against tobacco companies, opioid 25
manufacturers, etc.), shall also be put into the RICHIP trust fund. 26
(g) Assignments from RICHIP participants. Receipt of healthcare services under the plan 27
shall be deemed an assignment by the RICHIP participant of any right to payment for services from 28
a policy of insurance, a health benefit plan or other source. The other source of healthcare benefits 29
shall pay to the fund all amounts it is obligated to pay to, or on behalf of, the RICHIP participant 30
for covered healthcare services. The director may commence any action necessary to recover the 31
amounts due. 32
(h) Replacing current health insurance payments with progressive contributions. Instead of 33
making health insurance payments to multiple carriers (i.e., for premiums, co-pays deductibles, and 34
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costs in excess of caps) for limited coverage, individuals and entities subject to Rhode Island 1
taxation pursuant to § 44-30-1 shall pay progressive contributions to the RICHIP trust fund 2
(referred to collectively in this section as the "RICHIP contributions") for comprehensive coverage. 3
These RICHIP contributions shall be set and adjusted over time to an appropriate level to: 4
(1) Cover the actual cost of the program; 5
(2) Ensure that higher brackets of income subject to specified taxes shall be assessed at a 6
higher marginal rate than lower brackets; and 7
(3) Protect the economic welfare of small businesses, low-income earners and working 8
families through tax credits or exemptions. 9
(i) Contributions based on earned income. The amounts currently paid by employers and 10
employees for health insurance shall initially be replaced by a ten percent (10%) payroll tax, based 11
on the projected average payroll of employees over three (3) previous calendar years. The employer 12
shall pay eighty percent (80%) and the employee shall pay twenty percent (20%) of this payroll 13
tax, except that an employer may agree to pay all or part of the employee's share. Self- employed 14
individuals shall initially pay one-hundred percent (100%) of the payroll tax. The ten percent (10%) 15
initial rate will be adjusted by the director in order that higher brackets of income subject to these 16
taxes shall be assessed at a higher marginal rate than lower brackets and in order that small 17
businesses and lower income earners receive a credit or exemption. 18
(j) Contributions based on unearned income. There shall be a progressive contribution 19
based on unearned income, i.e., capital gains, dividends, interest, profits, and rents. Initially, the 20
unearned income RICHIP contributions shall be equal to ten percent (10%) of such unearned 21
income. The ten percent (10%) initial rate may be adjusted by the director to allow for a graduated 22
progressive exemption or credit for individuals with lower unearned income levels. 23
23-104-13. Implementation. 24
(a) State laws and regulations. 25
(1) In general. The director shall work with the executive board and receive such assistance 26
as may be necessary from other state agencies and entities to examine state laws and regulations 27
and to make recommendations necessary to conform such laws and regulations to properly 28
implement the RICHIP program. The director shall report recommendations to the governor and 29
the general assembly. 30
(2) Anti-trust laws. The intent of this chapter is to exempt activities provided for under this 31
chapter from state antitrust laws and to provide immunity from federal antitrust laws through the 32
state action doctrine. 33
(b) The director shall complete an implementation plan to provide healthcare coverage for 34
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qualified residents in accordance with this chapter within twelve (12) months of its effective date. 1
(c) The executive office of health and human services, in collaboration with the director, 2
the board, and the Medicaid director, will have the initial responsibility of negotiating the waivers. 3
(d) Severability. If any provision or application of this chapter shall be held to be invalid, 4
or to violate or be inconsistent with any applicable federal law or regulation, that shall not affect 5
other provisions or applications of this chapter which can be given effect without that provision or 6
application; and to that end, the provisions and applications of this chapter are severable. 7
SECTION 2. Chapter 22-11 of the General Laws entitled "Joint Committee on Legislative 8
Services" is hereby amended by adding thereto the following section: 9
22-11-4.1. Employees needed to maximize federal Medicaid funding. 10
The joint committee on legislative services shall fund five (5) new FTEs for the senate 11
fiscal office and five (5) new FTEs for the house fiscal office exclusively devoted to finding ways 12
to maximize federal Medicaid funding, including compiling proposals for expanding eligibility to 13
maximize the eligibility allowed by Centers for Medicare & Medicaid Services (CMS). 14
SECTION 3. Section 27-34.3-7 of the General Laws in Chapter 27-34.3 entitled "Rhode 15
Island Life and Health Insurance Guaranty Association Act" is hereby amended to read as follows: 16
27-34.3-7. Board of directors. 17
(a) The board of directors of the association shall consist of: 18
(1) Not less than five (5) nor more than nine (9) member insurers serving terms as 19
established in the plan of operation Nine (9) members appointed by the governor with advice and 20
consent of the senate; and 21
(2) The commissioner or the commissioner’s designee, who shall chair the board in a non-22
voting ex officio capacity. Only member insurers shall be eligible to vote. The members of the 23
board shall be selected by member insurers subject to the approval of the commissioner. The board 24
of directors, previously established under § 27-34.1-8 [repealed], shall continue to operate in 25
accordance with the provision of this section. Vacancies on the board shall be filled for the 26
remaining period of the term by a majority vote of the remaining board members, subject to the 27
approval of the commissioner. 28
(b) In approving selections to the board, the commissioner shall consider, among other 29
things, whether all member insurers are fairly represented. 30
(c) Members of the board may be reimbursed from the assets of the association for expenses 31
incurred by them as members of the board of directors but members of the board shall not be 32
compensated by the association for their services. 33
SECTION 4. Section 27-66-24 of the General Laws in Chapter 27-66 entitled "The Health 34
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Insurance Conversions Act" is hereby amended to read as follows: 1
27-66-24. Exceptions — Rehabilitation, liquidation, or conservation. 2
No proposed conversion shall be subject to this chapter in In the event that the a health 3
insurance corporation, health maintenance corporation, a nonprofit hospital service corporation, 4
nonprofit medical service corporation, pharmacy benefit manager, nonprofit dental service 5
corporation, managed care organization, nonprofit optometric service corporation, or affiliate or 6
subsidiary of them, hereinafter "the insurer," is subject to an order from the superior court directing 7
the director to rehabilitate, liquidate, or conserve, as provided in §§ 27-19-28, 27-20-24, 27-41-18, 8
or chapter 14.1, 14.2, 14.3, or 14.4 of this title., certain additional conditions shall apply to the 9
insurer: 10
(1) The insolvency, financial condition, or default of the insurer at any time shall not permit 11
the insurer to fail to pay claims in a timely manner. 12
(2) Should the insurer fail to pay claims in a timely manner, those claims shall become a 13
temporary obligation of the state, who shall pay them in a timely manner. Should the state be 14
compelled to pay claims for this reason, the insurer shall owe the state a fine ten (10) times the 15
value of all claims paid. 16
(3) The insolvency, financial condition, or default of the insurer at any time shall not permit 17
the insurer to fail to pay state taxes on time. Should the insurer fail to pay taxes on time, the size of 18
the tax obligation owed shall increase by a factor of ten (10). 19
(4) The Medicaid office shall be guaranteed a right of first refusal to acquire the insurer 20
before alternate buyers are considered. Any obligations due to the state by the insurer shall be 21
counted towards the purchase price of the insurer. The Rhode Island life and health insurance 22
guaranty association, created pursuant to § 27-34.3-6, shall pay the costs of the acquisition, but all 23
ownership shares shall be held by the Medicaid office. 24
SECTION 5. Title 27 of the General Laws entitled "INSURANCE" is hereby amended by 25
adding thereto the following chapter: 26
CHAPTER 83 27
PRIOR AUTHORIZATION OF CERTAIN HEALTH INSURANCE POLICY CHANGES 28
27-83-1. Definitions. 29
For purposes of this chapter: 30
"Health insurer" means any entity subject to the insurance laws and regulations of this state, 31
or subject to the jurisdiction of the health insurance commissioner, that contracts or offers to 32
contract, to provide and/or insuring health services on a prepaid basis, including, but not limited to, 33
policies of accident and sickness insurance subject to chapter 18 of title 27; any nonprofit hospital 34
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service corporation subject to chapter 19 of title 27; any nonprofit medical service corporation 1
subject to chapter 20 of title 27; any health maintenance organization subject to chapter 41 of title 2
27; any nonprofit dental service corporation subject to chapter 20.1 of title 27; any nonprofit 3
optometric service corporation subject to chapter 20.2 of title 27; any pharmacy benefit manager; 4
or any health benefit plan issued by the State of Rhode Island, a municipality, a quasi-public 5
agency, or any other political subdivision of the State of Rhode Island to cover employees. 6
27-83-2. Prior authorization of general assembly. 7
(a) Prior authorization of the general assembly shall be required for certain policy changes 8
by health insurers: 9
(1) Any change that increases the average amount charged annually to consumers on a per 10
beneficiary basis; 11
(2) Any change that in any way reduces any benefits offered to plan beneficiaries; 12
(3) Any change that increases any premiums, deductibles, or copays; 13
(4) Ceasing offering any plan a health insurer offers within the State of Rhode Island; or 14
(5) Any other change that the health insurance commissioner or attorney general shall, 15
through regulation, determine to require prior authorization of the general assembly. 16
(b) No rate reviews pursuant to those utilized in §§ 27-18-54, 27-19-30.1, 27-20-25.2, 27-17
41-27.2, and 42-62-13 shall be construed to exempt any health insurer from the prior authorization 18
requirements of this chapter. 19
SECTION 6. Section 28-57-5 of the General Laws in Chapter 28-57 entitled "Healthy and 20
Safe Families and Workplaces Act" is hereby amended to read as follows: 21
28-57-5. Accrual of paid sick and safe leave time. 22
(a) All employees employed by an employer of eighteen (18) or more employees in Rhode 23
Island shall accrue a minimum of one hour of paid sick and safe leave time for every thirty five 24
(35) hours worked up to a maximum of twenty-four (24) hours during calendar year 2018, thirty-25
two (32) hours during calendar year 2019, and up to a maximum of forty (40) hours per year from 26
calendar year 2020 through calendar year 2026, and one hundred sixty (160) hours per year 27
thereafter, unless the employer chooses to provide a higher annual limit in both accrual and use. In 28
determining the number of employees who are employed by an employer for compensation, all 29
employees defined in § 28-57-3(7) shall be counted. 30
(b) Employees who are exempt from the overtime requirements under 29 U.S.C. § 31
213(a)(1) of the federal Fair Labor Standards Act, 29 U.S.C. § 201 et seq., will be assumed to work 32
forty (40) hours in each workweek for purposes of paid sick and safe leave time accrual unless their 33
normal workweek is less than forty (40) hours, in which case paid sick and safe leave time accrues 34
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based upon that normal workweek. 1
(c) Paid sick and safe leave time as provided in this chapter shall begin to accrue at the 2
commencement of employment or pursuant to the law’s effective date [July 1, 2018], whichever is 3
later. An employer may provide all paid sick and safe leave time that an employee is expected to 4
accrue in a year at the beginning of the year. 5
(d) An employer may require a waiting period for newly hired employees of up to ninety 6
(90) days. During this waiting period, an employee shall accrue earned sick time pursuant to this 7
section or the employer’s policy, if exempt under § 28-57-4(b), but shall not be permitted to use 8
the earned sick time until after he or she has completed the waiting period. 9
(e) Paid sick and safe leave time shall be carried over to the following calendar year; 10
however, an employee’s use of paid sick and safe leave time provided under this chapter in each 11
calendar year shall not exceed twenty-four (24) hours during calendar year 2018, and thirty-two 12
(32) hours during calendar year 2019, and forty (40) hours per year thereafter. Alternatively, in lieu 13
of carryover of unused earned paid sick and safe leave time from one year to the next, an employer 14
may pay an employee for unused earned paid sick and safe leave time at the end of a year and 15
provide the employee with an amount of paid sick and safe leave that meets or exceeds the 16
requirements of this chapter that is available for the employee’s immediate use at the beginning of 17
the subsequent year. 18
(f) Nothing in this chapter shall be construed as requiring financial or other reimbursement 19
to an employee from an employer upon the employee’s termination, resignation, retirement, or 20
other separation from employment for accrued paid sick and safe leave time that has not been used. 21
(g) If an employee is transferred to a separate division, entity, or location within the state, 22
but remains employed by the same employer as defined in 29 C.F.R. § 791.2 of the federal Fair 23
Labor Standards Act, 29 U.S.C. § 201 et seq., the employee is entitled to all paid sick and safe leave 24
time accrued at the prior division, entity, or location and is entitled to use all paid sick and safe 25
leave time as provided in this act. When there is a separation from employment and the employee 26
is rehired within one hundred thirty-five (135) days of separation by the same employer, previously 27
accrued paid sick and safe leave time that had not been used shall be reinstated. Further, the 28
employee shall be entitled to use accrued paid sick and safe leave time and accrue additional sick 29
and safe leave time at the re-commencement of employment. 30
(h) When a different employer succeeds or takes the place of an existing employer, all 31
employees of the original employer who remain employed by the successor employer within the 32
state are entitled to all earned paid sick and safe leave time they accrued when employed by the 33
original employer, and are entitled to use earned paid sick and safe leave time previously accrued. 34
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(i) At its discretion, an employer may loan sick and safe leave time to an employee in 1
advance of accrual by such employee. 2
(j) Temporary employees shall be entitled to use accrued paid sick and safe leave time 3
beginning on the one hundred eightieth (180) calendar day following commencement of their 4
employment, unless otherwise permitted by the employer. On and after the one hundred eightieth 5
(180) calendar day of employment, employees may use paid sick and safe leave time as it is 6
accrued. During this waiting period, an employee shall accrue earned sick time pursuant to this 7
chapter, but shall not be permitted to use the earned sick time until after he or she has completed 8
the waiting period. 9
(k) Seasonal employees shall be entitled to use accrued paid sick and safe leave time 10
beginning on the one hundred fiftieth (150) calendar day following commencement of their 11
employment, unless otherwise permitted by the employer. On and after the one hundred fiftieth 12
(150) calendar day of employment, employees may use paid sick and safe leave time as it is 13
accrued. During this waiting period, an employee shall accrue earned sick time pursuant to this 14
chapter, but shall not be permitted to use the earned sick time until after he or she has completed 15
the waiting period. 16
SECTION 7. Sections 40-8-2, 40-8-6, 40-8-10, 40-8-13, 40-8-13.4, 40-8-16, 40-8-19, 40-17
8-26 and 40-8-32 of the General Laws in Chapter 40-8 entitled "Medical Assistance" are hereby 18
amended to read as follows: 19
40-8-2. Definitions. 20
As used in this chapter, unless the context shall otherwise require: 21
(1) “Dental service” means and includes emergency care, X-rays for diagnoses, extractions, 22
palliative treatment, and the refitting and relining of existing dentures and prosthesis. 23
(2) “Department” means the department of human services. 24
(3) “Director” means the director of human services Medicaid director. 25
(4) “Drug” means and includes only drugs and biologicals prescribed by a licensed dentist 26
or physician as are either included in the United States pharmacopoeia, national formulary, or are 27
new and nonofficial drugs and remedies. 28
(5) “Inpatient” means a person admitted to and under treatment or care of a physician or 29
surgeon in a hospital or nursing facility that meets standards of and complies with rules and 30
regulations promulgated by the director. 31
(6) “Inpatient hospital services” means the following items and services furnished to an 32
inpatient in a hospital other than a hospital, institution, or facility for tuberculosis or mental 33
diseases: 34
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(i) Bed and board; 1
(ii) Nursing services and other related services as are customarily furnished by the hospital 2
for the care and treatment of inpatients and drugs, biologicals, supplies, appliances, and equipment 3
for use in the hospital, as are customarily furnished by the hospital for the care and treatment of 4
patients; 5
(iii)(A) Other diagnostic or therapeutic items or services, including, but not limited to, 6
pathology, radiology, and anesthesiology furnished by the hospital or by others under arrangements 7
made by the hospital, as are customarily furnished to inpatients either by the hospital or by others 8
under such arrangements, and services as are customarily provided to inpatients in the hospital by 9
an intern or resident-in-training under a teaching program having the approval of the Council on 10
Medical Education and Hospitals of the American Medical Association or of any other recognized 11
medical society approved by the director. 12
(B) The term “inpatient hospital services” shall be taken to include medical and surgical 13
services provided by the inpatient’s physician, but shall not include the services of a private-duty 14
nurse or services in a hospital, institution, or facility maintained primarily for the treatment and 15
care of patients with tuberculosis or mental diseases. Provided, further, it shall be taken to include 16
only the following organ transplant operations: kidney, liver, cornea, pancreas, bone marrow, lung, 17
heart, and heart/lung, and other organ transplant operations as may be designated by the director 18
after consultation with medical advisory staff or medical consultants; and provided that any such 19
transplant operation is determined by the director or his or her designee to be medically necessary. 20
Prior written approval of the director, or his or her designee, shall be required for all covered organ 21
transplant operations. 22
(C) In determining medical necessity for organ transplant procedures, the state plan shall 23
adopt a case-by-case approach and shall focus on the medical indications and contra-indications in 24
each instance; the progressive nature of the disease; the existence of any alternative therapies; the 25
life-threatening nature of the disease; the general state of health of the patient apart from the 26
particular organ disease; and any other relevant facts and circumstances related to the applicant and 27
the particular transplant procedure. 28
(7) "Medicare equivalent rate" means the amount that would be paid for the relevant 29
services as furnished by the relevant group of facilities under Medicare payment principles 30
delineated in subchapter B of 42 CFR Chapter IV. Should no direct Medicare rates be available for 31
the particular service and facility group, the Medicaid director will estimate the rate. Providers will 32
have standing to bring an action in superior court for a higher rate, but intermediary insurers such 33
as managed care entities shall have no standing to bring an action for a lower rate. 34
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(7)(8) “Nursing services” means the following items and services furnished to an inpatient 1
in a nursing facility: 2
(i) Bed and board; 3
(ii) Nursing care and other related services as are customarily furnished to inpatients 4
admitted to the nursing facility, and drugs, biologicals, supplies, appliances, and equipment for use 5
in the facility, as are customarily furnished in the facility for the care and treatment of patients; 6
(iii) Other diagnostic or therapeutic items or services, legally furnished by the facility or 7
by others under arrangements made by the facility, as are customarily furnished to inpatients either 8
by the facility or by others under such arrangement; 9
(iv) Medical services provided in the facility by the inpatient’s physician, or by an intern 10
or resident-in-training of a hospital with which the facility is affiliated or that is under the same 11
control, under a teaching program of the hospital approved as provided in subsection (6); and 12
(v) A personal-needs allowance of seventy-five dollars ($75.00) two hundred dollars 13
($200) per month. 14
(8)(9) “Relative with whom the dependent child is living” means and includes the father, 15
mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, 16
uncle, aunt, first cousin, nephew, or niece of any dependent child who maintains a home for the 17
dependent child. 18
(9)(10) “Visiting nurse service” means part-time or intermittent nursing care provided by 19
or under the supervision of a registered professional nurse other than in a hospital or nursing home. 20
40-8-6. Review of application for benefits. 21
The director, or someone designated by him or her, shall review each application for 22
benefits filed in accordance with regulations, and shall make a determination of whether the 23
application will be honored and the extent of the benefits to be made available to the applicant, and 24
shall, within thirty (30) fifteen (15) days after the filing, notify the applicant, in writing, of the 25
determination. If the application is rejected, the notice to the applicant shall set forth therein the 26
reason therefor. The director may at any time reconsider any determination. 27
40-8-10. Recovery of benefits paid in error. 28
Any person, who through error or mistake of himself or herself or another willful and 29
knowingly fraudulent misrepresentation, receives medical care benefits to which he or she is not 30
entitled or with respect to which he or she was ineligible, shall be required to reimburse the state 31
for the benefits paid through error or mistake that were paid out during a time period, not to exceed 32
three years, where the person was not entitled to benefits but received them as a result of the willful 33
and knowing fraudulent misrepresentation. 34
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40-8-13. Rules, regulations, and fee schedules. 1
The director shall make and promulgate rules, regulations, and fee schedules not 2
inconsistent with state law and fiscal procedures as he or she deems necessary for the proper 3
administration of this chapter and to carry out the policy and purposes thereof, and to make the 4
department’s plan conform to the provisions of the federal Social Security Act, 42 U.S.C. § 1396 5
et seq., and any rules or regulations promulgated pursuant thereto. Except where explicitly 6
authorized by this title, the director shall have no power to set any fee schedule below the Medicare 7
equivalent rate; provided, however, that the director shall be empowered to provide a lower rate 8
equal to the maximum rate where federal reimbursement can be obtained in the event that federal 9
reimbursement cannot be obtained for the Medicare equivalent rate. For outpatient behavioral 10
health services, the minimum fee schedule shall be set at one hundred fifty percent (150%) of the 11
Medicare equivalent rate. The director shall attempt to obtain federal reimbursement for billing 12
outpatient behavioral health services at one hundred fifty percent (150%) of the Medicare 13
equivalent rate, but the state shall bear the costs of this higher rate for outpatient behavioral health 14
services even if federal reimbursement cannot be obtained. Should federal financial participation 15
be impossible to obtain for outpatient behavioral health services rate of one hundred fifty percent 16
(150%) of the Medicare equivalent rate, the director shall impose a surtax on the tax imposed on 17
health insurers pursuant to chapter 17 of title 44 in the amount necessary to defray the costs of the 18
inability to obtain federal reimbursement for an outpatient behavioral health services rate of one 19
hundred fifty percent (150%) of the Medicare equivalent rate. 20
40-8-13.4. Rate methodology for payment for in-state and out-of-state hospital 21
services. 22
(a) The executive office of health and human services (“executive office”) shall implement 23
a new methodology for payment for in-state and out-of-state hospital services in order to ensure 24
access to, and the provision of, high-quality and cost-effective hospital care to its eligible recipients. 25
(b) In order to improve efficiency and cost-effectiveness, the executive office shall: 26
(1)(i) With respect to inpatient services for persons in fee-for-service Medicaid, which is 27
non-managed care, implement a new payment methodology for inpatient services utilizing the 28
Diagnosis Related Groups (DRG) method of payment, which is, a patient-classification method 29
that provides a means of relating payment to the hospitals to the type of patients cared for by the 30
hospitals. It is understood that a payment method based on DRG may include cost outlier payments 31
and other specific exceptions. The executive office will review the DRG-payment method and the 32
DRG base price annually, making adjustments as appropriate in consideration of such elements as 33
trends in hospital input costs; patterns in hospital coding; beneficiary access to care; and the Centers 34
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for Medicare and Medicaid Services national CMS Prospective Payment System (IPPS) Hospital 1
Input Price Index. For the twelve-month (12) period beginning July 1, 2015, the DRG base rate for 2
Medicaid fee-for-service inpatient hospital services shall not exceed ninety-seven and one-half 3
percent (97.5%) of the payment rates in effect as of July 1, 2014. Beginning July 1, 2019, the DRG 4
base rate for Medicaid fee-for-service inpatient hospital services shall be 107.2% of the payment 5
rates in effect as of July 1, 2018. Increases in the Medicaid fee-for-service DRG hospital payments 6
for the twelve-month (12) period beginning July 1, 2020, shall be based on the payment rates in 7
effect as of July 1 of the preceding fiscal year, and shall be the Centers for Medicare and Medicaid 8
Services national Prospective Payment System (IPPS) Hospital Input Price Index. Beginning July 9
1, 2022, the DRG base rate for Medicaid fee-for-service inpatient hospital services shall be one 10
hundred five percent (105%) of the payment rates in effect as of July 1, 2021. Increases in the 11
Medicaid fee-for-service DRG hospital payments for each annual twelve-month (12) period 12
beginning July 1, 2023, shall be based on the payment rates in effect as of July 1 of the preceding 13
fiscal year, and shall be the Centers for Medicare and Medicaid Services national Prospective 14
Payment System (IPPS) Hospital Input Price Index. Beginning July 1, 2025, payments for inpatient 15
services in fee-for-service Medicaid shall cease utilizing the DRG method of payment, and 16
payments shall take place on a pure fee-for-services basis, unless a provider shall elect to utilize 17
the DRG payment methodology. DRG rates shall be set equal to ninety percent (90%) of a 18
reasonable estimate of the Medicare equivalent rate. Non-DRG rates shall be set by the Medicaid 19
director through regulation in order that the projected overall per capita expenditures shall equal 20
ninety-five percent (95%) of a reasonable estimate of the equivalent overall per capital expenditures 21
that would have been reached under the Medicare equivalent rate. 22
(ii) With respect to inpatient services, (A) It is required as of January 1, 2011, until 23
December 31, 2011, that the Medicaid managed care payment rates between each hospital and 24
health plan shall not exceed ninety and one-tenth percent (90.1%) of the rate in effect as of June 25
30, 2010. Increases in inpatient hospital payments for each annual twelve-month (12) period 26
beginning January 1, 2012, may not exceed the Centers for Medicare and Medicaid Services 27
national CMS Prospective Payment System (IPPS) Hospital Input Price Index for the applicable 28
period; (B) Provided, however, for the twenty-four-month (24) period beginning July 1, 2013, the 29
Medicaid managed care payment rates between each hospital and health plan shall not exceed the 30
payment rates in effect as of January 1, 2013, and for the twelve-month (12) period beginning July 31
1, 2015, the Medicaid managed care payment inpatient rates between each hospital and health plan 32
shall not exceed ninety-seven and one-half percent (97.5%) of the payment rates in effect as of 33
January 1, 2013; (C) Increases in inpatient hospital payments for each annual twelve-month (12) 34
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period beginning July 1, 2017, shall be the Centers for Medicare and Medicaid Services national 1
CMS Prospective Payment System (IPPS) Hospital Input Price Index, less Productivity 2
Adjustment, for the applicable period and shall be paid to each hospital retroactively to July 1; (D) 3
Beginning July 1, 2019, the Medicaid managed care payment inpatient rates between each hospital 4
and health plan shall be 107.2% of the payment rates in effect as of January 1, 2019, and shall be 5
paid to each hospital retroactively to July 1; (E) Increases in inpatient hospital payments for each 6
annual twelve-month (12) period beginning July 1, 2020, shall be based on the payment rates in 7
effect as of January 1 of the preceding fiscal year, and shall be the Centers for Medicare and 8
Medicaid Services national CMS Prospective Payment System (IPPS) Hospital Input Price Index, 9
less Productivity Adjustment, for the applicable period and shall be paid to each hospital 10
retroactively to July 1; the executive office will develop an audit methodology and process to assure 11
that savings associated with the payment reductions will accrue directly to the Rhode Island 12
Medicaid program through reduced managed care plan payments and shall not be retained by the 13
managed care plans; (F) Beginning July 1, 2022, the Medicaid managed care payment inpatient 14
rates between each hospital and health plan shall be one hundred five percent (105%) of the 15
payment rates in effect as of January 1, 2022, and shall be paid to each hospital retroactively to July 16
1 within ninety days of passage; (G) Increases in inpatient hospital payments for each annual 17
twelve-month (12) period beginning July 1, 2023, shall be based on the payment rates in effect as 18
of January 1 of the preceding fiscal year, and shall be the Centers for Medicare and Medicaid 19
Services national CMS Prospective Payment System (IPPS) Hospital Input Price Index, less 20
Productivity Adjustment, for the applicable period and shall be paid to each hospital retroactively 21
to July 1 within ninety days of passage; (H) All hospitals licensed in Rhode Island shall accept such 22
payment rates as payment in full; and (I) For all such hospitals, compliance with the provisions of 23
this section shall be a condition of participation in the Rhode Island Medicaid program. Beginning 24
July 1, 2025, Medicaid managed care payment rates shall equal one hundred five percent (105%) 25
of the fee-for-service rates set in subsection (b)(1)(i) of this section. 26
(2) With respect to outpatient services and notwithstanding any provisions of the law to the 27
contrary, for persons enrolled in fee-for-service Medicaid, the executive office will reimburse 28
hospitals for outpatient services using a rate methodology determined by the executive office and 29
in accordance with federal regulations. Fee-for-service outpatient rates shall align with Medicare 30
payments for similar services. Notwithstanding the above, there shall be no increase in the 31
Medicaid fee-for-service outpatient rates effective on July 1, 2013, July 1, 2014, or July 1, 2015. 32
For the twelve-month (12) period beginning July 1, 2015, Medicaid fee-for-service outpatient rates 33
shall not exceed ninety-seven and one-half percent (97.5%) of the rates in effect as of July 1, 2014. 34
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Increases in the outpatient hospital payments for the twelve-month (12) period beginning July 1, 1
2016, may not exceed the CMS national Outpatient Prospective Payment System (OPPS) Hospital 2
Input Price Index. Beginning July 1, 2019, the Medicaid fee-for-service outpatient rates shall be 3
107.2% of the payment rates in effect as of July 1, 2018. Increases in the outpatient hospital 4
payments for the twelve-month (12) period beginning July 1, 2020, shall be based on the payment 5
rates in effect as of July 1 of the preceding fiscal year, and shall be the CMS national Outpatient 6
Prospective Payment System (OPPS) Hospital Input Price Index. Beginning July 1, 2022, the 7
Medicaid fee-for-service outpatient rates shall be one hundred five percent (105%) of the payment 8
rates in effect as of July 1, 2021. Increases in the outpatient hospital payments for each annual 9
twelve-month (12) period beginning July 1, 2023, shall be based on the payment rates in effect as 10
of July 1 of the preceding fiscal year, and shall be the CMS national Outpatient Prospective 11
Payment System (OPPS) Hospital Input Price Index. With respect to the outpatient rate, (i) It is 12
required as of January 1, 2011, until December 31, 2011, that the Medicaid managed care payment 13
rates between each hospital and health plan shall not exceed one hundred percent (100%) of the 14
rate in effect as of June 30, 2010; (ii) Increases in hospital outpatient payments for each annual 15
twelve-month (12) period beginning January 1, 2012, until July 1, 2017, may not exceed the Centers 16
for Medicare and Medicaid Services national CMS Outpatient Prospective Payment System OPPS 17
Hospital Price Index for the applicable period; (iii) Provided, however, for the twenty-four-month 18
(24) period beginning July 1, 2013, the Medicaid managed care outpatient payment rates between 19
each hospital and health plan shall not exceed the payment rates in effect as of January 1, 2013, 20
and for the twelve-month (12) period beginning July 1, 2015, the Medicaid managed care outpatient 21
payment rates between each hospital and health plan shall not exceed ninety-seven and one-half 22
percent (97.5%) of the payment rates in effect as of January 1, 2013; (iv) Increases in outpatient 23
hospital payments for each annual twelve-month (12) period beginning July 1, 2017, shall be the 24
Centers for Medicare and Medicaid Services national CMS OPPS Hospital Input Price Index, less 25
Productivity Adjustment, for the applicable period and shall be paid to each hospital retroactively 26
to July 1; (v) Beginning July 1, 2019, the Medicaid managed care outpatient payment rates between 27
each hospital and health plan shall be one hundred seven and two-tenths percent (107.2%) of the 28
payment rates in effect as of January 1, 2019, and shall be paid to each hospital retroactively to July 29
1; (vi) Increases in outpatient hospital payments for each annual twelve-month (12) period 30
beginning July 1, 2020, shall be based on the payment rates in effect as of January 1 of the preceding 31
fiscal year, and shall be the Centers for Medicare and Medicaid Services national CMS OPPS 32
Hospital Input Price Index, less Productivity Adjustment, for the applicable period and shall be 33
paid to each hospital retroactively to July 1; (vii) Beginning July 1, 2022, the Medicaid managed 34
LC000271 - Page 29 of 93
care outpatient payment rates between each hospital and health plan shall be one hundred five 1
percent (105%) of the payment rates in effect as of January 1, 2022, and shall be paid to each 2
hospital retroactively to July 1 within ninety days of passage; (viii) Increases in outpatient hospital 3
payments for each annual twelve-month (12) period beginning July 1, 2020, shall be based on the 4
payment rates in effect as of January 1 of the preceding fiscal year, and shall be the Centers for 5
Medicare and Medicaid Services national CMS OPPS Hospital Input Price Index, less Productivity 6
Adjustment, for the applicable period and shall be paid to each hospital retroactively to July 1. 7
Beginning July 1, 2025, fee-for-service and managed care outpatient rates shall equal the Medicare 8
equivalent rate. 9
(3) “Hospital,” as used in this section, shall mean the actual facilities and buildings in 10
existence in Rhode Island, licensed pursuant to § 23-17-1 et seq. on June 30, 2010, and thereafter 11
any premises included on that license, regardless of changes in licensure status pursuant to chapter 12
17.14 of title 23 (hospital conversions) and § 23-17-6(b) (change in effective control), that provides 13
short-term, acute inpatient and/or outpatient care to persons who require definitive diagnosis and 14
treatment for injury, illness, disabilities, or pregnancy. Notwithstanding the preceding language, 15
the Medicaid managed care payment rates for a court-approved purchaser that acquires a hospital 16
through receivership, special mastership or other similar state insolvency proceedings (which court-17
approved purchaser is issued a hospital license after January 1, 2013), shall be based upon the new 18
rates between the court-approved purchaser and the health plan, and such rates shall be effective as 19
of the date that the court-approved purchaser and the health plan execute the initial agreement 20
containing the new rates. The rate-setting methodology for inpatient-hospital payments and 21
outpatient-hospital payments set forth in subsections (b)(1)(ii)(C) and (b)(2), respectively, shall 22
thereafter apply to increases for each annual twelve-month (12) period as of July 1 following the 23
completion of the first full year of the court-approved purchaser’s initial Medicaid managed care 24
contract. 25
(c) It is intended that payment utilizing phasing out the DRG method shall reward hospitals 26
for providing the most efficient highest quality care, and provide the executive office the 27
opportunity to conduct value-based purchasing of inpatient care. 28
(d) The secretary of the executive office is hereby authorized to promulgate such rules and 29
regulations consistent with this chapter, and to establish fiscal procedures he or she deems 30
necessary, for the proper implementation and administration of this chapter in order to provide 31
payment to hospitals using the DRG-payment methodology. Furthermore, amendment of the Rhode 32
Island state plan for Medicaid, pursuant to Title XIX of the federal Social Security Act, 42 U.S.C. 33
§ 1396 et seq., is hereby authorized to provide for payment to hospitals for services provided to 34
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eligible recipients in accordance with this chapter. 1
(e) The executive office shall comply with all public notice requirements necessary to 2
implement these rate changes. 3
(f) As a condition of participation in the DRG methodology for payment of hospital 4
services, every hospital shall submit year-end settlement reports to the executive office within one 5
year from the close of a hospital’s fiscal year. Should a participating hospital fail to timely submit 6
a year-end settlement report as required by this section, the executive office shall withhold 7
financial-cycle payments due by any state agency with respect to this hospital by not more than ten 8
percent (10%) until the report is submitted. For hospital fiscal year 2010 and all subsequent fiscal 9
years, hospitals will not be required to submit year-end settlement reports on payments for 10
outpatient services. For hospital fiscal year 2011 and all subsequent fiscal years, hospitals will not 11
be required to submit year-end settlement reports on claims for hospital inpatient services. Further, 12
for hospital fiscal year 2010, hospital inpatient claims subject to settlement shall include only those 13
claims received between October 1, 2009, and June 30, 2010. 14
(g) The provisions of this section shall be effective upon implementation of the new 15
payment methodology set forth in this section and § 40-8-13.3, which shall in any event be no later 16
than March 30, 2010, at which time the provisions of §§ 40-8-13.2, 27-19-14, 27-19-15, and 27-17
19-16 shall be repealed in their entirety. 18
40-8-16. Notification of long-term care alternative. 19
(a) The department of human services, before authorizing care in a nursing home or 20
intermediate-care facility for a person who is eligible to receive benefits pursuant to Title XIX of 21
the federal Social Security Act, 42 U.S.C. § 1396 et seq., and who is being discharged from a 22
hospital to a nursing home, shall notify the person, in writing, of the provisions of the long-term-23
care alternative, a home- and a community-based program. 24
(b) If a person, eligible to receive benefits pursuant to Title XIX of the federal Social 25
Security Act, requires services in a nursing home and desires to remain in his or her own home or 26
the home of a responsible relative or other adult, the person or his or her representative shall so 27
inform the department. 28
(c) The department shall not make payments pursuant to Title XIX of the federal Social 29
Security Act for benefits until written notification documenting the person’s choice as to a nursing 30
home or home- and community-based services has been filed with the department. 31
40-8-19. Rates of payment to nursing facilities. 32
(a) Rate reform. 33
(1) The rates to be paid by the state to nursing facilities licensed pursuant to chapter 17 of 34
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title 23, and certified to participate in Title XIX of the Social Security Act for services rendered to 1
Medicaid-eligible residents, shall be reasonable and adequate to meet the costs that must be 2
incurred by efficiently and economically operated facilities in accordance with 42 U.S.C. § 3
1396a(a)(13). The executive office of health and human services (“executive office”) shall 4
promulgate or modify the principles of reimbursement for nursing facilities in effect as of July 1, 5
2011, to be consistent with the provisions of this section and Title XIX, 42 U.S.C. § 1396 et seq., 6
of the Social Security Act. 7
(2) The executive office shall review the current methodology for providing Medicaid 8
payments to nursing facilities, including other long-term care services providers, and is authorized 9
to modify the principles of reimbursement to replace the current cost-based methodology rates with 10
rates based on a price-based methodology to be paid to all facilities with recognition of the acuity 11
of patients and the relative Medicaid occupancy, and to include the following elements to be 12
developed by the executive office: 13
(i) A direct-care rate adjusted for resident acuity; 14
(ii) An indirect-care and other direct-care rate comprised of a base per diem for all facilities; 15
(iii) Revision of rates as necessary based on increases in direct and indirect costs beginning 16
October 2024 utilizing data from the most recent finalized year of facility cost report. The per diem 17
rate components deferred in subsections (a)(2)(i) and (a)(2)(ii) of this section shall be adjusted 18
accordingly to reflect changes in direct and indirect care costs since the previous rate review; 19
(iv) Application of a fair-rental value system; 20
(v) Application of a pass-through system; and 21
(vi) Adjustment of rates by the change in a recognized national nursing home inflation 22
index to be applied on October 1 of each year, beginning October 1, 2012. This adjustment will not 23
occur on October 1, 2013, October 1, 2014, or October 1, 2015, but will occur on April 1, 2015. 24
The adjustment of rates will also not occur on October 1, 2017, October 1, 2018, October 1, 2019, 25
and October 2022. Effective July 1, 2018, rates paid to nursing facilities from the rates approved 26
by the Centers for Medicare and Medicaid Services and in effect on October 1, 2017, both fee-for-27
service and managed care, will be increased by one and one-half percent (1.5%) and further 28
increased by one percent (1%) on October 1, 2018, and further increased by one percent (1%) on 29
October 1, 2019. Effective October 1, 2022, rates paid to nursing facilities from the rates approved 30
by the Centers for Medicare and Medicaid Services and in effect on October 1, 2021, both fee-for-31
service and managed care, will be increased by three percent (3%). In addition to the annual nursing 32
home inflation index adjustment, there shall be a base rate staffing adjustment of one-half percent 33
(0.5%) on October 1, 2021, one percent (1.0%) on October 1, 2022, and one and one-half percent 34
LC000271 - Page 32 of 93
(1.5%) on October 1, 2023. The inflation index shall be applied without regard for the transition 1
factors in subsections (b)(1) and (b)(2). For purposes of October 1, 2016, adjustment only, any rate 2
increase that results from application of the inflation index to subsections (a)(2)(i) and (a)(2)(ii) 3
shall be dedicated to increase compensation for direct-care workers in the following manner: Not 4
less than 85% of this aggregate amount shall be expended to fund an increase in wages, benefits, 5
or related employer costs of direct-care staff of nursing homes. For purposes of this section, direct-6
care staff shall include registered nurses (RNs), licensed practical nurses (LPNs), certified nursing 7
assistants (CNAs), certified medical technicians, housekeeping staff, laundry staff, dietary staff, or 8
other similar employees providing direct-care services; provided, however, that this definition of 9
direct-care staff shall not include: (i) RNs and LPNs who are classified as “exempt employees” 10
under the federal Fair Labor Standards Act (29 U.S.C. § 201 et seq.); or (ii) CNAs, certified medical 11
technicians, RNs, or LPNs who are contracted, or subcontracted, through a third-party vendor or 12
staffing agency. By July 31, 2017, nursing facilities shall submit to the secretary, or designee, a 13
certification that they have complied with the provisions of this subsection (a)(2)(vi) with respect 14
to the inflation index applied on October 1, 2016. Any facility that does not comply with the terms 15
of such certification shall be subjected to a clawback, paid by the nursing facility to the state, in the 16
amount of increased reimbursement subject to this provision that was not expended in compliance 17
with that certification. 18
(3) Commencing on October 1, 2021, eighty percent (80%) of any rate increase that results 19
from application of the inflation index to subsections (a)(2)(i) and (a)(2)(ii) of this section shall be 20
dedicated to increase compensation for all eligible direct-care workers in the following manner on 21
October 1, of each year. 22
(i) For purposes of this subsection, compensation increases shall include base salary or 23
hourly wage increases, benefits, other compensation, and associated payroll tax increases for 24
eligible direct-care workers. This application of the inflation index shall apply for Medicaid 25
reimbursement in nursing facilities for both managed care and fee-for-service. For purposes of this 26
subsection, direct-care staff shall include registered nurses (RNs), licensed practical nurses (LPNs), 27
certified nursing assistants (CNAs), certified medication technicians, licensed physical therapists, 28
licensed occupational therapists, licensed speech-language pathologists, mental health workers 29
who are also certified nurse assistants, physical therapist assistants, housekeeping staff, laundry 30
staff, dietary staff, or other similar employees providing direct-care services; provided, however 31
that this definition of direct-care staff shall not include: 32
(A) RNs and LPNs who are classified as “exempt employees” under the federal Fair Labor 33
Standards Act (29 U.S.C. § 201 et seq.); or 34
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(B) CNAs, certified medication technicians, RNs, or LPNs who are contracted or 1
subcontracted through a third-party vendor or staffing agency. 2
(4)(i) By July 31, 2021, and July 31 of each year thereafter, nursing facilities shall submit 3
to the secretary or designee a certification that they have complied with the provisions of subsection 4
(a)(3) of this section with respect to the inflation index applied on October 1. The executive office 5
of health and human services (EOHHS) shall create the certification form nursing facilities must 6
complete with information on how each individual eligible employee’s compensation increased, 7
including information regarding hourly wages prior to the increase and after the compensation 8
increase, hours paid after the compensation increase, and associated increased payroll taxes. A 9
collective bargaining agreement can be used in lieu of the certification form for represented 10
employees. All data reported on the compliance form is subject to review and audit by EOHHS. 11
The audits may include field or desk audits, and facilities may be required to provide additional 12
supporting documents including, but not limited to, payroll records. 13
(ii) Any facility that does not comply with the terms of certification shall be subjected to a 14
clawback and twenty-five percent (25%) penalty of the unspent or impermissibly spent funds, paid 15
by the nursing facility to the state, in the amount of increased reimbursement subject to this 16
provision that was not expended in compliance with that certification. 17
(iii) In any calendar year where no inflationary index is applied, eighty percent (80%) of 18
the base rate staffing adjustment in that calendar year pursuant to subsection (a)(2)(vi) of this 19
section shall be dedicated to increase compensation for all eligible direct-care workers in the 20
manner referenced in subsections (a)(3)(i), (a)(3)(i)(A), and (a)(3)(i)(B) of this section. 21
(b) Transition to full implementation of rate reform. For no less than four (4) years after 22
the initial application of the price-based methodology described in subsection (a)(2) to payment 23
rates, the executive office of health and human services shall implement a transition plan to 24
moderate the impact of the rate reform on individual nursing facilities. The transition shall include 25
the following components: 26
(1) No nursing facility shall receive reimbursement for direct-care costs that is less than 27
the rate of reimbursement for direct-care costs received under the methodology in effect at the time 28
of passage of this act; for the year beginning October 1, 2017, the reimbursement for direct-care 29
costs under this provision will be phased out in twenty-five-percent (25%) increments each year 30
until October 1, 2021, when the reimbursement will no longer be in effect; and 31
(2) No facility shall lose or gain more than five dollars ($5.00) in its total, per diem rate the 32
first year of the transition. An adjustment to the per diem loss or gain may be phased out by twenty-33
five percent (25%) each year; except, however, for the years beginning October 1, 2015, there shall 34
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be no adjustment to the per diem gain or loss, but the phase out shall resume thereafter; and 1
(3) The transition plan and/or period may be modified upon full implementation of facility 2
per diem rate increases for quality of care-related measures. Said modifications shall be submitted 3
in a report to the general assembly at least six (6) months prior to implementation. 4
(4) Notwithstanding any law to the contrary, for the twelve-month (12) period beginning 5
July 1, 2015, Medicaid payment rates for nursing facilities established pursuant to this section shall 6
not exceed ninety-eight percent (98%) of the rates in effect on April 1, 2015. Consistent with the 7
other provisions of this chapter, nothing in this provision shall require the executive office to restore 8
the rates to those in effect on April 1, 2015, at the end of this twelve-month (12) period. 9
(5) Commencing July 1, 2025, and for each subsequent year, the executive office of health 10
and human services is hereby authorized and directed to amend its regulations for reimbursement 11
to nursing facilities in order that each nursing facility shall be paid the Medicare equivalent rate. 12
The provisions of subsection (a)(3)(iii) shall apply. 13
40-8-26. Community health centers. 14
(a) For the purposes of this section, the term community health centers refers to federally 15
qualified health centers and rural health centers. 16
(b) To support the ability of community health centers to provide high-quality medical care 17
to patients, the executive office of health and human services (“executive office”) may adopt and 18
implement an alternative payment methodology (APM) for determining a Medicaid per-visit 19
reimbursement for community health centers that is compliant with the prospective payment system 20
(PPS) provided for in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection 21
Act of 2000. The following principles are to ensure that the APM PPS rate determination 22
methodology is part of the executive office overall value purchasing approach. For community 23
health centers that do not agree to the principles of reimbursement that reflect the APM PPS, 24
EOHHS shall reimburse such community health centers at the federal PPS rate, as required per 25
section 1902(bb)(3) of the Social Security Act, 42 U.S.C. § 1396a(bb)(3). For community health 26
centers that are reimbursed at the federal PPS rate, subsections (d) through (f) of this section apply. 27
(c) The APM PPS rate determination methodology will (i) Fairly recognize the reasonable 28
costs of providing services. Recognized reasonable costs will be those appropriate for the 29
organization, management, and direct provision of services and (ii) Provide assurances to the 30
executive office that services are provided in an effective and efficient manner, consistent with 31
industry standards. Except for demonstrated cause and at the discretion of the executive office, the 32
maximum reimbursement rate for a service (e.g., medical, dental) provided by an individual 33
community health center shall not exceed one hundred twenty-five percent (125%) of the median 34
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rate for all community health centers within Rhode Island. not only bill the community health center 1
on a fee-for-service basis at the Medicare equivalent rate but also make a series of quality incentive 2
payments if the community health center meets certain quality incentives. Quality incentive 3
payments shall be set at a percentage of the aggregate monthly billing. The quality incentive 4
payments shall be as follows: 5
(1) Ten percent (10%) for meeting benchmarks set by the Medicaid director for screening 6
patients for Medicaid eligibility. 7
(2) Five percent (5%) for meeting benchmarks set by the Medicaid director for enrolling 8
patients who regularly smoke tobacco in smoking cessation programs. 9
(3) Ten percent (10%) for meeting benchmarks set by the director of human services for 10
screening patients for supplemental nutrition assistance program eligibility. 11
(4) Ten percent (10%) for ensuring that no more than one percent (1%) of patients are ever 12
not offered an appointment within a month if they request one. 13
(5) Up to fifteen percent (15%) for meeting benchmarks set by the Medicaid director for 14
the improvement of air quality in patients' homes through directly funding interventions such as: 15
air quality inspections, the installation of air filters, the installation of ventilation, and the 16
replacement of gas stoves with electric stoves. 17
(6) Up to fifteen percent (15%) for meeting benchmarks set by the Medicaid director for 18
the removal or mitigation of environmental toxins in patients' homes through the direct funding of 19
removal or mitigation of environmental toxins. These toxins shall include, but shall not be limited 20
to, lead, radon, asbestos, and carbon monoxide. 21
(d) Community health centers will cooperate fully and timely with reporting requirements 22
established by the executive office. 23
(e) Reimbursement rates established through this methodology shall be incorporated into 24
the PPS reconciliation for services provided to Medicaid-eligible persons who are enrolled in a 25
health plan on the date of service. Monthly payments by the executive office related to PPS for 26
persons enrolled in a health plan shall be made directly to the community health centers. 27
(f) Reimbursement rates established through this the APM methodology shall not be 28
incorporated into the actuarially certified capitation rates paid to a health plan. The health plan shall 29
be responsible for paying the full amount of the reimbursement rate to the community health center 30
for each service eligible for reimbursement under the Medicare, Medicaid, and SCHIP Benefits 31
Improvement and Protection Act of 2000. If the health plan has an alternative payment arrangement 32
with the community health center opts to utilize the APM methodology, the health plan may 33
establish a PPS reconciliation process for eligible services and make monthly payments related to 34
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PPS for persons enrolled in the health plan on the date of service shall bear the full upside and 1
downside risk of decreased or increased costs from the APM methodology. The executive office 2
will review, at least annually, the Medicaid reimbursement rates and reconciliation methodology 3
used by the health plans for community health centers to ensure payments to each are made in 4
compliance with the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 5
2000. 6
40-8-32. Support for certain patients of nursing facilities. 7
(a) Definitions. For purposes of this section: 8
(1) “Applied income” shall mean the amount of income a Medicaid beneficiary is required 9
to contribute to the cost of his or her care. 10
(2) “Authorized individual” shall mean a person who has authority over the income of a 11
patient of a nursing facility, such as a person who has been given or has otherwise obtained 12
authority over a patient’s bank account; has been named as or has rights as a joint account holder; 13
or is a fiduciary as defined below. 14
(3) “Costs of care” shall mean the costs of providing care to a patient of a nursing facility, 15
including nursing care, personal care, meals, transportation, and any other costs, charges, and 16
expenses incurred by a nursing facility in providing care to a patient. Costs of care shall not exceed 17
the customary rate the nursing facility charges to a patient who pays for his or her care directly 18
rather than through a governmental or other third-party payor. 19
(4) “Fiduciary” shall mean a person to whom power or property has been formally 20
entrusted for the benefit of another, such as an attorney-in-fact, legal guardian, trustee, or 21
representative payee. 22
(5) “Nursing facility” shall mean a nursing facility licensed under chapter 17 of title 23, 23
that is a participating provider in the Rhode Island Medicaid program. 24
(6) “Penalty period” means the period of Medicaid ineligibility imposed pursuant to 42 25
U.S.C. § 1396p(c), as amended from time to time, on a person whose assets have been transferred 26
for less than fair market value. 27
(7) “Uncompensated care” — Care and services provided by a nursing facility to a 28
Medicaid applicant without receiving compensation therefore from Medicaid, Medicare, the 29
Medicaid applicant, or other source. The acceptance of any payment representing actual or 30
estimated applied income shall not disqualify the care and services provided from qualifying as 31
uncompensated care. 32
(b) Penalty period resulting from transfer. Any transfer or assignment of assets resulting in 33
the establishment or imposition of a penalty period shall create a debt that shall be due and owing 34
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to a nursing facility for the unpaid costs of care provided during the penalty period to a patient of 1
that facility who has been subject to the penalty period. The amount of the debt established shall 2
not exceed the fair market value of the transferred assets at the time of transfer that are the subject 3
of the penalty period. A nursing facility may bring an action to collect a debt for the unpaid costs 4
of care given to a patient who has been subject to a penalty period, against either the transferor or 5
the transferee, or both. The provisions of this section shall not affect other rights or remedies of the 6
parties. 7
(c) Applied income. A nursing facility may provide written notice to a patient who is a 8
Medicaid recipient and any authorized individual of that patient: 9
(1) Of the amount of applied income due; 10
(2) Of the recipient’s legal obligation to pay the applied income to the nursing facility; and 11
(3) That the recipient’s failure to pay applied income due to a nursing facility not later than 12
thirty (30) days after receiving notice from the nursing facility may result in a court action to 13
recover the amount of applied income due. 14
A nursing facility that is owed applied income may, in addition to any other remedies 15
authorized under law, bring a claim to recover the applied income against a patient and any 16
authorized individual. If a court of competent jurisdiction determines, based upon clear and 17
convincing evidence, that a defendant willfully failed to pay or withheld applied income due and 18
owing to a nursing facility for more than thirty (30) days after receiving notice pursuant to 19
subsection (c), the court may award the amount of the debt owed, court costs, and reasonable 20
attorney’s fees to the nursing facility. 21
(d) Effects. Nothing contained in this section shall prohibit or otherwise diminish any other 22
causes of action possessed by any such nursing facility. The death of the person receiving nursing 23
facility care shall not nullify or otherwise affect the liability of the person or persons charged with 24
the costs of care rendered or the applied income amount as referenced in this section. 25
SECTION 8. Sections 40-8-3.1, 40-8-9.1, 40-8-13.5, 40-8-15, 40-8-19.2 and 40-8-27 of 26
the General Laws in Chapter 40-8 entitled "Medical Assistance" are hereby repealed. 27
40-8-3.1. Life estate in property — Retained powers. 28
When an applicant or recipient of Medicaid owns a life estate in property that is his or her 29
principal place of residence with the reserved power and authority, during his or her lifetime, to 30
sell, convey, mortgage, or otherwise dispose of the real property without the consent or joinder by 31
the holder(s) of the remainder interest, the principal place of residence shall not be regarded as an 32
excluded resource for the purpose of Medicaid eligibility, unless the applicant or recipient 33
individually, or through his or her guardian, conservator, or attorney in fact, conveys all outstanding 34
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remainder interest to him or herself. 1
An applicant or recipient who, by a deed created, executed and recorded on or before June 2
30, 2014, has reserved a life estate in property that is his or her principal place of residence with 3
the reserved power and authority, during his or her lifetime, to sell, convey, mortgage, or otherwise 4
dispose of the real property without the consent or joinder by the holder(s) of the remainder interest, 5
shall not be ineligible for Medicaid on the basis of the deed, regardless of whether the transferee of 6
the remainder interest is a person or persons, trust, or entity. 7
40-8-9.1. Notice. 8
Whenever an individual who is receiving medical assistance under this chapter transfers 9
an interest in real or personal property, the individual shall notify the executive office of health and 10
human services within ten (10) days of the transfer. The notice shall be sent to the individual’s local 11
office and the legal office of the executive office of health and human services and include, at a 12
minimum, the individual’s name, social security number or, if different, the executive office of 13
health and human services identification number, the date of transfer, and the dollar value, if any, 14
paid or received by the individual who received benefits under this chapter. In the event an 15
individual fails to provide notice required by this section to the executive office of health and human 16
services and in the event an individual has received medical assistance, any individual and/or entity, 17
who knew or should have known that the individual failed to provide the notice and who receives 18
any distribution of value as a result of the transfer, shall be liable to the executive office of health 19
and human services to the extent of the value of the transfer. Moreover, any such individual shall 20
be subject to the provisions of § 40-6-15 and any remedy provided by applicable state and federal 21
laws and rules and regulations. Failure to comply with the notice requirements set forth in the 22
section shall not affect the marketability of title to real estate transferred while the transferor is 23
receiving medical assistance. 24
40-8-13.5. Hospital Incentive Program (HIP). 25
The secretary of the executive office of health and human services is authorized to seek the 26
federal authorities required to implement a hospital incentive program (HIP). The HIP shall provide 27
the participating licensed hospitals the ability to obtain certain payments for achieving performance 28
goals established by the secretary. HIP payments shall commence no earlier than July 1, 2016. 29
40-8-15. Lien on deceased recipient’s estate for assistance. 30
(a)(1) Upon the death of a recipient of Medicaid under Title XIX of the federal Social 31
Security Act (42 U.S.C. § 1396 et seq. and referred to hereinafter as the “Act”), the total sum for 32
Medicaid benefits so paid on behalf of a beneficiary who was fifty-five (55) years of age or older 33
at the time of receipt shall be and constitute a lien upon the estate, as defined in subsection (a)(2), 34
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of the beneficiary in favor of the executive office of health and human services (“executive office”). 1
The lien shall not be effective and shall not attach as against the estate of a beneficiary who is 2
survived by a spouse, or a child who is under the age of twenty-one (21), or a child who is blind or 3
permanently and totally disabled as defined in Title XVI of the federal Social Security Act, 42 4
U.S.C. § 1381 et seq. The lien shall attach against property of a beneficiary, which is included or 5
includable in the decedent’s probate estate, regardless of whether or not a probate proceeding has 6
been commenced in the probate court by the executive office or by any other party. Provided, 7
however, that such lien shall only attach and shall only be effective against the beneficiary’s real 8
property included or includable in the beneficiary’s probate estate if such lien is recorded in the 9
land evidence records and is in accordance with subsection (e). Decedents who have received 10
Medicaid benefits are subject to the assignment and subrogation provisions of §§ 40-6-9 and 40-6-11
10. 12
(2) For purposes of this section, the term “estate” with respect to a deceased individual 13
shall include all real and personal property and other assets included or includable within the 14
individual’s probate estate. 15
(b) The executive office is authorized to promulgate regulations to implement the terms, 16
intent, and purpose of this section and to require the legal representative(s) and/or the heirs-at-law 17
of the decedent to provide reasonable written notice to the executive office of the death of a 18
beneficiary of Medicaid benefits who was fifty-five (55) years of age or older at the date of death, 19
and to provide a statement identifying the decedent’s property and the names and addresses of all 20
persons entitled to take any share or interest of the estate as legatees or distributees thereof. 21
(c) The amount of reimbursement for Medicaid benefits imposed under this section shall 22
also become a debt to the state from the person or entity liable for the payment thereof. 23
(d) Upon payment of the amount of reimbursement for Medicaid benefits imposed by this 24
section, the secretary of the executive office, or his or her designee, shall issue a written discharge 25
of lien. 26
(e) Provided, however, that no lien created under this section shall attach nor become 27
effective upon any real property unless and until a statement of claim is recorded naming the 28
debtor/owner of record of the property as of the date and time of recording of the statement of 29
claim, and describing the real property by a description containing all of the following: (1) Tax 30
assessor’s plat and lot; and (2) Street address. The statement of claim shall be recorded in the 31
records of land evidence in the town or city where the real property is situated. Notice of the lien 32
shall be sent to the duly appointed executor or administrator, the decedent’s legal representative, if 33
known, or to the decedent’s next of kin or heirs at law as stated in the decedent’s last application 34
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for Medicaid benefits. 1
(f) The executive office shall establish procedures, in accordance with the standards 2
specified by the Secretary, United States Department of Health and Human Services, under which 3
the executive office shall waive, in whole or in part, the lien and reimbursement established by this 4
section if the lien and reimbursement would cause an undue hardship, as determined by the 5
executive office, on the basis of the criteria established by the secretary in accordance with 42 6
U.S.C. § 1396p(b)(3). 7
(g) Upon the filing of a petition for admission to probate of a decedent’s will or for 8
administration of a decedent’s estate, when the decedent was fifty-five (55) years or older at the 9
time of death, a copy of the petition and a copy of the death certificate shall be sent to the executive 10
office. Within thirty (30) days of a request by the executive office, an executor or administrator 11
shall complete and send to the executive office a form prescribed by that office and shall provide 12
such additional information as the office may require. In the event a petitioner fails to send a copy 13
of the petition and a copy of the death certificate to the executive office and a decedent has received 14
Medicaid benefits for which the executive office is authorized to recover, no distribution and/or 15
payments, including administration fees, shall be disbursed. Any person and/or entity that receives 16
a distribution of assets from the decedent’s estate shall be liable to the executive office to the extent 17
of such distribution. 18
(h) Compliance with the provisions of this section shall be consistent with the requirements 19
set forth in § 33-11-5 and the requirements of the affidavit of notice set forth in § 33-11-5.2. Nothing 20
in these sections shall limit the executive office from recovery, to the extent of the distribution, in 21
accordance with all state and federal laws. 22
(i) To ensure the financial integrity of the Medicaid eligibility determination, benefit 23
renewal, and estate recovery processes in this and related sections, the secretary of health and 24
human services is authorized and directed to, by no later than August 1, 2018: (1) Implement an 25
automated asset verification system, as mandated by § 1940 of the Act, that uses electronic data 26
sources to verify the ownership and value of countable resources held in financial institutions and 27
any real property for applicants and beneficiaries subject to resource and asset tests pursuant to the 28
Act in § 1902(e)(14)(D); (2) Apply the provisions required under §§ 1902(a)(18) and 1917(c) of 29
the Act pertaining to the disposition of assets for less than fair market value by applicants and 30
beneficiaries for Medicaid long-term services and supports and their spouses, without regard to 31
whether they are subject to or exempted from resources and asset tests as mandated by federal 32
guidance; and (3) Pursue any state plan or waiver amendments from the United States Centers for 33
Medicare and Medicaid Services and promulgate such rules, regulations, and procedures he or she 34
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deems necessary to carry out the requirements set forth herein and ensure the state plan and 1
Medicaid policy conform and comply with applicable provisions of Title XIX. 2
40-8-19.2. Nursing Facility Incentive Program (NFIP). 3
The secretary of the executive office of health and human services is authorized to seek the 4
federal authority required to implement a nursing facility incentive program (NFIP). The NFIP 5
shall provide the participating licensed nursing facilities the ability to obtain certain payments for 6
achieving performance goals established by the secretary. NFIP payments shall commence no 7
earlier than July 1, 2016. 8
40-8-27. Cooperation by providers. 9
Medicaid providers who employ individuals applying for benefits under any chapter of this 10
title shall comply in a timely manner with requests made by the department for any documents 11
describing employer-sponsored health insurance coverage or benefits the provider offers that are 12
necessary to determine eligibility for the state’s premium assistance program pursuant to § 40-8.4-13
12. Documents requested by the department may include, but are not limited to, certificates of 14
coverage or a summary of benefits and employee obligations. Upon receiving notification that the 15
department has determined that the employee is eligible for premium assistance under § 40-8.4-12, 16
the provider shall accept the enrollment of the employee and his or her family in the employer-17
based health insurance plan without regard to any seasonal enrollment restrictions, including open-18
enrollment restrictions, and/or the impact on the employee’s wages. Additionally, the Medicaid 19
provider employing such persons shall not offer “pay in lieu of benefits.” Providers who do not 20
comply with the provisions set forth in this section shall be subject to suspension as a participating 21
Medicaid provider. 22
SECTION 9. Sections 40-8.4-4, 40-8.4-5, 40-8.4-10, 40-8.4-12, 40-8.4-15 and 40-8.4-19 23
of the General Laws in Chapter 40-8.4 entitled "Health Care for Families" are hereby amended to 24
read as follows: 25
40-8.4-4. Eligibility. 26
(a) Medical assistance for families. There is hereby established a category of medical 27
assistance eligibility pursuant to § 1931 of Title XIX of the Social Security Act, 42 U.S.C. § 1396u-28
1, for families whose income and resources are no greater than the standards in effect in the aid to 29
families with dependent children program on July 16, 1996, or such increased standards as the 30
department may determine. The executive office of health and human services is directed to amend 31
the medical assistance Title XIX state plan and to submit to the United States Department of Health 32
and Human Services an amendment to the RIte Care waiver project to provide for medical 33
assistance coverage to families under this chapter in the same amount, scope, and duration as 34
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coverage provided to comparable groups under the waiver. The department is further authorized 1
and directed to submit amendments and/or requests for waivers to the Title XXI state plan as may 2
be necessary to maximize federal contribution for provision of medical assistance coverage 3
provided pursuant to this chapter, including providing medical coverage as a “qualified state” in 4
accordance with Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. Implementation 5
of expanded coverage under this chapter shall not be delayed pending federal review of any Title 6
XXI amendment or waiver. 7
(b) Income. The secretary of the executive office of health and human services is authorized 8
and directed to amend the medical assistance Title XIX state plan or RIte Care waiver to provide 9
medical assistance coverage through expanded income disregards or other methodology for parents 10
or relative caretakers whose income levels are below one hundred thirty-three percent (133%) of 11
the federal poverty level. 12
(c) Healthcare coverage provided under this section shall also be provided without regard 13
to availability of federal financial participation to a noncitizen family member who is a resident of 14
Rhode Island, and who is otherwise eligible for such assistance. The department is further 15
authorized to promulgate any regulations necessary, and in accord with title XIX [42 U.S.C. § 1396 16
et seq.] and title XXI [42 U.S.C. § 1397 et seq.] of the Social Security Act as necessary in order to 17
implement the state plan amendment. The executive office of health and human services is directed 18
to ensure that federal financial participation is assessed to the maximum extent allowable to provide 19
coverage pursuant to this section, at least every two (2) years, and that state-only funds will be used 20
only if federal financial participation is not available. 21
40-8.4-5. Managed care. 22
The delivery and financing of the healthcare services provided under this chapter shall may 23
be provided through a system of managed care. A managed care system integrates an efficient 24
financing mechanism with quality service delivery; provides a “medical home” to ensure 25
appropriate care and deter unnecessary and inappropriate care; and places emphasis on preventive 26
and primary health care. Beginning July 1, 2029, all payments shall be provided directly by the 27
state without an intermediate payment to a managed care entity or other form of health insurance 28
company, unless it is owned by the state. Beginning July 1, 2025, no new contracts may be entered 29
into between the Medicaid office and an intermediate payor such as a managed care entity or other 30
form of health insurance company for the payment of healthcare services pursuant to this chapter, 31
unless it is owned by the state. 32
40-8.4-10. Regulations. 33
(a) The department of human services Medicaid director is authorized to promulgate any 34
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regulations necessary to implement this chapter. 1
(b) When promulgating any rule or regulation necessary to implement this chapter, or any 2
rule or regulation related to RIte Care, the department Medicaid director shall send the notice 3
referred to in § 42-35-3 and a true copy of the rule referred to in § 42-35-4 of the Rhode Island 4
administrative procedures act to each of the co-chairpersons of the permanent joint committee on 5
health care oversight established by § 40-8.4-14. 6
40-8.4-12. RIte Share health insurance premium assistance program. 7
(a) Basic RIte Share health insurance premium assistance program. Under the terms 8
of Section 1906 of Title XIX of the U.S. Social Security Act, 42 U.S.C. § 1396e, states are permitted 9
to pay a Medicaid-eligible person’s share of the costs for enrolling in employer-sponsored health 10
insurance (ESI) coverage if it is cost-effective to do so. Pursuant to the general assembly’s direction 11
in the Rhode Island health reform act of 2000, the Medicaid agency requested and obtained federal 12
approval under § 1916, 42 U.S.C. § 1396o, to establish the RIte Share premium assistance program 13
to subsidize the costs of enrolling Medicaid-eligible persons and families in employer-sponsored 14
health insurance plans that have been approved as meeting certain cost and coverage requirements. 15
The Medicaid agency also obtained, at the general assembly’s direction, federal authority to require 16
any such persons with access to ESI coverage to enroll as a condition of retaining eligibility 17
providing that doing so meets the criteria established in Title XIX for obtaining federal matching 18
funds. 19
(b) Definitions. For the purposes of this section, the following definitions apply: 20
(1) “Cost-effective” means that the portion of the ESI that the state would subsidize, as 21
well as wrap-around costs, would on average cost less to the state than enrolling that same 22
person/family in a managed-care delivery system. 23
(2) “Cost sharing” means any co-payments, deductibles, or co-insurance associated with 24
ESI. 25
(3) “Employee premium” means the monthly premium share a person or family is required 26
to pay to the employer to obtain and maintain ESI coverage. 27
(4) “Employer-sponsored insurance” or “ESI” means health insurance or a group health 28
plan offered to employees by an employer. This includes plans purchased by small employers 29
through the state health insurance marketplace, healthsource, RI (HSRI). 30
(5) “Policy holder” means the person in the household with access to ESI, typically the 31
employee. 32
(6) “RIte Share-approved employer-sponsored insurance (ESI)” means an employer-33
sponsored health insurance plan that meets the coverage and cost-effectiveness criteria for RIte 34
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Share. 1
(7) “RIte Share buy-in” means the monthly amount an Medicaid-ineligible policy holder 2
must pay toward RIte Share-approved ESI that covers the Medicaid-eligible children, young adults, 3
or spouses with access to the ESI. The buy-in only applies in instances when household income is 4
above one hundred fifty percent (150%) of the FPL. 5
(8) “RIte Share premium assistance program” means the Rhode Island Medicaid premium 6
assistance program in which the State pays the eligible Medicaid member’s share of the cost of 7
enrolling in a RIte Share-approved ESI plan. This allows the state to share the cost of the health 8
insurance coverage with the employer. 9
(9) “RIte Share unit” means the entity within the executive office of health and human 10
services (EOHHS) responsible for assessing the cost-effectiveness of ESI, contacting employers 11
about ESI as appropriate, initiating the RIte Share enrollment and disenrollment process, handling 12
member communications, and managing the overall operations of the RIte Share program. 13
(10) “Third-party liability (TPL)” means other health insurance coverage. This insurance 14
is in addition to Medicaid and is usually provided through an employer. Since Medicaid is always 15
the payer of last resort, the TPL is always the primary coverage. 16
(11) “Wrap-around services or coverage” means any healthcare services not included in 17
the ESI plan that would have been covered had the Medicaid member been enrolled in a RIte Care 18
or Rhody Health Partners plan. Coverage of deductibles and co-insurance is included in the wrap. 19
Co-payments to providers are not covered as part of the wrap-around coverage. 20
(c) RIte Share populations. Medicaid beneficiaries subject to eligible for RIte Share 21
include: children, families, parent and caretakers eligible for Medicaid or the children’s health 22
insurance program (CHIP) under this chapter or chapter 12.3 of title 42; and adults between the 23
ages of nineteen (19) and sixty-four (64) who are eligible under chapter 8.12 of this title, not 24
receiving or eligible to receive Medicare, and are enrolled in managed care delivery systems. The 25
following conditions apply: 26
(1) The income of Medicaid beneficiaries shall affect whether and in what manner they 27
must may participate in RIte Share as follows: 28
(i) Income at or below one hundred fifty percent (150%) of FPL — Persons and families 29
determined to have household income at or below one hundred fifty percent (150%) of the federal 30
poverty level (FPL) guidelines based on the modified adjusted gross income (MAGI) standard or 31
other standard approved by the secretary are required to participate in RIte Share if a Medicaid-32
eligible adult or parent/caretaker has access to cost-effective ESI. Enrolling in ESI through RIte 33
Share shall be a condition of maintaining Medicaid health coverage for any eligible adult with 34
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access to such coverage. 1
(ii) Income above one hundred fifty percent (150%) of FPL and policy holder is not 2
Medicaid-eligible — Premium assistance is available when the household includes Medicaid-3
eligible members, but the ESI policy holder (typically a parent/caretaker, or spouse) is not eligible 4
for Medicaid. Premium assistance for parents/caretakers and other household members who are not 5
Medicaid-eligible may be provided in circumstances when enrollment of the Medicaid-eligible 6
family members in the approved ESI plan is contingent upon enrollment of the ineligible policy 7
holder and the executive office of health and human services (executive office) determines, based 8
on a methodology adopted for such purposes, that it is cost-effective to provide premium assistance 9
for family or spousal coverage. 10
(d) RIte Share enrollment as not a condition of eligibility. RIte Share enrollment shall 11
be purely voluntary and shall never be a condition of eligibility for Medicaid. For Medicaid 12
beneficiaries over the age of nineteen (19), enrollment in RIte Share shall be a condition of 13
eligibility except as exempted below and by regulations promulgated by the executive office. 14
(1) Medicaid-eligible children and young adults up to age nineteen (19) shall not be 15
required to enroll in a parent/caretaker relative’s ESI as a condition of maintaining Medicaid 16
eligibility if the person with access to RIte Share-approved ESI does not enroll as required. These 17
Medicaid-eligible children and young adults shall remain eligible for Medicaid and shall be 18
enrolled in a RIte Care plan. 19
(2) There shall be a limited six-month (6) exemption from the mandatory enrollment 20
requirement for persons participating in the RI works program pursuant to chapter 5.2 of this title. 21
(e) Approval of health insurance plans for premium assistance. The executive office of 22
health and human services shall adopt regulations providing for the approval of employer-based 23
health insurance plans for premium assistance and shall approve employer-based health insurance 24
plans based on these regulations. In order for an employer-based health insurance plan to gain 25
approval, the executive office must determine that the benefits offered by the employer-based 26
health insurance plan are substantially similar in amount, scope, and duration to the benefits 27
provided to Medicaid-eligible persons enrolled in a Medicaid managed care plan, when the plan is 28
evaluated in conjunction with available supplemental benefits provided by the office. The office 29
shall obtain and make available to persons otherwise eligible for Medicaid identified in this section 30
as supplemental benefits those benefits not reasonably available under employer-based health 31
insurance plans that are required for Medicaid beneficiaries by state law or federal law or 32
regulation. Once it has been determined by the Medicaid agency that the ESI offered by a particular 33
employer is RIte Share-approved, all Medicaid members with access to that employer’s plan are 34
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required to participate in RIte Share. Failure to meet the mandatory enrollment requirement shall 1
result in the termination of the Medicaid eligibility of the policy holder and other Medicaid 2
members nineteen (19) or older in the household who could be covered under the ESI until the 3
policy holder complies with the RIte Share enrollment procedures established by the executive 4
office. 5
(f) Premium assistance. The executive office shall provide premium assistance by paying 6
all or a portion of the employee’s cost for covering the eligible person and/or his or her family 7
under such a RIte Share-approved ESI plan subject to the buy-in provisions in this section. 8
(g) Buy-in. Persons who can afford it shall share in the cost. — The executive office is 9
authorized and directed to apply for and obtain any necessary state plan and/or waiver amendments 10
from the Secretary of the United States Department of Health and Human Services (DHHS) to 11
require that persons enrolled in a RIte Share-approved employer-based health plan who have 12
income equal to or greater than one hundred fifty percent (150%) of the FPL to buy-in to pay a 13
share of the costs based on the ability to pay, provided that the buy-in cost shall not exceed five 14
percent (5%) of the person’s annual income. The executive office shall implement the buy-in by 15
regulation, and shall consider co-payments, premium shares, or other reasonable means to do so. 16
(h) Maximization of federal contribution. The executive office of health and human 17
services is authorized and directed to apply for and obtain federal approvals and waivers necessary 18
to maximize the federal contribution for provision of medical assistance coverage under this 19
section, including the authorization to amend the Title XXI state plan and to obtain any waivers 20
necessary to reduce barriers to provide premium assistance to recipients as provided for in Title 21
XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. 22
(i) Implementation by regulation. The executive office of health and human services is 23
authorized and directed to adopt regulations to ensure the establishment and implementation of the 24
premium assistance program in accordance with the intent and purpose of this section, the 25
requirements of Title XIX, Title XXI, and any approved federal waivers. 26
(j) Outreach and reporting. The executive office of health and human services shall 27
develop a plan to identify Medicaid-eligible individuals who have access to employer-sponsored 28
insurance and increase the use of RIte Share benefits. Beginning October 1, 2019, the executive 29
office shall submit the plan to be included as part of the reporting requirements under § 35-17-1. 30
Starting January 1, 2020, the executive office of health and human services shall include the number 31
of Medicaid recipients with access to employer-sponsored insurance, the number of plans that did 32
not meet the cost-effectiveness criteria for RIte Share, and enrollment in the premium assistance 33
program as part of the reporting requirements under § 35-17-1. 34
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(k) Employer-sponsored insurance. The executive office of health and human services 1
shall dedicate staff and resources to reporting monthly as part of the requirements under § 35-17-1 2
which employer-sponsored insurance plans meet the cost-effectiveness criteria for RIte Share. 3
Information in the report shall be used for screening for Medicaid enrollment to encourage Rite 4
Share participation. By October 1, 2021, the report shall include any employers with 300 or more 5
employees. By January 1, 2022, the report shall include employers with 100 or more employees. 6
The January report shall also be provided to the chairperson of the house finance committee; the 7
chairperson of the senate finance committee; the house fiscal advisor; the senate fiscal advisor; and 8
the state budget officer. 9
40-8.4-15. Advisory commission on health care. 10
(a) There is hereby established an advisory commission to be known as the “advisory 11
commission on health care” to advise the director of the department of human services on all 12
matters relating to the RIte Care and RIte Share programs, and other matters concerning access for 13
all Rhode Islanders to quality health care in the most affordable, economical manner. The director 14
of the department of human services shall serve ex officio as chairperson. The director shall appoint 15
the eighteen (18) members: 16
(1) Three (3) of whom shall represent the healthcare providers; 17
(2) Three (3) of whom shall represent the healthcare insurers; 18
(3)(2) Three (3) of whom shall represent healthcare consumers or consumer organizations; 19
(4)(3) Two (2) of whom shall represent organized labor; 20
(5)(4) One of whom shall be the health care advocate in the office of the attorney general; 21
and 22
(6) Three (3) of whom shall represent employers; and 23
(7)(5) Three (3) Nine (9) of whom shall be other members of the public. 24
(b) The commission may study all aspects of the provisions of the RIte Care and RIte Share 25
programs involving purchasers of health care, including employers, consumers, and the state, health 26
insurers, providers of health care, and healthcare facilities, and all matters related to the interaction 27
among these groups, including methods to achieve more effective and timely resolution of disputes, 28
better communication, speedier, more reliable and less-costly administrative processes, claims, 29
payments, and other reimbursement matters, and the application of new processes or technologies 30
to such issues. 31
(c) Members of the commission shall be appointed in the month of July, each to hold office 32
until the last day of June in the second year of his or her appointment or until his or her successor 33
is appointed by the director. 34
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(d) The commission shall meet at least quarterly, and the initial meeting of the commission 1
shall take place on or before September 15, 2000. The commission may meet more frequently than 2
quarterly at the call of the chair or at the call of any three (3) members of the commission. 3
(e) Members of the permanent joint committee on health care oversight established 4
pursuant to § 40-8.4-14 shall be notified of each meeting of the commission and shall be invited to 5
participate. 6
40-8.4-19. Managed healthcare delivery systems for families. Cost sharing. 7
(a) Notwithstanding any other provision of state law, the delivery and financing of the 8
healthcare services provided under this chapter shall be provided through a system of managed 9
care. “Managed care” is defined as systems that: integrate an efficient financing mechanism with 10
quality service delivery; provide a “medical home” to ensure appropriate care and deter 11
unnecessary services; and place emphasis on preventive and primary care. 12
(b) Enrollment in managed care health delivery systems is mandatory for individuals 13
eligible for medical assistance under this chapter. This includes children in substitute care, children 14
receiving medical assistance through an adoption subsidy, and children eligible for medical 15
assistance based on their disability. Beneficiaries with third-party medical coverage or insurance 16
may be exempt from mandatory managed care in accordance with rules and regulations 17
promulgated by the department of human services for such purposes. 18
(c) Individuals who can afford to contribute shall share in the cost. The department of 19
human services is authorized and directed to apply for and obtain any necessary waivers and/or 20
state plan amendments from the Secretary of the United States Department of Health and Human 21
Services, including, but not limited to, a waiver of the appropriate sections of Title XIX, 42 U.S.C. 22
§ 1396 et seq., to require that beneficiaries eligible under this chapter or chapter 12.3 of title 42, 23
with incomes equal to or greater than one hundred fifty percent (150%) of the federal poverty level, 24
pay a share of the costs of health coverage based on the ability to pay. The department of human 25
services shall implement this cost-sharing obligation by regulation, and shall consider co-payments, 26
premium shares, or other reasonable means to do so in accordance with approved provisions of 27
appropriate waivers and/or state plan amendments approved by the Secretary of the United States 28
Department of Health and Human Services. 29
SECTION 10. Section 40-8.4-13 of the General Laws in Chapter 40-8.4 entitled "Health 30
Care for Families" is hereby repealed. 31
40-8.4-13. Utilization of available employer-based health insurance. 32
To the extent permitted under Titles XIX and XXI of the Social Security Act, 42 U.S.C. § 33
1396 et seq. and 42 U.S.C. § 1397aa et seq., or by waiver from the Secretary of the United States 34
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Department of Health and Human Services, the department of human services shall adopt 1
regulations to restrict eligibility for RIte Care under this chapter and/or chapter 12.3 of title 42, or 2
the RIte Share program under § 40-8.4-12, for certain periods of time for certain individuals or 3
families who have access to, or have refused or terminated employer-based health insurance and 4
for certain periods of time for certain individuals but not including children whose employer has 5
terminated their employer-based health insurance. The department is authorized and directed to 6
amend the medical assistance Title XIX and XXI state plans, and/or to seek and obtain appropriate 7
federal approvals or waivers to implement this section. 8
SECTION 11. Sections 40-8.5-1 and 40-8.5-1.1 of the General Laws in Chapter 40-8.5 9
entitled "Health Care for Elderly and Disabled Residents Act" are hereby amended to read as 10
follows: 11
40-8.5-1. Categorically needy medical assistance coverage. 12
The department of human services is hereby authorized and directed to amend its Title XIX 13
state plan to provide for categorically needy medical assistance coverage as permitted pursuant to 14
Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., as amended, to individuals who are 15
sixty-five (65) years or older or are disabled, as determined under § 1614(a)(3) of the Social 16
Security Act, 42 U.S.C. § 1382c(a)(3), as amended, whose income does not exceed one hundred 17
percent (100%) one hundred thirty-three percent (133%) of the federal poverty level (as revised 18
annually) applicable to the individual’s family size, and whose resources do not exceed four 19
thousand dollars ($4,000) per individual, or six thousand dollars ($6,000) per couple. The 20
department shall provide medical assistance coverage to such elderly or disabled persons in the 21
same amount, duration, and scope as provided to other categorically needy persons under the state’s 22
Title XIX state plan. 23
40-8.5-1.1. Managed healthcare delivery systems. 24
(a) The delivery and financing of the healthcare services provided under this chapter may 25
be provided through a system of managed care. Beginning July 1, 2029, all payments shall be 26
provided directly by the state without an intermediate payment to a managed care entity or other 27
form of health insurance company. Beginning July 1, 2025, no new contracts may be entered into 28
between the Medicaid office and an intermediate payor such as a managed care entity or other form 29
of health insurance company for the payment of healthcare services pursuant to this chapter. To 30
ensure that all medical assistance beneficiaries, including the elderly and all individuals with 31
disabilities, have access to quality and affordable health care, the executive office of health and 32
human services (“executive office”) is authorized to implement mandatory managed-care health 33
systems. 34
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(b) “Managed care” is defined as systems that: integrate an efficient financing mechanism 1
with quality service delivery; provide a “medical home” to ensure appropriate care and deter 2
unnecessary services; and place emphasis on preventive and primary care. For purposes of this 3
section, managed care systems may also be defined to include a primary care case-management 4
model, community health teams, and/or other such arrangements that meet standards established 5
by the executive office and serve the purposes of this section. Managed care systems may also 6
include services and supports that optimize the health and independence of beneficiaries who are 7
determined to need Medicaid-funded long-term care under chapter 8.10 of this title or to be at risk 8
for the care under applicable federal state plan or waiver authorities and the rules and regulations 9
promulgated by the executive office. Any Medicaid beneficiaries who have third-party medical 10
coverage or insurance may be provided such services through an entity certified by, or in a 11
contractual arrangement with, the executive office or, as deemed appropriate, exempt from 12
mandatory managed care in accordance with rules and regulations promulgated by the executive 13
office. 14
(c) In accordance with § 42-12.4-7, the executive office is authorized to obtain any approval 15
through waiver(s), category II or III changes, and/or state-plan amendments, from the Secretary of 16
the United States Department of Health and Human Services, that are necessary to implement 17
mandatory, managed healthcare delivery systems for all Medicaid beneficiaries. The waiver(s), 18
category II or III changes, and/or state-plan amendments shall include the authorization to extend 19
managed care to cover long-term-care services and supports. Authorization shall also include, as 20
deemed appropriate, exempting certain beneficiaries with third-party medical coverage or 21
insurance from mandatory managed care in accordance with rules and regulations promulgated by 22
the executive office. 23
(d)(b) To ensure the delivery of timely and appropriate services to persons who become 24
eligible for Medicaid by virtue of their eligibility for a United States Social Security Administration 25
program, the executive office is authorized to seek any and all data-sharing agreements or other 26
agreements with the Social Security Administration as may be necessary to receive timely and 27
accurate diagnostic data and clinical assessments. This information shall be used exclusively for 28
the purpose of service planning, and shall be held and exchanged in accordance with all applicable 29
state and federal medical record confidentiality laws and regulations. 30
SECTION 12. Sections 40-8.12-2 and 40-8.12-3 of the General Laws in Chapter 40-8.12 31
entitled "Health Care for Adults" are hereby amended to read as follows: 32
40-8.12-2. Eligibility. 33
(a) Medicaid coverage for nonpregnant adults without children. There is hereby 34
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established, effective January 1, 2014, a category of Medicaid eligibility pursuant to Title XIX of 1
the Social Security Act, as amended by the U.S. Patient Protection and Affordable Care Act (ACA) 2
of 2010, 42 U.S.C. § 1396u-1, for adults ages nineteen (19) to sixty-four (64) who do not have 3
dependent children and do not qualify for Medicaid under Rhode Island general laws applying to 4
families with children and adults who are blind, aged, or living with a disability. The executive 5
office of health and human services is directed to make any amendments to the Medicaid state plan 6
and waiver authorities established under Title XIX necessary to implement this expansion in 7
eligibility and ensure the maximum federal contribution for health insurance coverage provided 8
pursuant to this chapter. 9
(b) Income. The secretary of the executive office of health and human services is authorized 10
and directed to amend the Medicaid Title XIX state plan and, as deemed necessary, any waiver 11
authority to effectuate this expansion of coverage to any Rhode Islander who qualifies for Medicaid 12
eligibility under this chapter with income at or below one hundred and thirty-three percent (133%) 13
of the federal poverty level, based on modified adjusted-gross income. 14
(c) Delivery system. The executive office of health and human services is authorized and 15
directed to apply for and obtain any waiver authorities necessary to provide persons eligible under 16
this chapter with managed, coordinated healthcare coverage consistent with the principles set forth 17
in chapter 12.4 of title 42, pertaining to a healthcare home. Beginning July 1, 2029, all payments 18
shall be provided directly by the state without an intermediate payment to a managed care entity or 19
other form of health insurance company. Beginning July 1, 2025, no new contracts may be entered 20
into between the Medicaid office and an intermediate payor such as a managed care entity or other 21
form of health insurance company for the payment of healthcare services pursuant to this chapter. 22
40-8.12-3. Premium assistance program. 23
(a) The executive office of health and human services is directed to amend its rules and 24
regulations to implement a premium assistance program for adults with dependent children, 25
enrolled in the state’s health-benefits exchange, whose annual income and resources meet the 26
guidelines established in § 40-8.4-4 in effect on December 1, 2013. The premium assistance will 27
pay one-half of the cost of a commercial plan that a parent may incur after subtracting the cost-28
sharing requirement under § 40-8.4-4 as of December 31, 2013, and any applicable federal tax 29
credits available. The office is also directed to amend the 1115 waiver demonstration extension and 30
the medical assistance Title XIX state plan for this program if it is determined that it is eligible for 31
funding pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. 32
(b) The executive office of health and human services shall require any individual receiving 33
benefits under a state-funded, healthcare assistance program to apply for any health insurance for 34
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which he or she is eligible, including health insurance available through the health benefits 1
exchange. Nothing shall preclude the state from using funds appropriated for Affordable Care Act 2
transition expenses to reduce the impact on an individual who has been transitioned from a state 3
program to a health insurance plan available through the health benefits exchange. It shall not be 4
deemed cost-effective for the state if it would result in a loss of benefits or an increase in the cost 5
of healthcare services for the person above an amount deemed de minimus as determined by state 6
regulation. 7
SECTION 13. Chapter 40-8.13 of the General Laws entitled "Long-Term Managed Care 8
Arrangements" is hereby repealed in its entirety. 9
CHAPTER 40-8.13 10
Long-Term Managed Care Arrangements 11
40-8.13-1. Definitions. 12
For purposes of this section the following terms shall have the meanings indicated: 13
(1) “Beneficiary” means an individual who is eligible for medical assistance under the 14
Rhode Island Medicaid state plan established in accordance with 42 U.S.C. § 1396, and includes 15
individuals who are additionally eligible for benefits under the Medicare program (42 U.S.C. § 16
1395 et seq.) or other health plan. 17
(2) “Duals demonstration project” means a demonstration project established pursuant to 18
the financial alignment demonstration established under section 2602 of the Patient Protection and 19
Affordable Care Act (Pub. L. No. 111-148) [42 U.S.C. § 1315b], involving a three-way contract 20
between Rhode Island, the federal Centers for Medicare and Medicaid Services (“CMS”), and 21
qualified health plans, and covering healthcare services provided to beneficiaries. 22
(3) “EOHHS” means the Rhode Island executive office of health and human services. 23
(4) “EOHHS level-of-care tool” refers to a set of criteria established by EOHHS and used 24
in January, 2014 to determine the long-term-care needs of a beneficiary as well as the appropriate 25
setting for delivery of that care. 26
(5) “Long-term-care services and supports” means a spectrum of services covered by the 27
Rhode Island Medicaid program and/or the Medicare program, that are required by individuals with 28
functional impairments and/or chronic illness, and includes skilled or custodial nursing facility 29
care, as well as various home- and community-based services. 30
(6) “Managed care organization” means any health plan, health-maintenance organization, 31
managed care plan, or other person or entity that enters into a contract with the state under which 32
it is granted the authority to arrange for the provision of, and/or payment for, long-term-care 33
supports and services to eligible beneficiaries under a managed long-term-care arrangement. 34
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(7) “Managed long-term-care arrangement” means any arrangement under which a 1
managed care organization is granted some or all of the responsibility for providing and/or paying 2
for long-term-care services and supports that would otherwise be provided or paid under the Rhode 3
Island Medicaid program. The term includes, but is not limited to, a duals demonstration project, 4
and/or phase I and phase II of the integrated care initiative established by the executive office of 5
health and human services. 6
(8) “Plan of care” means a care plan established by a nursing facility in accordance with 7
state and federal regulations and that identifies specific care and services provided to a beneficiary. 8
40-8.13-2. Beneficiary choice. 9
Any managed long-term-care arrangement shall offer beneficiaries the option to decline 10
participation and remain in traditional Medicaid and, if a duals demonstration project, traditional 11
Medicare. Beneficiaries must be provided with sufficient information to make an informed choice 12
regarding enrollment, including: 13
(1) Any changes in the beneficiary’s payment or other financial obligations with respect to 14
long-term-care services and supports as a result of enrollment; 15
(2) Any changes in the nature of the long-term-care services and supports available to the 16
beneficiary as a result of enrollment, including specific descriptions of new services that will be 17
available or existing services that will be curtailed or terminated; 18
(3) A contact person who can assist the beneficiary in making decisions about enrollment; 19
(4) Individualized information regarding whether the managed care organization’s network 20
includes the healthcare providers with whom beneficiaries have established provider relationships. 21
Directing beneficiaries to a website identifying the plan’s provider network shall not be sufficient 22
to satisfy this requirement; and 23
(5) The deadline by which the beneficiary must make a choice regarding enrollment, and 24
the length of time a beneficiary must remain enrolled in a managed care organization before being 25
permitted to change plans or opt out of the arrangement. 26
40-8.13-3. Ombudsman process. 27
EOHHS shall designate an ombudsperson to advocate for beneficiaries enrolled in a 28
managed long-term-care arrangement. The ombudsperson shall advocate for beneficiaries through 29
complaint and appeal processes and ensure that necessary healthcare services are provided. At the 30
time of enrollment, a managed care organization must inform enrollees of the availability of the 31
ombudsperson, including contact information. 32
40-8.13-4. Provider/plan liaison. 33
EOHHS shall designate an individual, not employed by or otherwise under contract with a 34
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participating managed care organization, who shall act as liaison between healthcare providers and 1
managed care organizations, for the purpose of facilitating communications and ensuring that issues 2
and concerns are promptly addressed. 3
40-8.13-5. Financial principles under managed care. 4
(a) To the extent that financial savings are a goal under any managed long-term-care 5
arrangement, it is the intent of the legislature to achieve savings through administrative efficiencies, 6
care coordination, improvements in care outcomes and in a way that encourages the highest quality 7
care for patients and maximizes value for the managed-care organization and the state. Therefore, 8
any managed long-term-care arrangement shall include a requirement that the managed care 9
organization reimburse providers for services in accordance with these principles. Notwithstanding 10
any law to the contrary, for the twelve-month (12) period beginning July 1, 2015, Medicaid 11
managed long-term-care payment rates to nursing facilities established pursuant to this section shall 12
not exceed ninety-eight percent (98.0%) of the rates in effect on April 1, 2015. 13
(1) For a duals demonstration project, the managed care organization: 14
(i) Shall not combine the rates of payment for post-acute skilled and rehabilitation care 15
provided by a nursing facility and long-term and chronic care provided by a nursing facility in order 16
to establish a single-payment rate for dual eligible beneficiaries requiring skilled nursing services; 17
(ii) Shall pay nursing facilities providing post-acute skilled and rehabilitation care or long-18
term and chronic care rates that reflect the different level of services and intensity required to 19
provide these services; and 20
(iii) For purposes of determining the appropriate rate for the type of care identified in 21
subsection (a)(1)(ii) of this section, the managed care organization shall pay no less than the rates 22
that would be paid for that care under traditional Medicare and Rhode Island Medicaid for these 23
service types. The managed care organization shall not, however, be required to use the same 24
payment methodology. 25
The state shall not enter into any agreement with a managed care organization in connection 26
with a duals demonstration project unless that agreement conforms to this section, and any existing 27
such agreement shall be amended as necessary to conform to this subsection. 28
(2) For a managed long-term-care arrangement that is not a duals demonstration project, 29
the managed care organization shall reimburse providers in an amount not less than the amount that 30
would be paid for the same care by the executive office of health and human services under the 31
Medicaid program. The managed care organization shall not, however, be required to use the same 32
payment methodology as the executive office of health and human services. 33
(3) Notwithstanding any provisions of the general or public laws to the contrary, the 34
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protections of subsections (a)(1) and (a)(2) of this section may be waived by a nursing facility in 1
the event it elects to accept a payment model developed jointly by the managed care organization 2
and skilled nursing facilities, that is intended to promote quality of care and cost-effectiveness, 3
including, but not limited to, bundled-payment initiatives, value-based purchasing arrangements, 4
gainsharing, and similar models. 5
(b) Notwithstanding any law to the contrary, for the twelve-month (12) period beginning 6
July 1, 2015, Medicaid managed long-term-care payment rates to nursing facilities established 7
pursuant to this section shall not exceed ninety-eight percent (98.0%) of the rates in effect on April 8
1, 2015. 9
40-8.13-6. Payment incentives. 10
In order to encourage quality improvement and promote appropriate utilization incentives 11
for providers in a managed long-term-care arrangement, a managed care organization may use 12
incentive or bonus payment programs that are in addition to the rates identified in § 40-8.13-5. 13
40-8.13-7. Willing provider. 14
A managed care organization must contract with and cover services furnished by any 15
nursing facility licensed under chapter 17 of title 23 and certified by CMS that provides Medicaid-16
covered nursing facility services pursuant to a provider agreement with the state, provided that the 17
nursing facility is not disqualified under the managed care organization’s quality standards that are 18
applicable to all nursing facilities; and the nursing facility is willing to accept the reimbursement 19
rates described in § 40-8.13-5. 20
40-8.13-8. Level-of-care tool. 21
A managed long-term-care arrangement must require that all participating managed care 22
organizations use only the EOHHS level-of-care tool in determining coverage of long-term-care 23
supports and services for beneficiaries. EOHHS may amend the level-of-care tool provided that 24
any changes are established in consultation with beneficiaries and providers of Medicaid-covered 25
long-term-care supports and services, and are based upon reasonable medical evidence or 26
consensus, in consideration of the specific needs of Rhode Island beneficiaries. Notwithstanding 27
any other provisions herein, however, in the case of a duals demonstration project, a managed care 28
organization may use a different level-of-care tool for determining coverage of services that would 29
otherwise be covered by Medicare, since the criteria established by EOHHS are directed towards 30
Medicaid-covered services; provided, that the level-of-care tool is based on reasonable medical 31
evidence or consensus in consideration of the specific needs of Rhode Island beneficiaries. 32
40-8.13-9. Case management/plan of care. 33
No managed care organization acting under a managed long-term-care arrangement may 34
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require a provider to change a plan of care if the provider reasonably believes that such an action 1
would conflict with the provider’s responsibility to develop an appropriate care plan under state 2
and federal regulations. 3
40-8.13-10. Care transitions. 4
In the event that a beneficiary: 5
(1) Has been determined to meet level-of-care requirements for nursing facility coverage 6
as of the date of his or her enrollment in a managed care organization; or 7
(2) Has been determined to meet level of care requirements for nursing facility coverage 8
by a managed care organization after enrollment; and there is a change in condition whereby the 9
managed care organization determines that the beneficiary no longer meets such level-of-care 10
requirements, the nursing facility shall promptly arrange for an appropriate and safe discharge (with 11
the assistance of the managed care organization if the facility requests it), and the managed care 12
organization shall continue to pay for the beneficiary’s nursing facility care at the same rate until 13
the beneficiary is discharged. 14
40-8.13-11. Reporting requirements. 15
EOHHS shall report to the general assembly and shall make available to interested persons 16
a separate accounting of state expenditures for long-term-care supports and services under any 17
managed long-term-care arrangement, specifically and separately identifying expenditures for 18
home- and community-based services, assisted-living services, hospice services within nursing 19
facilities, hospice services outside of nursing facilities, and nursing facility services. Such reports 20
shall be made twice annually, six (6) months apart, beginning six (6) months following the 21
implementation of any managed long-term-care arrangement, and shall include a detailed report of 22
utilization of each service. In order to facilitate reporting, any managed long-term-care arrangement 23
shall include a requirement that a participating managed care organization make timely reports of 24
the data necessary to compile the reports. 25
SECTION 14. Sections 42-7.2-10, 42-7.2-16 and 42-7.2-16.1 of the General Laws in 26
Chapter 42-7.2 entitled "Office of Health and Human Services" are hereby amended to read as 27
follows: 28
42-7.2-10. Appropriations and disbursements. 29
(a) The general assembly shall annually appropriate such sums as it may deem necessary 30
for the purpose of carrying out the provisions of this chapter. The state controller is hereby 31
authorized and directed to draw his or her orders upon the general treasurer for the payment of such 32
sum or sums, or so much thereof as may from time to time be required, upon receipt by him or her 33
of proper vouchers approved by the secretary of the executive office of health and human services, 34
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or his or her designee. 1
(b) The general assembly shall, through the utilization of federal Medicaid reimbursement 2
for administrative costs, and additional funds, appropriate such funds as may be necessary to hire 3
additional personnel for the Medicaid office as follows: one hundred (100) outreach social workers 4
to encourage, assist and expedite individuals applying for Medicaid benefits; one hundred (100) 5
new programmers in order to build digital infrastructure for the Medicaid office; thirty (30) new 6
social workers and ten (10) new programmers to help increase spend down program utilization and 7
feasibility and examine possible legal changes necessary to increase spend down program 8
eligibility; and fifty (50) additional personnel for building administrative capacity. The Medicaid 9
office shall be exempt from any limitations placed on the number of full-time equivalent personnel 10
employed by the executive office of health and human services. 11
(b)(c) For the purpose of recording federal financial participation associated with 12
qualifying healthcare workforce development activities at the state’s public institutions of higher 13
education, and pursuant to the Rhode Island designated state health programs (DSHP), as approved 14
by the Centers for Medicare & Medicaid Services (CMC) October 20, 2016, in the 11-W-00242/1 15
amendment to Rhode Island’s section 1115 Demonstration Waiver, there is hereby established a 16
restricted-receipt account entitled “Health System Transformation Project” in the general fund of 17
the state and included in the budget of the office of health and human services. Due to the COVID-18
19 pandemic, the office of health and human services is forbidden from utilizing any funds within 19
the health system transformation project restricted receipts account for any imposition of downside 20
risk for providers. No payment models that impose downside risk or in any way deviate from fee-21
for-service shall be utilized for the Medicaid program without explicit authorization by the general 22
assembly. 23
(c)(d) There are hereby created within the general fund of the state and housed within the 24
budget of the office of health and human services two restricted receipt accounts, respectively 25
entitled “HCBS Support-ARPA” and “HCBS Admin Support-ARPA”. Amounts deposited into 26
these accounts are equivalent to the general revenue savings generated by the enhanced federal 27
match received on eligible home and community-based services between April 1, 2021, and March 28
31, 2022, allowable under Section 9817 of the American Rescue Plan Act of 2021, Pub. L. No. 29
117-2. Funds deposited into the “HCBS Support-ARPA” account will be used to finance the state 30
share of newly eligible Medicaid expenditures by the office of health and human services and its 31
sister agencies, including the department of children, youth and families, the department of health, 32
and the department of behavioral healthcare, developmental disabilities and hospitals. Funds 33
deposited into the “HCBS Admin Support-ARPA” account will be used to finance the state share 34
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of allowable administrative expenditures attendant to the implementation of these newly eligible 1
Medicaid expenditures. The accounts created under this subsection shall be exempt from the 2
indirect cost recovery provisions of § 35-4-27. 3
(d)(e) There is hereby created within the general fund of the state and housed within the 4
budget of the office of health and human services a restricted receipt account entitled “Rhode Island 5
Statewide Opioid Abatement Account” for the purpose of receiving and expending monies from 6
settlement agreements with opioid manufacturers, pharmaceutical distributors, pharmacies, or their 7
affiliates, as well as monies resulting from bankruptcy proceedings of the same entities. The 8
executive office of health and human services shall deposit any revenues from such sources that 9
are designated for opioid abatement purposes into the restricted receipt account. Funds from this 10
account shall only be used for forward-looking opioid abatement efforts as defined and limited by 11
any settlement agreements, state-city and town agreements, or court orders pertaining to the use of 12
such funds. By January 1 of each calendar year, the secretary of health and human services shall 13
report to the governor, the speaker of the house of representatives, the president of the senate, and 14
the attorney general on the expenditures that were funded using monies from the Rhode Island 15
statewide opioid abatement account and the amount of funds spent. The account created under this 16
subsection shall be exempt from the indirect cost recovery provisions of § 35-4-27. No 17
governmental entity has the authority to assert a claim against the entities with which the attorney 18
general has entered into settlement agreements concerning the manufacturing, marketing, 19
distributing, or selling of opioids that are the subject of the Rhode Island Memorandum of 20
Understanding Between the State and Cities and Towns Receiving Opioid Settlement Funds 21
executed by every city and town and the attorney general and wherein every city and town agreed 22
to release all such claims against these settling entities, and any amendment thereto. Governmental 23
entity means any state or local governmental entity or sub-entity and includes, but is not limited to, 24
school districts, fire districts, and any other such districts. The claims that shall not be asserted are 25
the released claims, as that term is defined in the settlement agreements executed by the attorney 26
general, or, if not defined therein, the claims sought to be released in such settlement agreements. 27
42-7.2-16. Medicaid System Reform 2008. Medicaid System Reform. 28
(a) The executive office of health and human services, in conjunction with the department 29
of human services, the department of children, youth and families, the department of health and the 30
department of behavioral healthcare, developmental disabilities and hospitals, is authorized to 31
design options that further the reforms in Medicaid initiated in 2008 Medicaid reform to ensure that 32
the program: transitions to a Medicare level of care as a first step in the transition to a state-level 33
Medicare for All system; phases out the use of intermediary privatized insurance companies such 34
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as managed care entities; transitions to the management of health insurers acquired due to 1
insolvency, smoothly integrating publicly owned health insurers with the Medicaid system; utilizes 2
payment models such as fee-for-service that incentivize higher quality of care and more utilization 3
of care; provides for the financial health of Rhode Island healthcare providers; encourages fair 4
wages and benefits for Rhode Island's healthcare workforce; develops and builds out the Medicaid 5
office's human capital, technological infrastructure, expertise, and general ability to manage 6
healthcare payments to prepare for the transition to a single-payer Medicare-for-All system; and 7
guides the transition of the Rhode Island healthcare funding system to a state-level Medicare-for-8
All system. utilizes competitive and value based purchasing to maximize the available service 9
options, promotes accountability and transparency, and encourages and rewards healthy outcomes, 10
independence, and responsible choices; promotes efficiencies and the coordination of services 11
across all health and human services agencies; and ensures the state will have a fiscally sound 12
source of publicly-financed health care for Rhode Islanders in need. 13
(b) Principles and goals. In developing and implementing this system of reform, the 14
executive office of health and human services and the four (4) health and human services 15
departments shall pursue the following principles and goals: 16
(1) Empower consumers to make reasoned and cost-effective choices about their health by 17
providing them with the information and array of service options they need and offering rewards 18
for healthy decisions; 19
(2) Encourage personal responsibility by assuring the information available to beneficiaries 20
is easy to understand and accurate, provide that a fiscal intermediary is provided when necessary, 21
and adequate access to needed services; 22
(3) When appropriate, promote community-based care solutions by transitioning 23
beneficiaries from institutional settings back into the community and by providing the needed 24
assistance and supports to beneficiaries requiring long-term care or residential services who wish 25
to remain, or are better served in the community; 26
(4) Enable consumers to receive individualized health care that is outcome-oriented, 27
focused on prevention, disease management, recovery and maintaining independence; 28
(5) Promote competition between healthcare providers to ensure best value purchasing, to 29
leverage resources and to create opportunities for improving service quality and performance; 30
(6) Redesign purchasing and payment methods to assure fiscal accountability and 31
encourage and to reward service quality and cost-effectiveness by tying reimbursements to 32
evidence-based performance measures and standards, including those related to patient satisfaction 33
promote payment models such as fee-for-service that incentivize higher quality of care and phase 34
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out the use of payment models that shift risk to providers, such as capitation, episode-based 1
payments, global budgets, and similar models; and 2
(7) Continually improve technology to take advantage of recent innovations and advances 3
that help decision makers, consumers and providers to make informed and cost-effective decisions 4
regarding health care. 5
(c) The executive office of health and human services shall annually submit a report to the 6
governor and the general assembly describing the status of the administration and implementation 7
of the Medicaid Section 1115 demonstration waiver. 8
42-7.2-16.1. Reinventing Medicaid Act of 2015. 9
(a) Findings. The Rhode Island Medicaid program is an integral component of the state’s 10
healthcare system that provides crucial services and supports to many Rhode Islanders. As the 11
program’s reach has expanded, the costs of the program have continued to rise and the delivery of 12
care has become more fragmented and uncoordinated. Given the crucial role of the Medicaid 13
program to the state, it is of compelling importance that the state conduct a fundamental 14
restructuring of its Medicaid program that achieves measurable improvement in health outcomes 15
for the people and transforms the healthcare system to one that pays for the outcomes and quality 16
they deserve at a sustainable, predictable and affordable cost. The Reinventing Medicaid Act of 17
2015, as implemented in the budget for fiscal year two thousand sixteen (FY2016), involved drastic 18
cuts to the Medicaid program, along with policies that shifted risk to providers away from 19
intermediary insurers. Since the passage of that act, the finances of healthcare providers in Rhode 20
Island have deteriorated significantly, and it is therefore the duty of the general assembly to seek 21
corrective action to restore critical investments in the Medicaid system and redesign payment 22
models to remove risk from providers and concentrate risk in private insurance companies during 23
their phase-out period along the transition to Medicare-for-All. 24
(b) The Working Group to Reinvent Medicaid, which was established to refine the 25
principles and goals of the Medicaid reforms begun in 2008, was directed to present to the general 26
assembly and the governor initiatives to improve the value, quality, and outcomes of the health care 27
funded by the Medicaid program. 28
SECTION 15. Chapter 42-12.1 of the General Laws entitled "Department of Behavioral 29
Healthcare, Developmental Disabilities and Hospitals" is hereby amended by adding thereto the 30
following section: 31
42-12.1-11. The Rhode Island mental health nursing facility. 32
(a) There is hereby established a state nursing facility for the care for Rhode Islanders in 33
need of nursing facility-level inpatient behavioral healthcare known as the Rhode Island mental 34
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health nursing facility. The Rhode Island mental health nursing facility shall fall within the purview 1
of the department, and the chief executive officer, chief financial officer, and chief medical officer 2
shall be appointed by the governor with advice and consent of the senate. 3
SECTION 16. Sections 42-12.3-3, 42-12.3-5, 42-12.3-7 and 42-12.3-9 of the General Laws 4
in Chapter 42-12.3 entitled "Health Care for Children and Pregnant Women" are hereby amended 5
to read as follows: 6
42-12.3-3. Medical assistance expansion for pregnancy/RIte Start. 7
(a) The secretary of the executive office of health and human services is authorized to 8
amend its Title XIX state plan pursuant to Title XIX of the Social Security Act to provide Medicaid 9
coverage and to amend its Title XXI state plan pursuant to Title XXI of the Social Security Act to 10
provide medical assistance coverage through expanded family income disregards for pregnant 11
persons whose family income levels are between one hundred eighty-five percent (185%) and two 12
hundred fifty percent (250%) of the federal poverty level. The department is further authorized to 13
promulgate any regulations necessary and in accord with Title XIX [42 U.S.C. § 1396 et seq.] and 14
Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act necessary in order to implement 15
said state plan amendment. The services provided shall be in accord with Title XIX [42 U.S.C. § 16
1396 et seq.] and Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act. 17
(b) The secretary of health and human services is authorized and directed to establish a 18
payor of last resort program to cover prenatal, delivery and postpartum care. The program shall 19
cover the cost of maternity care for any person who lacks health insurance coverage for maternity 20
care and who is not eligible for medical assistance under Title XIX [42 U.S.C. § 1396 et seq.] and 21
Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act including, but not limited to, a 22
noncitizen pregnant person lawfully admitted for permanent residence on or after August 22, 1996, 23
without regard to the availability of federal financial participation, provided such pregnant person 24
satisfies all other eligibility requirements. The secretary shall promulgate regulations to implement 25
this program. Such regulations shall include specific eligibility criteria; the scope of services to be 26
covered; procedures for administration and service delivery; referrals for non-covered services; 27
outreach; and public education. 28
(c) The secretary of health and human services may enter into cooperative agreements with 29
the department of health and/or other state agencies to provide services to individuals eligible for 30
services under subsections (a) and (b) above. 31
(d) The following services shall be provided through the program: 32
(1) Ante-partum and postpartum care; 33
(2) Delivery; 34
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(3) Cesarean section; 1
(4) Newborn hospital care; 2
(5) Inpatient transportation from one hospital to another when authorized by a medical 3
provider; and 4
(6) Prescription medications and laboratory tests. 5
(e) The secretary of health and human services shall provide enhanced services, as 6
appropriate, to pregnant persons as defined in subsections (a) and (b), as well as to other pregnant 7
persons eligible for medical assistance. These services shall include: care coordination; nutrition 8
and social service counseling; high-risk obstetrical care; childbirth and parenting preparation 9
programs; smoking cessation programs; outpatient counseling for drug-alcohol use; interpreter 10
services; mental health services; and home visitation. The provision of enhanced services is subject 11
to available appropriations. In the event that appropriations are not adequate for the provision of 12
these services, the executive office has the authority to limit the amount, scope, and duration of 13
these enhanced services. 14
(f) The executive office of health and human services shall provide for extended family 15
planning services for up to twenty-four (24) months postpartum. These services shall be available 16
to persons who have been determined eligible for RIte Start or for medical assistance under Title 17
XIX [42 U.S.C. § 1396 et seq.] or Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security 18
Act. 19
(g) Effective October 1, 2022, individuals eligible for RIte Start pursuant to this section or 20
for medical assistance under Title XIX or Title XXI of the Social Security Act while pregnant 21
(including during a period of retroactive eligibility), are eligible for full Medicaid benefits through 22
the last day of the month in which their twelve-month (12) postpartum period ends. This benefit 23
will be provided to eligible Rhode Island residents without regard to the availability of federal 24
financial participation. The executive office of health and human services is directed to ensure that 25
federal financial participation is used to the maximum extent allowable to provide coverage 26
pursuant to this section, and that state-only funds will be used only if federal financial participation 27
is not available. 28
(h) Any person eligible for services under subsections (a) and (b) of this section, or 29
otherwise eligible for medical assistance under Title XIX [42 U.S.C. § 1396 et seq.] and Title XXI 30
[42 U.S.C. § 1397aa et seq.] of the Social Security Act, shall also be entitled to services for any 31
termination of pregnancy permitted under § 23-4.13-2; provided, however, that no federal funds 32
shall be used to pay for such services, except as authorized under federal law. 33
42-12.3-5. Managed care. 34
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The delivery and financing of the health care services provided pursuant to §§ 42-12.3-3 1
and 42-12.3-4 shall may be provided through a system of managed care. The delivery and financing 2
of the healthcare services provided under this chapter may be provided through a system of 3
managed care. Beginning July 1, 2029, all payments shall be provided directly by the state without 4
an intermediate payment to a managed care entity or other form of health insurance company, 5
unless the intermediate payor is owned by the Medicaid office or another branch of state 6
government. Beginning July 1, 2025, no new contracts may be entered into between the Medicaid 7
office and an intermediate payor such as a managed care entity or other form of health insurance 8
company for the payment of healthcare services pursuant to this chapter, unless the intermediate 9
payor is owned by the Medicaid office or another branch of state government. 10
A managed care system integrates an efficient financing mechanism with quality service 11
delivery, provides a “medical home” to assure appropriate care and deter unnecessary and 12
inappropriate care, and places emphasis on preventive and primary health care. In developing a 13
managed care system the department of human services shall consider managed care models 14
recognized by the health care financing administration. The department of human services is hereby 15
authorized and directed to seek any necessary approvals or waivers from the U.S. Department of 16
Health and Human Services, Health Care Financing Administration, needed to assure that services 17
are provided through a mandatory managed care system. Certain health services may be provided 18
on an interim basis through a fee for service arrangement upon a finding that there are temporary 19
barriers to implementation of mandatory managed care for a particular population or particular 20
geographic area. Nothing in this section shall prohibit the department of human services from 21
providing enhanced services to medical assistance recipients within existing appropriations. 22
42-12.3-7. Financial contributions. 23
The department of human services may not require the payment of enrollment fees, sliding 24
fees, deductibles, co-payments, and/or other contributions based on ability to pay. These fees shall 25
be established by rules and regulations to be promulgated by the department of human services or 26
the department of health, as appropriate. 27
42-12.3-9. Insurance coverage — Third party insurance. 28
(a) No payment will be made nor service provided in the RIte Start or RIte Track program 29
with respect to any health care that is covered or would be covered, by any employee welfare benefit 30
plan under which a woman or child is either covered or eligible to be covered either as an employee 31
or dependent, whether or not coverage under such plan is elected. 32
(b) A premium may be charged for participation in the RIte Track or RIte Start programs 33
for eligible individuals whose family incomes are in excess of two hundred fifty percent (250%) of 34
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the federal poverty level and who have voluntarily terminated health care insurance within one year 1
of the date of application for benefits under this chapter. 2
(c)(b) Every family who is eligible to participate in the RIte Track program, who has an 3
additional child who because of age is not eligible for RIte Track, or whose child becomes ineligible 4
for RIte Track because of his or her age, may be offered by the managed care provider with whom 5
the family is enrolled, the opportunity to enroll such ineligible child or children in the same 6
managed care program on a self-pay basis at the same cost, charge or premium as is being charged 7
to the state under the provisions of this chapter for other covered children within the managed care 8
program. The family may also purchase a package of enhanced services at the same cost or charge 9
to the department. 10
SECTION 17. Section 42-12.3-14 of the General Laws in Chapter 42-12.3 entitled "Health 11
Care for Children and Pregnant Women" is hereby repealed. 12
42-12.3-14. Benefits and coverage — Exclusion. 13
For as long as the United States Department of Health and Human Services, Health Care 14
Financing Administration Project No. 11-W-0004/1-01 entitled “RIte Care” remains in effect, any 15
health care services provided pursuant to this chapter shall be exempt from all mandatory benefits 16
and coverage as may otherwise be provided for in the general laws. 17
SECTION 18. Sections 42-14.5-2 and 42-14.5-3 of the General Laws in Chapter 42-14.5 18
entitled "The Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" are 19
hereby amended to read as follows: 20
42-14.5-2. Purpose. 21
With respect to health insurance as defined in § 42-14-5, the health insurance commissioner 22
shall discharge the powers and duties of office to: 23
(1) Guard the solvency of health insurers Claw back excessive profits, reserves charges, 24
and other monies that health insurers may have accumulated against the public interest of the people 25
of Rhode Island; 26
(2) Protect the interests of consumers; 27
(3) Encourage fair treatment of health care providers; 28
(4) Encourage policies and developments that improve the quality and efficiency of health 29
care service delivery and outcomes; and 30
(5) View the health care system as a comprehensive entity and encourage and direct 31
insurers towards policies that advance the welfare of the public through overall efficiency, 32
improved health care quality, and appropriate access; and 33
(6) Facilitate the transformation of the healthcare payments system to a state-level 34
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Medicare-for-All system. 1
42-14.5-3. Powers and duties. 2
The health insurance commissioner shall have the following powers and duties: 3
(a) To conduct quarterly public meetings throughout the state, separate and distinct from 4
rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 5
licensed to provide health insurance in the state; the effects of such rates, services, and operations 6
on consumers, medical care providers, patients, and the market environment in which the insurers 7
operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 8
than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 9
Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 10
general, and the chambers of commerce. Public notice shall be posted on the department’s website 11
and given in the newspaper of general circulation, and to any entity in writing requesting notice. 12
(b) To make recommendations to the governor and the house of representatives and senate 13
finance committees regarding healthcare insurance and the regulations, rates, services, 14
administrative expenses, reserve requirements, and operations of insurers providing health 15
insurance in the state, and to prepare or comment on, upon the request of the governor or 16
chairpersons of the house or senate finance committees, draft legislation to improve the regulation 17
of health insurance. In making the recommendations, the commissioner shall recognize that it is 18
the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 19
of individual administrative expenditures as well as total administrative costs. The commissioner 20
shall make recommendations on the levels of reserves, including consideration of: targeted reserve 21
levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 22
reserves. 23
(c) To establish a consumer/business/labor/medical advisory council to obtain information 24
and present concerns of consumers, business, and medical providers affected by health insurance 25
decisions. The council shall develop proposals to allow the market for small business health 26
insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 27
the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 28
measures to inform small businesses of an insurance complaint process to ensure that small 29
businesses that experience rate increases in a given year may request and receive a formal review 30
by the department. The advisory council shall assess views of the health provider community 31
relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 32
insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 33
an annual report of findings and recommendations to the governor and the general assembly and 34
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present its findings at hearings before the house and senate finance committees. The advisory 1
council is to be diverse in interests and shall include representatives of community consumer 2
organizations; small businesses, other than those involved in the sale of insurance products; and 3
hospital, medical, and other health provider organizations. Such representatives shall be nominated 4
by their respective organizations. The advisory council shall be co-chaired by the health insurance 5
commissioner and a community consumer organization or small business member to be elected by 6
the full advisory council. 7
(d) To establish and provide guidance and assistance to a subcommittee (“the professional-8
provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 9
composed of healthcare providers and Rhode Island licensed health plans. This subcommittee The 10
health commissioner shall include provide in its annual report and presentation before the house 11
and senate finance committees the following information: 12
(1) A method whereby health plans shall disclose to contracted providers the fee schedules 13
used to provide payment to those providers for services rendered to covered patients; 14
(2) A standardized provider application and credentials verification process, for the 15
purpose of verifying professional qualifications of participating healthcare providers; 16
(3) The uniform health plan claim form utilized by participating providers; 17
(4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 18
hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make 19
facility-specific data and other medical service-specific data available in reasonably consistent 20
formats to patients regarding quality and costs. This information would help consumers make 21
informed choices regarding the facilities and clinicians or physician practices at which to seek care. 22
Among the items considered would be the unique health services and other public goods provided 23
by facilities and clinicians or physician practices in establishing the most appropriate cost 24
comparisons; 25
(5) All activities related to contractual disclosure to participating providers of the 26
mechanisms for resolving health plan/provider disputes; 27
(6) The uniform process being utilized for confirming, in real time, patient insurance 28
enrollment status, benefits coverage, including copays and deductibles; 29
(7) Information related to temporary credentialing of providers seeking to participate in the 30
plan’s network and the impact of the activity on health plan accreditation; 31
(8) The feasibility of regular contract renegotiations between plans and the providers in 32
their networks; and 33
(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 34
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(e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). 1
(f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 2
fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 3
(g) To analyze the impact of changing the rating guidelines and/or merging the individual 4
health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 5
insurance market, as defined in chapter 50 of title 27, in accordance with the following: 6
(1) The analysis shall forecast the likely rate increases required to effect the changes 7
recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 8
health insurance market over the next five (5) years, based on the current rating structure and 9
current products. 10
(2) The analysis shall include examining the impact of merging the individual and small-11
employer markets on premiums charged to individuals and small-employer groups. 12
(3) The analysis shall include examining the impact on rates in each of the individual and 13
small-employer health insurance markets and the number of insureds in the context of possible 14
changes to the rating guidelines used for small-employer groups, including: community rating 15
principles; expanding small-employer rate bonds beyond the current range; increasing the employer 16
group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 17
(4) The analysis shall include examining the adequacy of current statutory and regulatory 18
oversight of the rating process and factors employed by the participants in the proposed, new 19
merged market. 20
(5) The analysis shall include assessment of possible reinsurance mechanisms and/or 21
federal high-risk pool structures and funding to support the health insurance market in Rhode Island 22
by reducing the risk of adverse selection and the incremental insurance premiums charged for this 23
risk, and/or by making health insurance affordable for a selected at-risk population. 24
(6) The health insurance commissioner shall work with an insurance market merger task 25
force to assist with the analysis. The task force shall be chaired by the health insurance 26
commissioner and shall include, but not be limited to, representatives of the general assembly, the 27
business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 28
the individual market in Rhode Island, health insurance brokers, and members of the general public. 29
(7) For the purposes of conducting this analysis, the commissioner may contract with an 30
outside organization with expertise in fiscal analysis of the private insurance market. In conducting 31
its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 32
data shall be subject to state and federal laws and regulations governing confidentiality of health 33
care and proprietary information. 34
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(8) The task force shall meet as necessary and include its findings in the annual report, and 1
the commissioner shall include the information in the annual presentation before the house and 2
senate finance committees. 3
(h) To establish and convene a workgroup representing healthcare providers and health 4
insurers for the purpose of coordinating the development of processes, guidelines, and standards to 5
streamline healthcare administration that are to be adopted by payors and providers of healthcare 6
services operating in the state. This workgroup shall include representatives with expertise who 7
would contribute to the streamlining of healthcare administration and who are selected from 8
hospitals, physician practices, community behavioral health organizations, each health insurer, 9
labor union representing healthcare workers, and other affected entities. The workgroup shall also 10
include at least one designee each from the Rhode Island Medical Society, Rhode Island Council 11
of Community Mental Health Organizations, the Rhode Island Health Center Association, and the 12
Hospital Association of Rhode Island. In any year that the workgroup meets and submits 13
recommendations to the office of the health insurance commissioner, the office of the health 14
insurance commissioner shall submit such recommendations to the health and human services 15
committees of the Rhode Island house of representatives and the Rhode Island senate prior to the 16
implementation of any such recommendations and subsequently shall submit a report to the general 17
assembly by June 30, 2024. The report shall include the recommendations the commissioner may 18
implement, with supporting rationale. The workgroup shall consider and make recommendations 19
for: 20
(1) Establishing a consistent standard for electronic eligibility and coverage verification. 21
Such standard shall: 22
(i) Include standards for eligibility inquiry and response and, wherever possible, be 23
consistent with the standards adopted by nationally recognized organizations, such as the Centers 24
for Medicare & Medicaid Services; 25
(ii) Enable providers and payors to exchange eligibility requests and responses on a system-26
to-system basis or using a payor-supported web browser; 27
(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 28
coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 29
requirements for specific services at the specific time of the inquiry; current deductible amounts; 30
accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 31
other information required for the provider to collect the patient’s portion of the bill; 32
(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 33
and benefits information; 34
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(v) Recommend a standard or common process to protect all providers from the costs of 1
services to patients who are ineligible for insurance coverage in circumstances where a payor 2
provides eligibility verification based on best information available to the payor at the date of the 3
request of eligibility. 4
(2) Developing implementation guidelines and promoting adoption of the guidelines for: 5
(i) The use of the National Correct Coding Initiative code-edit policy by payors and 6
providers in the state; 7
(ii) Publishing any variations from codes and mutually exclusive codes by payors in a 8
manner that makes for simple retrieval and implementation by providers; 9
(iii) Use of Health Insurance Portability and Accountability Act standard group codes, 10
reason codes, and remark codes by payors in electronic remittances sent to providers; 11
(iv) Uniformity in the processing of claims by payors; and the processing of corrections to 12
claims by providers and payors; 13
(v) A standard payor-denial review process for providers when they request a 14
reconsideration of a denial of a claim that results from differences in clinical edits where no single, 15
common-standards body or process exists and multiple conflicting sources are in use by payors and 16
providers. 17
(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 18
payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 19
detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 20
disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 21
the application of such edits and that the provider have access to the payor’s review and appeal 22
process to challenge the payor’s adjudication decision. 23
(vii) Nothing in this subsection shall be construed to modify the rights or obligations of 24
payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 25
prosecution under applicable law of potentially fraudulent billing activities. 26
(3) Developing and promoting widespread adoption by payors and providers of guidelines 27
to: 28
(i) Ensure payors do not automatically deny claims for services when extenuating 29
circumstances make it impossible for the provider to obtain a preauthorization before services are 30
performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 31
(ii) Require payors to use common and consistent processes and time frames when 32
responding to provider requests for medical management approvals. Whenever possible, such time 33
frames shall be consistent with those established by leading national organizations and be based 34
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upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 1
management includes prior authorization of services, preauthorization of services, precertification 2
of services, post-service review, medical-necessity review, and benefits advisory; 3
(iii) Develop, maintain, and promote widespread adoption of a single, common website 4
where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 5
requirements; 6
(iv) Establish guidelines for payors to develop and maintain a website that providers can 7
use to request a preauthorization, including a prospective clinical necessity review; receive an 8
authorization number; and transmit an admission notification; 9
(v) Develop and implement the use of programs that implement selective prior 10
authorization requirements, based on stratification of healthcare providers’ performance and 11
adherence to evidence-based medicine with the input of contracted healthcare providers and/or 12
provider organizations. Such criteria shall be transparent and easily accessible to contracted 13
providers. Such selective prior authorization programs shall be available when healthcare providers 14
participate directly with the insurer in risk-based payment contracts and may be available to 15
providers who do not participate in risk-based contracts; 16
(vi) Require the review of medical services, including behavioral health services, and 17
prescription drugs, subject to prior authorization on at least an annual basis, with the input of 18
contracted healthcare providers and/or provider organizations. Any changes to the list of medical 19
services, including behavioral health services, and prescription drugs requiring prior authorization, 20
shall be shared via provider-accessible websites; 21
(vii) Improve communication channels between health plans, healthcare providers, and 22
patients by: 23
(A) Requiring transparency and easy accessibility of prior authorization requirements, 24
criteria, rationale, and program changes to contracted healthcare providers and patients/health plan 25
enrollees which may be satisfied by posting to provider-accessible and member-accessible 26
websites; and 27
(B) Supporting: 28
(I) Timely submission by healthcare providers of the complete information necessary to 29
make a prior authorization determination, as early in the process as possible; and 30
(II) Timely notification of prior authorization determinations by health plans to impacted 31
health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, 32
and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 33
provider-accessible websites or similar electronic portals or services; 34
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(viii) Increase and strengthen continuity of patient care by: 1
(A) Defining protections for continuity of care during a transition period for patients 2
undergoing an active course of treatment, when there is a formulary or treatment coverage change 3
or change of health plan that may disrupt their current course of treatment and when the treating 4
physician determines that a transition may place the patient at risk; and for prescription medication 5
by allowing a grace period of coverage to allow consideration of referred health plan options or 6
establishment of medical necessity of the current course of treatment; 7
(B) Requiring continuity of care for medical services, including behavioral health services, 8
and prescription medications for patients on appropriate, chronic, stable therapy through 9
minimizing repetitive prior authorization requirements; and which for prescription medication shall 10
be allowed only on an annual review, with exception for labeled limitation, to establish continued 11
benefit of treatment; and 12
(C) Requiring communication between healthcare providers, health plans, and patients to 13
facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 14
by posting to provider-accessible websites or similar electronic portals or services; 15
(D) Continuity of care for formulary or drug coverage shall distinguish between FDA 16
designated interchangeable products and proprietary or marketed versions of a medication; 17
(ix) Encourage healthcare providers and/or provider organizations and health plans to 18
accelerate use of electronic prior authorization technology, including adoption of national standards 19
where applicable; and 20
(x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 21
workgroup meeting may be conducted in part or whole through electronic methods. 22
(4) To provide a report to the house and senate, on or before January 1, 2017, with 23
recommendations for establishing guidelines and regulations for systems that give patients 24
electronic access to their claims information, particularly to information regarding their obligations 25
to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 26
(5) No provision of this subsection (h) shall preclude the ongoing work of the office of 27
health insurance commissioner’s administrative simplification task force, which includes meetings 28
with key stakeholders in order to improve, and provide recommendations regarding, the prior 29
authorization process. 30
(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 31
thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 32
committee on health and human services, and the house committee on corporations, with: (1) 33
Information on the availability in the commercial market of coverage for anti-cancer medication 34
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options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 1
options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 2
utilization and cost-sharing expense. 3
(j) To monitor the adequacy of each health plan’s compliance with the provisions of the 4
federal Mental Health Parity Act, including a review of related claims processing and 5
reimbursement procedures. Findings, recommendations, and assessments shall be made available 6
to the public. 7
(k) To monitor the prevent by regulation transition from fee-for-service and toward global 8
and other alternative payment methodologies for the payment for healthcare services that the health 9
insurance commissioner shall deem against the interest of public health. The health insurance 10
commissioner shall have no power to impose, encourage, or in any way incentivize any rate caps, 11
global budgets, episode-based payments, or capitation structures in the payment models utilized in 12
contracts between health insurers and providers. Alternative payment methodologies should be 13
assessed for their likelihood to promote damage access to affordable health insurance care, health 14
outcomes, and performance. 15
(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 16
payment variation, including findings and recommendations, subject to available resources. 17
(m) Notwithstanding any provision of the general or public laws or regulation to the 18
contrary, provide a report with findings and recommendations to the president of the senate and the 19
speaker of the house, on or before April 1, 2014, including, but not limited to, the following 20
information: 21
(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 22
27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-23
18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 24
insurance for fully insured employers, subject to available resources; 25
(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 26
the existing standards of care and/or delivery of services in the healthcare system; 27
(3) A state-by-state comparison of health insurance mandates and the extent to which 28
Rhode Island mandates exceed other states benefits; and 29
(4) Recommendations for amendments to existing mandated benefits based on the findings 30
in (m)(1), (m)(2), and (m)(3) above. 31
(n) On or before July 1, 2014, the office of the health insurance commissioner, in 32
collaboration with the director of health and lieutenant governor’s office, shall submit a report to 33
the general assembly and the governor to inform the design of accountable care organizations 34
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(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-1
based payment arrangements, that shall include, but not be limited to: 2
(1) Utilization review; 3
(2) Contracting; and 4
(3) Licensing and regulation. 5
(o) On or before February 3, 2015, the office of the health insurance commissioner shall 6
submit a report to the general assembly and the governor that describes, analyzes, and proposes 7
recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 8
to patients with mental health and substance use disorders. 9
(p) To work to ensure the health insurance coverage of behavioral health care under the 10
same terms and conditions as other health care, and to integrate behavioral health parity 11
requirements into the office of the health insurance commissioner insurance oversight and 12
healthcare transformation efforts. 13
(q) To work with other state agencies to seek delivery system improvements that enhance 14
access to a continuum of mental health and substance use disorder treatment in the state; and 15
integrate that treatment with primary and other medical care to the fullest extent possible. 16
(r) To direct insurers toward policies and practices that address the behavioral health needs 17
of the public and greater integration of physical and behavioral healthcare delivery. 18
(s) The office of the health insurance commissioner shall conduct an analysis of the impact 19
of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 20
submit a report of its findings to the general assembly on or before June 1, 2023. 21
(t) To undertake the analyses, reports, and studies contained in this section: 22
(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 23
and competent firm or firms to undertake the following analyses, reports, and studies: 24
(i) The firm shall undertake a comprehensive review of all social and human service 25
programs having a contract with or licensed by the state or any subdivision of the department of 26
children, youth and families (DCYF), the department of behavioral healthcare, developmental 27
disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 28
health (DOH), and Medicaid for the purposes of: 29
(A) Establishing a baseline of the eligibility factors for receiving services; 30
(B) Establishing a baseline of the service offering through each agency for those 31
determined eligible; 32
(C) Establishing a baseline understanding of reimbursement rates for all social and human 33
service programs including rates currently being paid, the date of the last increase, and a proposed 34
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model that the state may use to conduct future studies and analyses; 1
(D) Ensuring accurate and adequate reimbursement to social and human service providers 2
that facilitate the availability of high-quality services to individuals receiving home and 3
community-based long-term services and supports provided by social and human service providers; 4
(E) Ensuring the general assembly is provided accurate financial projections on social and 5
human service program costs, demand for services, and workforce needs to ensure access to entitled 6
beneficiaries and services; 7
(F) Establishing a baseline and determining the relationship between state government and 8
the provider network including functions, responsibilities, and duties; 9
(G) Determining a set of measures and accountability standards to be used by EOHHS and 10
the general assembly to measure the outcomes of the provision of services including budgetary 11
reporting requirements, transparency portals, and other methods; and 12
(H) Reporting the findings of human services analyses and reports to the speaker of the 13
house, senate president, chairs of the house and senate finance committees, chairs of the house and 14
senate health and human services committees, and the governor. 15
(2) The analyses, reports, and studies required pursuant to this section shall be 16
accomplished and published as follows and shall provide: 17
(i) An assessment and detailed reporting on all social and human service program rates to 18
be completed by January 1, 2023, including rates currently being paid and the date of the last 19
increase; 20
(ii) An assessment and detailed reporting on eligibility standards and processes of all 21
mandatory and discretionary social and human service programs to be completed by January 1, 22
2023; 23
(iii) An assessment and detailed reporting on utilization trends from the period of January 24
1, 2017, through December 31, 2021, for social and human service programs to be completed by 25
January 1, 2023; 26
(iv) An assessment and detailed reporting on the structure of the state government as it 27
relates to the provision of services by social and human service providers including eligibility and 28
functions of the provider network to be completed by January 1, 2023; 29
(v) An assessment and detailed reporting on accountability standards for services for social 30
and human service programs to be completed by January 1, 2023; 31
(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 32
and unlicensed personnel requirements for established rates for social and human service programs 33
pursuant to a contract or established fee schedule; 34
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(vii) An assessment and reporting on access to social and human service programs, to 1
include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 2
(viii) An assessment and reporting of national and regional Medicaid rates in comparison 3
to Rhode Island social and human service provider rates by April 1, 2023; 4
(ix) An assessment and reporting on usual and customary rates paid by private insurers and 5
private pay for similar social and human service providers, both nationally and regionally, by April 6
1, 2023; and 7
(x) Completion of the development of an assessment and review process that includes the 8
following components: eligibility; scope of services; relationship of social and human service 9
provider and the state; national and regional rate comparisons and accountability standards that 10
result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 11
and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 12
requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 13
1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 14
results and findings of this process shall be transparent, and public meetings shall be conducted to 15
allow providers, recipients, and other interested parties an opportunity to ask questions and provide 16
comment beginning in September 2023 and biennially thereafter. 17
(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 18
insurance commissioner shall consult with the Executive Office of Health and Human Services. 19
(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 20
include the corresponding components of the assessment and review (i.e., eligibility; scope of 21
services; relationship of social and human service provider and the state; and national and regional 22
rate comparisons and accountability standards including any changes or substantive issues between 23
biennial reviews) including the recommended rates from the most recent assessment and review 24
with their annual budget submission to the office of management and budget and provide a detailed 25
explanation and impact statement if any rate variances exist between submitted recommended 26
budget and the corresponding recommended rate from the most recent assessment and review 27
process starting October 1, 2023, and biennially thereafter. 28
(v) The general assembly shall appropriate adequate funding as it deems necessary to 29
undertake the analyses, reports, and studies contained in this section relating to the powers and 30
duties of the office of the health insurance commissioner. 31
(w) To approve or deny any compensation of employees of health insurers subject to the 32
laws of the State of Rhode Island in excess of one million dollars ($1,000,000) per employee. 33
(x) To approve or deny dividends of stock buybacks of health insurers subject to the laws 34
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of the State of Rhode Island. 1
SECTION 19. Section 44-17-1 of the General Laws in Chapter 44-17 entitled "Taxation of 2
Insurance Companies" is hereby amended to read as follows: 3
44-17-1. Companies required to file — Payment of tax — Retaliatory rates. 4
(a) Every domestic, foreign, or alien insurance company, mutual association, organization, 5
or other insurer, including any health maintenance organization as defined in § 27-41-2, any 6
medical malpractice insurance joint underwriters association as defined in § 42-14.1-1, any 7
nonprofit dental service corporation as defined in § 27-20.1-2 and any nonprofit hospital or medical 8
service corporation as defined in chapters 19 and 20 of title 27, except companies mentioned in § 9
44-17-6 and organizations defined in § 27-25-1, transacting business in this state, shall, on or before 10
April 15 in each year, file with the tax administrator, in the form that he or she may prescribe, a 11
return under oath or affirmation signed by a duly authorized officer or agent of the company, 12
containing information that may be deemed necessary for the determination of the tax imposed by 13
this chapter, and shall at the same time pay an annual tax to the tax administrator of two percent 14
(2%) three percent (3%) of the gross premiums on contracts of insurance and six percent (6%) of 15
all Medicaid payments received by an insurance company, except for ocean marine insurance as 16
referred to in § 44-17-6, covering property and risks within the state, written during the calendar 17
year ending December 31st next preceding. 18
(b) Qualifying insurers for purposes of this section means every domestic, foreign, or alien 19
insurance company, mutual association, organization, or other insurer and excludes: 20
(1) Health maintenance organizations, as defined in § 27-41-2; 21
(2) Nonprofit dental service corporations, as defined in § 27-20.1-2; and 22
(3) Nonprofit hospital or medical service corporations, as defined in §§ 27-19-1 and 27-23
20-1. 24
(c) For tax years 2018 and thereafter, the rate of taxation may be reduced as set forth below 25
and, if so reduced, shall be fully applicable to qualifying insurers instead of the two percent (2%) 26
rate listed in subsection (a). In the case of foreign or alien companies, except as provided in § 27-27
2-17(d), the tax shall not be less in amount than is imposed by the laws of the state or country under 28
which the companies are organized upon like companies incorporated in this state or upon its 29
agents, if doing business to the same extent in the state or country. The tax rate shall not be reduced 30
for gross premiums written on contracts of health insurance as defined in § 42-14-5(c) but shall 31
remain at two percent (2%) three percent (3%) or the appropriate retaliatory tax rate, whichever is 32
higher. 33
(d) For qualifying insurers, the premium tax rate may be decreased based upon Rhode 34
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Island jobs added by the industry as detailed below: 1
(1) A committee shall be established for the purpose of implementing tax rates using the 2
framework established herein. The committee shall be comprised of the following persons or their 3
designees: the secretary of commerce, the director of the department of business regulation, the 4
director of the department of revenue, and the director of the office of management and budget. No 5
rule may be issued pursuant to this section without the prior, unanimous approval of the committee; 6
(2) On the timetable listed below, the committee shall determine whether qualifying 7
insurers have added new qualifying jobs in this state in the preceding calendar year. A qualifying 8
job for purposes of this section is any employee with total annual wages equal to or greater than 9
forty percent (40%) of the average annual wages of the Rhode Island insurance industry, as 10
published by the annual employment and wages report of the Rhode Island department of labor and 11
training, in NAICS code 5241; 12
(3) If the committee determines that there has been a sufficient net increase in qualifying 13
jobs in the preceding calendar year(s) to offset a material reduction in the premium tax, it shall 14
calculate a reduced premium tax rate. Such rate shall be determined via a method selected by the 15
committee and designed such that the estimated personal income tax generated by the increase in 16
qualifying jobs is at least one hundred and twenty-five percent (125%) of the anticipated reduction 17
in premium tax receipts resulting from the new rate. For purposes of this calculation, the committee 18
may consider personal income tax withholdings or receipts, but in no event may the committee 19
include for the purposes of determining revenue neutrality income taxes that are subject to 20
segregation pursuant to § 44-48.3-8(f) or that are otherwise available to the general fund; 21
(4) Any reduced rate established pursuant to this section must be established in a 22
rulemaking proceeding pursuant to chapter 35 of title 42, subject to the following conditions: 23
(i) Any net increase in qualifying jobs and the resultant premium tax reduction and revenue 24
impact shall be determined in any rulemaking proceeding conducted under this section and shall 25
be set forth in a report included in the rulemaking record, which report shall also include a 26
description of the data sources and calculation methods used. The first such report shall also include 27
a calculation of the baseline level of employment of qualifying insurers for the calendar year 2015; 28
and 29
(ii) Notwithstanding any provision of the law to the contrary, no rule changing the tax rate 30
shall take effect until one hundred and twenty (120) days after notice of the rate change is provided 31
to the speaker of the house, the president of the senate, the house and senate fiscal advisors, and 32
the auditor general, which notice shall include the report required under the preceding provision. 33
(5) For each of the first three (3) rulemaking proceedings required under this section, the 34
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tax rate may remain unchanged or be decreased consistent with the requirements of this section, 1
but may not be increased. These first three (3) rulemaking proceedings shall be conducted by the 2
division of taxation and occur in the following manner: 3
(i) The first rulemaking proceeding shall take place in calendar year 2017. This proceeding 4
shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the requirements 5
of this section, which rate shall take effect in 2018, and (B) A method for calculating the number 6
of jobs at qualifying insurers; 7
(ii) The second rulemaking proceeding shall take place in calendar year 2018. This 8
proceeding shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the 9
requirements of this section, which rate shall take effect in 2019, and (B) The changes, if any, to 10
the method for calculating the number of jobs at qualifying insurers; and 11
(iii) The third rulemaking proceeding shall take place in calendar year 2019. This 12
proceeding shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the 13
requirements of this section, which rate shall take effect in 2020, and (B) The changes, if any, to 14
the method for calculating the number of jobs at qualifying insurers. 15
(6) The tax rate established in the regulation following regulatory proceedings that take 16
place in 2019 shall remain in effect through and including 2023. In calendar year 2023, the 17
department of business regulation will conduct a rulemaking proceeding and issue a rule that sets 18
forth: (A) A new premium tax rate, if allowed under the requirements of this section, which rate 19
shall take effect in 2024, and (B) The changes, if any, to the method for calculating the number of 20
jobs at qualifying insurers. A rule issued by the department of business regulation may decrease 21
the tax rate if the requirements for a rate reduction contained in this section are met, or it may 22
increase the tax rate to the extent necessary to achieve the overall revenue level sought when the 23
then-existing tax rate was established. Any rate established shall be no lower than one percent (1%) 24
and no higher than two percent (2%). This proceeding shall be repeated every three (3) calendar 25
years thereafter, however, the base for determination of job increases or decreases shall remain the 26
number of jobs existing during calendar year 2022; 27
(7) No reduction in the premium tax rate pursuant to this section shall be allowed absent a 28
determination that qualifying insurers have added in this state at least three hundred fifty (350) 29
new, full-time, qualifying jobs above the baseline level of employment of qualifying insurers for 30
the calendar year 2015; 31
(8) Notwithstanding any provision of this section to the contrary, the premium tax rate shall 32
never be set lower than one percent (1%); 33
(9) The division of taxation may adopt implementation guidelines, directives, criteria, rules 34
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and regulations pursuant to chapter 35 of title 42 as are necessary to implement this section; and 1
(10) The calculation of revenue impacts under this section is at the sole discretion of the 2
committee established under subsection (d)(1). Notwithstanding any provision of law to the 3
contrary, any administrative action or rule setting a tax rate pursuant to this section or failing or 4
declining to alter a tax rate pursuant to this section shall not be subject to judicial review under 5
chapter 35 of title 42. 6
(d) The department of revenue shall calculate the impacts of changes made to Medicaid 7
taking effect during or after fiscal year two thousand twenty-six (FY2026) on state funds, excluding 8
increased federal reimbursements, hereinafter the "Medicaid adjustment." Should the Medicaid 9
adjustment exceed the revenue impact of raising the gross premiums tax rate from two percent (2%) 10
to three percent (3%), hereinafter the "insurance premium tax rate adjustment revenue bonus," a 11
surtax shall be imposed on gross premiums written on contracts of health insurance as defined in § 12
42-14-5(c) at the rate that shall raise aggregate revenue equal to the Medicaid adjustment minus 13
the insurance premium tax rate adjustment revenue bonus. 14
SECTION 20. Section 44-51-3 of the General Laws in Chapter 44-51 entitled "Nursing 15
Facility Provider Assessment Act" is hereby amended to read as follows: 16
44-51-3. Imposition of assessment — Nursing facilities. 17
(a) For purposes of this section, a “nursing facility” means a person or governmental unit 18
licensed in accordance with chapter 17 of title 23 to establish, maintain, and operate a nursing 19
facility. 20
(b) An assessment is imposed upon the gross patient revenue received by every nursing 21
facility in each month beginning January 1, 2008, at a rate of five and one-half percent (5.5%) six 22
percent (6%) for services provided on or after January 1, 2008. Every provider shall pay the 23
monthly assessment no later than the twenty-fifth (25th) day of each month following the month of 24
receipt of gross patient revenue. 25
(c) The assessment imposed by this section shall be repealed on the effective date of the 26
repeal or a restricted amendment of those provisions of the Medicaid Voluntary Contribution and 27
Provider-Specific Tax Amendments of 1991 (P.L. 102-234) that permit federal financial 28
participation to match state funds generated by taxes. 29
(d) If, after applying the applicable federal law and/or rules, regulations, or standards 30
relating to health care providers, the tax administrator determines that the assessment rate 31
established in subsection (b) of this section exceeds the maximum rate of assessment that federal 32
law will allow without reduction in federal financial participation, then the tax administrator is 33
directed to reduce the assessment to a rate equal to the maximum rate which the federal law will 34
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allow without reduction in federal participation. Provided, however, that the authority of the tax 1
administrator to lower the assessment rate established in subsection (b) of this section shall be 2
limited solely to such determination. 3
(e) In order that the tax administrator may properly carry out his/her responsibilities under 4
this section, the director of the department of human services shall notify the tax administrator of 5
any damages in federal law and/or any rules, regulations, or standards which affect any rates for 6
health care provider assessments. 7
SECTION 21. Title 44 of the General Laws entitled "TAXATION" is hereby amended by 8
adding thereto the following chapter: 9
CHAPTER 72 10
PRIVATE HEALTHCARE PROVIDERS ASSESSMENT ACT 11
44-72-1. Short title. 12
This chapter shall be known and may be cited as the "Private HealthCare Providers 13
Assessment Act." 14
44-72-2. Definitions. 15
Except where the context otherwise requires, the following words and phrases as used in 16
this chapter shall have the following meaning: 17
(1) "Administrator" means the tax administrator. 18
(2) "Assessment" means the assessment imposed upon gross patient revenue pursuant to 19
this chapter. 20
(3) "Eligible provider" means a privately operated healthcare facility, which is eligible for 21
taxation up to six percent (6%) of gross patient revenue pursuant to 42 CFR 433.68. Nursing 22
facilities taxed pursuant to § 44-51-3 and hospital facilities taxed pursuant to § 23-17-38.1 shall not 23
be considered providers subject to taxation under this chapter. 24
(4) "Gross patient revenue" means the gross amount received on a cash basis by the 25
provider from all patient care services. Charitable contributions, donated goods and services, fund 26
raising proceeds, endowment support, income from meals on wheels, income from investments, 27
and other nonpatient revenues defined by the tax administrator upon the recommendation of the 28
department of human services shall not be considered as "gross patient revenue". 29
(5) "Person" means any individual, corporation, company, association, partnership, joint 30
stock association, and the legal successor thereof. 31
44-72-3. Imposition of assessment. 32
(a) An assessment is imposed upon the gross patient revenue received by every eligible 33
provider in each month beginning July 1, 2025, at a rate of six percent (6%) for services provided 34
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on or after July 1, 2025. Every eligible provider shall pay the monthly assessment no later than the 1
twenty-fifth day of each month following the month of receipt of gross patient revenue. 2
(b) The assessment rate established in subsection (a) of this section shall be reduced by the 3
effective rate of any tax subject to the six percent (6%) limit established pursuant to 42 CFR 433.68 4
imposed on the eligible provider in other chapters of the general laws in order that the total 5
aggregate tax shall be at a rate of six percent (6%). 6
(c) If, after applying the applicable federal law and/or rules, regulations, or standards 7
relating to healthcare providers, the tax administrator determines that the assessment rate 8
established in subsection (a) of this section exceeds the maximum rate of assessment that federal 9
law will allow without reduction in federal financial participation, then the tax administrator is 10
directed to reduce the assessment to a rate equal to the maximum rate which the federal law will 11
allow without reduction in federal participation. Provided, however, that the authority of the tax 12
administrator to lower the assessment rate established in subsection (a) of this section shall be 13
limited solely to such determination. In order that the tax administrator may properly carry out 14
his/her responsibilities under this section, the director of the department of human services shall 15
notify the tax administrator of any changes in federal law and/or any rules, regulations, or standards 16
which affect any rates for healthcare provider assessments. 17
44-72-4. Returns. 18
(a) Every eligible provider shall on or before the twenty-fifth day of the month following 19
the month of receipt of gross patient revenue make a return to the tax administrator. 20
(b) The tax administrator shall adopt rules, pursuant to this chapter, relative to the form of 21
the return and the data which it must contain for the correct computation of gross patient revenue 22
and the assessment upon that amount. All returns shall be signed by the eligible provider or by its 23
authorized representative, subject to the pains and penalties of perjury. If a return shows an 24
overpayment of the assessment due, the tax administrator shall refund or credit the overpayment to 25
the eligible provider. 26
(c) For good cause, the tax administrator may extend the time within which an eligible 27
provider is required to file a return, and if the return is filed during the period of extension, no 28
penalty or late filing charge may be imposed for failure to file the return at the time required by this 29
chapter, but the provider may be liable for interest as prescribed in this chapter. Failure to file the 30
return during the period for the extension shall void the extension. 31
44-72-5. Set-off for delinquent assessments. 32
If an eligible provider shall fail to pay an assessment within thirty (30) days of its due date, 33
the tax administrator may request any agency of state government making payments to the eligible 34
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provider to set off the amount of the delinquency against any payment due the provider from the 1
agency of state government and remit the sum to the tax administrator. Upon receipt of the set off 2
request from the tax administrator, any agency of state government is authorized and empowered 3
to set off the amount of the delinquency against any payment or amounts due the eligible provider. 4
The amount of set-off shall be credited against the assessment due from the eligible provider. 5
44-72-6. Assessment on available information -- Interest on delinquencies -- Penalties 6
-- Collection powers. 7
If any eligible provider shall fail to file a return within the time required by this chapter, or 8
shall file an insufficient or incorrect return, or shall not pay the assessment imposed by this chapter 9
when it is due, the tax administrator shall assess upon the information as may be available, which 10
shall be payable upon demand and shall bear interest at the annual rate provided by § 44-1-7 from 11
the date when the assessment should have been paid. If any part of the assessment made is due to 12
negligence or intentional disregard of the provisions of this chapter, a penalty of ten percent (10%) 13
of the amount of the determination shall be added to the assessment. The tax administrator shall 14
collect the assessment with interest in the same manner and with the same powers as are prescribed 15
for collection of taxes in this title. 16
44-72-7. Claims for refund -- Hearing upon denial. 17
(a) Any eligible provider subject to the provisions of this chapter may file a claim for refund 18
with the tax administrator at any time within two (2) years after the assessment has been paid. If 19
the tax administrator shall determine that the assessment has been overpaid, he or she shall make a 20
refund with interest from the date of overpayment. 21
(b) Any eligible provider whose claim for refund has been denied may, within thirty (30) 22
days from the date of the mailing by the tax administrator of the notice of the decision, request a 23
hearing and the tax administrator shall, as soon as practicable, set a time and place for the hearing 24
and shall notify the eligible provider. 25
44-72-8. Hearing by administrator on application. 26
Any eligible provider aggrieved by the action of the tax administrator in determining the 27
amount of any assessment or penalty imposed under the provisions of this chapter may apply to the 28
tax administrator, in writing, within thirty (30) days after the notice of the action is mailed to it, for 29
a hearing relative to the assessment or penalty. The tax administrator shall fix a time and place for 30
the hearing and shall notify the provider. Upon the hearing, the tax administrator shall correct 31
manifest errors, if any, disclosed at the hearing and assess and collect the amount lawfully due 32
together with any penalty or interest. 33
44-72-9. Appeals. 34
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Appeals from administrative orders or decisions made pursuant to any provisions of this 1
chapter shall be to the sixth division district court pursuant to §§ 8-8-24 through 8-8-29. The eligible 2
provider's right to appeal under this section shall be expressly made conditional upon prepayment 3
of all assessments, interest, and penalties unless the provider moves for and is granted an exemption 4
from the prepayment requirement pursuant to § 8-8-26. If the court, after appeal, holds that the 5
eligible provider is entitled to a refund, the eligible provider shall also be paid interest on the amount 6
at the rate provided in § 44-1-7.1. 7
44-72-10. Eligible provider records. 8
Every eligible provider shall: 9
(1) Keep records as may be necessary to determine the amount of its liability under this 10
chapter. 11
(2) Preserve those records for the period of three (3) years following the date of filing of 12
any return required by this chapter, or until any litigation or prosecution under this chapter is finally 13
determined. 14
(3) Make those records available for inspection by the tax administrator or the 15
administrator's authorized agents, upon demand, at reasonable times during regular business hours. 16
44-72-11. Method of payment and deposit of assessment. 17
(a) The payments required by this chapter may be made by electronic transfer of monies to 18
the general treasurer and deposited to the general fund. 19
(b) The general treasurer is authorized to establish an account or accounts and to take all 20
steps necessary to facilitate the electronic transfer of monies. The general treasurer shall provide 21
the tax administrator with a record of any monies transferred and deposited. 22
44-72-12. Rules and regulations. 23
The tax administrator shall make and promulgate rules, regulations, and procedures not 24
inconsistent with state law and fiscal procedures as the tax administrator deems necessary for the 25
proper administration of this chapter and to implement the provisions, policy, and purposes of this 26
chapter. 27
44-72-13. Release of assessment information. 28
Notwithstanding any other provisions of the general laws, the tax administrator shall not 29
be prohibited from providing assessment information to the director of the department of human 30
services or his or her designee, with respect to the assessment imposed by this chapter; provided 31
that, the director of human services and the director's agents and employees may use or disclose 32
that information only for purposes directly connected with the administration of the duties and 33
programs of the department of human services. 34
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44-72-14. Severability. 1
If any provision of this chapter or the application of this chapter to any person or 2
circumstances is held invalid, that invalidity shall not affect other provisions or applications of the 3
chapter which can be given effect without the invalid provision or application, and to this end the 4
provisions of this chapter are declared to be severable. 5
SECTION 22. Relating to Capital Development Programs - Statewide Referendum. 6
Section 1. Proposition to be submitted to the people. -- At the general election to be held 7
on the Tuesday next after the first Monday in November, 2026, there shall be submitted to the 8
people of the State of Rhode Island, for their approval or rejection, the following proposition: 9
"Shall the action of the general assembly, by an act passed at the January 2023 session, 10
authorizing the issuance of a bond, refunding bond, and/or temporary note of the State of Rhode 11
Island for the local capital projects and in the total amount with respect to the projects listed below 12
be approved, and the issuance of a bond, refunding bond, and/or temporary note authorized in 13
accordance with the provisions of said act? 14
Funding 15
The bond, refunding bond and/or temporary note shall be allocated to the Medicaid office 16
for oversight of the funds. 17
Project 18
(1) Group homes, assisted living facilities, and recovery beds $300,000,000 19
Approval of this question will allow the State of Rhode Island to issue general obligation 20
bonds, refunding bonds, and/or temporary notes in an amount not to exceed three hundred million 21
dollars ($300,000,000) for expansion of and investment in Rhode Island Community Living and 22
Supports. One hundred million dollars ($100,000,000) shall be allocated for investment in and 23
expansion of state group homes operated by Rhode Island Community Living and Supports. One 24
hundred million dollars ($100,000,000) shall be allocated for the construction of assisted living-25
level care facilities for people with mental illnesses and developmental disabilities operated by 26
Rhode Island Community Living and Supports for persons who are eligible for Medicaid. One 27
hundred million dollars ($100,000,000) shall be allocated for the construction of inpatient recovery 28
facilities operated by Rhode Island Community Living and Supports for persons who are eligible 29
for Medicaid and suffering from substance abuse issues in need of inpatient recovery services. 30
None of these funds may be allocated to private facilities. 31
(2) Hospital facilities expansion $50,000,000 32
Approval of this question will allow the State of Rhode Island to issue general obligation 33
bonds, refunding bonds, and/or temporary notes in an amount not to exceed fifty million dollars 34
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($50,000,000) for the improvement of state operated hospital facilities. 1
(3) University of Rhode Island Medical School $500,000,000 2
Approval of this question will allow the State of Rhode Island to issue a general obligation 3
bond, refunding bond, and/or temporary note in an amount not to exceed five hundred million 4
dollars ($500,000,000) for the construction of a medical school at the University of Rhode Island. 5
The Medicaid office shall work with the University of Rhode Island Medical School to establish a 6
reasonable annual contribution to fund the debt service on this bond from tuition revenue. While 7
these contributions shall continue until the entire debt service costs are paid, the Medicaid office 8
may allow for an amortization schedule that lasts for up to fifty (50) years." 9
Section 2. Ballot labels and applicability of general election laws. -- The secretary of state 10
shall prepare and deliver to the state board of elections ballot labels for each of the projects provided 11
for in Section 1 hereof with the designations "approve" or "reject" provided next to the description 12
of each such project to enable voters to approve or reject each such proposition. The general 13
election laws, so far as consistent herewith, shall apply to this proposition. 14
Section 3. Approval of projects by people. -- If a majority of the people voting on the 15
proposition in Section 1 hereof shall vote to approve any project stated therein, said project shall 16
be deemed to be approved by the people. The authority to issue bonds, refunding bonds and/or 17
temporary notes of the state shall be limited to the aggregate amount for all such projects as set 18
forth in the proposition, which have been approved by the people. 19
Section 4. Bonds for capital development program. -- The general treasurer is hereby 20
authorized and empowered, with the approval of the governor, and in accordance with the 21
provisions of this act to issue capital development bonds in serial form, in the name of and on behalf 22
of the State of Rhode Island, in amounts as may be specified by the governor in an aggregate 23
principal amount not to exceed the total amount for all projects approved by the people and 24
designated as "capital development loan of 2026 bonds." Provided, however, that the aggregate 25
principal amount of such capital development bonds and of any temporary notes outstanding at any 26
one time issued in anticipation thereof pursuant to Section 7 hereof shall not exceed the total amount 27
for all such projects approved by the people. All provisions in this act relating to "bonds" shall also 28
be deemed to apply to "refunding bonds." 29
Capital development bonds issued under this act shall be in denominations of one thousand 30
dollars ($1,000) each, or multiples thereof, and shall be payable in any coin or currency of the 31
United States which at the time of payment shall be legal tender for public and private debts. 32
These capital development bonds shall bear such date or dates, mature at specified time or 33
times, but not mature beyond the end of the twentieth state fiscal year following the fiscal year in 34
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which they are issued; bear interest payable semi-annually at a specified rate or different or varying 1
rates; be payable at designated time or times at specified place or places; be subject to express terms 2
of redemption or recall, with or without premium; be in a form, with or without interest coupons 3
attached; carry such registration, conversion, reconversion, transfer, debt retirement, acceleration 4
and other provisions as may be fixed by the general treasurer, with the approval of the governor, 5
upon each issue of such capital development bonds at the time of each issue. Whenever the 6
governor shall approve the issuance of such capital development bonds, the governor's approval 7
shall be certified to the secretary of state; the bonds shall be signed by the general treasurer and 8
countersigned by the secretary of state and shall bear the seal of the state. The signature approval 9
of the governor shall be endorsed on each bond. 10
Section 5. Refunding bonds for 2026 capital development program. -- The general treasurer 11
is hereby authorized and empowered, with the approval of the governor, and in accordance with 12
the provisions of this act, to issue bonds to refund the 2026 capital development program bonds, in 13
the name of and on behalf of the state, in amounts as may be specified by the governor in an 14
aggregate principal amount not to exceed the total amount approved by the people, to be designated 15
as "capital development program loan of 2026 refunding bonds" (hereinafter "refunding bonds"). 16
The general treasurer with the approval of the governor shall fix the terms and form of any 17
refunding bonds issued under this act in the same manner as the capital development bonds issued 18
under this act, except that the refunding bonds may not mature more than twenty (20) years from 19
the date of original issue of the capital development bonds being refunded. The proceeds of the 20
refunding bonds, exclusive of any premium and accrual interest and net the underwriters' cost, and 21
cost of bond insurance, shall, upon their receipt, be paid by the general treasurer immediately to 22
the paying agent for the capital development bonds which are to be called and prepaid. The paying 23
agent shall hold the refunding bond proceeds in trust until they are applied to prepay the capital 24
development bonds. While the proceeds are held in trust, the proceeds may be invested for the 25
benefit of the state in obligations of the United States of America or the State of Rhode Island. 26
If the general treasurer shall deposit with the paying agent for the capital development 27
bonds the proceeds of the refunding bonds, or proceeds from other sources, amounts that, when 28
invested in obligations of the United States or the State of Rhode Island, are sufficient to pay all 29
principal, interest, and premium, if any, on the capital development bonds until these bonds are 30
called for prepayment, then such capital development bonds shall not be considered debts of the 31
State of Rhode Island for any purpose starting from the date of deposit of such monies with the 32
paying agent. The refunding bonds shall continue to be a debt of the state until paid. 33
The term "bond" shall include "note," and the term "refunding bonds" shall include 34
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"refunding notes" when used in this act. 1
Section 6. Proceeds of capital development program. -- The general treasurer is directed to 2
deposit the proceeds from the sale of capital development bonds issued under this act, exclusive of 3
premiums and accrued interest and net the underwriters' cost, and cost of bond insurance, in one or 4
more of the depositories in which the funds of the state may be lawfully kept in special accounts 5
(hereinafter cumulatively referred to as "such capital development bond fund") appropriately 6
designated for each of the projects set forth in Section 1 hereof which shall have been approved by 7
the people to be used for the purpose of paying the cost of all such projects so approved. 8
All monies in the capital development bond fund shall be expended for the purposes 9
specified in the proposition provided for in Section 1 hereof under the direction and supervision of 10
the director of administration (hereinafter referred to as "director"). The director, or designee, shall 11
be vested with all power and authority necessary or incidental to the purposes of this act, including, 12
but not limited to, the following authority: 13
(1) To acquire land or other real property or any interest, estate, or right therein as may be 14
necessary or advantageous to accomplish the purposes of this act; 15
(2) To direct payment for the preparation of any reports, plans and specifications, and 16
relocation expenses and other costs such as for furnishings, equipment designing, inspecting, and 17
engineering, required in connection with the implementation of any projects set forth in Section 1 18
hereof; 19
(3) To direct payment for the costs of construction, rehabilitation, enlargement, provision 20
of service utilities, and razing of facilities, and other improvements to land in connection with the 21
implementation of any projects set forth in Section 1 hereof; and 22
(4) To direct payment for the cost of equipment, supplies, devices, materials, and labor for 23
repair, renovation, or conversion of systems and structures as necessary for the 2023 capital 24
development program bonds or notes hereunder from the proceeds thereof. No funds shall be 25
expended in excess of the amount of the capital development bond fund designated for each project 26
authorized in Section 1 hereof. 27
Section 7. Sale of bonds and notes. --Any bonds or notes issued under the authority of this 28
act shall be sold at not less than the principal amount thereof, in such mode and on such terms and 29
conditions as the general treasurer, with the approval of the governor, shall deem to be in the best 30
interests of the state. 31
Any bonds or notes issued under the provisions of this act and coupons on any capital 32
development bonds, if properly executed by the manual or electronic signatures of officers of the 33
state in office on the date of execution, shall be valid and binding according. to their tenor, 34
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notwithstanding that before the delivery thereof and payment therefor, any or all such officers shall 1
for any reason have ceased to hold office. 2
Section 8. Bonds and notes to be tax exempt and general obligations of the state. -- All 3
bonds and notes issued under the authority of this act shall be exempt from taxation in the state and 4
shall be general obligations of the state, and the full faith and credit of the state is hereby pledged 5
for the due payment of the principal and interest on each of such bonds and notes as the same shall 6
become due. 7
Section 9. Investment of monies in fund. -- All monies in the capital development fund not 8
immediately required for payment pursuant to the provisions of this act may be invested by the 9
investment commission, as established by chapter 10 of title 35, entitled "state investment 10
commission," pursuant to the provisions of such chapter; provided, however, that the securities in 11
which the capital development fund is invested shall remain a part of the capital development fund 12
until exchanged for other securities; and provided further, that the income from investments of the 13
capital development fund shall become a part of the general fund of the state and shall be applied 14
to the payment of debt service charges of the state, unless directed by federal law or regulation to 15
be used for some other purpose, or to the extent necessary, to rebate to the United States treasury 16
any income from investments (including gains from the disposition of investments) of proceeds of 17
bonds or notes to the extent deemed necessary to exempt (in whole or in part) the interest paid on 18
such bonds or notes from federal income taxation. 19
Section 10. Appropriation. -- To the extent the debt service on these bonds is not otherwise 20
provided, a sum sufficient to pay the interest and principal due each year on bonds and notes 21
hereunder is hereby annually appropriated out of any money in the treasury not otherwise 22
appropriated. 23
Section 11. Advances from general fund. -- The general treasurer is authorized, with the 24
approval of the director and the governor, in anticipation of the issuance of bonds or notes under 25
the authority of this act, to advance to the capital development bond fund for the purposes specified 26
in Section 1 hereof, any funds of the state not specifically held for any particular purpose; provided, 27
however, that all advances made to the capital development bond fund shall be returned to the 28
general fund from the capital development bond fund forthwith upon the receipt by the capital 29
development fund of proceeds resulting from the issue of bonds or notes to the extent of such 30
advances. 31
Section 12. Federal assistance and private funds. -- In carrying out this act, the director, or 32
designee, is authorized on behalf of the state, with the approval of the governor, to apply for and 33
accept any federal assistance which may become available for the purpose of this act, whether in 34
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the form of a loan or grant or otherwise, to accept the provision of any federal legislation therefor, 1
to enter into, act and carry out contracts in connection therewith, to act as agent for the federal 2
government in connection therewith, or to designate a subordinate so to act. Where federal 3
assistance is made available, the project shall be carried out in accordance with applicable federal 4
law, the rules and regulations thereunder and the contract or contracts providing for federal 5
assistance, notwithstanding any contrary provisions of state law. Subject to the foregoing, any 6
federal funds received for the purposes of this act shall be deposited in the capital development 7
bond fund and expended as a part thereof. The director or designee may also utilize any private 8
funds that may be made available for the purposes of this act. 9
Section 13. Effective Date. -- Sections 1, 2, 3, 10, 11 and 12 of this act shall take effect 10
upon passage. The remaining sections of this act shall take effect when and if the state board of 11
elections shall certify to the secretary of state that a majority of the qualified electors voting on the 12
proposition contained in Section 1 hereof have indicated their approval of all or any projects 13
thereunder. 14
SECTION 22. Rhode Island Medicaid Reform Act of 2008 Joint Resolution. 15
WHEREAS, The General Assembly enacted chapter 12.4 of title 42 entitled "The Rhode 16
Island Medicaid Reform Act of 2008"; and 17
WHEREAS, A legislative enactment is required pursuant to Rhode Island General Laws 18
chapter 12.4 of title 42; and 19
WHEREAS, Rhode Island General Laws § 42-7.2-5(3)(i) provides that the Secretary of the 20
Executive Office of Health and Human Services ("Executive Office") is responsible for the 21
implementation of Medicaid policies; and 22
WHEREAS, In pursuit of a higher quality system of care, the General Assembly grants 23
legislative approval of the following proposals and directs the Secretary to implement them; and 24
WHEREAS, If implementation requires changes to rules, regulations, procedures, the 25
Medicaid state plan, and/or the section 1115 waiver, the General Assembly directs and empowers 26
the Secretary to make said changes; further, adoption of new or amended rules, regulations and 27
procedures may also be required: 28
(a) Raising Nursing Facility Personal Needs Allowance. The Executive Office will raise 29
the personal needs allowance for nursing facility residents to two hundred dollars ($200). 30
(b) Medicare Equivalent Rate. The Executive Office will raise all Medicaid rates, except 31
for hospital rates, dental rates, and outpatient behavioral health rates to equal the Medicare 32
equivalent rate. Specific to early intervention services, a payment of fifty dollars ($50.00) per 33
member per month payment shall be established in addition to these rates, and a floor of fifty 34
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percent (50%) rate increase shall be established within the calculation of the Medicare equivalent 1
rate. 2
(c) Setting Outpatient Behavioral Healthcare Rates at one hundred fifty percent (150%) of 3
Medicare Equivalent Rates. The Executive Office will set outpatient behavioral health rates at one 4
hundred fifty percent (150%) of the Medicare equivalent rate. The Executive Office will maximize 5
federal financial participation if and when available, though state-only funds will be used if federal 6
financial participation is not available. 7
(d) FQHC APM Modernization. The Executive Office will make certain modifications to 8
modernize and standardize the alternative payment methodology option for federally qualified 9
health centers. 10
(e) Hospital Payment Modernization. The Executive Office will make changes to hospital 11
payment rates to modernize payment methodologies to encourage utilization and quality. Inpatient 12
FFS DRG rates will be set at ninety percent (90%) of the Medicare equivalent rate, inpatient non-13
DRG FFS rates will be established at ninety-five percent (95%) of the Medicare equivalent rate, 14
inpatient managed care rates will be set at one hundred five percent (105%) of FFS rates, and 15
outpatient rates will be set at one hundred percent (100%) of Medicare rates. 16
(f) RIteShare Freedom of Choice. The Executive Office will make employee participation 17
in the RIteShare program voluntary. 18
(g) Elderly and Disabled Eligibility Expansion. The Executive Office will expand 19
Medicaid eligibility for elderly and disabled residents to one hundred thirty-three percent (133%) 20
of the federal poverty level. 21
(h) Payments Streamlining. The Executive Office will conduct a multifaceted initiative to 22
begin the phase-out of intermediary payers such as managed care entities, streamlining payments 23
and reducing wasteful expenditures on intermediary payers. 24
(i) Medicaid Office Expansion. The Executive Office will expand Medicaid office staffing 25
to improve administrative capacities. 26
(j) End to Health System Transformation Project. The Executive Office will end the Health 27
System Transformation Project to reduce risk exposure to providers and increase the efficiency of 28
the payments system. 29
(k) Rhode Island Mental Health Nursing Facility. The Executive Office will open a state 30
nursing facility to serve patients with significant mental health needs. 31
(l) Raising Nursing Facility Assessment Rate. The Executive Office will raise the nursing 32
facility assessment rate to six percent (6%). 33
(m) Universal Provider Assessment. Consistent with overall goals of transitioning all 34
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services to a model where rates are at the Medicare equivalent rate, the Executive Office will extend 1
the existing nursing facility assessment model to cover all providers eligible for taxation under 2
federal regulations to help defray the costs of the state component. 3
(n) Dental Optimization. The Executive Office will make an array of changes to dental 4
benefits offered under Medicaid. Rates will be the rates utilized in § 27-18-54; § 27-19-30.1 § 27-5
20-25.2; and § 27-41-27.2; billing will be extended to teledentistry services, Silver Diamine 6
Fluoride (code D1354), and denture billing (codes D5130, D5140, D5221, D5222, D5213, and 7
D5214); the mobile dentistry encounter rate will be raised to the FQHC rate; and a fifty percent 8
(50%) payment shall be established for undeliverable dentures. 9
(o) Transition to State-Level Medicare for All. The Executive Office is empowered to 10
begin the process of negotiating the necessary waivers for a transition to a state-level Medicare for 11
All health care payments system for Rhode Island. These waivers shall include the combining of 12
all federal health care funding streams into the system financing including, but not limited to, 13
Medicaid, Medicare, federal health care tax exemptions, and exchange subsides established 14
pursuant to the U.S. Patient Protection and Affordable Care Act of 2010. The Executive Office 15
plans to begin the transition process after the completion of the raising of the Medicaid system to 16
a Medicare standard of care and the associated stabilization of the Rhode Island health care 17
workforce and provider network; provided, however, that the Executive Office, understanding the 18
complexity of the proposed waiver application, reserves the right to begin the waiver negotiation 19
process before the transition of Medicaid to a Medicare standard is complete. The Executive Office 20
shall only proceed with the waiver and transition should waiver conditions be favorable to the state 21
as a whole, in the judgment of the Executive Office. In the event that a full waiver cannot be 22
complete, and health insurers have been acquired by the Medicaid Office due to insolvency and the 23
Medicaid Office's goal of payer system stabilization, the Executive Office is empowered to seek 24
limited waivers for the streamlining and integration of acquired health insurers with the Medicaid 25
system. The Executive Office shall submit the final approved waiver and transition plan to the 26
general assembly for final approval. 27
Now, therefore, be it: 28
RESOLVED, That the General Assembly hereby approves the proposals stated above in 29
the recitals; and be it further; 30
RESOLVED, That the Secretary of the Executive Office of Health and Human Services is 31
authorized to pursue and implement any waiver amendments, state plan amendments, and/or 32
changes to the applicable department's rules, regulations and procedures approved herein and as 33
authorized by chapter 12.4 of title 42; and be it further; 34
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RESOLVED, That this Joint Resolution shall take effect upon passage. 1
SECTION 23. This act shall take effect upon passage; however, the RICHIP program shall 2
not come into operation until the necessary waivers are obtained, and the final financing proposal 3
is approved by the general assembly. 4
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EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO HEALTH AND SAFETY -- THE RHODE ISLAND COMPREHENS IVE
HEALTH INSURANCE PRO GRAM
***
This act would establish a universal, comprehensive, affordable single-payer health care 1
insurance program and help control health care costs, which would be referred to as, "the Rhode 2
Island Comprehensive Health Insurance Program" (RICHIP). The program would be paid for by 3
consolidating government and private payments to multiple insurance carriers into a more 4
economical and efficient improved Medicare-for-all style single-payer program and substituting 5
lower progressive taxes for higher health insurance premiums, co-pays, deductibles and costs due 6
to caps. This program would save Rhode Islanders from the current overly expensive, inefficient 7
and unsustainable multi-payer health insurance system that unnecessarily prevents access to 8
medically necessary health care. 9
This act would take effect upon passage; however, the RICHIP program would not come 10
into operation until the necessary waivers are obtained, and the final financing proposal is approved 11
by the general assembly. 12
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