Rhode Island 2025 Regular Session

Rhode Island Senate Bill S0346 Compare Versions

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

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5	5	2025 -- S 0346
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7	7	LC000271
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9	9	S T A T E O F R H O D E I S L A N D
10	10	IN GENERAL ASSEMBLY
11	11	JANUARY SESSION, A.D. 2025
12	12	____________
13	13
14	14	A N A C T
15	15	RELATING TO HEALTH AND SAFETY -- THE RHODE ISLAND COMPREH ENSIVE
16	16	HEALTH INSURANCE PRO GRAM
17	17	Introduced By: Senators Bell, Ujifusa, Murray, Valverde, Lawson, DiMario, Mack, Euer,
18	18	Quezada, and Kallman
19	19	Date Introduced: February 21, 2025
20	20	Referred To: Senate Health & Human Services
21	21
22	22
23	23	It is enacted by the General Assembly as follows:
24	24	SECTION 1. Title 23 of the General Laws entitled "HEALTH AND SAFETY" is hereby 1
25	25	amended by adding thereto the following chapter: 2
26	26	CHAPTER 104 3
27	27	THE RHODE ISLAND COMPREHENSIVE HEALTH INSURANCE PROGRAM 4
28	28	23-104-1. Legislative findings. 5
29	29	(1) Health care is a human right, not a commodity available only to those who can afford 6
30	30	it; 7
31	31	(2) Although the federal Affordable Care Act (ACA) allowed states to offer more people 8
32	32	taxpayer subsidized private health insurance, the ACA has not provided universal, comprehensive, 9
33	33	affordable coverage for all Rhode Islanders: 10
34	34	(i) In 2019, about four and three-tenths percent (4.3%) of Rhode Islanders had no health 11
35	35	insurance, causing about forty-three (43) (1 per 1,000 uninsured) unnecessary deaths each year; 12
36	36	(ii) An estimated forty-five percent (45%) of Rhode Islanders are under-insured (e.g., not 13
37	37	seeking health care because of high deductibles and co-pays); 14
38	38	(3) COVID-19 exacerbated and highlighted problems with the status quo health insurance 15
39	39	system including: 16
40	40	(i) Coverage is too easily lost when health insurance is tied to jobs - between February and 17
41	41	May, 2020, about twenty-one thousand (21,000) more Rhode Islanders lost their jobs and their 18
42	42
43	43
44	44	LC000271 - Page 2 of 93
45	45	health insurance; 1
46	46	(ii) Systemic racism is reinforced - Black and Hispanic/Latinx Rhode Islanders, are more 2
47	47	likely to be uninsured or underinsured, have suffered the highest rates of COVID-19 mortality and 3
48	48	morbidity; 4
49	49	(iii) The fear of out-of-pocket costs for uninsured and underinsured puts everyone at risk 5
50	50	because they avoid testing and treatment; 6
51	51	(4) In 2016, sixty million (60,000,000) people separated from their job at some point during 7
52	52	the year (i.e., about forty-two percent (42%) of the American workforce) and although this act may 8
53	53	cause some job loss, on balance, single payer would increase employment in Rhode Island by nearly 9
54	54	three percent (3%); 10
55	55	(5) The existing US health insurance system has failed to control the cost of health care 11
56	56	and to provide universal access to health care in a system which is widely accepted to waste thirty 12
57	57	percent (30%) of its revenues on activities that do not improve the health of Americans; 13
58	58	(6) Every industrialized nation in the world, except the United States, offers universal 14
59	59	health care to its citizens and enjoys better health outcomes for less than two thirds (2/3) to one-15
60	60	half (1/2) the cost; 16
61	61	(7) Health care is rationed under our current multi-payer system, despite the fact that Rhode 17
62	62	Island patients, businesses and taxpayers already pay enough to have comprehensive and universal 18
63	63	health insurance under a single-payer system; 19
64	64	(8) About one-third (1/3) of every "healthcare" dollar spent in the U.S. is wasted on 20
65	65	unnecessary administrative costs and excessive pharmaceutical company profits due to laws 21
66	66	preventing Medicare from negotiating prices and private health insurance companies lacking 22
67	67	adequate market share to effectively negotiate prices; 23
68	68	(9) Private health insurance companies are incentivized to let the cost of health care rise 24
69	69	because higher costs require health insurance companies to charge higher health insurance 25
70	70	premiums, increasing companies' revenue and stock price; 26
71	71	(10) The healthcare marketplace is not an efficient market and because it represents only 27
72	72	eighteen percent (18%) of the US domestic market, significantly restricts economic growth and 28
73	73	thus the financial well-being of every American, including every Rhode Islander; 29
74	74	(11) Rhode Islanders cannot afford to keep the current multi-payer health insurance system: 30
75	75	(i) Between 1991 and 2014, healthcare spending in Rhode Island per person rose by over 31
76	76	two hundred fifty percent (250%) rising much faster than income and greatly reducing disposable 32
77	77	income; 33
78	78	(ii) It is estimated that by 2025, the cost of health insurance for an average family of four 34
79	79
80	80
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82	82	(4) will equal about one-half (1/2) of their annual income; 1
83	83	(iii) In the U.S., about two-thirds (2/3) of personal bankruptcies are medical cost-related 2
84	84	and of these, about three-fourths (3/4) had health insurance at the onset of their medical problems. 3
85	85	In no other industrialized country do people worry about going bankrupt over medical costs; 4
86	86	(12) Rhode Island private businesses bear most of the costs of employee health insurance 5
87	87	coverage and spend significant time and money choosing from a confusing array of increasingly 6
88	88	expensive plans which do not provide comprehensive coverage; 7
89	89	(13) Rhode Island employees and retirees lose significant wages and pensions as they are 8
90	90	forced to pay higher amounts of health insurance and healthcare costs; 9
91	91	(14) Rhode Island's hospitals are under increasing financial distress i.e., closing, sold to 10
92	92	out-of-state entities, attempting mergers largely due to health insurance reimbursement problems 11
93	93	that other nations do not face and are fixed by a single-payer system; 12
94	94	(15) The state and its municipalities face enormous other post-employment benefits 13
95	95	(OPEB) unfunded liabilities due mostly to health insurance costs; 14
96	96	(16) An improved Medicare-for-all style single-payer program would, based on the 15
97	97	performance of existing Medicare, eliminate fifty percent (50%) of the administrative waste in the 16
98	98	current system of private insurance before other savings achieved through meaningful negotiation 17
99	99	of prices and other savings are considered; 18
100	100	(17) The high costs of medical care could be lowered significantly if the state could 19
101	101	negotiate on behalf of all its residents for bulk purchasing, as well as gain access to usage and price 20
102	102	information currently kept confidential by private health insurers as "proprietary information;" 21
103	103	(18) Single payer health care would establish a true "free market" system where doctors 22
104	104	compete for patients rather than health insurance companies dictating which patients are able to see 23
105	105	which doctors and setting reimbursement rates; 24
106	106	(19) Healthcare providers would spend significantly less time with administrative work 25
107	107	caused by multiple health insurance company requirements and barriers to care delivery and would 26
108	108	spend significantly less for overhead costs because of streamlined billing; 27
109	109	(20) Rhode Island must act because there are currently no effective state or federal laws 28
110	110	that can provide universal coverage and adequately control rising premiums, co-pays, deductibles 29
111	111	and medical costs, or prevent private insurance companies from continuing to limit available 30
112	112	providers and coverage; 31
113	113	(21) In 1962, Canada's successful single-payer program began in the province of 32
114	114	Saskatchewan (with approximately the same population as Rhode Island) and became a national 33
115	115	program within ten (10) years; and 34
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119	119	(22) The proposed Rhode Island single payer program was studied by Professor Gerald 1
120	120	Friedman at UMass Amherst in 2015 and he concluded that: 2
121	121	"Single-payer in Rhode Island will finance medical care with substantial savings compared 3
122	122	with the existing multi-payer system of public and private insurers and would improve access to 4
123	123	health care by extending coverage to the four percent (4%) of Rhode Island residents still without 5
124	124	insurance under the Affordable Care Act and expanding coverage for the growing number with 6
125	125	inadequate healthcare coverage. Single-payer would improve the economic health of Rhode Island 7
126	126	by: increasing real disposable income for most residents; reducing the burden of health care on 8
127	127	businesses and promoting increased employment; and shifting the costs of health care away from 9
128	128	working and middle-class residents." 10
129	129	23-104-2. Legislative purpose. 11
130	130	It is the intent of the general assembly that this chapter establish a universal, 12
131	131	comprehensive, affordable single-payer healthcare insurance program that will help control 13
132	132	healthcare costs which shall be referred to as, "the Rhode Island comprehensive health insurance 14
133	133	program" (RICHIP). The program will be paid for by consolidating government and private 15
134	134	payments to multiple insurance carriers into a more economical and efficient improved Medicare- 16
135	135	for-all style single-payer program and substituting lower progressive taxes for higher health 17
136	136	insurance premiums, co-pays, deductibles and costs in excess of caps. This program will save 18
137	137	Rhode Islanders from the current overly expensive, inefficient and unsustainable multi-payer health 19
138	138	insurance system that unnecessarily prevents access to medically necessary health care. The 20
139	139	program will be established after the standard of care funded by Medicaid has been raised to a 21
140	140	Medicare standard. 22
141	141	23-104-3. Definitions. 23
142	142	As used in this chapter: 24
143	143	(1) "Affordable Care Act" or "ACA" means the Federal Patient Protection and Affordable 25
144	144	Care Act (Pub. L. 111-148), as amended by the Federal Health Care and Education Reconciliation 26
145	145	Act of 2010 (Pub. L. 111-152), and any amendments to, or regulations or guidance issued under, 27
146	146	those acts. 28
147	147	(2) "Carrier" means either a private health insurer authorized to sell health insurance in 29
148	148	Rhode Island or a healthcare service plan, i.e., any person who undertakes to arrange for the 30
149	149	provision of healthcare services to subscribers or enrollees, or to pay for or to reimburse any part 31
150	150	of the cost for those services, in return for a prepaid or periodic charge paid by or on behalf of the 32
151	151	subscribers or enrollees, or any person, whether located within or outside of this state, who solicits 33
152	152	or contracts with a subscriber or enrollee in this state to pay for or reimburse any part of the cost 34
153	153
154	154
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156	156	of, or who undertakes to arrange or arranges for, the provision of healthcare services that are to be 1
157	157	provided, wholly or in part, in a foreign country in return for a prepaid or periodic charge paid by 2
158	158	or on behalf of the subscriber or enrollee. 3
159	159	(3) "Dependent" has the same definition as set forth in federal tax law (26 U.S.C. § 152). 4
160	160	(4) "Emergency and urgently needed services" has the same definition as set forth in the 5
161	161	federal Medicare law (42 CFR 422.113). 6
162	162	(5) "Federally matched public health program" means the state's Medicaid program under 7
163	163	Title XIX of the Social Security Act (42 U.S.C. Sec. 1396 et seq.) and the state's Children's Health 8
164	164	Insurance Program (CHIP) under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa et 9
165	165	seq.). 10
166	166	(6) "For-profit provider" means any healthcare professional or healthcare institution that 11
167	167	provides payments, profits or dividends to investors or owners who do not directly provide health 12
168	168	care. 13
169	169	(7) "Health insurance" means any entity subject to the insurance laws and regulations of 14
170	170	this state, or subject to the jurisdiction of the health insurance commissioner, that contracts or offers 15
171	171	to contract, to provide and/or insuring health services on a prepaid basis, including, but not limited 16
172	172	to, policies of accident and sickness insurance, as defined by chapter 18 of title 27, nonprofit 17
173	173	hospital service corporation as defined by chapter 19 of title 27, and nonprofit medical service 18
174	174	corporation as defined in chapter 20 of title 27, a health maintenance organizations, as defined in 19
175	175	chapter 41 of title 27 and also includes a nonprofit dental service corporation, as defined in chapter 20
176	176	20.1 of title 27, all nonprofit optometric service corporations, as defined in chapter 20.2 of title 27, 21
177	177	a domestic insurance company subject to chapter 1 of title 27 that offers or provides health 22
178	178	insurance coverage in the state, and a foreign insurance company, subject to chapter 2 of title 27, 23
179	179	all pharmacy benefit managers (PBMs) that contracts to administer or manage prescription drug 24
180	180	benefits, any plan preempted by ERISA, but subject to state control (specifically state government, 25
181	181	local government, and quasi-public agency ERISA plans). 26
182	182	(8) "Medicaid" or "medical assistance" means a program that is one of the following: 27
183	183	(i) The state's Medicaid program under Title XIX of the Social Security Act (42 U.S.C. 28
184	184	Sec. 1396 et seq.); or 29
185	185	(ii) The state's Children's Health Insurance Program under Title XXI of the Social Security 30
186	186	Act (42 U.S.C. Sec. 1397aa et seq.). 31
187	187	(9) "Medically necessary" means medical, surgical or other services or goods (including 32
188	188	prescription drugs) required for the prevention, diagnosis, cure, or treatment of a health-related 33
189	189	condition including any such services that are necessary to prevent a detrimental change in either 34
190	190
191	191
192	192	LC000271 - Page 6 of 93
193	193	medical or mental health status. Medically necessary services shall be provided in a cost-effective 1
194	194	and appropriate setting and shall not be provided solely for the convenience of the patient or service 2
195	195	provider. "Medically necessary" does not include services or goods that are primarily for cosmetic 3
196	196	purposes; and does not include services or goods that are experimental, unless approved pursuant 4
197	197	to § 23-104-6(b). 5
198	198	(10) "Medicare" means Title XVIII of the Social Security Act (42 U.S.C. Sec. 1395 et seq.) 6
199	199	and the programs thereunder. 7
200	200	(11) "Qualified healthcare provider" means any individual who meets requirements set 8
201	201	forth in § 23-104-7(a)(1). 9
202	202	(12) "Qualified Rhode Island resident" means any individual who is a "resident" as defined 10
203	203	by §§ 44-30-5(a)(1) and (a)(2) or a dependent of that resident. 11
204	204	(13) "Rhode Island comprehensive health insurance program" or ("RICHIP") means the 12
205	205	affordable, comprehensive and effective health insurance program as set forth in this chapter. 13
206	206	(14) "RICHIP participant" means a qualified Rhode Island resident who is enrolled in 14
207	207	RICHIP (and not disenrolled or disqualified) at the time they seek health care. 15
208	208	23-104-4. Rhode Island health insurance program. 16
209	209	(a) Organization. This chapter creates the Rhode Island comprehensive health insurance 17
210	210	program (RICHIP), as an independent state government agency. 18
211	211	(b) Director. A director shall be appointed by the governor, with the advice and consent of 19
212	212	the senate, to lead RICHIP and serve a term of four (4) years, subject to oversight by an executive 20
213	213	board. The director shall be compensated in accordance with the job title and job classification 21
214	214	established by the division of human resources and approved by the general assembly. The duties 22
215	215	of the director shall include: 23
216	216	(1) Employ staff and authorize reasonable expenditures, as necessary, from the RICHIP 24
217	217	trust fund, to pay program expenses and to administer the program, including creation and oversight 25
218	218	of RICHIP budgets; 26
219	219	(2) Oversee management of the RICHIP trust fund set forth in § 23-104-12(a) to ensure the 27
220	220	operational well-being and fiscal solvency of the program, including ensuring that all available 28
221	221	funds from all appropriate sources are collected and placed into the trust fund; 29
222	222	(3) Take any actions necessary and proper to implement the provisions of this chapter; 30
223	223	(4) Implement standardized claims and reporting procedures; 31
224	224	(5) Provide for timely payments to participating providers through a structure that is well 32
225	225	organized and that eliminates unnecessary administrative costs, i.e., coordinate with the state 33
226	226	comptroller to facilitate billing from and payments to providers using the state's computerized 34
227	227
228	228
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230	230	financial system, the Rhode Island financial and accounting network system (RIFANS); 1
231	231	(6) Coordinate with federal healthcare programs, including Medicare and Medicaid, to 2
232	232	obtain necessary waivers and streamline federal funding and reimbursement; 3
233	233	(7) Monitor billing and reimbursements to detect inappropriate behavior by providers and 4
234	234	patients and create prohibitions and penalties regarding bad faith or criminal RICHIP participation, 5
235	235	and procedures by which they will be enforced; 6
236	236	(8) Support the development of an integrated healthcare database for healthcare planning 7
237	237	and quality assurance and ensure the legally required confidentiality of all health records it 8
238	238	contains; 9
239	239	(9) Determine eligibility for RICHIP and establish procedures for enrollment, 10
240	240	disenrollment and disqualification from RICHIP, as well as procedures for handling complaints 11
241	241	and appeals from affected individuals, as set forth in § 29-104-5; 12
242	242	(10) Create RICHIP expenditure, status, and assessment reports, including, but not limited 13
243	243	to, annual reports with the following: 14
244	244	(i) Performance of the program; 15
245	245	(ii) Fiscal condition of the program; 16
246	246	(iii) Recommendations for statutory changes; 17
247	247	(iv) Receipt of payments from the federal government; 18
248	248	(v) Whether current year goals and priorities were met; and 19
249	249	(vi) Future goals and priorities; 20
250	250	(11) Review RICHIP collections and disbursements on at least a quarterly basis and 21
251	251	recommend adjustments needed to achieve budgetary targets and permit adequate access to care; 22
252	252	(12) Develop procedures for accommodating: 23
253	253	(i) Employer retiree health benefits for people who have been members of RICHIP but go 24
254	254	to live as retirees out of the state; 25
255	255	(ii) Employer retiree health benefits for people who earned or accrued those benefits while 26
256	256	residing in the state prior to the implementation of RICHIP and live as retirees out of the state; and 27
257	257	(iii) RICHIP coverage of healthcare services currently covered under the workers' 28
258	258	compensation system, including whether and how to continue funding for those services under that 29
259	259	system and whether and how to incorporate an element of experience rating; and 30
260	260	(13) No later than two (2) years after the effective date of this chapter, develop a proposal, 31
261	261	consistent with the principles of this chapter, for provision and funding by the program of long- 32
262	262	term care coverage. 33
263	263	(c) Board. There shall be a RICHIP board composed of nine (9) members serving terms of 34
264	264
265	265
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267	267	four (4) years. Members shall be appointed by the governor with advice and consent of the senate. 1
268	268	Members of the board shall have no pecuniary interest in any health insurance company or any 2
269	269	business subject to regulation of the board and cannot have previously worked for a health 3
270	270	insurance company. The duties of the board shall include: 4
271	271	(1) Annually establish a RICHIP benefits package for participants, including a formulary 5
272	272	and a list of other medically necessary goods, as well as a procedure for handling complaints and 6
273	273	appeals relating to the benefits package, pursuant to § 23-104-6. 7
274	274	(2) Establish RICHIP provider reimbursement and a procedure for handling provider 8
275	275	complaints and appeals as set forth in § 23-104-9; 9
276	276	(3) Review budget proposals from providers pursuant to § 23-104-11(b); and 10
277	277	(4) The board shall be subject to chapter 46 of title 42 ("open meetings"). 11
278	278	23-104-5. Coverage. 12
279	279	(a) All qualified Rhode Island residents may participate in RICHIP. The director shall 13
280	280	establish procedures to determine eligibility, enrollment, disenrollment and disqualification, 14
281	281	including criteria and procedures by which RICHIP can: 15
282	282	(1) Identify, automatically enroll, and provide a RICHIP card to qualified Rhode Island 16
283	283	residents; 17
284	284	(2) Process applications from individuals seeking to obtain RICHIP coverage for 18
285	285	dependents after the implementation date; 19
286	286	(3) Ensure eligible residents are knowledgeable and aware of their rights to health care; 20
287	287	(4) Determine whether an individual should be disenrolled (e.g., for leaving the state); 21
288	288	(5) Determine whether an individual should be disqualified (e.g., for fraudulent receipt of 22
289	289	benefits or reimbursements); 23
290	290	(6) Determine appropriate actions that should be taken with respect to individuals who are 24
291	291	disenrolled or disqualified (including civil and criminal penalties); and 25
292	292	(7) Permit individuals to request review and appeal decisions to disenroll or disqualify 26
293	293	them. 27
294	294	(b) Medicare and Medicaid eligible coverage under RICHIP shall be as follows: 28
295	295	(1) If all necessary federal waivers are obtained, qualified Rhode Island residents eligible 29
296	296	for federal Medicare ("Medicare eligible residents") shall continue to pay required fees to the 30
297	297	federal government. RICHIP shall establish procedures to ensure that Medicare eligible residents 31
298	298	shall have such amounts deducted from what they owe to RICHIP under § 23-104-12(h). RICHIP 32
299	299	shall become the equivalent of qualifying coverage under Medicare part D and Medicare advantage 33
300	300	programs, and as such shall be the vendor for coverage to RICHIP participants. RICHIP shall 34
301	301
302	302
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304	304	provide Medicare eligible residents benefits equal to those available to all other RICHIP 1
305	305	participants and equal to or greater than those available through the federal Medicare program. To 2
306	306	streamline the process, RICHIP shall seek to receive federal reimbursements for services and goods 3
307	307	to Medicare eligible residents and administer all Medicare funds. 4
308	308	(2) If all necessary federal waivers are obtained, RICHIP shall become the state's sole 5
309	309	Medicaid provider. RICHIP shall create procedures to enroll all qualified Rhode Island residents 6
310	310	eligible for Medicaid ("Medicaid eligible residents") in the federal Medicaid program to ensure a 7
311	311	maximum amount of federal Medicaid funds go to the RICHIP trust fund. RICHIP shall provide 8
312	312	benefits to Medicaid eligible residents equal to those available to all other RICHIP participants. 9
313	313	(3) If all necessary federal waivers are not granted from the Medicaid or Medicare 10
314	314	programs operated under Title XVIII or XIX of the Social Security Act, the Medicaid or Medicare 11
315	315	program for which a waiver is not granted shall act as the primary insurer for those eligible for such 12
316	316	coverage, and RICHIP shall serve as the secondary or supplemental plan of health insurance 13
317	317	coverage. Until such time as a waiver is granted, the plan shall not pay for services for persons 14
318	318	otherwise eligible for the same healthcare benefits under the Medicaid or Medicare program. The 15
319	319	director shall establish procedures for determining amounts owed by Medicare and Medicaid 16
320	320	eligible residents for supplemental RICHIP coverage and the extent of such coverage. 17
321	321	(4) The director may require Rhode Island residents to provide information necessary to 18
322	322	determine whether the resident is eligible for a federally matched public health program or for 19
323	323	Medicare, or any program or benefit under Medicare. 20
324	324	(5) As a condition of eligibility or continued eligibility for healthcare services under 21
325	325	RICHIP, a qualified Rhode Island resident who is eligible for benefits under Medicare shall enroll 22
326	326	in Medicare, including Parts A, B, and D. 23
327	327	(c) Veterans. RICHIP shall serve as the secondary or supplemental plan of health insurance 24
328	328	coverage for military veterans. The director shall establish procedures for determining amounts 25
329	329	owed by military veterans who are qualified residents for such supplemental RICHIP coverage and 26
330	330	the extent of such coverage. 27
331	331	(d) This chapter does not create any employment benefit, nor require, prohibit, or limit the 28
332	332	providing of any employment benefit. 29
333	333	(e) This chapter does not affect or limit collective action or collective bargaining on the 30
334	334	part of a healthcare provider with their employer or any other lawful collective action or collective 31
335	335	bargaining. 32
336	336	23-104-6. Benefits. 33
337	337	(a) This chapter shall provide insurance coverage for services and goods (including 34
338	338
339	339
340	340	LC000271 - Page 10 of 93
341	341	prescription drugs) deemed medically necessary by a qualified healthcare provider and that is 1
342	342	currently covered under: 2
343	343	(1) Services and goods currently covered by the federal Medicare program (Social Security 3
344	344	Act title XVIII) parts A, B and D; 4
345	345	(2) Services and goods covered by Medicaid as of January 1, 2026; 5
346	346	(3) Services and goods currently covered by the state's Children's Health Insurance 6
347	347	Program; 7
348	348	(4) Essential health benefits mandated by the Affordable Care Act; and 8
349	349	(5) Services and goods within the following categories: 9
350	350	(i) Primary and preventive care; 10
351	351	(ii) Approved dietary and nutritional therapies; 11
352	352	(iii) Inpatient care; 12
353	353	(iv) Outpatient care; 13
354	354	(v) Emergency and urgently needed care; 14
355	355	(vi) Prescription drugs and medical devices; 15
356	356	(vii) Laboratory and diagnostic services; 16
357	357	(viii) Palliative care; 17
358	358	(ix) Mental health services; 18
359	359	(x) Oral health, including dental services, periodontics, oral surgery, and endodontics; 19
360	360	(xi) Substance abuse treatment services; 20
361	361	(xii) Physical therapy and chiropractic services; 21
362	362	(xiii) Vision care and vision correction; 22
363	363	(xiv) Hearing services, including coverage of hearing aids; 23
364	364	(xv) Podiatric care; 24
365	365	(xvi) Comprehensive family planning, reproductive, maternity, and newborn care; 25
366	366	(xvii) Short-term rehabilitative services and devices; 26
367	367	(xviii) Durable medical equipment; 27
368	368	(xix) Gender affirming health care; and 28
369	369	(xx) Diagnostic and routine medical testing. 29
370	370	(b) Additional coverage. The director shall create a procedure that may permit additional 30
371	371	medically necessary goods and services beyond that provided by federal laws cited herein and 31
372	372	within the areas set forth in § 23-104-5, if the coverage is for services and goods deemed medically 32
373	373	necessary based on credible scientific evidence published in peer-reviewed medical literature 33
374	374	generally recognized by the relevant medical community, physician specialty society 34
375	375
376	376
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378	378	recommendations, and the views of physicians practicing in relevant clinical areas and any other 1
379	379	relevant factors. The director shall create procedures for handling complaints and appeals 2
380	380	concerning the benefits package. 3
381	381	(c) Restrictions shall not apply. In order for RICHIP participants to be able to receive 4
382	382	medically necessary goods and services, this chapter shall override any state law that restricts the 5
383	383	provision or use of state funds for any medically necessary goods or services, including those 6
384	384	related to family planning and reproductive healthcare. 7
385	385	(d) Medically necessary goods: 8
386	386	(1) Prescription drug formulary: 9
387	387	(i) In general. The director shall establish a prescription drug formulary system, to be 10
388	388	approved by the board, and encourage best-practices in prescribing and discourage the use of 11
389	389	ineffective, dangerous, or excessively costly medications when better alternatives are available. 12
390	390	(ii) Promotion of generics. The formulary under this subsection shall promote the use of 13
391	391	generic medications to the greatest extent possible. 14
392	392	(iii) Formulary updates and petition rights. The formulary under this subsection shall be 15
393	393	updated frequently and the director shall create a procedure for patients and providers to make 16
394	394	requests and appeal denials to add new pharmaceuticals or to remove ineffective or dangerous 17
395	395	medications from the formulary. 18
396	396	(iv) Use of off-formulary medications. The director shall promulgate rules regarding the 19
397	397	use of off-formulary medications which allow for patient access but do not compromise the 20
398	398	formulary. 21
399	399	(v) Approved devices and equipment. The director shall present a list of medically 22
400	400	necessary devices and equipment that shall be covered by RICHIP, subject to final approval by the 23
401	401	board. 24
402	402	(vi) Bulk purchasing. The director shall seek and implement ways to obtain goods at the 25
403	403	lowest possible cost, including bulk purchasing agreements. 26
404	404	23-104-7. Providers. 27
405	405	(a) Rhode Island providers. 28
406	406	(1) Licensing. Participating providers shall meet state licensing requirements in order to 29
407	407	participate in RICHIP. No provider whose license is under suspension or has been revoked shall 30
408	408	participate in the program. 31
409	409	(2) Participation. All providers may participate in RICHIP by providing items on the 32
410	410	RICHIP benefits list for which they are licensed. Providers may elect either to participate fully, or 33
411	411	not at all, in the program. 34
412	412
413	413
414	414	LC000271 - Page 12 of 93
415	415	(3) For-profit providers. For-profit providers may continue to offer services and goods in 1
416	416	Rhode Island, but are prohibited from charging patients more than RICHIP reimbursement rates 2
417	417	for covered services and goods and shall notify qualified Rhode Island residents when the services 3
418	418	and goods they offer will not be reimbursed fully under RICHIP. 4
419	419	(b) Out-of-state providers. Except for emergency and urgently needed service, as set forth 5
420	420	in § 23-104-7(d), RICHIP shall not pay for healthcare services obtained outside of Rhode Island 6
421	421	unless the following requirements are met: 7
422	422	(1) The out-of-state provider agrees to accept the RICHIP rate for out-of-state providers; 8
423	423	and 9
424	424	(2) The services are medically necessary care. 10
425	425	(c) Out-of-state provider reimbursement. The program shall pay out-of-state healthcare 11
426	426	providers at a rate equal to the average rate paid by commercial insurers or Medicare for the services 12
427	427	rendered, whichever is higher. 13
428	428	(d) Out-of-state residents. 14
429	429	(1) In general. Rhode Island providers who provide any services to individuals who are not 15
430	430	RICHIP participants shall not be reimbursed by RICHIP and shall seek reimbursement from those 16
431	431	individuals or other sources. 17
432	432	(2) Emergency care exception. Nothing in this chapter shall prevent any individual from 18
433	433	receiving or any provider from providing emergency healthcare services and goods in Rhode 19
434	434	Island. The director shall adopt rules to provide reimbursement; however, the rules shall reasonably 20
435	435	limit reimbursement to protect the fiscal integrity of RICHIP. The director shall implement 21
436	436	procedures to secure reimbursement from any appropriate third-party funding source or from the 22
437	437	individual to whom the emergency services were rendered. 23
438	438	23-104-8. Cross border employees. 24
439	439	(a) State residents employed out-of-state. If an individual is employed out-of-state by an 25
440	440	employer that is subject to Rhode Island state law, the employer and employee shall be required to 26
441	441	pay the payroll taxes as to that employee as if the employment were in the state. If an individual is 27
442	442	employed out-of-state by an employer that is not subject to Rhode Island state law, the employee 28
443	443	health coverage provided by the out-of-state employer to a resident working out-of-state shall serve 29
444	444	as the employee's primary plan of health coverage, and RICHIP shall serve as the employee's 30
445	445	secondary plan of health coverage. The director shall establish procedures for determining amounts 31
446	446	owed by residents employed out-of-state for such supplemental secondary RICHIP coverage and 32
447	447	the extent of such coverage. 33
448	448	(b) Out-of-state residents employed in the state. The payroll tax set forth in § 23-104-12(i) 34
449	449
450	450
451	451	LC000271 - Page 13 of 93
452	452	shall apply to any out-of-state resident who is employed or self-employed in the state. However, 1
453	453	such out-of-state residents shall be able to take a credit for amounts they spend on health benefits 2
454	454	for themselves that would otherwise be covered by RICHIP if the individual were a RICHIP 3
455	455	participant. The out-of-state resident's employer shall be able to take a credit against such payroll 4
456	456	taxes regardless of the form of the health benefit (e.g., health insurance, a self-insured plan, direct 5
457	457	services, or reimbursement for services), to ensure that the revenue proposal does not relate to 6
458	458	employment benefits in violation of the Federal Employee Retirement Income Security Act 7
459	459	("ERISA") law. For non-employment-based spending by individuals, the credit shall be available 8
460	460	for and limited to spending for health coverage (not out-of-pocket health spending). The credit shall 9
461	461	be available without regard to how little is spent or how sparse the benefit. The credit may only be 10
462	462	taken against the payroll taxes set forth in § 23-104-12(i). Any excess amount may not be applied 11
463	463	to other tax liability. For employment-based health benefits, the credit shall be distributed between 12
464	464	the employer and employee in the same proportion as the spending by each for the benefit. The 13
465	465	employer and employee may each apply their respective portion of the credit to their respective 14
466	466	portion of the payroll taxes set forth in § 23-104-12(i). If any provision of this clause or any 15
467	467	application of it shall be ruled to violate ERISA, the provision or the application of it shall be null 16
468	468	and void and the ruling shall not affect any other provision or application of this section or this 17
469	469	chapter. 18
470	470	23-104-9. Provider reimbursement. 19
471	471	(a) Rates for services and goods. RICHIP reimbursement rates to providers shall be 20
472	472	determined by the RICHIP board. These rates shall be equal to or greater than the federal Medicare 21
473	473	rates available to Rhode Island qualified residents that are in effect at the time services and goods 22
474	474	are provided. For outpatient behavioral health services, the minimum rate shall equal one hundred 23
475	475	fifty percent (150%) of federal Medicare rates. If the director determines that there are no such 24
476	476	federal Medicare reimbursement rates, the director shall set the minimum rate. The director shall 25
477	477	review the rates at least annually, recommend changes to the board, and establish procedures by 26
478	478	which complaints about reimbursement rates may be reviewed by the board. 27
479	479	(b) Billing and payments. Providers shall submit billing for services to RICHIP participants 28
480	480	in the form of electronic invoices entered into RIFANS, the state's computerized financial system. 29
481	481	The director shall coordinate the manner of processing and payment with the office of accounts and 30
482	482	control and the RIFANS support team within the division of information technology. Payments 31
483	483	shall be made by check or electronic funds transfer in accordance with terms and procedures 32
484	484	coordinated by the director and the office of accounts and control and consistent with the fiduciary 33
485	485	management of the RICHIP trust fund. 34
486	486
487	487
488	488	LC000271 - Page 14 of 93
489	489	(c) Provider restrictions. In-state providers who accept any payment from RICHIP shall 1
490	490	not bill any patient for any covered benefit. In-state providers cannot use any of their operating 2
491	491	budgets for expansion, profit, excessive executive income, including bonuses, marketing, or major 3
492	492	capital purchases or leases. 4
493	493	23-104-10. Private insurance companies. 5
494	494	(a) Non-duplication. It is unlawful for a private health insurer to sell health insurance 6
495	495	coverage to qualified Rhode Island residents that duplicates the benefits provided under this 7
496	496	chapter. Nothing in this chapter shall be construed as prohibiting the sale of health insurance 8
497	497	coverage for any additional benefits not covered by this chapter, including additional benefits that 9
498	498	an employer may provide to employees or their dependents, or to former employees or their 10
499	499	dependents (e.g., multiemployer plans can continue to provide wrap-around coverage for any 11
500	500	benefits not provided by RICHIP). 12
501	501	(b) Displaced employees. Re-education and job placement of persons employed in Rhode 13
502	502	Island-located enterprises who have lost their jobs as a result of this chapter shall be managed by 14
503	503	the Rhode Island department of labor and training or an appropriate federal retraining program. The 15
504	504	director may provide funds from RICHIP or funds otherwise appropriated for this purpose for 16
505	505	retraining and assisting job transition for individuals employed or previously employed in the fields 17
506	506	of health insurance, healthcare service plans, and other third-party payments for health care or those 18
507	507	individuals providing services to healthcare providers to deal with third-party payers for health 19
508	508	care, whose jobs may be or have been ended as a result of the implementation of the program, 20
509	509	consistent with applicable laws. 21
510	510	23-104-11. Budgeting. 22
511	511	(a) Operating budget. Annually, the director shall create an operating budget for the 23
512	512	program that includes the costs for all benefits set forth in § 23-104-5 and the costs for RICHIP 24
513	513	administration. The director shall determine appropriate reimbursement rates for benefits pursuant 25
514	514	to § 23-104-9(a). The operating budget shall be approved by the executive board prior to 26
515	515	submission to the governor and general assembly. 27
516	516	(b) Capital expenditures. The director shall work with representatives from state entities 28
517	517	involved with provider capital expenditures (e.g., the Rhode Island department of administration 29
518	518	office of capital projects, the Rhode Island health and educational building corporation, etc.), and 30
519	519	providers to help ensure that capital expenditures proposed by providers, including amounts to be 31
520	520	spent on construction and renovation of health facilities and major equipment purchases, will 32
521	521	address healthcare needs of RICHIP participants. To the extent that providers are seeking to use 33
522	522	RICHIP funds for capital expenditures, the director shall have the authority to approve or deny such 34
523	523
524	524
525	525	LC000271 - Page 15 of 93
526	526	expenditures. 1
527	527	(c) Prohibition against co-mingling operations and capital improvement funds. It is 2
528	528	prohibited to use funds under this chapter that are earmarked: 3
529	529	(1) For operations for capital expenditures; or 4
530	530	(2) For capital expenditures for operations. 5
531	531	23-104-12. Financing. 6
532	532	(a) RICHIP trust fund. There shall be established a RICHIP trust fund into which funds 7
533	533	collected pursuant to this chapter are deposited and from which funds are distributed. All money 8
534	534	collected and received shall be used exclusively to finance RICHIP. The governor or general 9
535	535	assembly may provide funds to the RICHIP trust fund, but may not remove or borrow funds from 10
536	536	the RICHIP trust fund. 11
537	537	(b) Revenue proposal. After approval of the RICHIP executive board, the director shall 12
538	538	submit to the governor and the general assembly a revenue plan and, if required, legislation 13
539	539	(referred to collectively in this section as the "revenue proposal") to provide the revenue necessary 14
540	540	to finance RICHIP. The initial revenue proposal shall be submitted once waiver negotiations have 15
541	541	proceeded to a level deemed sufficient by the director and annually, thereafter. The basic structure 16
542	542	of the initial revenue proposal will be based on a consideration of: 17
543	543	(1) Anticipated savings from a single payer program; 18
544	544	(2) Government funds available for health care; 19
545	545	(3) Private funds available for health care; and 20
546	546	(4) Replacing current regressive health insurance payments made to multiple health 21
547	547	insurance carriers with progressive contributions to a single payer (RICHIP) in order to make 22
548	548	healthcare insurance affordable and remove unnecessary barriers to healthcare access. 23
549	549	Subsequent proposals shall adjust the RICHIP contributions, based on projections from the 24
550	550	total RICHIP costs in the previous year, and shall include a five (5) year plan for adjusting RICHIP 25
551	551	contributions to best meet the goals set forth in this section and § 23-104-2. 26
552	552	(c) Anticipated savings. It is anticipated that RICHIP will lower healthcare costs by: 27
553	553	(1) Eliminating payments to private health insurance carriers; 28
554	554	(2) Reducing paperwork and administrative expenses for both providers and payers created 29
555	555	by the marketing, sales, eligibility checks, network contract management, issues associated 30
556	556	multiple benefit packages, and other administrative waste associated with the current multi-payer 31
557	557	private health insurance system; 32
558	558	(3) Allowing the planning and delivery of a public health strategy for the entire population 33
559	559	of Rhode Island; 34
560	560
561	561
562	562	LC000271 - Page 16 of 93
563	563	(4) Improving access to preventive healthcare; and 1
564	564	(5) Negotiating on behalf of the state for bulk purchasing of medical supplies and 2
565	565	pharmaceuticals. 3
566	566	(d) Federal funds. The executive office of health and human services, in collaboration with 4
567	567	the director, the board and the Medicaid office, shall seek and obtain waivers and other approvals 5
568	568	relating to Medicaid, the Children's Health Insurance Program, Medicare, federal tax exemptions 6
569	569	for health care, the ACA, and any other relevant federal programs in order that: 7
570	570	(1) Federal funds and other subsidies for health care that would otherwise be paid to the 8
571	571	state and its residents and healthcare providers, would be paid by the federal government to the 9
572	572	state and deposited into the RICHIP trust fund; 10
573	573	(2) Programs would be waived and such funding from federal programs in Rhode Island 11
574	574	would be replaced or merged into RICHIP in order that it can operate as a single payer program; 12
575	575	(3) Maximum federal funding for health care is sought even if any necessary waivers or 13
576	576	approvals are not obtained and multiple sources of funding with RICHIP trust fund monies are 14
577	577	pooled, in order that RICHIP can act as much as possible like a single payer program to maximize 15
578	578	benefits to Rhode Islanders; and 16
579	579	(4) Federal financial participation in the programs that are incorporated into RICHIP are 17
580	580	not jeopardized. 18
581	581	(e) State funds. State funds that would otherwise be appropriated to any governmental 19
582	582	agency, office, program, instrumentality, or institution for services and benefits covered under 20
583	583	RICHIP shall be directed into the RICHIP trust fund. Payments to the fund pursuant to this section 21
584	584	shall be in an amount equal to the money appropriated for those purposes in the fiscal year 22
585	585	beginning immediately preceding the effective date of this chapter. 23
586	586	(f) Private funds. Private grants (e.g., from nonprofit corporations) and other funds 24
587	587	specifically ear-marked for health care (e.g., from litigation against tobacco companies, opioid 25
588	588	manufacturers, etc.), shall also be put into the RICHIP trust fund. 26
589	589	(g) Assignments from RICHIP participants. Receipt of healthcare services under the plan 27
590	590	shall be deemed an assignment by the RICHIP participant of any right to payment for services from 28
591	591	a policy of insurance, a health benefit plan or other source. The other source of healthcare benefits 29
592	592	shall pay to the fund all amounts it is obligated to pay to, or on behalf of, the RICHIP participant 30
593	593	for covered healthcare services. The director may commence any action necessary to recover the 31
594	594	amounts due. 32
595	595	(h) Replacing current health insurance payments with progressive contributions. Instead of 33
596	596	making health insurance payments to multiple carriers (i.e., for premiums, co-pays deductibles, and 34
597	597
598	598
599	599	LC000271 - Page 17 of 93
600	600	costs in excess of caps) for limited coverage, individuals and entities subject to Rhode Island 1
601	601	taxation pursuant to § 44-30-1 shall pay progressive contributions to the RICHIP trust fund 2
602	602	(referred to collectively in this section as the "RICHIP contributions") for comprehensive coverage. 3
603	603	These RICHIP contributions shall be set and adjusted over time to an appropriate level to: 4
604	604	(1) Cover the actual cost of the program; 5
605	605	(2) Ensure that higher brackets of income subject to specified taxes shall be assessed at a 6
606	606	higher marginal rate than lower brackets; and 7
607	607	(3) Protect the economic welfare of small businesses, low-income earners and working 8
608	608	families through tax credits or exemptions. 9
609	609	(i) Contributions based on earned income. The amounts currently paid by employers and 10
610	610	employees for health insurance shall initially be replaced by a ten percent (10%) payroll tax, based 11
611	611	on the projected average payroll of employees over three (3) previous calendar years. The employer 12
612	612	shall pay eighty percent (80%) and the employee shall pay twenty percent (20%) of this payroll 13
613	613	tax, except that an employer may agree to pay all or part of the employee's share. Self- employed 14
614	614	individuals shall initially pay one-hundred percent (100%) of the payroll tax. The ten percent (10%) 15
615	615	initial rate will be adjusted by the director in order that higher brackets of income subject to these 16
616	616	taxes shall be assessed at a higher marginal rate than lower brackets and in order that small 17
617	617	businesses and lower income earners receive a credit or exemption. 18
618	618	(j) Contributions based on unearned income. There shall be a progressive contribution 19
619	619	based on unearned income, i.e., capital gains, dividends, interest, profits, and rents. Initially, the 20
620	620	unearned income RICHIP contributions shall be equal to ten percent (10%) of such unearned 21
621	621	income. The ten percent (10%) initial rate may be adjusted by the director to allow for a graduated 22
622	622	progressive exemption or credit for individuals with lower unearned income levels. 23
623	623	23-104-13. Implementation. 24
624	624	(a) State laws and regulations. 25
625	625	(1) In general. The director shall work with the executive board and receive such assistance 26
626	626	as may be necessary from other state agencies and entities to examine state laws and regulations 27
627	627	and to make recommendations necessary to conform such laws and regulations to properly 28
628	628	implement the RICHIP program. The director shall report recommendations to the governor and 29
629	629	the general assembly. 30
630	630	(2) Anti-trust laws. The intent of this chapter is to exempt activities provided for under this 31
631	631	chapter from state antitrust laws and to provide immunity from federal antitrust laws through the 32
632	632	state action doctrine. 33
633	633	(b) The director shall complete an implementation plan to provide healthcare coverage for 34
634	634
635	635
636	636	LC000271 - Page 18 of 93
637	637	qualified residents in accordance with this chapter within twelve (12) months of its effective date. 1
638	638	(c) The executive office of health and human services, in collaboration with the director, 2
639	639	the board, and the Medicaid director, will have the initial responsibility of negotiating the waivers. 3
640	640	(d) Severability. If any provision or application of this chapter shall be held to be invalid, 4
641	641	or to violate or be inconsistent with any applicable federal law or regulation, that shall not affect 5
642	642	other provisions or applications of this chapter which can be given effect without that provision or 6
643	643	application; and to that end, the provisions and applications of this chapter are severable. 7
644	644	SECTION 2. Chapter 22-11 of the General Laws entitled "Joint Committee on Legislative 8
645	645	Services" is hereby amended by adding thereto the following section: 9
646	646	22-11-4.1. Employees needed to maximize federal Medicaid funding. 10
647	647	The joint committee on legislative services shall fund five (5) new FTEs for the senate 11
648	648	fiscal office and five (5) new FTEs for the house fiscal office exclusively devoted to finding ways 12
649	649	to maximize federal Medicaid funding, including compiling proposals for expanding eligibility to 13
650	650	maximize the eligibility allowed by Centers for Medicare & Medicaid Services (CMS). 14
651	651	SECTION 3. Section 27-34.3-7 of the General Laws in Chapter 27-34.3 entitled "Rhode 15
652	652	Island Life and Health Insurance Guaranty Association Act" is hereby amended to read as follows: 16
653	653	27-34.3-7. Board of directors. 17
654	654	(a) The board of directors of the association shall consist of: 18
655	655	(1) Not less than five (5) nor more than nine (9) member insurers serving terms as 19
656	656	established in the plan of operation Nine (9) members appointed by the governor with advice and 20
657	657	consent of the senate; and 21
658	658	(2) The commissioner or the commissioner’s designee, who shall chair the board in a non-22
659	659	voting ex officio capacity. Only member insurers shall be eligible to vote. The members of the 23
660	660	board shall be selected by member insurers subject to the approval of the commissioner. The board 24
661	661	of directors, previously established under § 27-34.1-8 [repealed], shall continue to operate in 25
662	662	accordance with the provision of this section. Vacancies on the board shall be filled for the 26
663	663	remaining period of the term by a majority vote of the remaining board members, subject to the 27
664	664	approval of the commissioner. 28
665	665	(b) In approving selections to the board, the commissioner shall consider, among other 29
666	666	things, whether all member insurers are fairly represented. 30
667	667	(c) Members of the board may be reimbursed from the assets of the association for expenses 31
668	668	incurred by them as members of the board of directors but members of the board shall not be 32
669	669	compensated by the association for their services. 33
670	670	SECTION 4. Section 27-66-24 of the General Laws in Chapter 27-66 entitled "The Health 34
671	671
672	672
673	673	LC000271 - Page 19 of 93
674	674	Insurance Conversions Act" is hereby amended to read as follows: 1
675	675	27-66-24. Exceptions — Rehabilitation, liquidation, or conservation. 2
676	676	No proposed conversion shall be subject to this chapter in In the event that the a health 3
677	677	insurance corporation, health maintenance corporation, a nonprofit hospital service corporation, 4
678	678	nonprofit medical service corporation, pharmacy benefit manager, nonprofit dental service 5
679	679	corporation, managed care organization, nonprofit optometric service corporation, or affiliate or 6
680	680	subsidiary of them, hereinafter "the insurer," is subject to an order from the superior court directing 7
681	681	the director to rehabilitate, liquidate, or conserve, as provided in §§ 27-19-28, 27-20-24, 27-41-18, 8
682	682	or chapter 14.1, 14.2, 14.3, or 14.4 of this title., certain additional conditions shall apply to the 9
683	683	insurer: 10
684	684	(1) The insolvency, financial condition, or default of the insurer at any time shall not permit 11
685	685	the insurer to fail to pay claims in a timely manner. 12
686	686	(2) Should the insurer fail to pay claims in a timely manner, those claims shall become a 13
687	687	temporary obligation of the state, who shall pay them in a timely manner. Should the state be 14
688	688	compelled to pay claims for this reason, the insurer shall owe the state a fine ten (10) times the 15
689	689	value of all claims paid. 16
690	690	(3) The insolvency, financial condition, or default of the insurer at any time shall not permit 17
691	691	the insurer to fail to pay state taxes on time. Should the insurer fail to pay taxes on time, the size of 18
692	692	the tax obligation owed shall increase by a factor of ten (10). 19
693	693	(4) The Medicaid office shall be guaranteed a right of first refusal to acquire the insurer 20
694	694	before alternate buyers are considered. Any obligations due to the state by the insurer shall be 21
695	695	counted towards the purchase price of the insurer. The Rhode Island life and health insurance 22
696	696	guaranty association, created pursuant to § 27-34.3-6, shall pay the costs of the acquisition, but all 23
697	697	ownership shares shall be held by the Medicaid office. 24
698	698	SECTION 5. Title 27 of the General Laws entitled "INSURANCE" is hereby amended by 25
699	699	adding thereto the following chapter: 26
700	700	CHAPTER 83 27
701	701	PRIOR AUTHORIZATION OF CERTAIN HEALTH INSURANCE POLICY CHANGES 28
702	702	27-83-1. Definitions. 29
703	703	For purposes of this chapter: 30
704	704	"Health insurer" means any entity subject to the insurance laws and regulations of this state, 31
705	705	or subject to the jurisdiction of the health insurance commissioner, that contracts or offers to 32
706	706	contract, to provide and/or insuring health services on a prepaid basis, including, but not limited to, 33
707	707	policies of accident and sickness insurance subject to chapter 18 of title 27; any nonprofit hospital 34
708	708
709	709
710	710	LC000271 - Page 20 of 93
711	711	service corporation subject to chapter 19 of title 27; any nonprofit medical service corporation 1
712	712	subject to chapter 20 of title 27; any health maintenance organization subject to chapter 41 of title 2
713	713	27; any nonprofit dental service corporation subject to chapter 20.1 of title 27; any nonprofit 3
714	714	optometric service corporation subject to chapter 20.2 of title 27; any pharmacy benefit manager; 4
715	715	or any health benefit plan issued by the State of Rhode Island, a municipality, a quasi-public 5
716	716	agency, or any other political subdivision of the State of Rhode Island to cover employees. 6
717	717	27-83-2. Prior authorization of general assembly. 7
718	718	(a) Prior authorization of the general assembly shall be required for certain policy changes 8
719	719	by health insurers: 9
720	720	(1) Any change that increases the average amount charged annually to consumers on a per 10
721	721	beneficiary basis; 11
722	722	(2) Any change that in any way reduces any benefits offered to plan beneficiaries; 12
723	723	(3) Any change that increases any premiums, deductibles, or copays; 13
724	724	(4) Ceasing offering any plan a health insurer offers within the State of Rhode Island; or 14
725	725	(5) Any other change that the health insurance commissioner or attorney general shall, 15
726	726	through regulation, determine to require prior authorization of the general assembly. 16
727	727	(b) No rate reviews pursuant to those utilized in §§ 27-18-54, 27-19-30.1, 27-20-25.2, 27-17
728	728	41-27.2, and 42-62-13 shall be construed to exempt any health insurer from the prior authorization 18
729	729	requirements of this chapter. 19
730	730	SECTION 6. Section 28-57-5 of the General Laws in Chapter 28-57 entitled "Healthy and 20
731	731	Safe Families and Workplaces Act" is hereby amended to read as follows: 21
732	732	28-57-5. Accrual of paid sick and safe leave time. 22
733	733	(a) All employees employed by an employer of eighteen (18) or more employees in Rhode 23
734	734	Island shall accrue a minimum of one hour of paid sick and safe leave time for every thirty five 24
735	735	(35) hours worked up to a maximum of twenty-four (24) hours during calendar year 2018, thirty-25
736	736	two (32) hours during calendar year 2019, and up to a maximum of forty (40) hours per year from 26
737	737	calendar year 2020 through calendar year 2026, and one hundred sixty (160) hours per year 27
738	738	thereafter, unless the employer chooses to provide a higher annual limit in both accrual and use. In 28
739	739	determining the number of employees who are employed by an employer for compensation, all 29
740	740	employees defined in § 28-57-3(7) shall be counted. 30
741	741	(b) Employees who are exempt from the overtime requirements under 29 U.S.C. § 31
742	742	213(a)(1) of the federal Fair Labor Standards Act, 29 U.S.C. § 201 et seq., will be assumed to work 32
743	743	forty (40) hours in each workweek for purposes of paid sick and safe leave time accrual unless their 33
744	744	normal workweek is less than forty (40) hours, in which case paid sick and safe leave time accrues 34
745	745
746	746
747	747	LC000271 - Page 21 of 93
748	748	based upon that normal workweek. 1
749	749	(c) Paid sick and safe leave time as provided in this chapter shall begin to accrue at the 2
750	750	commencement of employment or pursuant to the law’s effective date [July 1, 2018], whichever is 3
751	751	later. An employer may provide all paid sick and safe leave time that an employee is expected to 4
752	752	accrue in a year at the beginning of the year. 5
753	753	(d) An employer may require a waiting period for newly hired employees of up to ninety 6
754	754	(90) days. During this waiting period, an employee shall accrue earned sick time pursuant to this 7
755	755	section or the employer’s policy, if exempt under § 28-57-4(b), but shall not be permitted to use 8
756	756	the earned sick time until after he or she has completed the waiting period. 9
757	757	(e) Paid sick and safe leave time shall be carried over to the following calendar year; 10
758	758	however, an employee’s use of paid sick and safe leave time provided under this chapter in each 11
759	759	calendar year shall not exceed twenty-four (24) hours during calendar year 2018, and thirty-two 12
760	760	(32) hours during calendar year 2019, and forty (40) hours per year thereafter. Alternatively, in lieu 13
761	761	of carryover of unused earned paid sick and safe leave time from one year to the next, an employer 14
762	762	may pay an employee for unused earned paid sick and safe leave time at the end of a year and 15
763	763	provide the employee with an amount of paid sick and safe leave that meets or exceeds the 16
764	764	requirements of this chapter that is available for the employee’s immediate use at the beginning of 17
765	765	the subsequent year. 18
766	766	(f) Nothing in this chapter shall be construed as requiring financial or other reimbursement 19
767	767	to an employee from an employer upon the employee’s termination, resignation, retirement, or 20
768	768	other separation from employment for accrued paid sick and safe leave time that has not been used. 21
769	769	(g) If an employee is transferred to a separate division, entity, or location within the state, 22
770	770	but remains employed by the same employer as defined in 29 C.F.R. § 791.2 of the federal Fair 23
771	771	Labor Standards Act, 29 U.S.C. § 201 et seq., the employee is entitled to all paid sick and safe leave 24
772	772	time accrued at the prior division, entity, or location and is entitled to use all paid sick and safe 25
773	773	leave time as provided in this act. When there is a separation from employment and the employee 26
774	774	is rehired within one hundred thirty-five (135) days of separation by the same employer, previously 27
775	775	accrued paid sick and safe leave time that had not been used shall be reinstated. Further, the 28
776	776	employee shall be entitled to use accrued paid sick and safe leave time and accrue additional sick 29
777	777	and safe leave time at the re-commencement of employment. 30
778	778	(h) When a different employer succeeds or takes the place of an existing employer, all 31
779	779	employees of the original employer who remain employed by the successor employer within the 32
780	780	state are entitled to all earned paid sick and safe leave time they accrued when employed by the 33
781	781	original employer, and are entitled to use earned paid sick and safe leave time previously accrued. 34
782	782
783	783
784	784	LC000271 - Page 22 of 93
785	785	(i) At its discretion, an employer may loan sick and safe leave time to an employee in 1
786	786	advance of accrual by such employee. 2
787	787	(j) Temporary employees shall be entitled to use accrued paid sick and safe leave time 3
788	788	beginning on the one hundred eightieth (180) calendar day following commencement of their 4
789	789	employment, unless otherwise permitted by the employer. On and after the one hundred eightieth 5
790	790	(180) calendar day of employment, employees may use paid sick and safe leave time as it is 6
791	791	accrued. During this waiting period, an employee shall accrue earned sick time pursuant to this 7
792	792	chapter, but shall not be permitted to use the earned sick time until after he or she has completed 8
793	793	the waiting period. 9
794	794	(k) Seasonal employees shall be entitled to use accrued paid sick and safe leave time 10
795	795	beginning on the one hundred fiftieth (150) calendar day following commencement of their 11
796	796	employment, unless otherwise permitted by the employer. On and after the one hundred fiftieth 12
797	797	(150) calendar day of employment, employees may use paid sick and safe leave time as it is 13
798	798	accrued. During this waiting period, an employee shall accrue earned sick time pursuant to this 14
799	799	chapter, but shall not be permitted to use the earned sick time until after he or she has completed 15
800	800	the waiting period. 16
801	801	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
802	802	8-26 and 40-8-32 of the General Laws in Chapter 40-8 entitled "Medical Assistance" are hereby 18
803	803	amended to read as follows: 19
804	804	40-8-2. Definitions. 20
805	805	As used in this chapter, unless the context shall otherwise require: 21
806	806	(1) “Dental service” means and includes emergency care, X-rays for diagnoses, extractions, 22
807	807	palliative treatment, and the refitting and relining of existing dentures and prosthesis. 23
808	808	(2) “Department” means the department of human services. 24
809	809	(3) “Director” means the director of human services Medicaid director. 25
810	810	(4) “Drug” means and includes only drugs and biologicals prescribed by a licensed dentist 26
811	811	or physician as are either included in the United States pharmacopoeia, national formulary, or are 27
812	812	new and nonofficial drugs and remedies. 28
813	813	(5) “Inpatient” means a person admitted to and under treatment or care of a physician or 29
814	814	surgeon in a hospital or nursing facility that meets standards of and complies with rules and 30
815	815	regulations promulgated by the director. 31
816	816	(6) “Inpatient hospital services” means the following items and services furnished to an 32
817	817	inpatient in a hospital other than a hospital, institution, or facility for tuberculosis or mental 33
818	818	diseases: 34
819	819
820	820
821	821	LC000271 - Page 23 of 93
822	822	(i) Bed and board; 1
823	823	(ii) Nursing services and other related services as are customarily furnished by the hospital 2
824	824	for the care and treatment of inpatients and drugs, biologicals, supplies, appliances, and equipment 3
825	825	for use in the hospital, as are customarily furnished by the hospital for the care and treatment of 4
826	826	patients; 5
827	827	(iii)(A) Other diagnostic or therapeutic items or services, including, but not limited to, 6
828	828	pathology, radiology, and anesthesiology furnished by the hospital or by others under arrangements 7
829	829	made by the hospital, as are customarily furnished to inpatients either by the hospital or by others 8
830	830	under such arrangements, and services as are customarily provided to inpatients in the hospital by 9
831	831	an intern or resident-in-training under a teaching program having the approval of the Council on 10
832	832	Medical Education and Hospitals of the American Medical Association or of any other recognized 11
833	833	medical society approved by the director. 12
834	834	(B) The term “inpatient hospital services” shall be taken to include medical and surgical 13
835	835	services provided by the inpatient’s physician, but shall not include the services of a private-duty 14
836	836	nurse or services in a hospital, institution, or facility maintained primarily for the treatment and 15
837	837	care of patients with tuberculosis or mental diseases. Provided, further, it shall be taken to include 16
838	838	only the following organ transplant operations: kidney, liver, cornea, pancreas, bone marrow, lung, 17
839	839	heart, and heart/lung, and other organ transplant operations as may be designated by the director 18
840	840	after consultation with medical advisory staff or medical consultants; and provided that any such 19
841	841	transplant operation is determined by the director or his or her designee to be medically necessary. 20
842	842	Prior written approval of the director, or his or her designee, shall be required for all covered organ 21
843	843	transplant operations. 22
844	844	(C) In determining medical necessity for organ transplant procedures, the state plan shall 23
845	845	adopt a case-by-case approach and shall focus on the medical indications and contra-indications in 24
846	846	each instance; the progressive nature of the disease; the existence of any alternative therapies; the 25
847	847	life-threatening nature of the disease; the general state of health of the patient apart from the 26
848	848	particular organ disease; and any other relevant facts and circumstances related to the applicant and 27
849	849	the particular transplant procedure. 28
850	850	(7) "Medicare equivalent rate" means the amount that would be paid for the relevant 29
851	851	services as furnished by the relevant group of facilities under Medicare payment principles 30
852	852	delineated in subchapter B of 42 CFR Chapter IV. Should no direct Medicare rates be available for 31
853	853	the particular service and facility group, the Medicaid director will estimate the rate. Providers will 32
854	854	have standing to bring an action in superior court for a higher rate, but intermediary insurers such 33
855	855	as managed care entities shall have no standing to bring an action for a lower rate. 34
856	856
857	857
858	858	LC000271 - Page 24 of 93
859	859	(7)(8) “Nursing services” means the following items and services furnished to an inpatient 1
860	860	in a nursing facility: 2
861	861	(i) Bed and board; 3
862	862	(ii) Nursing care and other related services as are customarily furnished to inpatients 4
863	863	admitted to the nursing facility, and drugs, biologicals, supplies, appliances, and equipment for use 5
864	864	in the facility, as are customarily furnished in the facility for the care and treatment of patients; 6
865	865	(iii) Other diagnostic or therapeutic items or services, legally furnished by the facility or 7
866	866	by others under arrangements made by the facility, as are customarily furnished to inpatients either 8
867	867	by the facility or by others under such arrangement; 9
868	868	(iv) Medical services provided in the facility by the inpatient’s physician, or by an intern 10
869	869	or resident-in-training of a hospital with which the facility is affiliated or that is under the same 11
870	870	control, under a teaching program of the hospital approved as provided in subsection (6); and 12
871	871	(v) A personal-needs allowance of seventy-five dollars ($75.00) two hundred dollars 13
872	872	($200) per month. 14
873	873	(8)(9) “Relative with whom the dependent child is living” means and includes the father, 15
874	874	mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, 16
875	875	uncle, aunt, first cousin, nephew, or niece of any dependent child who maintains a home for the 17
876	876	dependent child. 18
877	877	(9)(10) “Visiting nurse service” means part-time or intermittent nursing care provided by 19
878	878	or under the supervision of a registered professional nurse other than in a hospital or nursing home. 20
879	879	40-8-6. Review of application for benefits. 21
880	880	The director, or someone designated by him or her, shall review each application for 22
881	881	benefits filed in accordance with regulations, and shall make a determination of whether the 23
882	882	application will be honored and the extent of the benefits to be made available to the applicant, and 24
883	883	shall, within thirty (30) fifteen (15) days after the filing, notify the applicant, in writing, of the 25
884	884	determination. If the application is rejected, the notice to the applicant shall set forth therein the 26
885	885	reason therefor. The director may at any time reconsider any determination. 27
886	886	40-8-10. Recovery of benefits paid in error. 28
887	887	Any person, who through error or mistake of himself or herself or another willful and 29
888	888	knowingly fraudulent misrepresentation, receives medical care benefits to which he or she is not 30
889	889	entitled or with respect to which he or she was ineligible, shall be required to reimburse the state 31
890	890	for the benefits paid through error or mistake that were paid out during a time period, not to exceed 32
891	891	three years, where the person was not entitled to benefits but received them as a result of the willful 33
892	892	and knowing fraudulent misrepresentation. 34
893	893
894	894
895	895	LC000271 - Page 25 of 93
896	896	40-8-13. Rules, regulations, and fee schedules. 1
897	897	The director shall make and promulgate rules, regulations, and fee schedules not 2
898	898	inconsistent with state law and fiscal procedures as he or she deems necessary for the proper 3
899	899	administration of this chapter and to carry out the policy and purposes thereof, and to make the 4
900	900	department’s plan conform to the provisions of the federal Social Security Act, 42 U.S.C. § 1396 5
901	901	et seq., and any rules or regulations promulgated pursuant thereto. Except where explicitly 6
902	902	authorized by this title, the director shall have no power to set any fee schedule below the Medicare 7
903	903	equivalent rate; provided, however, that the director shall be empowered to provide a lower rate 8
904	904	equal to the maximum rate where federal reimbursement can be obtained in the event that federal 9
905	905	reimbursement cannot be obtained for the Medicare equivalent rate. For outpatient behavioral 10
906	906	health services, the minimum fee schedule shall be set at one hundred fifty percent (150%) of the 11
907	907	Medicare equivalent rate. The director shall attempt to obtain federal reimbursement for billing 12
908	908	outpatient behavioral health services at one hundred fifty percent (150%) of the Medicare 13
909	909	equivalent rate, but the state shall bear the costs of this higher rate for outpatient behavioral health 14
910	910	services even if federal reimbursement cannot be obtained. Should federal financial participation 15
911	911	be impossible to obtain for outpatient behavioral health services rate of one hundred fifty percent 16
912	912	(150%) of the Medicare equivalent rate, the director shall impose a surtax on the tax imposed on 17
913	913	health insurers pursuant to chapter 17 of title 44 in the amount necessary to defray the costs of the 18
914	914	inability to obtain federal reimbursement for an outpatient behavioral health services rate of one 19
915	915	hundred fifty percent (150%) of the Medicare equivalent rate. 20
916	916	40-8-13.4. Rate methodology for payment for in-state and out-of-state hospital 21
917	917	services. 22
918	918	(a) The executive office of health and human services (“executive office”) shall implement 23
919	919	a new methodology for payment for in-state and out-of-state hospital services in order to ensure 24
920	920	access to, and the provision of, high-quality and cost-effective hospital care to its eligible recipients. 25
921	921	(b) In order to improve efficiency and cost-effectiveness, the executive office shall: 26
922	922	(1)(i) With respect to inpatient services for persons in fee-for-service Medicaid, which is 27
923	923	non-managed care, implement a new payment methodology for inpatient services utilizing the 28
924	924	Diagnosis Related Groups (DRG) method of payment, which is, a patient-classification method 29
925	925	that provides a means of relating payment to the hospitals to the type of patients cared for by the 30
926	926	hospitals. It is understood that a payment method based on DRG may include cost outlier payments 31
927	927	and other specific exceptions. The executive office will review the DRG-payment method and the 32
928	928	DRG base price annually, making adjustments as appropriate in consideration of such elements as 33
929	929	trends in hospital input costs; patterns in hospital coding; beneficiary access to care; and the Centers 34
930	930
931	931
932	932	LC000271 - Page 26 of 93
933	933	for Medicare and Medicaid Services national CMS Prospective Payment System (IPPS) Hospital 1
934	934	Input Price Index. For the twelve-month (12) period beginning July 1, 2015, the DRG base rate for 2
935	935	Medicaid fee-for-service inpatient hospital services shall not exceed ninety-seven and one-half 3
936	936	percent (97.5%) of the payment rates in effect as of July 1, 2014. Beginning July 1, 2019, the DRG 4
937	937	base rate for Medicaid fee-for-service inpatient hospital services shall be 107.2% of the payment 5
938	938	rates in effect as of July 1, 2018. Increases in the Medicaid fee-for-service DRG hospital payments 6
939	939	for the twelve-month (12) period beginning July 1, 2020, shall be based on the payment rates in 7
940	940	effect as of July 1 of the preceding fiscal year, and shall be the Centers for Medicare and Medicaid 8
941	941	Services national Prospective Payment System (IPPS) Hospital Input Price Index. Beginning July 9
942	942	1, 2022, the DRG base rate for Medicaid fee-for-service inpatient hospital services shall be one 10
943	943	hundred five percent (105%) of the payment rates in effect as of July 1, 2021. Increases in the 11
944	944	Medicaid fee-for-service DRG hospital payments for each annual twelve-month (12) period 12
945	945	beginning July 1, 2023, shall be based on the payment rates in effect as of July 1 of the preceding 13
946	946	fiscal year, and shall be the Centers for Medicare and Medicaid Services national Prospective 14
947	947	Payment System (IPPS) Hospital Input Price Index. Beginning July 1, 2025, payments for inpatient 15
948	948	services in fee-for-service Medicaid shall cease utilizing the DRG method of payment, and 16
949	949	payments shall take place on a pure fee-for-services basis, unless a provider shall elect to utilize 17
950	950	the DRG payment methodology. DRG rates shall be set equal to ninety percent (90%) of a 18
951	951	reasonable estimate of the Medicare equivalent rate. Non-DRG rates shall be set by the Medicaid 19
952	952	director through regulation in order that the projected overall per capita expenditures shall equal 20
953	953	ninety-five percent (95%) of a reasonable estimate of the equivalent overall per capital expenditures 21
954	954	that would have been reached under the Medicare equivalent rate. 22
955	955	(ii) With respect to inpatient services, (A) It is required as of January 1, 2011, until 23
956	956	December 31, 2011, that the Medicaid managed care payment rates between each hospital and 24
957	957	health plan shall not exceed ninety and one-tenth percent (90.1%) of the rate in effect as of June 25
958	958	30, 2010. Increases in inpatient hospital payments for each annual twelve-month (12) period 26
959	959	beginning January 1, 2012, may not exceed the Centers for Medicare and Medicaid Services 27
960	960	national CMS Prospective Payment System (IPPS) Hospital Input Price Index for the applicable 28
961	961	period; (B) Provided, however, for the twenty-four-month (24) period beginning July 1, 2013, the 29
962	962	Medicaid managed care payment rates between each hospital and health plan shall not exceed the 30
963	963	payment rates in effect as of January 1, 2013, and for the twelve-month (12) period beginning July 31
964	964	1, 2015, the Medicaid managed care payment inpatient rates between each hospital and health plan 32
965	965	shall not exceed ninety-seven and one-half percent (97.5%) of the payment rates in effect as of 33
966	966	January 1, 2013; (C) Increases in inpatient hospital payments for each annual twelve-month (12) 34
967	967
968	968
969	969	LC000271 - Page 27 of 93
970	970	period beginning July 1, 2017, shall be the Centers for Medicare and Medicaid Services national 1
971	971	CMS Prospective Payment System (IPPS) Hospital Input Price Index, less Productivity 2
972	972	Adjustment, for the applicable period and shall be paid to each hospital retroactively to July 1; (D) 3
973	973	Beginning July 1, 2019, the Medicaid managed care payment inpatient rates between each hospital 4
974	974	and health plan shall be 107.2% of the payment rates in effect as of January 1, 2019, and shall be 5
975	975	paid to each hospital retroactively to July 1; (E) Increases in inpatient hospital payments for each 6
976	976	annual twelve-month (12) period beginning July 1, 2020, shall be based on the payment rates in 7
977	977	effect as of January 1 of the preceding fiscal year, and shall be the Centers for Medicare and 8
978	978	Medicaid Services national CMS Prospective Payment System (IPPS) Hospital Input Price Index, 9
979	979	less Productivity Adjustment, for the applicable period and shall be paid to each hospital 10
980	980	retroactively to July 1; the executive office will develop an audit methodology and process to assure 11
981	981	that savings associated with the payment reductions will accrue directly to the Rhode Island 12
982	982	Medicaid program through reduced managed care plan payments and shall not be retained by the 13
983	983	managed care plans; (F) Beginning July 1, 2022, the Medicaid managed care payment inpatient 14
984	984	rates between each hospital and health plan shall be one hundred five percent (105%) of the 15
985	985	payment rates in effect as of January 1, 2022, and shall be paid to each hospital retroactively to July 16
986	986	1 within ninety days of passage; (G) Increases in inpatient hospital payments for each annual 17
987	987	twelve-month (12) period beginning July 1, 2023, shall be based on the payment rates in effect as 18
988	988	of January 1 of the preceding fiscal year, and shall be the Centers for Medicare and Medicaid 19
989	989	Services national CMS Prospective Payment System (IPPS) Hospital Input Price Index, less 20
990	990	Productivity Adjustment, for the applicable period and shall be paid to each hospital retroactively 21
991	991	to July 1 within ninety days of passage; (H) All hospitals licensed in Rhode Island shall accept such 22
992	992	payment rates as payment in full; and (I) For all such hospitals, compliance with the provisions of 23
993	993	this section shall be a condition of participation in the Rhode Island Medicaid program. Beginning 24
994	994	July 1, 2025, Medicaid managed care payment rates shall equal one hundred five percent (105%) 25
995	995	of the fee-for-service rates set in subsection (b)(1)(i) of this section. 26
996	996	(2) With respect to outpatient services and notwithstanding any provisions of the law to the 27
997	997	contrary, for persons enrolled in fee-for-service Medicaid, the executive office will reimburse 28
998	998	hospitals for outpatient services using a rate methodology determined by the executive office and 29
999	999	in accordance with federal regulations. Fee-for-service outpatient rates shall align with Medicare 30
1000	1000	payments for similar services. Notwithstanding the above, there shall be no increase in the 31
1001	1001	Medicaid fee-for-service outpatient rates effective on July 1, 2013, July 1, 2014, or July 1, 2015. 32
1002	1002	For the twelve-month (12) period beginning July 1, 2015, Medicaid fee-for-service outpatient rates 33
1003	1003	shall not exceed ninety-seven and one-half percent (97.5%) of the rates in effect as of July 1, 2014. 34
1004	1004
1005	1005
1006	1006	LC000271 - Page 28 of 93
1007	1007	Increases in the outpatient hospital payments for the twelve-month (12) period beginning July 1, 1
1008	1008	2016, may not exceed the CMS national Outpatient Prospective Payment System (OPPS) Hospital 2
1009	1009	Input Price Index. Beginning July 1, 2019, the Medicaid fee-for-service outpatient rates shall be 3
1010	1010	107.2% of the payment rates in effect as of July 1, 2018. Increases in the outpatient hospital 4
1011	1011	payments for the twelve-month (12) period beginning July 1, 2020, shall be based on the payment 5
1012	1012	rates in effect as of July 1 of the preceding fiscal year, and shall be the CMS national Outpatient 6
1013	1013	Prospective Payment System (OPPS) Hospital Input Price Index. Beginning July 1, 2022, the 7
1014	1014	Medicaid fee-for-service outpatient rates shall be one hundred five percent (105%) of the payment 8
1015	1015	rates in effect as of July 1, 2021. Increases in the outpatient hospital payments for each annual 9
1016	1016	twelve-month (12) period beginning July 1, 2023, shall be based on the payment rates in effect as 10
1017	1017	of July 1 of the preceding fiscal year, and shall be the CMS national Outpatient Prospective 11
1018	1018	Payment System (OPPS) Hospital Input Price Index. With respect to the outpatient rate, (i) It is 12
1019	1019	required as of January 1, 2011, until December 31, 2011, that the Medicaid managed care payment 13
1020	1020	rates between each hospital and health plan shall not exceed one hundred percent (100%) of the 14
1021	1021	rate in effect as of June 30, 2010; (ii) Increases in hospital outpatient payments for each annual 15
1022	1022	twelve-month (12) period beginning January 1, 2012, until July 1, 2017, may not exceed the Centers 16
1023	1023	for Medicare and Medicaid Services national CMS Outpatient Prospective Payment System OPPS 17
1024	1024	Hospital Price Index for the applicable period; (iii) Provided, however, for the twenty-four-month 18
1025	1025	(24) period beginning July 1, 2013, the Medicaid managed care outpatient payment rates between 19
1026	1026	each hospital and health plan shall not exceed the payment rates in effect as of January 1, 2013, 20
1027	1027	and for the twelve-month (12) period beginning July 1, 2015, the Medicaid managed care outpatient 21
1028	1028	payment rates between each hospital and health plan shall not exceed ninety-seven and one-half 22
1029	1029	percent (97.5%) of the payment rates in effect as of January 1, 2013; (iv) Increases in outpatient 23
1030	1030	hospital payments for each annual twelve-month (12) period beginning July 1, 2017, shall be the 24
1031	1031	Centers for Medicare and Medicaid Services national CMS OPPS Hospital Input Price Index, less 25
1032	1032	Productivity Adjustment, for the applicable period and shall be paid to each hospital retroactively 26
1033	1033	to July 1; (v) Beginning July 1, 2019, the Medicaid managed care outpatient payment rates between 27
1034	1034	each hospital and health plan shall be one hundred seven and two-tenths percent (107.2%) of the 28
1035	1035	payment rates in effect as of January 1, 2019, and shall be paid to each hospital retroactively to July 29
1036	1036	1; (vi) Increases in outpatient hospital payments for each annual twelve-month (12) period 30
1037	1037	beginning July 1, 2020, shall be based on the payment rates in effect as of January 1 of the preceding 31
1038	1038	fiscal year, and shall be the Centers for Medicare and Medicaid Services national CMS OPPS 32
1039	1039	Hospital Input Price Index, less Productivity Adjustment, for the applicable period and shall be 33
1040	1040	paid to each hospital retroactively to July 1; (vii) Beginning July 1, 2022, the Medicaid managed 34
1041	1041
1042	1042
1043	1043	LC000271 - Page 29 of 93
1044	1044	care outpatient payment rates between each hospital and health plan shall be one hundred five 1
1045	1045	percent (105%) of the payment rates in effect as of January 1, 2022, and shall be paid to each 2
1046	1046	hospital retroactively to July 1 within ninety days of passage; (viii) Increases in outpatient hospital 3
1047	1047	payments for each annual twelve-month (12) period beginning July 1, 2020, shall be based on the 4
1048	1048	payment rates in effect as of January 1 of the preceding fiscal year, and shall be the Centers for 5
1049	1049	Medicare and Medicaid Services national CMS OPPS Hospital Input Price Index, less Productivity 6
1050	1050	Adjustment, for the applicable period and shall be paid to each hospital retroactively to July 1. 7
1051	1051	Beginning July 1, 2025, fee-for-service and managed care outpatient rates shall equal the Medicare 8
1052	1052	equivalent rate. 9
1053	1053	(3) “Hospital,” as used in this section, shall mean the actual facilities and buildings in 10
1054	1054	existence in Rhode Island, licensed pursuant to § 23-17-1 et seq. on June 30, 2010, and thereafter 11
1055	1055	any premises included on that license, regardless of changes in licensure status pursuant to chapter 12
1056	1056	17.14 of title 23 (hospital conversions) and § 23-17-6(b) (change in effective control), that provides 13
1057	1057	short-term, acute inpatient and/or outpatient care to persons who require definitive diagnosis and 14
1058	1058	treatment for injury, illness, disabilities, or pregnancy. Notwithstanding the preceding language, 15
1059	1059	the Medicaid managed care payment rates for a court-approved purchaser that acquires a hospital 16
1060	1060	through receivership, special mastership or other similar state insolvency proceedings (which court-17
1061	1061	approved purchaser is issued a hospital license after January 1, 2013), shall be based upon the new 18
1062	1062	rates between the court-approved purchaser and the health plan, and such rates shall be effective as 19
1063	1063	of the date that the court-approved purchaser and the health plan execute the initial agreement 20
1064	1064	containing the new rates. The rate-setting methodology for inpatient-hospital payments and 21
1065	1065	outpatient-hospital payments set forth in subsections (b)(1)(ii)(C) and (b)(2), respectively, shall 22
1066	1066	thereafter apply to increases for each annual twelve-month (12) period as of July 1 following the 23
1067	1067	completion of the first full year of the court-approved purchaser’s initial Medicaid managed care 24
1068	1068	contract. 25
1069	1069	(c) It is intended that payment utilizing phasing out the DRG method shall reward hospitals 26
1070	1070	for providing the most efficient highest quality care, and provide the executive office the 27
1071	1071	opportunity to conduct value-based purchasing of inpatient care. 28
1072	1072	(d) The secretary of the executive office is hereby authorized to promulgate such rules and 29
1073	1073	regulations consistent with this chapter, and to establish fiscal procedures he or she deems 30
1074	1074	necessary, for the proper implementation and administration of this chapter in order to provide 31
1075	1075	payment to hospitals using the DRG-payment methodology. Furthermore, amendment of the Rhode 32
1076	1076	Island state plan for Medicaid, pursuant to Title XIX of the federal Social Security Act, 42 U.S.C. 33
1077	1077	§ 1396 et seq., is hereby authorized to provide for payment to hospitals for services provided to 34
1078	1078
1079	1079
1080	1080	LC000271 - Page 30 of 93
1081	1081	eligible recipients in accordance with this chapter. 1
1082	1082	(e) The executive office shall comply with all public notice requirements necessary to 2
1083	1083	implement these rate changes. 3
1084	1084	(f) As a condition of participation in the DRG methodology for payment of hospital 4
1085	1085	services, every hospital shall submit year-end settlement reports to the executive office within one 5
1086	1086	year from the close of a hospital’s fiscal year. Should a participating hospital fail to timely submit 6
1087	1087	a year-end settlement report as required by this section, the executive office shall withhold 7
1088	1088	financial-cycle payments due by any state agency with respect to this hospital by not more than ten 8
1089	1089	percent (10%) until the report is submitted. For hospital fiscal year 2010 and all subsequent fiscal 9
1090	1090	years, hospitals will not be required to submit year-end settlement reports on payments for 10
1091	1091	outpatient services. For hospital fiscal year 2011 and all subsequent fiscal years, hospitals will not 11
1092	1092	be required to submit year-end settlement reports on claims for hospital inpatient services. Further, 12
1093	1093	for hospital fiscal year 2010, hospital inpatient claims subject to settlement shall include only those 13
1094	1094	claims received between October 1, 2009, and June 30, 2010. 14
1095	1095	(g) The provisions of this section shall be effective upon implementation of the new 15
1096	1096	payment methodology set forth in this section and § 40-8-13.3, which shall in any event be no later 16
1097	1097	than March 30, 2010, at which time the provisions of §§ 40-8-13.2, 27-19-14, 27-19-15, and 27-17
1098	1098	19-16 shall be repealed in their entirety. 18
1099	1099	40-8-16. Notification of long-term care alternative. 19
1100	1100	(a) The department of human services, before authorizing care in a nursing home or 20
1101	1101	intermediate-care facility for a person who is eligible to receive benefits pursuant to Title XIX of 21
1102	1102	the federal Social Security Act, 42 U.S.C. § 1396 et seq., and who is being discharged from a 22
1103	1103	hospital to a nursing home, shall notify the person, in writing, of the provisions of the long-term-23
1104	1104	care alternative, a home- and a community-based program. 24
1105	1105	(b) If a person, eligible to receive benefits pursuant to Title XIX of the federal Social 25
1106	1106	Security Act, requires services in a nursing home and desires to remain in his or her own home or 26
1107	1107	the home of a responsible relative or other adult, the person or his or her representative shall so 27
1108	1108	inform the department. 28
1109	1109	(c) The department shall not make payments pursuant to Title XIX of the federal Social 29
1110	1110	Security Act for benefits until written notification documenting the person’s choice as to a nursing 30
1111	1111	home or home- and community-based services has been filed with the department. 31
1112	1112	40-8-19. Rates of payment to nursing facilities. 32
1113	1113	(a) Rate reform. 33
1114	1114	(1) The rates to be paid by the state to nursing facilities licensed pursuant to chapter 17 of 34
1115	1115
1116	1116
1117	1117	LC000271 - Page 31 of 93
1118	1118	title 23, and certified to participate in Title XIX of the Social Security Act for services rendered to 1
1119	1119	Medicaid-eligible residents, shall be reasonable and adequate to meet the costs that must be 2
1120	1120	incurred by efficiently and economically operated facilities in accordance with 42 U.S.C. § 3
1121	1121	1396a(a)(13). The executive office of health and human services (“executive office”) shall 4
1122	1122	promulgate or modify the principles of reimbursement for nursing facilities in effect as of July 1, 5
1123	1123	2011, to be consistent with the provisions of this section and Title XIX, 42 U.S.C. § 1396 et seq., 6
1124	1124	of the Social Security Act. 7
1125	1125	(2) The executive office shall review the current methodology for providing Medicaid 8
1126	1126	payments to nursing facilities, including other long-term care services providers, and is authorized 9
1127	1127	to modify the principles of reimbursement to replace the current cost-based methodology rates with 10
1128	1128	rates based on a price-based methodology to be paid to all facilities with recognition of the acuity 11
1129	1129	of patients and the relative Medicaid occupancy, and to include the following elements to be 12
1130	1130	developed by the executive office: 13
1131	1131	(i) A direct-care rate adjusted for resident acuity; 14
1132	1132	(ii) An indirect-care and other direct-care rate comprised of a base per diem for all facilities; 15
1133	1133	(iii) Revision of rates as necessary based on increases in direct and indirect costs beginning 16
1134	1134	October 2024 utilizing data from the most recent finalized year of facility cost report. The per diem 17
1135	1135	rate components deferred in subsections (a)(2)(i) and (a)(2)(ii) of this section shall be adjusted 18
1136	1136	accordingly to reflect changes in direct and indirect care costs since the previous rate review; 19
1137	1137	(iv) Application of a fair-rental value system; 20
1138	1138	(v) Application of a pass-through system; and 21
1139	1139	(vi) Adjustment of rates by the change in a recognized national nursing home inflation 22
1140	1140	index to be applied on October 1 of each year, beginning October 1, 2012. This adjustment will not 23
1141	1141	occur on October 1, 2013, October 1, 2014, or October 1, 2015, but will occur on April 1, 2015. 24
1142	1142	The adjustment of rates will also not occur on October 1, 2017, October 1, 2018, October 1, 2019, 25
1143	1143	and October 2022. Effective July 1, 2018, rates paid to nursing facilities from the rates approved 26
1144	1144	by the Centers for Medicare and Medicaid Services and in effect on October 1, 2017, both fee-for-27
1145	1145	service and managed care, will be increased by one and one-half percent (1.5%) and further 28
1146	1146	increased by one percent (1%) on October 1, 2018, and further increased by one percent (1%) on 29
1147	1147	October 1, 2019. Effective October 1, 2022, rates paid to nursing facilities from the rates approved 30
1148	1148	by the Centers for Medicare and Medicaid Services and in effect on October 1, 2021, both fee-for-31
1149	1149	service and managed care, will be increased by three percent (3%). In addition to the annual nursing 32
1150	1150	home inflation index adjustment, there shall be a base rate staffing adjustment of one-half percent 33
1151	1151	(0.5%) on October 1, 2021, one percent (1.0%) on October 1, 2022, and one and one-half percent 34
1152	1152
1153	1153
1154	1154	LC000271 - Page 32 of 93
1155	1155	(1.5%) on October 1, 2023. The inflation index shall be applied without regard for the transition 1
1156	1156	factors in subsections (b)(1) and (b)(2). For purposes of October 1, 2016, adjustment only, any rate 2
1157	1157	increase that results from application of the inflation index to subsections (a)(2)(i) and (a)(2)(ii) 3
1158	1158	shall be dedicated to increase compensation for direct-care workers in the following manner: Not 4
1159	1159	less than 85% of this aggregate amount shall be expended to fund an increase in wages, benefits, 5
1160	1160	or related employer costs of direct-care staff of nursing homes. For purposes of this section, direct-6
1161	1161	care staff shall include registered nurses (RNs), licensed practical nurses (LPNs), certified nursing 7
1162	1162	assistants (CNAs), certified medical technicians, housekeeping staff, laundry staff, dietary staff, or 8
1163	1163	other similar employees providing direct-care services; provided, however, that this definition of 9
1164	1164	direct-care staff shall not include: (i) RNs and LPNs who are classified as “exempt employees” 10
1165	1165	under the federal Fair Labor Standards Act (29 U.S.C. § 201 et seq.); or (ii) CNAs, certified medical 11
1166	1166	technicians, RNs, or LPNs who are contracted, or subcontracted, through a third-party vendor or 12
1167	1167	staffing agency. By July 31, 2017, nursing facilities shall submit to the secretary, or designee, a 13
1168	1168	certification that they have complied with the provisions of this subsection (a)(2)(vi) with respect 14
1169	1169	to the inflation index applied on October 1, 2016. Any facility that does not comply with the terms 15
1170	1170	of such certification shall be subjected to a clawback, paid by the nursing facility to the state, in the 16
1171	1171	amount of increased reimbursement subject to this provision that was not expended in compliance 17
1172	1172	with that certification. 18
1173	1173	(3) Commencing on October 1, 2021, eighty percent (80%) of any rate increase that results 19
1174	1174	from application of the inflation index to subsections (a)(2)(i) and (a)(2)(ii) of this section shall be 20
1175	1175	dedicated to increase compensation for all eligible direct-care workers in the following manner on 21
1176	1176	October 1, of each year. 22
1177	1177	(i) For purposes of this subsection, compensation increases shall include base salary or 23
1178	1178	hourly wage increases, benefits, other compensation, and associated payroll tax increases for 24
1179	1179	eligible direct-care workers. This application of the inflation index shall apply for Medicaid 25
1180	1180	reimbursement in nursing facilities for both managed care and fee-for-service. For purposes of this 26
1181	1181	subsection, direct-care staff shall include registered nurses (RNs), licensed practical nurses (LPNs), 27
1182	1182	certified nursing assistants (CNAs), certified medication technicians, licensed physical therapists, 28
1183	1183	licensed occupational therapists, licensed speech-language pathologists, mental health workers 29
1184	1184	who are also certified nurse assistants, physical therapist assistants, housekeeping staff, laundry 30
1185	1185	staff, dietary staff, or other similar employees providing direct-care services; provided, however 31
1186	1186	that this definition of direct-care staff shall not include: 32
1187	1187	(A) RNs and LPNs who are classified as “exempt employees” under the federal Fair Labor 33
1188	1188	Standards Act (29 U.S.C. § 201 et seq.); or 34
1189	1189
1190	1190
1191	1191	LC000271 - Page 33 of 93
1192	1192	(B) CNAs, certified medication technicians, RNs, or LPNs who are contracted or 1
1193	1193	subcontracted through a third-party vendor or staffing agency. 2
1194	1194	(4)(i) By July 31, 2021, and July 31 of each year thereafter, nursing facilities shall submit 3
1195	1195	to the secretary or designee a certification that they have complied with the provisions of subsection 4
1196	1196	(a)(3) of this section with respect to the inflation index applied on October 1. The executive office 5
1197	1197	of health and human services (EOHHS) shall create the certification form nursing facilities must 6
1198	1198	complete with information on how each individual eligible employee’s compensation increased, 7
1199	1199	including information regarding hourly wages prior to the increase and after the compensation 8
1200	1200	increase, hours paid after the compensation increase, and associated increased payroll taxes. A 9
1201	1201	collective bargaining agreement can be used in lieu of the certification form for represented 10
1202	1202	employees. All data reported on the compliance form is subject to review and audit by EOHHS. 11
1203	1203	The audits may include field or desk audits, and facilities may be required to provide additional 12
1204	1204	supporting documents including, but not limited to, payroll records. 13
1205	1205	(ii) Any facility that does not comply with the terms of certification shall be subjected to a 14
1206	1206	clawback and twenty-five percent (25%) penalty of the unspent or impermissibly spent funds, paid 15
1207	1207	by the nursing facility to the state, in the amount of increased reimbursement subject to this 16
1208	1208	provision that was not expended in compliance with that certification. 17
1209	1209	(iii) In any calendar year where no inflationary index is applied, eighty percent (80%) of 18
1210	1210	the base rate staffing adjustment in that calendar year pursuant to subsection (a)(2)(vi) of this 19
1211	1211	section shall be dedicated to increase compensation for all eligible direct-care workers in the 20
1212	1212	manner referenced in subsections (a)(3)(i), (a)(3)(i)(A), and (a)(3)(i)(B) of this section. 21
1213	1213	(b) Transition to full implementation of rate reform. For no less than four (4) years after 22
1214	1214	the initial application of the price-based methodology described in subsection (a)(2) to payment 23
1215	1215	rates, the executive office of health and human services shall implement a transition plan to 24
1216	1216	moderate the impact of the rate reform on individual nursing facilities. The transition shall include 25
1217	1217	the following components: 26
1218	1218	(1) No nursing facility shall receive reimbursement for direct-care costs that is less than 27
1219	1219	the rate of reimbursement for direct-care costs received under the methodology in effect at the time 28
1220	1220	of passage of this act; for the year beginning October 1, 2017, the reimbursement for direct-care 29
1221	1221	costs under this provision will be phased out in twenty-five-percent (25%) increments each year 30
1222	1222	until October 1, 2021, when the reimbursement will no longer be in effect; and 31
1223	1223	(2) No facility shall lose or gain more than five dollars ($5.00) in its total, per diem rate the 32
1224	1224	first year of the transition. An adjustment to the per diem loss or gain may be phased out by twenty-33
1225	1225	five percent (25%) each year; except, however, for the years beginning October 1, 2015, there shall 34
1226	1226
1227	1227
1228	1228	LC000271 - Page 34 of 93
1229	1229	be no adjustment to the per diem gain or loss, but the phase out shall resume thereafter; and 1
1230	1230	(3) The transition plan and/or period may be modified upon full implementation of facility 2
1231	1231	per diem rate increases for quality of care-related measures. Said modifications shall be submitted 3
1232	1232	in a report to the general assembly at least six (6) months prior to implementation. 4
1233	1233	(4) Notwithstanding any law to the contrary, for the twelve-month (12) period beginning 5
1234	1234	July 1, 2015, Medicaid payment rates for nursing facilities established pursuant to this section shall 6
1235	1235	not exceed ninety-eight percent (98%) of the rates in effect on April 1, 2015. Consistent with the 7
1236	1236	other provisions of this chapter, nothing in this provision shall require the executive office to restore 8
1237	1237	the rates to those in effect on April 1, 2015, at the end of this twelve-month (12) period. 9
1238	1238	(5) Commencing July 1, 2025, and for each subsequent year, the executive office of health 10
1239	1239	and human services is hereby authorized and directed to amend its regulations for reimbursement 11
1240	1240	to nursing facilities in order that each nursing facility shall be paid the Medicare equivalent rate. 12
1241	1241	The provisions of subsection (a)(3)(iii) shall apply. 13
1242	1242	40-8-26. Community health centers. 14
1243	1243	(a) For the purposes of this section, the term community health centers refers to federally 15
1244	1244	qualified health centers and rural health centers. 16
1245	1245	(b) To support the ability of community health centers to provide high-quality medical care 17
1246	1246	to patients, the executive office of health and human services (“executive office”) may adopt and 18
1247	1247	implement an alternative payment methodology (APM) for determining a Medicaid per-visit 19
1248	1248	reimbursement for community health centers that is compliant with the prospective payment system 20
1249	1249	(PPS) provided for in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection 21
1250	1250	Act of 2000. The following principles are to ensure that the APM PPS rate determination 22
1251	1251	methodology is part of the executive office overall value purchasing approach. For community 23
1252	1252	health centers that do not agree to the principles of reimbursement that reflect the APM PPS, 24
1253	1253	EOHHS shall reimburse such community health centers at the federal PPS rate, as required per 25
1254	1254	section 1902(bb)(3) of the Social Security Act, 42 U.S.C. § 1396a(bb)(3). For community health 26
1255	1255	centers that are reimbursed at the federal PPS rate, subsections (d) through (f) of this section apply. 27
1256	1256	(c) The APM PPS rate determination methodology will (i) Fairly recognize the reasonable 28
1257	1257	costs of providing services. Recognized reasonable costs will be those appropriate for the 29
1258	1258	organization, management, and direct provision of services and (ii) Provide assurances to the 30
1259	1259	executive office that services are provided in an effective and efficient manner, consistent with 31
1260	1260	industry standards. Except for demonstrated cause and at the discretion of the executive office, the 32
1261	1261	maximum reimbursement rate for a service (e.g., medical, dental) provided by an individual 33
1262	1262	community health center shall not exceed one hundred twenty-five percent (125%) of the median 34
1263	1263
1264	1264
1265	1265	LC000271 - Page 35 of 93
1266	1266	rate for all community health centers within Rhode Island. not only bill the community health center 1
1267	1267	on a fee-for-service basis at the Medicare equivalent rate but also make a series of quality incentive 2
1268	1268	payments if the community health center meets certain quality incentives. Quality incentive 3
1269	1269	payments shall be set at a percentage of the aggregate monthly billing. The quality incentive 4
1270	1270	payments shall be as follows: 5
1271	1271	(1) Ten percent (10%) for meeting benchmarks set by the Medicaid director for screening 6
1272	1272	patients for Medicaid eligibility. 7
1273	1273	(2) Five percent (5%) for meeting benchmarks set by the Medicaid director for enrolling 8
1274	1274	patients who regularly smoke tobacco in smoking cessation programs. 9
1275	1275	(3) Ten percent (10%) for meeting benchmarks set by the director of human services for 10
1276	1276	screening patients for supplemental nutrition assistance program eligibility. 11
1277	1277	(4) Ten percent (10%) for ensuring that no more than one percent (1%) of patients are ever 12
1278	1278	not offered an appointment within a month if they request one. 13
1279	1279	(5) Up to fifteen percent (15%) for meeting benchmarks set by the Medicaid director for 14
1280	1280	the improvement of air quality in patients' homes through directly funding interventions such as: 15
1281	1281	air quality inspections, the installation of air filters, the installation of ventilation, and the 16
1282	1282	replacement of gas stoves with electric stoves. 17
1283	1283	(6) Up to fifteen percent (15%) for meeting benchmarks set by the Medicaid director for 18
1284	1284	the removal or mitigation of environmental toxins in patients' homes through the direct funding of 19
1285	1285	removal or mitigation of environmental toxins. These toxins shall include, but shall not be limited 20
1286	1286	to, lead, radon, asbestos, and carbon monoxide. 21
1287	1287	(d) Community health centers will cooperate fully and timely with reporting requirements 22
1288	1288	established by the executive office. 23
1289	1289	(e) Reimbursement rates established through this methodology shall be incorporated into 24
1290	1290	the PPS reconciliation for services provided to Medicaid-eligible persons who are enrolled in a 25
1291	1291	health plan on the date of service. Monthly payments by the executive office related to PPS for 26
1292	1292	persons enrolled in a health plan shall be made directly to the community health centers. 27
1293	1293	(f) Reimbursement rates established through this the APM methodology shall not be 28
1294	1294	incorporated into the actuarially certified capitation rates paid to a health plan. The health plan shall 29
1295	1295	be responsible for paying the full amount of the reimbursement rate to the community health center 30
1296	1296	for each service eligible for reimbursement under the Medicare, Medicaid, and SCHIP Benefits 31
1297	1297	Improvement and Protection Act of 2000. If the health plan has an alternative payment arrangement 32
1298	1298	with the community health center opts to utilize the APM methodology, the health plan may 33
1299	1299	establish a PPS reconciliation process for eligible services and make monthly payments related to 34
1300	1300
1301	1301
1302	1302	LC000271 - Page 36 of 93
1303	1303	PPS for persons enrolled in the health plan on the date of service shall bear the full upside and 1
1304	1304	downside risk of decreased or increased costs from the APM methodology. The executive office 2
1305	1305	will review, at least annually, the Medicaid reimbursement rates and reconciliation methodology 3
1306	1306	used by the health plans for community health centers to ensure payments to each are made in 4
1307	1307	compliance with the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 5
1308	1308	2000. 6
1309	1309	40-8-32. Support for certain patients of nursing facilities. 7
1310	1310	(a) Definitions. For purposes of this section: 8
1311	1311	(1) “Applied income” shall mean the amount of income a Medicaid beneficiary is required 9
1312	1312	to contribute to the cost of his or her care. 10
1313	1313	(2) “Authorized individual” shall mean a person who has authority over the income of a 11
1314	1314	patient of a nursing facility, such as a person who has been given or has otherwise obtained 12
1315	1315	authority over a patient’s bank account; has been named as or has rights as a joint account holder; 13
1316	1316	or is a fiduciary as defined below. 14
1317	1317	(3) “Costs of care” shall mean the costs of providing care to a patient of a nursing facility, 15
1318	1318	including nursing care, personal care, meals, transportation, and any other costs, charges, and 16
1319	1319	expenses incurred by a nursing facility in providing care to a patient. Costs of care shall not exceed 17
1320	1320	the customary rate the nursing facility charges to a patient who pays for his or her care directly 18
1321	1321	rather than through a governmental or other third-party payor. 19
1322	1322	(4) “Fiduciary” shall mean a person to whom power or property has been formally 20
1323	1323	entrusted for the benefit of another, such as an attorney-in-fact, legal guardian, trustee, or 21
1324	1324	representative payee. 22
1325	1325	(5) “Nursing facility” shall mean a nursing facility licensed under chapter 17 of title 23, 23
1326	1326	that is a participating provider in the Rhode Island Medicaid program. 24
1327	1327	(6) “Penalty period” means the period of Medicaid ineligibility imposed pursuant to 42 25
1328	1328	U.S.C. § 1396p(c), as amended from time to time, on a person whose assets have been transferred 26
1329	1329	for less than fair market value. 27
1330	1330	(7) “Uncompensated care” — Care and services provided by a nursing facility to a 28
1331	1331	Medicaid applicant without receiving compensation therefore from Medicaid, Medicare, the 29
1332	1332	Medicaid applicant, or other source. The acceptance of any payment representing actual or 30
1333	1333	estimated applied income shall not disqualify the care and services provided from qualifying as 31
1334	1334	uncompensated care. 32
1335	1335	(b) Penalty period resulting from transfer. Any transfer or assignment of assets resulting in 33
1336	1336	the establishment or imposition of a penalty period shall create a debt that shall be due and owing 34
1337	1337
1338	1338
1339	1339	LC000271 - Page 37 of 93
1340	1340	to a nursing facility for the unpaid costs of care provided during the penalty period to a patient of 1
1341	1341	that facility who has been subject to the penalty period. The amount of the debt established shall 2
1342	1342	not exceed the fair market value of the transferred assets at the time of transfer that are the subject 3
1343	1343	of the penalty period. A nursing facility may bring an action to collect a debt for the unpaid costs 4
1344	1344	of care given to a patient who has been subject to a penalty period, against either the transferor or 5
1345	1345	the transferee, or both. The provisions of this section shall not affect other rights or remedies of the 6
1346	1346	parties. 7
1347	1347	(c) Applied income. A nursing facility may provide written notice to a patient who is a 8
1348	1348	Medicaid recipient and any authorized individual of that patient: 9
1349	1349	(1) Of the amount of applied income due; 10
1350	1350	(2) Of the recipient’s legal obligation to pay the applied income to the nursing facility; and 11
1351	1351	(3) That the recipient’s failure to pay applied income due to a nursing facility not later than 12
1352	1352	thirty (30) days after receiving notice from the nursing facility may result in a court action to 13
1353	1353	recover the amount of applied income due. 14
1354	1354	A nursing facility that is owed applied income may, in addition to any other remedies 15
1355	1355	authorized under law, bring a claim to recover the applied income against a patient and any 16
1356	1356	authorized individual. If a court of competent jurisdiction determines, based upon clear and 17
1357	1357	convincing evidence, that a defendant willfully failed to pay or withheld applied income due and 18
1358	1358	owing to a nursing facility for more than thirty (30) days after receiving notice pursuant to 19
1359	1359	subsection (c), the court may award the amount of the debt owed, court costs, and reasonable 20
1360	1360	attorney’s fees to the nursing facility. 21
1361	1361	(d) Effects. Nothing contained in this section shall prohibit or otherwise diminish any other 22
1362	1362	causes of action possessed by any such nursing facility. The death of the person receiving nursing 23
1363	1363	facility care shall not nullify or otherwise affect the liability of the person or persons charged with 24
1364	1364	the costs of care rendered or the applied income amount as referenced in this section. 25
1365	1365	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
1366	1366	the General Laws in Chapter 40-8 entitled "Medical Assistance" are hereby repealed. 27
1367	1367	40-8-3.1. Life estate in property — Retained powers. 28
1368	1368	When an applicant or recipient of Medicaid owns a life estate in property that is his or her 29
1369	1369	principal place of residence with the reserved power and authority, during his or her lifetime, to 30
1370	1370	sell, convey, mortgage, or otherwise dispose of the real property without the consent or joinder by 31
1371	1371	the holder(s) of the remainder interest, the principal place of residence shall not be regarded as an 32
1372	1372	excluded resource for the purpose of Medicaid eligibility, unless the applicant or recipient 33
1373	1373	individually, or through his or her guardian, conservator, or attorney in fact, conveys all outstanding 34
1374	1374
1375	1375
1376	1376	LC000271 - Page 38 of 93
1377	1377	remainder interest to him or herself. 1
1378	1378	An applicant or recipient who, by a deed created, executed and recorded on or before June 2
1379	1379	30, 2014, has reserved a life estate in property that is his or her principal place of residence with 3
1380	1380	the reserved power and authority, during his or her lifetime, to sell, convey, mortgage, or otherwise 4
1381	1381	dispose of the real property without the consent or joinder by the holder(s) of the remainder interest, 5
1382	1382	shall not be ineligible for Medicaid on the basis of the deed, regardless of whether the transferee of 6
1383	1383	the remainder interest is a person or persons, trust, or entity. 7
1384	1384	40-8-9.1. Notice. 8
1385	1385	Whenever an individual who is receiving medical assistance under this chapter transfers 9
1386	1386	an interest in real or personal property, the individual shall notify the executive office of health and 10
1387	1387	human services within ten (10) days of the transfer. The notice shall be sent to the individual’s local 11
1388	1388	office and the legal office of the executive office of health and human services and include, at a 12
1389	1389	minimum, the individual’s name, social security number or, if different, the executive office of 13
1390	1390	health and human services identification number, the date of transfer, and the dollar value, if any, 14
1391	1391	paid or received by the individual who received benefits under this chapter. In the event an 15
1392	1392	individual fails to provide notice required by this section to the executive office of health and human 16
1393	1393	services and in the event an individual has received medical assistance, any individual and/or entity, 17
1394	1394	who knew or should have known that the individual failed to provide the notice and who receives 18
1395	1395	any distribution of value as a result of the transfer, shall be liable to the executive office of health 19
1396	1396	and human services to the extent of the value of the transfer. Moreover, any such individual shall 20
1397	1397	be subject to the provisions of § 40-6-15 and any remedy provided by applicable state and federal 21
1398	1398	laws and rules and regulations. Failure to comply with the notice requirements set forth in the 22
1399	1399	section shall not affect the marketability of title to real estate transferred while the transferor is 23
1400	1400	receiving medical assistance. 24
1401	1401	40-8-13.5. Hospital Incentive Program (HIP). 25
1402	1402	The secretary of the executive office of health and human services is authorized to seek the 26
1403	1403	federal authorities required to implement a hospital incentive program (HIP). The HIP shall provide 27
1404	1404	the participating licensed hospitals the ability to obtain certain payments for achieving performance 28
1405	1405	goals established by the secretary. HIP payments shall commence no earlier than July 1, 2016. 29
1406	1406	40-8-15. Lien on deceased recipient’s estate for assistance. 30
1407	1407	(a)(1) Upon the death of a recipient of Medicaid under Title XIX of the federal Social 31
1408	1408	Security Act (42 U.S.C. § 1396 et seq. and referred to hereinafter as the “Act”), the total sum for 32
1409	1409	Medicaid benefits so paid on behalf of a beneficiary who was fifty-five (55) years of age or older 33
1410	1410	at the time of receipt shall be and constitute a lien upon the estate, as defined in subsection (a)(2), 34
1411	1411
1412	1412
1413	1413	LC000271 - Page 39 of 93
1414	1414	of the beneficiary in favor of the executive office of health and human services (“executive office”). 1
1415	1415	The lien shall not be effective and shall not attach as against the estate of a beneficiary who is 2
1416	1416	survived by a spouse, or a child who is under the age of twenty-one (21), or a child who is blind or 3
1417	1417	permanently and totally disabled as defined in Title XVI of the federal Social Security Act, 42 4
1418	1418	U.S.C. § 1381 et seq. The lien shall attach against property of a beneficiary, which is included or 5
1419	1419	includable in the decedent’s probate estate, regardless of whether or not a probate proceeding has 6
1420	1420	been commenced in the probate court by the executive office or by any other party. Provided, 7
1421	1421	however, that such lien shall only attach and shall only be effective against the beneficiary’s real 8
1422	1422	property included or includable in the beneficiary’s probate estate if such lien is recorded in the 9
1423	1423	land evidence records and is in accordance with subsection (e). Decedents who have received 10
1424	1424	Medicaid benefits are subject to the assignment and subrogation provisions of §§ 40-6-9 and 40-6-11
1425	1425	10. 12
1426	1426	(2) For purposes of this section, the term “estate” with respect to a deceased individual 13
1427	1427	shall include all real and personal property and other assets included or includable within the 14
1428	1428	individual’s probate estate. 15
1429	1429	(b) The executive office is authorized to promulgate regulations to implement the terms, 16
1430	1430	intent, and purpose of this section and to require the legal representative(s) and/or the heirs-at-law 17
1431	1431	of the decedent to provide reasonable written notice to the executive office of the death of a 18
1432	1432	beneficiary of Medicaid benefits who was fifty-five (55) years of age or older at the date of death, 19
1433	1433	and to provide a statement identifying the decedent’s property and the names and addresses of all 20
1434	1434	persons entitled to take any share or interest of the estate as legatees or distributees thereof. 21
1435	1435	(c) The amount of reimbursement for Medicaid benefits imposed under this section shall 22
1436	1436	also become a debt to the state from the person or entity liable for the payment thereof. 23
1437	1437	(d) Upon payment of the amount of reimbursement for Medicaid benefits imposed by this 24
1438	1438	section, the secretary of the executive office, or his or her designee, shall issue a written discharge 25
1439	1439	of lien. 26
1440	1440	(e) Provided, however, that no lien created under this section shall attach nor become 27
1441	1441	effective upon any real property unless and until a statement of claim is recorded naming the 28
1442	1442	debtor/owner of record of the property as of the date and time of recording of the statement of 29
1443	1443	claim, and describing the real property by a description containing all of the following: (1) Tax 30
1444	1444	assessor’s plat and lot; and (2) Street address. The statement of claim shall be recorded in the 31
1445	1445	records of land evidence in the town or city where the real property is situated. Notice of the lien 32
1446	1446	shall be sent to the duly appointed executor or administrator, the decedent’s legal representative, if 33
1447	1447	known, or to the decedent’s next of kin or heirs at law as stated in the decedent’s last application 34
1448	1448
1449	1449
1450	1450	LC000271 - Page 40 of 93
1451	1451	for Medicaid benefits. 1
1452	1452	(f) The executive office shall establish procedures, in accordance with the standards 2
1453	1453	specified by the Secretary, United States Department of Health and Human Services, under which 3
1454	1454	the executive office shall waive, in whole or in part, the lien and reimbursement established by this 4
1455	1455	section if the lien and reimbursement would cause an undue hardship, as determined by the 5
1456	1456	executive office, on the basis of the criteria established by the secretary in accordance with 42 6
1457	1457	U.S.C. § 1396p(b)(3). 7
1458	1458	(g) Upon the filing of a petition for admission to probate of a decedent’s will or for 8
1459	1459	administration of a decedent’s estate, when the decedent was fifty-five (55) years or older at the 9
1460	1460	time of death, a copy of the petition and a copy of the death certificate shall be sent to the executive 10
1461	1461	office. Within thirty (30) days of a request by the executive office, an executor or administrator 11
1462	1462	shall complete and send to the executive office a form prescribed by that office and shall provide 12
1463	1463	such additional information as the office may require. In the event a petitioner fails to send a copy 13
1464	1464	of the petition and a copy of the death certificate to the executive office and a decedent has received 14
1465	1465	Medicaid benefits for which the executive office is authorized to recover, no distribution and/or 15
1466	1466	payments, including administration fees, shall be disbursed. Any person and/or entity that receives 16
1467	1467	a distribution of assets from the decedent’s estate shall be liable to the executive office to the extent 17
1468	1468	of such distribution. 18
1469	1469	(h) Compliance with the provisions of this section shall be consistent with the requirements 19
1470	1470	set forth in § 33-11-5 and the requirements of the affidavit of notice set forth in § 33-11-5.2. Nothing 20
1471	1471	in these sections shall limit the executive office from recovery, to the extent of the distribution, in 21
1472	1472	accordance with all state and federal laws. 22
1473	1473	(i) To ensure the financial integrity of the Medicaid eligibility determination, benefit 23
1474	1474	renewal, and estate recovery processes in this and related sections, the secretary of health and 24
1475	1475	human services is authorized and directed to, by no later than August 1, 2018: (1) Implement an 25
1476	1476	automated asset verification system, as mandated by § 1940 of the Act, that uses electronic data 26
1477	1477	sources to verify the ownership and value of countable resources held in financial institutions and 27
1478	1478	any real property for applicants and beneficiaries subject to resource and asset tests pursuant to the 28
1479	1479	Act in § 1902(e)(14)(D); (2) Apply the provisions required under §§ 1902(a)(18) and 1917(c) of 29
1480	1480	the Act pertaining to the disposition of assets for less than fair market value by applicants and 30
1481	1481	beneficiaries for Medicaid long-term services and supports and their spouses, without regard to 31
1482	1482	whether they are subject to or exempted from resources and asset tests as mandated by federal 32
1483	1483	guidance; and (3) Pursue any state plan or waiver amendments from the United States Centers for 33
1484	1484	Medicare and Medicaid Services and promulgate such rules, regulations, and procedures he or she 34
1485	1485
1486	1486
1487	1487	LC000271 - Page 41 of 93
1488	1488	deems necessary to carry out the requirements set forth herein and ensure the state plan and 1
1489	1489	Medicaid policy conform and comply with applicable provisions of Title XIX. 2
1490	1490	40-8-19.2. Nursing Facility Incentive Program (NFIP). 3
1491	1491	The secretary of the executive office of health and human services is authorized to seek the 4
1492	1492	federal authority required to implement a nursing facility incentive program (NFIP). The NFIP 5
1493	1493	shall provide the participating licensed nursing facilities the ability to obtain certain payments for 6
1494	1494	achieving performance goals established by the secretary. NFIP payments shall commence no 7
1495	1495	earlier than July 1, 2016. 8
1496	1496	40-8-27. Cooperation by providers. 9
1497	1497	Medicaid providers who employ individuals applying for benefits under any chapter of this 10
1498	1498	title shall comply in a timely manner with requests made by the department for any documents 11
1499	1499	describing employer-sponsored health insurance coverage or benefits the provider offers that are 12
1500	1500	necessary to determine eligibility for the state’s premium assistance program pursuant to § 40-8.4-13
1501	1501	12. Documents requested by the department may include, but are not limited to, certificates of 14
1502	1502	coverage or a summary of benefits and employee obligations. Upon receiving notification that the 15
1503	1503	department has determined that the employee is eligible for premium assistance under § 40-8.4-12, 16
1504	1504	the provider shall accept the enrollment of the employee and his or her family in the employer-17
1505	1505	based health insurance plan without regard to any seasonal enrollment restrictions, including open-18
1506	1506	enrollment restrictions, and/or the impact on the employee’s wages. Additionally, the Medicaid 19
1507	1507	provider employing such persons shall not offer “pay in lieu of benefits.” Providers who do not 20
1508	1508	comply with the provisions set forth in this section shall be subject to suspension as a participating 21
1509	1509	Medicaid provider. 22
1510	1510	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
1511	1511	of the General Laws in Chapter 40-8.4 entitled "Health Care for Families" are hereby amended to 24
1512	1512	read as follows: 25
1513	1513	40-8.4-4. Eligibility. 26
1514	1514	(a) Medical assistance for families. There is hereby established a category of medical 27
1515	1515	assistance eligibility pursuant to § 1931 of Title XIX of the Social Security Act, 42 U.S.C. § 1396u-28
1516	1516	1, for families whose income and resources are no greater than the standards in effect in the aid to 29
1517	1517	families with dependent children program on July 16, 1996, or such increased standards as the 30
1518	1518	department may determine. The executive office of health and human services is directed to amend 31
1519	1519	the medical assistance Title XIX state plan and to submit to the United States Department of Health 32
1520	1520	and Human Services an amendment to the RIte Care waiver project to provide for medical 33
1521	1521	assistance coverage to families under this chapter in the same amount, scope, and duration as 34
1522	1522
1523	1523
1524	1524	LC000271 - Page 42 of 93
1525	1525	coverage provided to comparable groups under the waiver. The department is further authorized 1
1526	1526	and directed to submit amendments and/or requests for waivers to the Title XXI state plan as may 2
1527	1527	be necessary to maximize federal contribution for provision of medical assistance coverage 3
1528	1528	provided pursuant to this chapter, including providing medical coverage as a “qualified state” in 4
1529	1529	accordance with Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. Implementation 5
1530	1530	of expanded coverage under this chapter shall not be delayed pending federal review of any Title 6
1531	1531	XXI amendment or waiver. 7
1532	1532	(b) Income. The secretary of the executive office of health and human services is authorized 8
1533	1533	and directed to amend the medical assistance Title XIX state plan or RIte Care waiver to provide 9
1534	1534	medical assistance coverage through expanded income disregards or other methodology for parents 10
1535	1535	or relative caretakers whose income levels are below one hundred thirty-three percent (133%) of 11
1536	1536	the federal poverty level. 12
1537	1537	(c) Healthcare coverage provided under this section shall also be provided without regard 13
1538	1538	to availability of federal financial participation to a noncitizen family member who is a resident of 14
1539	1539	Rhode Island, and who is otherwise eligible for such assistance. The department is further 15
1540	1540	authorized to promulgate any regulations necessary, and in accord with title XIX [42 U.S.C. § 1396 16
1541	1541	et seq.] and title XXI [42 U.S.C. § 1397 et seq.] of the Social Security Act as necessary in order to 17
1542	1542	implement the state plan amendment. The executive office of health and human services is directed 18
1543	1543	to ensure that federal financial participation is assessed to the maximum extent allowable to provide 19
1544	1544	coverage pursuant to this section, at least every two (2) years, and that state-only funds will be used 20
1545	1545	only if federal financial participation is not available. 21
1546	1546	40-8.4-5. Managed care. 22
1547	1547	The delivery and financing of the healthcare services provided under this chapter shall may 23
1548	1548	be provided through a system of managed care. A managed care system integrates an efficient 24
1549	1549	financing mechanism with quality service delivery; provides a “medical home” to ensure 25
1550	1550	appropriate care and deter unnecessary and inappropriate care; and places emphasis on preventive 26
1551	1551	and primary health care. Beginning July 1, 2029, all payments shall be provided directly by the 27
1552	1552	state without an intermediate payment to a managed care entity or other form of health insurance 28
1553	1553	company, unless it is owned by the state. Beginning July 1, 2025, no new contracts may be entered 29
1554	1554	into between the Medicaid office and an intermediate payor such as a managed care entity or other 30
1555	1555	form of health insurance company for the payment of healthcare services pursuant to this chapter, 31
1556	1556	unless it is owned by the state. 32
1557	1557	40-8.4-10. Regulations. 33
1558	1558	(a) The department of human services Medicaid director is authorized to promulgate any 34
1559	1559
1560	1560
1561	1561	LC000271 - Page 43 of 93
1562	1562	regulations necessary to implement this chapter. 1
1563	1563	(b) When promulgating any rule or regulation necessary to implement this chapter, or any 2
1564	1564	rule or regulation related to RIte Care, the department Medicaid director shall send the notice 3
1565	1565	referred to in § 42-35-3 and a true copy of the rule referred to in § 42-35-4 of the Rhode Island 4
1566	1566	administrative procedures act to each of the co-chairpersons of the permanent joint committee on 5
1567	1567	health care oversight established by § 40-8.4-14. 6
1568	1568	40-8.4-12. RIte Share health insurance premium assistance program. 7
1569	1569	(a) Basic RIte Share health insurance premium assistance program. Under the terms 8
1570	1570	of Section 1906 of Title XIX of the U.S. Social Security Act, 42 U.S.C. § 1396e, states are permitted 9
1571	1571	to pay a Medicaid-eligible person’s share of the costs for enrolling in employer-sponsored health 10
1572	1572	insurance (ESI) coverage if it is cost-effective to do so. Pursuant to the general assembly’s direction 11
1573	1573	in the Rhode Island health reform act of 2000, the Medicaid agency requested and obtained federal 12
1574	1574	approval under § 1916, 42 U.S.C. § 1396o, to establish the RIte Share premium assistance program 13
1575	1575	to subsidize the costs of enrolling Medicaid-eligible persons and families in employer-sponsored 14
1576	1576	health insurance plans that have been approved as meeting certain cost and coverage requirements. 15
1577	1577	The Medicaid agency also obtained, at the general assembly’s direction, federal authority to require 16
1578	1578	any such persons with access to ESI coverage to enroll as a condition of retaining eligibility 17
1579	1579	providing that doing so meets the criteria established in Title XIX for obtaining federal matching 18
1580	1580	funds. 19
1581	1581	(b) Definitions. For the purposes of this section, the following definitions apply: 20
1582	1582	(1) “Cost-effective” means that the portion of the ESI that the state would subsidize, as 21
1583	1583	well as wrap-around costs, would on average cost less to the state than enrolling that same 22
1584	1584	person/family in a managed-care delivery system. 23
1585	1585	(2) “Cost sharing” means any co-payments, deductibles, or co-insurance associated with 24
1586	1586	ESI. 25
1587	1587	(3) “Employee premium” means the monthly premium share a person or family is required 26
1588	1588	to pay to the employer to obtain and maintain ESI coverage. 27
1589	1589	(4) “Employer-sponsored insurance” or “ESI” means health insurance or a group health 28
1590	1590	plan offered to employees by an employer. This includes plans purchased by small employers 29
1591	1591	through the state health insurance marketplace, healthsource, RI (HSRI). 30
1592	1592	(5) “Policy holder” means the person in the household with access to ESI, typically the 31
1593	1593	employee. 32
1594	1594	(6) “RIte Share-approved employer-sponsored insurance (ESI)” means an employer-33
1595	1595	sponsored health insurance plan that meets the coverage and cost-effectiveness criteria for RIte 34
1596	1596
1597	1597
1598	1598	LC000271 - Page 44 of 93
1599	1599	Share. 1
1600	1600	(7) “RIte Share buy-in” means the monthly amount an Medicaid-ineligible policy holder 2
1601	1601	must pay toward RIte Share-approved ESI that covers the Medicaid-eligible children, young adults, 3
1602	1602	or spouses with access to the ESI. The buy-in only applies in instances when household income is 4
1603	1603	above one hundred fifty percent (150%) of the FPL. 5
1604	1604	(8) “RIte Share premium assistance program” means the Rhode Island Medicaid premium 6
1605	1605	assistance program in which the State pays the eligible Medicaid member’s share of the cost of 7
1606	1606	enrolling in a RIte Share-approved ESI plan. This allows the state to share the cost of the health 8
1607	1607	insurance coverage with the employer. 9
1608	1608	(9) “RIte Share unit” means the entity within the executive office of health and human 10
1609	1609	services (EOHHS) responsible for assessing the cost-effectiveness of ESI, contacting employers 11
1610	1610	about ESI as appropriate, initiating the RIte Share enrollment and disenrollment process, handling 12
1611	1611	member communications, and managing the overall operations of the RIte Share program. 13
1612	1612	(10) “Third-party liability (TPL)” means other health insurance coverage. This insurance 14
1613	1613	is in addition to Medicaid and is usually provided through an employer. Since Medicaid is always 15
1614	1614	the payer of last resort, the TPL is always the primary coverage. 16
1615	1615	(11) “Wrap-around services or coverage” means any healthcare services not included in 17
1616	1616	the ESI plan that would have been covered had the Medicaid member been enrolled in a RIte Care 18
1617	1617	or Rhody Health Partners plan. Coverage of deductibles and co-insurance is included in the wrap. 19
1618	1618	Co-payments to providers are not covered as part of the wrap-around coverage. 20
1619	1619	(c) RIte Share populations. Medicaid beneficiaries subject to eligible for RIte Share 21
1620	1620	include: children, families, parent and caretakers eligible for Medicaid or the children’s health 22
1621	1621	insurance program (CHIP) under this chapter or chapter 12.3 of title 42; and adults between the 23
1622	1622	ages of nineteen (19) and sixty-four (64) who are eligible under chapter 8.12 of this title, not 24
1623	1623	receiving or eligible to receive Medicare, and are enrolled in managed care delivery systems. The 25
1624	1624	following conditions apply: 26
1625	1625	(1) The income of Medicaid beneficiaries shall affect whether and in what manner they 27
1626	1626	must may participate in RIte Share as follows: 28
1627	1627	(i) Income at or below one hundred fifty percent (150%) of FPL — Persons and families 29
1628	1628	determined to have household income at or below one hundred fifty percent (150%) of the federal 30
1629	1629	poverty level (FPL) guidelines based on the modified adjusted gross income (MAGI) standard or 31
1630	1630	other standard approved by the secretary are required to participate in RIte Share if a Medicaid-32
1631	1631	eligible adult or parent/caretaker has access to cost-effective ESI. Enrolling in ESI through RIte 33
1632	1632	Share shall be a condition of maintaining Medicaid health coverage for any eligible adult with 34
1633	1633
1634	1634
1635	1635	LC000271 - Page 45 of 93
1636	1636	access to such coverage. 1
1637	1637	(ii) Income above one hundred fifty percent (150%) of FPL and policy holder is not 2
1638	1638	Medicaid-eligible — Premium assistance is available when the household includes Medicaid-3
1639	1639	eligible members, but the ESI policy holder (typically a parent/caretaker, or spouse) is not eligible 4
1640	1640	for Medicaid. Premium assistance for parents/caretakers and other household members who are not 5
1641	1641	Medicaid-eligible may be provided in circumstances when enrollment of the Medicaid-eligible 6
1642	1642	family members in the approved ESI plan is contingent upon enrollment of the ineligible policy 7
1643	1643	holder and the executive office of health and human services (executive office) determines, based 8
1644	1644	on a methodology adopted for such purposes, that it is cost-effective to provide premium assistance 9
1645	1645	for family or spousal coverage. 10
1646	1646	(d) RIte Share enrollment as not a condition of eligibility. RIte Share enrollment shall 11
1647	1647	be purely voluntary and shall never be a condition of eligibility for Medicaid. For Medicaid 12
1648	1648	beneficiaries over the age of nineteen (19), enrollment in RIte Share shall be a condition of 13
1649	1649	eligibility except as exempted below and by regulations promulgated by the executive office. 14
1650	1650	(1) Medicaid-eligible children and young adults up to age nineteen (19) shall not be 15
1651	1651	required to enroll in a parent/caretaker relative’s ESI as a condition of maintaining Medicaid 16
1652	1652	eligibility if the person with access to RIte Share-approved ESI does not enroll as required. These 17
1653	1653	Medicaid-eligible children and young adults shall remain eligible for Medicaid and shall be 18
1654	1654	enrolled in a RIte Care plan. 19
1655	1655	(2) There shall be a limited six-month (6) exemption from the mandatory enrollment 20
1656	1656	requirement for persons participating in the RI works program pursuant to chapter 5.2 of this title. 21
1657	1657	(e) Approval of health insurance plans for premium assistance. The executive office of 22
1658	1658	health and human services shall adopt regulations providing for the approval of employer-based 23
1659	1659	health insurance plans for premium assistance and shall approve employer-based health insurance 24
1660	1660	plans based on these regulations. In order for an employer-based health insurance plan to gain 25
1661	1661	approval, the executive office must determine that the benefits offered by the employer-based 26
1662	1662	health insurance plan are substantially similar in amount, scope, and duration to the benefits 27
1663	1663	provided to Medicaid-eligible persons enrolled in a Medicaid managed care plan, when the plan is 28
1664	1664	evaluated in conjunction with available supplemental benefits provided by the office. The office 29
1665	1665	shall obtain and make available to persons otherwise eligible for Medicaid identified in this section 30
1666	1666	as supplemental benefits those benefits not reasonably available under employer-based health 31
1667	1667	insurance plans that are required for Medicaid beneficiaries by state law or federal law or 32
1668	1668	regulation. Once it has been determined by the Medicaid agency that the ESI offered by a particular 33
1669	1669	employer is RIte Share-approved, all Medicaid members with access to that employer’s plan are 34
1670	1670
1671	1671
1672	1672	LC000271 - Page 46 of 93
1673	1673	required to participate in RIte Share. Failure to meet the mandatory enrollment requirement shall 1
1674	1674	result in the termination of the Medicaid eligibility of the policy holder and other Medicaid 2
1675	1675	members nineteen (19) or older in the household who could be covered under the ESI until the 3
1676	1676	policy holder complies with the RIte Share enrollment procedures established by the executive 4
1677	1677	office. 5
1678	1678	(f) Premium assistance. The executive office shall provide premium assistance by paying 6
1679	1679	all or a portion of the employee’s cost for covering the eligible person and/or his or her family 7
1680	1680	under such a RIte Share-approved ESI plan subject to the buy-in provisions in this section. 8
1681	1681	(g) Buy-in. Persons who can afford it shall share in the cost. — The executive office is 9
1682	1682	authorized and directed to apply for and obtain any necessary state plan and/or waiver amendments 10
1683	1683	from the Secretary of the United States Department of Health and Human Services (DHHS) to 11
1684	1684	require that persons enrolled in a RIte Share-approved employer-based health plan who have 12
1685	1685	income equal to or greater than one hundred fifty percent (150%) of the FPL to buy-in to pay a 13
1686	1686	share of the costs based on the ability to pay, provided that the buy-in cost shall not exceed five 14
1687	1687	percent (5%) of the person’s annual income. The executive office shall implement the buy-in by 15
1688	1688	regulation, and shall consider co-payments, premium shares, or other reasonable means to do so. 16
1689	1689	(h) Maximization of federal contribution. The executive office of health and human 17
1690	1690	services is authorized and directed to apply for and obtain federal approvals and waivers necessary 18
1691	1691	to maximize the federal contribution for provision of medical assistance coverage under this 19
1692	1692	section, including the authorization to amend the Title XXI state plan and to obtain any waivers 20
1693	1693	necessary to reduce barriers to provide premium assistance to recipients as provided for in Title 21
1694	1694	XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. 22
1695	1695	(i) Implementation by regulation. The executive office of health and human services is 23
1696	1696	authorized and directed to adopt regulations to ensure the establishment and implementation of the 24
1697	1697	premium assistance program in accordance with the intent and purpose of this section, the 25
1698	1698	requirements of Title XIX, Title XXI, and any approved federal waivers. 26
1699	1699	(j) Outreach and reporting. The executive office of health and human services shall 27
1700	1700	develop a plan to identify Medicaid-eligible individuals who have access to employer-sponsored 28
1701	1701	insurance and increase the use of RIte Share benefits. Beginning October 1, 2019, the executive 29
1702	1702	office shall submit the plan to be included as part of the reporting requirements under § 35-17-1. 30
1703	1703	Starting January 1, 2020, the executive office of health and human services shall include the number 31
1704	1704	of Medicaid recipients with access to employer-sponsored insurance, the number of plans that did 32
1705	1705	not meet the cost-effectiveness criteria for RIte Share, and enrollment in the premium assistance 33
1706	1706	program as part of the reporting requirements under § 35-17-1. 34
1707	1707
1708	1708
1709	1709	LC000271 - Page 47 of 93
1710	1710	(k) Employer-sponsored insurance. The executive office of health and human services 1
1711	1711	shall dedicate staff and resources to reporting monthly as part of the requirements under § 35-17-1 2
1712	1712	which employer-sponsored insurance plans meet the cost-effectiveness criteria for RIte Share. 3
1713	1713	Information in the report shall be used for screening for Medicaid enrollment to encourage Rite 4
1714	1714	Share participation. By October 1, 2021, the report shall include any employers with 300 or more 5
1715	1715	employees. By January 1, 2022, the report shall include employers with 100 or more employees. 6
1716	1716	The January report shall also be provided to the chairperson of the house finance committee; the 7
1717	1717	chairperson of the senate finance committee; the house fiscal advisor; the senate fiscal advisor; and 8
1718	1718	the state budget officer. 9
1719	1719	40-8.4-15. Advisory commission on health care. 10
1720	1720	(a) There is hereby established an advisory commission to be known as the “advisory 11
1721	1721	commission on health care” to advise the director of the department of human services on all 12
1722	1722	matters relating to the RIte Care and RIte Share programs, and other matters concerning access for 13
1723	1723	all Rhode Islanders to quality health care in the most affordable, economical manner. The director 14
1724	1724	of the department of human services shall serve ex officio as chairperson. The director shall appoint 15
1725	1725	the eighteen (18) members: 16
1726	1726	(1) Three (3) of whom shall represent the healthcare providers; 17
1727	1727	(2) Three (3) of whom shall represent the healthcare insurers; 18
1728	1728	(3)(2) Three (3) of whom shall represent healthcare consumers or consumer organizations; 19
1729	1729	(4)(3) Two (2) of whom shall represent organized labor; 20
1730	1730	(5)(4) One of whom shall be the health care advocate in the office of the attorney general; 21
1731	1731	and 22
1732	1732	(6) Three (3) of whom shall represent employers; and 23
1733	1733	(7)(5) Three (3) Nine (9) of whom shall be other members of the public. 24
1734	1734	(b) The commission may study all aspects of the provisions of the RIte Care and RIte Share 25
1735	1735	programs involving purchasers of health care, including employers, consumers, and the state, health 26
1736	1736	insurers, providers of health care, and healthcare facilities, and all matters related to the interaction 27
1737	1737	among these groups, including methods to achieve more effective and timely resolution of disputes, 28
1738	1738	better communication, speedier, more reliable and less-costly administrative processes, claims, 29
1739	1739	payments, and other reimbursement matters, and the application of new processes or technologies 30
1740	1740	to such issues. 31
1741	1741	(c) Members of the commission shall be appointed in the month of July, each to hold office 32
1742	1742	until the last day of June in the second year of his or her appointment or until his or her successor 33
1743	1743	is appointed by the director. 34
1744	1744
1745	1745
1746	1746	LC000271 - Page 48 of 93
1747	1747	(d) The commission shall meet at least quarterly, and the initial meeting of the commission 1
1748	1748	shall take place on or before September 15, 2000. The commission may meet more frequently than 2
1749	1749	quarterly at the call of the chair or at the call of any three (3) members of the commission. 3
1750	1750	(e) Members of the permanent joint committee on health care oversight established 4
1751	1751	pursuant to § 40-8.4-14 shall be notified of each meeting of the commission and shall be invited to 5
1752	1752	participate. 6
1753	1753	40-8.4-19. Managed healthcare delivery systems for families. Cost sharing. 7
1754	1754	(a) Notwithstanding any other provision of state law, the delivery and financing of the 8
1755	1755	healthcare services provided under this chapter shall be provided through a system of managed 9
1756	1756	care. “Managed care” is defined as systems that: integrate an efficient financing mechanism with 10
1757	1757	quality service delivery; provide a “medical home” to ensure appropriate care and deter 11
1758	1758	unnecessary services; and place emphasis on preventive and primary care. 12
1759	1759	(b) Enrollment in managed care health delivery systems is mandatory for individuals 13
1760	1760	eligible for medical assistance under this chapter. This includes children in substitute care, children 14
1761	1761	receiving medical assistance through an adoption subsidy, and children eligible for medical 15
1762	1762	assistance based on their disability. Beneficiaries with third-party medical coverage or insurance 16
1763	1763	may be exempt from mandatory managed care in accordance with rules and regulations 17
1764	1764	promulgated by the department of human services for such purposes. 18
1765	1765	(c) Individuals who can afford to contribute shall share in the cost. The department of 19
1766	1766	human services is authorized and directed to apply for and obtain any necessary waivers and/or 20
1767	1767	state plan amendments from the Secretary of the United States Department of Health and Human 21
1768	1768	Services, including, but not limited to, a waiver of the appropriate sections of Title XIX, 42 U.S.C. 22
1769	1769	§ 1396 et seq., to require that beneficiaries eligible under this chapter or chapter 12.3 of title 42, 23
1770	1770	with incomes equal to or greater than one hundred fifty percent (150%) of the federal poverty level, 24
1771	1771	pay a share of the costs of health coverage based on the ability to pay. The department of human 25
1772	1772	services shall implement this cost-sharing obligation by regulation, and shall consider co-payments, 26
1773	1773	premium shares, or other reasonable means to do so in accordance with approved provisions of 27
1774	1774	appropriate waivers and/or state plan amendments approved by the Secretary of the United States 28
1775	1775	Department of Health and Human Services. 29
1776	1776	SECTION 10. Section 40-8.4-13 of the General Laws in Chapter 40-8.4 entitled "Health 30
1777	1777	Care for Families" is hereby repealed. 31
1778	1778	40-8.4-13. Utilization of available employer-based health insurance. 32
1779	1779	To the extent permitted under Titles XIX and XXI of the Social Security Act, 42 U.S.C. § 33
1780	1780	1396 et seq. and 42 U.S.C. § 1397aa et seq., or by waiver from the Secretary of the United States 34
1781	1781
1782	1782
1783	1783	LC000271 - Page 49 of 93
1784	1784	Department of Health and Human Services, the department of human services shall adopt 1
1785	1785	regulations to restrict eligibility for RIte Care under this chapter and/or chapter 12.3 of title 42, or 2
1786	1786	the RIte Share program under § 40-8.4-12, for certain periods of time for certain individuals or 3
1787	1787	families who have access to, or have refused or terminated employer-based health insurance and 4
1788	1788	for certain periods of time for certain individuals but not including children whose employer has 5
1789	1789	terminated their employer-based health insurance. The department is authorized and directed to 6
1790	1790	amend the medical assistance Title XIX and XXI state plans, and/or to seek and obtain appropriate 7
1791	1791	federal approvals or waivers to implement this section. 8
1792	1792	SECTION 11. Sections 40-8.5-1 and 40-8.5-1.1 of the General Laws in Chapter 40-8.5 9
1793	1793	entitled "Health Care for Elderly and Disabled Residents Act" are hereby amended to read as 10
1794	1794	follows: 11
1795	1795	40-8.5-1. Categorically needy medical assistance coverage. 12
1796	1796	The department of human services is hereby authorized and directed to amend its Title XIX 13
1797	1797	state plan to provide for categorically needy medical assistance coverage as permitted pursuant to 14
1798	1798	Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., as amended, to individuals who are 15
1799	1799	sixty-five (65) years or older or are disabled, as determined under § 1614(a)(3) of the Social 16
1800	1800	Security Act, 42 U.S.C. § 1382c(a)(3), as amended, whose income does not exceed one hundred 17
1801	1801	percent (100%) one hundred thirty-three percent (133%) of the federal poverty level (as revised 18
1802	1802	annually) applicable to the individual’s family size, and whose resources do not exceed four 19
1803	1803	thousand dollars ($4,000) per individual, or six thousand dollars ($6,000) per couple. The 20
1804	1804	department shall provide medical assistance coverage to such elderly or disabled persons in the 21
1805	1805	same amount, duration, and scope as provided to other categorically needy persons under the state’s 22
1806	1806	Title XIX state plan. 23
1807	1807	40-8.5-1.1. Managed healthcare delivery systems. 24
1808	1808	(a) The delivery and financing of the healthcare services provided under this chapter may 25
1809	1809	be provided through a system of managed care. Beginning July 1, 2029, all payments shall be 26
1810	1810	provided directly by the state without an intermediate payment to a managed care entity or other 27
1811	1811	form of health insurance company. Beginning July 1, 2025, no new contracts may be entered into 28
1812	1812	between the Medicaid office and an intermediate payor such as a managed care entity or other form 29
1813	1813	of health insurance company for the payment of healthcare services pursuant to this chapter. To 30
1814	1814	ensure that all medical assistance beneficiaries, including the elderly and all individuals with 31
1815	1815	disabilities, have access to quality and affordable health care, the executive office of health and 32
1816	1816	human services (“executive office”) is authorized to implement mandatory managed-care health 33
1817	1817	systems. 34
1818	1818
1819	1819
1820	1820	LC000271 - Page 50 of 93
1821	1821	(b) “Managed care” is defined as systems that: integrate an efficient financing mechanism 1
1822	1822	with quality service delivery; provide a “medical home” to ensure appropriate care and deter 2
1823	1823	unnecessary services; and place emphasis on preventive and primary care. For purposes of this 3
1824	1824	section, managed care systems may also be defined to include a primary care case-management 4
1825	1825	model, community health teams, and/or other such arrangements that meet standards established 5
1826	1826	by the executive office and serve the purposes of this section. Managed care systems may also 6
1827	1827	include services and supports that optimize the health and independence of beneficiaries who are 7
1828	1828	determined to need Medicaid-funded long-term care under chapter 8.10 of this title or to be at risk 8
1829	1829	for the care under applicable federal state plan or waiver authorities and the rules and regulations 9
1830	1830	promulgated by the executive office. Any Medicaid beneficiaries who have third-party medical 10
1831	1831	coverage or insurance may be provided such services through an entity certified by, or in a 11
1832	1832	contractual arrangement with, the executive office or, as deemed appropriate, exempt from 12
1833	1833	mandatory managed care in accordance with rules and regulations promulgated by the executive 13
1834	1834	office. 14
1835	1835	(c) In accordance with § 42-12.4-7, the executive office is authorized to obtain any approval 15
1836	1836	through waiver(s), category II or III changes, and/or state-plan amendments, from the Secretary of 16
1837	1837	the United States Department of Health and Human Services, that are necessary to implement 17
1838	1838	mandatory, managed healthcare delivery systems for all Medicaid beneficiaries. The waiver(s), 18
1839	1839	category II or III changes, and/or state-plan amendments shall include the authorization to extend 19
1840	1840	managed care to cover long-term-care services and supports. Authorization shall also include, as 20
1841	1841	deemed appropriate, exempting certain beneficiaries with third-party medical coverage or 21
1842	1842	insurance from mandatory managed care in accordance with rules and regulations promulgated by 22
1843	1843	the executive office. 23
1844	1844	(d)(b) To ensure the delivery of timely and appropriate services to persons who become 24
1845	1845	eligible for Medicaid by virtue of their eligibility for a United States Social Security Administration 25
1846	1846	program, the executive office is authorized to seek any and all data-sharing agreements or other 26
1847	1847	agreements with the Social Security Administration as may be necessary to receive timely and 27
1848	1848	accurate diagnostic data and clinical assessments. This information shall be used exclusively for 28
1849	1849	the purpose of service planning, and shall be held and exchanged in accordance with all applicable 29
1850	1850	state and federal medical record confidentiality laws and regulations. 30
1851	1851	SECTION 12. Sections 40-8.12-2 and 40-8.12-3 of the General Laws in Chapter 40-8.12 31
1852	1852	entitled "Health Care for Adults" are hereby amended to read as follows: 32
1853	1853	40-8.12-2. Eligibility. 33
1854	1854	(a) Medicaid coverage for nonpregnant adults without children. There is hereby 34
1855	1855
1856	1856
1857	1857	LC000271 - Page 51 of 93
1858	1858	established, effective January 1, 2014, a category of Medicaid eligibility pursuant to Title XIX of 1
1859	1859	the Social Security Act, as amended by the U.S. Patient Protection and Affordable Care Act (ACA) 2
1860	1860	of 2010, 42 U.S.C. § 1396u-1, for adults ages nineteen (19) to sixty-four (64) who do not have 3
1861	1861	dependent children and do not qualify for Medicaid under Rhode Island general laws applying to 4
1862	1862	families with children and adults who are blind, aged, or living with a disability. The executive 5
1863	1863	office of health and human services is directed to make any amendments to the Medicaid state plan 6
1864	1864	and waiver authorities established under Title XIX necessary to implement this expansion in 7
1865	1865	eligibility and ensure the maximum federal contribution for health insurance coverage provided 8
1866	1866	pursuant to this chapter. 9
1867	1867	(b) Income. The secretary of the executive office of health and human services is authorized 10
1868	1868	and directed to amend the Medicaid Title XIX state plan and, as deemed necessary, any waiver 11
1869	1869	authority to effectuate this expansion of coverage to any Rhode Islander who qualifies for Medicaid 12
1870	1870	eligibility under this chapter with income at or below one hundred and thirty-three percent (133%) 13
1871	1871	of the federal poverty level, based on modified adjusted-gross income. 14
1872	1872	(c) Delivery system. The executive office of health and human services is authorized and 15
1873	1873	directed to apply for and obtain any waiver authorities necessary to provide persons eligible under 16
1874	1874	this chapter with managed, coordinated healthcare coverage consistent with the principles set forth 17
1875	1875	in chapter 12.4 of title 42, pertaining to a healthcare home. Beginning July 1, 2029, all payments 18
1876	1876	shall be provided directly by the state without an intermediate payment to a managed care entity or 19
1877	1877	other form of health insurance company. Beginning July 1, 2025, no new contracts may be entered 20
1878	1878	into between the Medicaid office and an intermediate payor such as a managed care entity or other 21
1879	1879	form of health insurance company for the payment of healthcare services pursuant to this chapter. 22
1880	1880	40-8.12-3. Premium assistance program. 23
1881	1881	(a) The executive office of health and human services is directed to amend its rules and 24
1882	1882	regulations to implement a premium assistance program for adults with dependent children, 25
1883	1883	enrolled in the state’s health-benefits exchange, whose annual income and resources meet the 26
1884	1884	guidelines established in § 40-8.4-4 in effect on December 1, 2013. The premium assistance will 27
1885	1885	pay one-half of the cost of a commercial plan that a parent may incur after subtracting the cost-28
1886	1886	sharing requirement under § 40-8.4-4 as of December 31, 2013, and any applicable federal tax 29
1887	1887	credits available. The office is also directed to amend the 1115 waiver demonstration extension and 30
1888	1888	the medical assistance Title XIX state plan for this program if it is determined that it is eligible for 31
1889	1889	funding pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. 32
1890	1890	(b) The executive office of health and human services shall require any individual receiving 33
1891	1891	benefits under a state-funded, healthcare assistance program to apply for any health insurance for 34
1892	1892
1893	1893
1894	1894	LC000271 - Page 52 of 93
1895	1895	which he or she is eligible, including health insurance available through the health benefits 1
1896	1896	exchange. Nothing shall preclude the state from using funds appropriated for Affordable Care Act 2
1897	1897	transition expenses to reduce the impact on an individual who has been transitioned from a state 3
1898	1898	program to a health insurance plan available through the health benefits exchange. It shall not be 4
1899	1899	deemed cost-effective for the state if it would result in a loss of benefits or an increase in the cost 5
1900	1900	of healthcare services for the person above an amount deemed de minimus as determined by state 6
1901	1901	regulation. 7
1902	1902	SECTION 13. Chapter 40-8.13 of the General Laws entitled "Long-Term Managed Care 8
1903	1903	Arrangements" is hereby repealed in its entirety. 9
1904	1904	CHAPTER 40-8.13 10
1905	1905	Long-Term Managed Care Arrangements 11
1906	1906	40-8.13-1. Definitions. 12
1907	1907	For purposes of this section the following terms shall have the meanings indicated: 13
1908	1908	(1) “Beneficiary” means an individual who is eligible for medical assistance under the 14
1909	1909	Rhode Island Medicaid state plan established in accordance with 42 U.S.C. § 1396, and includes 15
1910	1910	individuals who are additionally eligible for benefits under the Medicare program (42 U.S.C. § 16
1911	1911	1395 et seq.) or other health plan. 17
1912	1912	(2) “Duals demonstration project” means a demonstration project established pursuant to 18
1913	1913	the financial alignment demonstration established under section 2602 of the Patient Protection and 19
1914	1914	Affordable Care Act (Pub. L. No. 111-148) [42 U.S.C. § 1315b], involving a three-way contract 20
1915	1915	between Rhode Island, the federal Centers for Medicare and Medicaid Services (“CMS”), and 21
1916	1916	qualified health plans, and covering healthcare services provided to beneficiaries. 22
1917	1917	(3) “EOHHS” means the Rhode Island executive office of health and human services. 23
1918	1918	(4) “EOHHS level-of-care tool” refers to a set of criteria established by EOHHS and used 24
1919	1919	in January, 2014 to determine the long-term-care needs of a beneficiary as well as the appropriate 25
1920	1920	setting for delivery of that care. 26
1921	1921	(5) “Long-term-care services and supports” means a spectrum of services covered by the 27
1922	1922	Rhode Island Medicaid program and/or the Medicare program, that are required by individuals with 28
1923	1923	functional impairments and/or chronic illness, and includes skilled or custodial nursing facility 29
1924	1924	care, as well as various home- and community-based services. 30
1925	1925	(6) “Managed care organization” means any health plan, health-maintenance organization, 31
1926	1926	managed care plan, or other person or entity that enters into a contract with the state under which 32
1927	1927	it is granted the authority to arrange for the provision of, and/or payment for, long-term-care 33
1928	1928	supports and services to eligible beneficiaries under a managed long-term-care arrangement. 34
1929	1929
1930	1930
1931	1931	LC000271 - Page 53 of 93
1932	1932	(7) “Managed long-term-care arrangement” means any arrangement under which a 1
1933	1933	managed care organization is granted some or all of the responsibility for providing and/or paying 2
1934	1934	for long-term-care services and supports that would otherwise be provided or paid under the Rhode 3
1935	1935	Island Medicaid program. The term includes, but is not limited to, a duals demonstration project, 4
1936	1936	and/or phase I and phase II of the integrated care initiative established by the executive office of 5
1937	1937	health and human services. 6
1938	1938	(8) “Plan of care” means a care plan established by a nursing facility in accordance with 7
1939	1939	state and federal regulations and that identifies specific care and services provided to a beneficiary. 8
1940	1940	40-8.13-2. Beneficiary choice. 9
1941	1941	Any managed long-term-care arrangement shall offer beneficiaries the option to decline 10
1942	1942	participation and remain in traditional Medicaid and, if a duals demonstration project, traditional 11
1943	1943	Medicare. Beneficiaries must be provided with sufficient information to make an informed choice 12
1944	1944	regarding enrollment, including: 13
1945	1945	(1) Any changes in the beneficiary’s payment or other financial obligations with respect to 14
1946	1946	long-term-care services and supports as a result of enrollment; 15
1947	1947	(2) Any changes in the nature of the long-term-care services and supports available to the 16
1948	1948	beneficiary as a result of enrollment, including specific descriptions of new services that will be 17
1949	1949	available or existing services that will be curtailed or terminated; 18
1950	1950	(3) A contact person who can assist the beneficiary in making decisions about enrollment; 19
1951	1951	(4) Individualized information regarding whether the managed care organization’s network 20
1952	1952	includes the healthcare providers with whom beneficiaries have established provider relationships. 21
1953	1953	Directing beneficiaries to a website identifying the plan’s provider network shall not be sufficient 22
1954	1954	to satisfy this requirement; and 23
1955	1955	(5) The deadline by which the beneficiary must make a choice regarding enrollment, and 24
1956	1956	the length of time a beneficiary must remain enrolled in a managed care organization before being 25
1957	1957	permitted to change plans or opt out of the arrangement. 26
1958	1958	40-8.13-3. Ombudsman process. 27
1959	1959	EOHHS shall designate an ombudsperson to advocate for beneficiaries enrolled in a 28
1960	1960	managed long-term-care arrangement. The ombudsperson shall advocate for beneficiaries through 29
1961	1961	complaint and appeal processes and ensure that necessary healthcare services are provided. At the 30
1962	1962	time of enrollment, a managed care organization must inform enrollees of the availability of the 31
1963	1963	ombudsperson, including contact information. 32
1964	1964	40-8.13-4. Provider/plan liaison. 33
1965	1965	EOHHS shall designate an individual, not employed by or otherwise under contract with a 34
1966	1966
1967	1967
1968	1968	LC000271 - Page 54 of 93
1969	1969	participating managed care organization, who shall act as liaison between healthcare providers and 1
1970	1970	managed care organizations, for the purpose of facilitating communications and ensuring that issues 2
1971	1971	and concerns are promptly addressed. 3
1972	1972	40-8.13-5. Financial principles under managed care. 4
1973	1973	(a) To the extent that financial savings are a goal under any managed long-term-care 5
1974	1974	arrangement, it is the intent of the legislature to achieve savings through administrative efficiencies, 6
1975	1975	care coordination, improvements in care outcomes and in a way that encourages the highest quality 7
1976	1976	care for patients and maximizes value for the managed-care organization and the state. Therefore, 8
1977	1977	any managed long-term-care arrangement shall include a requirement that the managed care 9
1978	1978	organization reimburse providers for services in accordance with these principles. Notwithstanding 10
1979	1979	any law to the contrary, for the twelve-month (12) period beginning July 1, 2015, Medicaid 11
1980	1980	managed long-term-care payment rates to nursing facilities established pursuant to this section shall 12
1981	1981	not exceed ninety-eight percent (98.0%) of the rates in effect on April 1, 2015. 13
1982	1982	(1) For a duals demonstration project, the managed care organization: 14
1983	1983	(i) Shall not combine the rates of payment for post-acute skilled and rehabilitation care 15
1984	1984	provided by a nursing facility and long-term and chronic care provided by a nursing facility in order 16
1985	1985	to establish a single-payment rate for dual eligible beneficiaries requiring skilled nursing services; 17
1986	1986	(ii) Shall pay nursing facilities providing post-acute skilled and rehabilitation care or long-18
1987	1987	term and chronic care rates that reflect the different level of services and intensity required to 19
1988	1988	provide these services; and 20
1989	1989	(iii) For purposes of determining the appropriate rate for the type of care identified in 21
1990	1990	subsection (a)(1)(ii) of this section, the managed care organization shall pay no less than the rates 22
1991	1991	that would be paid for that care under traditional Medicare and Rhode Island Medicaid for these 23
1992	1992	service types. The managed care organization shall not, however, be required to use the same 24
1993	1993	payment methodology. 25
1994	1994	The state shall not enter into any agreement with a managed care organization in connection 26
1995	1995	with a duals demonstration project unless that agreement conforms to this section, and any existing 27
1996	1996	such agreement shall be amended as necessary to conform to this subsection. 28
1997	1997	(2) For a managed long-term-care arrangement that is not a duals demonstration project, 29
1998	1998	the managed care organization shall reimburse providers in an amount not less than the amount that 30
1999	1999	would be paid for the same care by the executive office of health and human services under the 31
2000	2000	Medicaid program. The managed care organization shall not, however, be required to use the same 32
2001	2001	payment methodology as the executive office of health and human services. 33
2002	2002	(3) Notwithstanding any provisions of the general or public laws to the contrary, the 34
2003	2003
2004	2004
2005	2005	LC000271 - Page 55 of 93
2006	2006	protections of subsections (a)(1) and (a)(2) of this section may be waived by a nursing facility in 1
2007	2007	the event it elects to accept a payment model developed jointly by the managed care organization 2
2008	2008	and skilled nursing facilities, that is intended to promote quality of care and cost-effectiveness, 3
2009	2009	including, but not limited to, bundled-payment initiatives, value-based purchasing arrangements, 4
2010	2010	gainsharing, and similar models. 5
2011	2011	(b) Notwithstanding any law to the contrary, for the twelve-month (12) period beginning 6
2012	2012	July 1, 2015, Medicaid managed long-term-care payment rates to nursing facilities established 7
2013	2013	pursuant to this section shall not exceed ninety-eight percent (98.0%) of the rates in effect on April 8
2014	2014	1, 2015. 9
2015	2015	40-8.13-6. Payment incentives. 10
2016	2016	In order to encourage quality improvement and promote appropriate utilization incentives 11
2017	2017	for providers in a managed long-term-care arrangement, a managed care organization may use 12
2018	2018	incentive or bonus payment programs that are in addition to the rates identified in § 40-8.13-5. 13
2019	2019	40-8.13-7. Willing provider. 14
2020	2020	A managed care organization must contract with and cover services furnished by any 15
2021	2021	nursing facility licensed under chapter 17 of title 23 and certified by CMS that provides Medicaid-16
2022	2022	covered nursing facility services pursuant to a provider agreement with the state, provided that the 17
2023	2023	nursing facility is not disqualified under the managed care organization’s quality standards that are 18
2024	2024	applicable to all nursing facilities; and the nursing facility is willing to accept the reimbursement 19
2025	2025	rates described in § 40-8.13-5. 20
2026	2026	40-8.13-8. Level-of-care tool. 21
2027	2027	A managed long-term-care arrangement must require that all participating managed care 22
2028	2028	organizations use only the EOHHS level-of-care tool in determining coverage of long-term-care 23
2029	2029	supports and services for beneficiaries. EOHHS may amend the level-of-care tool provided that 24
2030	2030	any changes are established in consultation with beneficiaries and providers of Medicaid-covered 25
2031	2031	long-term-care supports and services, and are based upon reasonable medical evidence or 26
2032	2032	consensus, in consideration of the specific needs of Rhode Island beneficiaries. Notwithstanding 27
2033	2033	any other provisions herein, however, in the case of a duals demonstration project, a managed care 28
2034	2034	organization may use a different level-of-care tool for determining coverage of services that would 29
2035	2035	otherwise be covered by Medicare, since the criteria established by EOHHS are directed towards 30
2036	2036	Medicaid-covered services; provided, that the level-of-care tool is based on reasonable medical 31
2037	2037	evidence or consensus in consideration of the specific needs of Rhode Island beneficiaries. 32
2038	2038	40-8.13-9. Case management/plan of care. 33
2039	2039	No managed care organization acting under a managed long-term-care arrangement may 34
2040	2040
2041	2041
2042	2042	LC000271 - Page 56 of 93
2043	2043	require a provider to change a plan of care if the provider reasonably believes that such an action 1
2044	2044	would conflict with the provider’s responsibility to develop an appropriate care plan under state 2
2045	2045	and federal regulations. 3
2046	2046	40-8.13-10. Care transitions. 4
2047	2047	In the event that a beneficiary: 5
2048	2048	(1) Has been determined to meet level-of-care requirements for nursing facility coverage 6
2049	2049	as of the date of his or her enrollment in a managed care organization; or 7
2050	2050	(2) Has been determined to meet level of care requirements for nursing facility coverage 8
2051	2051	by a managed care organization after enrollment; and there is a change in condition whereby the 9
2052	2052	managed care organization determines that the beneficiary no longer meets such level-of-care 10
2053	2053	requirements, the nursing facility shall promptly arrange for an appropriate and safe discharge (with 11
2054	2054	the assistance of the managed care organization if the facility requests it), and the managed care 12
2055	2055	organization shall continue to pay for the beneficiary’s nursing facility care at the same rate until 13
2056	2056	the beneficiary is discharged. 14
2057	2057	40-8.13-11. Reporting requirements. 15
2058	2058	EOHHS shall report to the general assembly and shall make available to interested persons 16
2059	2059	a separate accounting of state expenditures for long-term-care supports and services under any 17
2060	2060	managed long-term-care arrangement, specifically and separately identifying expenditures for 18
2061	2061	home- and community-based services, assisted-living services, hospice services within nursing 19
2062	2062	facilities, hospice services outside of nursing facilities, and nursing facility services. Such reports 20
2063	2063	shall be made twice annually, six (6) months apart, beginning six (6) months following the 21
2064	2064	implementation of any managed long-term-care arrangement, and shall include a detailed report of 22
2065	2065	utilization of each service. In order to facilitate reporting, any managed long-term-care arrangement 23
2066	2066	shall include a requirement that a participating managed care organization make timely reports of 24
2067	2067	the data necessary to compile the reports. 25
2068	2068	SECTION 14. Sections 42-7.2-10, 42-7.2-16 and 42-7.2-16.1 of the General Laws in 26
2069	2069	Chapter 42-7.2 entitled "Office of Health and Human Services" are hereby amended to read as 27
2070	2070	follows: 28
2071	2071	42-7.2-10. Appropriations and disbursements. 29
2072	2072	(a) The general assembly shall annually appropriate such sums as it may deem necessary 30
2073	2073	for the purpose of carrying out the provisions of this chapter. The state controller is hereby 31
2074	2074	authorized and directed to draw his or her orders upon the general treasurer for the payment of such 32
2075	2075	sum or sums, or so much thereof as may from time to time be required, upon receipt by him or her 33
2076	2076	of proper vouchers approved by the secretary of the executive office of health and human services, 34
2077	2077
2078	2078
2079	2079	LC000271 - Page 57 of 93
2080	2080	or his or her designee. 1
2081	2081	(b) The general assembly shall, through the utilization of federal Medicaid reimbursement 2
2082	2082	for administrative costs, and additional funds, appropriate such funds as may be necessary to hire 3
2083	2083	additional personnel for the Medicaid office as follows: one hundred (100) outreach social workers 4
2084	2084	to encourage, assist and expedite individuals applying for Medicaid benefits; one hundred (100) 5
2085	2085	new programmers in order to build digital infrastructure for the Medicaid office; thirty (30) new 6
2086	2086	social workers and ten (10) new programmers to help increase spend down program utilization and 7
2087	2087	feasibility and examine possible legal changes necessary to increase spend down program 8
2088	2088	eligibility; and fifty (50) additional personnel for building administrative capacity. The Medicaid 9
2089	2089	office shall be exempt from any limitations placed on the number of full-time equivalent personnel 10
2090	2090	employed by the executive office of health and human services. 11
2091	2091	(b)(c) For the purpose of recording federal financial participation associated with 12
2092	2092	qualifying healthcare workforce development activities at the state’s public institutions of higher 13
2093	2093	education, and pursuant to the Rhode Island designated state health programs (DSHP), as approved 14
2094	2094	by the Centers for Medicare & Medicaid Services (CMC) October 20, 2016, in the 11-W-00242/1 15
2095	2095	amendment to Rhode Island’s section 1115 Demonstration Waiver, there is hereby established a 16
2096	2096	restricted-receipt account entitled “Health System Transformation Project” in the general fund of 17
2097	2097	the state and included in the budget of the office of health and human services. Due to the COVID-18
2098	2098	19 pandemic, the office of health and human services is forbidden from utilizing any funds within 19
2099	2099	the health system transformation project restricted receipts account for any imposition of downside 20
2100	2100	risk for providers. No payment models that impose downside risk or in any way deviate from fee-21
2101	2101	for-service shall be utilized for the Medicaid program without explicit authorization by the general 22
2102	2102	assembly. 23
2103	2103	(c)(d) There are hereby created within the general fund of the state and housed within the 24
2104	2104	budget of the office of health and human services two restricted receipt accounts, respectively 25
2105	2105	entitled “HCBS Support-ARPA” and “HCBS Admin Support-ARPA”. Amounts deposited into 26
2106	2106	these accounts are equivalent to the general revenue savings generated by the enhanced federal 27
2107	2107	match received on eligible home and community-based services between April 1, 2021, and March 28
2108	2108	31, 2022, allowable under Section 9817 of the American Rescue Plan Act of 2021, Pub. L. No. 29
2109	2109	117-2. Funds deposited into the “HCBS Support-ARPA” account will be used to finance the state 30
2110	2110	share of newly eligible Medicaid expenditures by the office of health and human services and its 31
2111	2111	sister agencies, including the department of children, youth and families, the department of health, 32
2112	2112	and the department of behavioral healthcare, developmental disabilities and hospitals. Funds 33
2113	2113	deposited into the “HCBS Admin Support-ARPA” account will be used to finance the state share 34
2114	2114
2115	2115
2116	2116	LC000271 - Page 58 of 93
2117	2117	of allowable administrative expenditures attendant to the implementation of these newly eligible 1
2118	2118	Medicaid expenditures. The accounts created under this subsection shall be exempt from the 2
2119	2119	indirect cost recovery provisions of § 35-4-27. 3
2120	2120	(d)(e) There is hereby created within the general fund of the state and housed within the 4
2121	2121	budget of the office of health and human services a restricted receipt account entitled “Rhode Island 5
2122	2122	Statewide Opioid Abatement Account” for the purpose of receiving and expending monies from 6
2123	2123	settlement agreements with opioid manufacturers, pharmaceutical distributors, pharmacies, or their 7
2124	2124	affiliates, as well as monies resulting from bankruptcy proceedings of the same entities. The 8
2125	2125	executive office of health and human services shall deposit any revenues from such sources that 9
2126	2126	are designated for opioid abatement purposes into the restricted receipt account. Funds from this 10
2127	2127	account shall only be used for forward-looking opioid abatement efforts as defined and limited by 11
2128	2128	any settlement agreements, state-city and town agreements, or court orders pertaining to the use of 12
2129	2129	such funds. By January 1 of each calendar year, the secretary of health and human services shall 13
2130	2130	report to the governor, the speaker of the house of representatives, the president of the senate, and 14
2131	2131	the attorney general on the expenditures that were funded using monies from the Rhode Island 15
2132	2132	statewide opioid abatement account and the amount of funds spent. The account created under this 16
2133	2133	subsection shall be exempt from the indirect cost recovery provisions of § 35-4-27. No 17
2134	2134	governmental entity has the authority to assert a claim against the entities with which the attorney 18
2135	2135	general has entered into settlement agreements concerning the manufacturing, marketing, 19
2136	2136	distributing, or selling of opioids that are the subject of the Rhode Island Memorandum of 20
2137	2137	Understanding Between the State and Cities and Towns Receiving Opioid Settlement Funds 21
2138	2138	executed by every city and town and the attorney general and wherein every city and town agreed 22
2139	2139	to release all such claims against these settling entities, and any amendment thereto. Governmental 23
2140	2140	entity means any state or local governmental entity or sub-entity and includes, but is not limited to, 24
2141	2141	school districts, fire districts, and any other such districts. The claims that shall not be asserted are 25
2142	2142	the released claims, as that term is defined in the settlement agreements executed by the attorney 26
2143	2143	general, or, if not defined therein, the claims sought to be released in such settlement agreements. 27
2144	2144	42-7.2-16. Medicaid System Reform 2008. Medicaid System Reform. 28
2145	2145	(a) The executive office of health and human services, in conjunction with the department 29
2146	2146	of human services, the department of children, youth and families, the department of health and the 30
2147	2147	department of behavioral healthcare, developmental disabilities and hospitals, is authorized to 31
2148	2148	design options that further the reforms in Medicaid initiated in 2008 Medicaid reform to ensure that 32
2149	2149	the program: transitions to a Medicare level of care as a first step in the transition to a state-level 33
2150	2150	Medicare for All system; phases out the use of intermediary privatized insurance companies such 34
2151	2151
2152	2152
2153	2153	LC000271 - Page 59 of 93
2154	2154	as managed care entities; transitions to the management of health insurers acquired due to 1
2155	2155	insolvency, smoothly integrating publicly owned health insurers with the Medicaid system; utilizes 2
2156	2156	payment models such as fee-for-service that incentivize higher quality of care and more utilization 3
2157	2157	of care; provides for the financial health of Rhode Island healthcare providers; encourages fair 4
2158	2158	wages and benefits for Rhode Island's healthcare workforce; develops and builds out the Medicaid 5
2159	2159	office's human capital, technological infrastructure, expertise, and general ability to manage 6
2160	2160	healthcare payments to prepare for the transition to a single-payer Medicare-for-All system; and 7
2161	2161	guides the transition of the Rhode Island healthcare funding system to a state-level Medicare-for-8
2162	2162	All system. utilizes competitive and value based purchasing to maximize the available service 9
2163	2163	options, promotes accountability and transparency, and encourages and rewards healthy outcomes, 10
2164	2164	independence, and responsible choices; promotes efficiencies and the coordination of services 11
2165	2165	across all health and human services agencies; and ensures the state will have a fiscally sound 12
2166	2166	source of publicly-financed health care for Rhode Islanders in need. 13
2167	2167	(b) Principles and goals. In developing and implementing this system of reform, the 14
2168	2168	executive office of health and human services and the four (4) health and human services 15
2169	2169	departments shall pursue the following principles and goals: 16
2170	2170	(1) Empower consumers to make reasoned and cost-effective choices about their health by 17
2171	2171	providing them with the information and array of service options they need and offering rewards 18
2172	2172	for healthy decisions; 19
2173	2173	(2) Encourage personal responsibility by assuring the information available to beneficiaries 20
2174	2174	is easy to understand and accurate, provide that a fiscal intermediary is provided when necessary, 21
2175	2175	and adequate access to needed services; 22
2176	2176	(3) When appropriate, promote community-based care solutions by transitioning 23
2177	2177	beneficiaries from institutional settings back into the community and by providing the needed 24
2178	2178	assistance and supports to beneficiaries requiring long-term care or residential services who wish 25
2179	2179	to remain, or are better served in the community; 26
2180	2180	(4) Enable consumers to receive individualized health care that is outcome-oriented, 27
2181	2181	focused on prevention, disease management, recovery and maintaining independence; 28
2182	2182	(5) Promote competition between healthcare providers to ensure best value purchasing, to 29
2183	2183	leverage resources and to create opportunities for improving service quality and performance; 30
2184	2184	(6) Redesign purchasing and payment methods to assure fiscal accountability and 31
2185	2185	encourage and to reward service quality and cost-effectiveness by tying reimbursements to 32
2186	2186	evidence-based performance measures and standards, including those related to patient satisfaction 33
2187	2187	promote payment models such as fee-for-service that incentivize higher quality of care and phase 34
2188	2188
2189	2189
2190	2190	LC000271 - Page 60 of 93
2191	2191	out the use of payment models that shift risk to providers, such as capitation, episode-based 1
2192	2192	payments, global budgets, and similar models; and 2
2193	2193	(7) Continually improve technology to take advantage of recent innovations and advances 3
2194	2194	that help decision makers, consumers and providers to make informed and cost-effective decisions 4
2195	2195	regarding health care. 5
2196	2196	(c) The executive office of health and human services shall annually submit a report to the 6
2197	2197	governor and the general assembly describing the status of the administration and implementation 7
2198	2198	of the Medicaid Section 1115 demonstration waiver. 8
2199	2199	42-7.2-16.1. Reinventing Medicaid Act of 2015. 9
2200	2200	(a) Findings. The Rhode Island Medicaid program is an integral component of the state’s 10
2201	2201	healthcare system that provides crucial services and supports to many Rhode Islanders. As the 11
2202	2202	program’s reach has expanded, the costs of the program have continued to rise and the delivery of 12
2203	2203	care has become more fragmented and uncoordinated. Given the crucial role of the Medicaid 13
2204	2204	program to the state, it is of compelling importance that the state conduct a fundamental 14
2205	2205	restructuring of its Medicaid program that achieves measurable improvement in health outcomes 15
2206	2206	for the people and transforms the healthcare system to one that pays for the outcomes and quality 16
2207	2207	they deserve at a sustainable, predictable and affordable cost. The Reinventing Medicaid Act of 17
2208	2208	2015, as implemented in the budget for fiscal year two thousand sixteen (FY2016), involved drastic 18
2209	2209	cuts to the Medicaid program, along with policies that shifted risk to providers away from 19
2210	2210	intermediary insurers. Since the passage of that act, the finances of healthcare providers in Rhode 20
2211	2211	Island have deteriorated significantly, and it is therefore the duty of the general assembly to seek 21
2212	2212	corrective action to restore critical investments in the Medicaid system and redesign payment 22
2213	2213	models to remove risk from providers and concentrate risk in private insurance companies during 23
2214	2214	their phase-out period along the transition to Medicare-for-All. 24
2215	2215	(b) The Working Group to Reinvent Medicaid, which was established to refine the 25
2216	2216	principles and goals of the Medicaid reforms begun in 2008, was directed to present to the general 26
2217	2217	assembly and the governor initiatives to improve the value, quality, and outcomes of the health care 27
2218	2218	funded by the Medicaid program. 28
2219	2219	SECTION 15. Chapter 42-12.1 of the General Laws entitled "Department of Behavioral 29
2220	2220	Healthcare, Developmental Disabilities and Hospitals" is hereby amended by adding thereto the 30
2221	2221	following section: 31
2222	2222	42-12.1-11. The Rhode Island mental health nursing facility. 32
2223	2223	(a) There is hereby established a state nursing facility for the care for Rhode Islanders in 33
2224	2224	need of nursing facility-level inpatient behavioral healthcare known as the Rhode Island mental 34
2225	2225
2226	2226
2227	2227	LC000271 - Page 61 of 93
2228	2228	health nursing facility. The Rhode Island mental health nursing facility shall fall within the purview 1
2229	2229	of the department, and the chief executive officer, chief financial officer, and chief medical officer 2
2230	2230	shall be appointed by the governor with advice and consent of the senate. 3
2231	2231	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
2232	2232	in Chapter 42-12.3 entitled "Health Care for Children and Pregnant Women" are hereby amended 5
2233	2233	to read as follows: 6
2234	2234	42-12.3-3. Medical assistance expansion for pregnancy/RIte Start. 7
2235	2235	(a) The secretary of the executive office of health and human services is authorized to 8
2236	2236	amend its Title XIX state plan pursuant to Title XIX of the Social Security Act to provide Medicaid 9
2237	2237	coverage and to amend its Title XXI state plan pursuant to Title XXI of the Social Security Act to 10
2238	2238	provide medical assistance coverage through expanded family income disregards for pregnant 11
2239	2239	persons whose family income levels are between one hundred eighty-five percent (185%) and two 12
2240	2240	hundred fifty percent (250%) of the federal poverty level. The department is further authorized to 13
2241	2241	promulgate any regulations necessary and in accord with Title XIX [42 U.S.C. § 1396 et seq.] and 14
2242	2242	Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act necessary in order to implement 15
2243	2243	said state plan amendment. The services provided shall be in accord with Title XIX [42 U.S.C. § 16
2244	2244	1396 et seq.] and Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act. 17
2245	2245	(b) The secretary of health and human services is authorized and directed to establish a 18
2246	2246	payor of last resort program to cover prenatal, delivery and postpartum care. The program shall 19
2247	2247	cover the cost of maternity care for any person who lacks health insurance coverage for maternity 20
2248	2248	care and who is not eligible for medical assistance under Title XIX [42 U.S.C. § 1396 et seq.] and 21
2249	2249	Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act including, but not limited to, a 22
2250	2250	noncitizen pregnant person lawfully admitted for permanent residence on or after August 22, 1996, 23
2251	2251	without regard to the availability of federal financial participation, provided such pregnant person 24
2252	2252	satisfies all other eligibility requirements. The secretary shall promulgate regulations to implement 25
2253	2253	this program. Such regulations shall include specific eligibility criteria; the scope of services to be 26
2254	2254	covered; procedures for administration and service delivery; referrals for non-covered services; 27
2255	2255	outreach; and public education. 28
2256	2256	(c) The secretary of health and human services may enter into cooperative agreements with 29
2257	2257	the department of health and/or other state agencies to provide services to individuals eligible for 30
2258	2258	services under subsections (a) and (b) above. 31
2259	2259	(d) The following services shall be provided through the program: 32
2260	2260	(1) Ante-partum and postpartum care; 33
2261	2261	(2) Delivery; 34
2262	2262
2263	2263
2264	2264	LC000271 - Page 62 of 93
2265	2265	(3) Cesarean section; 1
2266	2266	(4) Newborn hospital care; 2
2267	2267	(5) Inpatient transportation from one hospital to another when authorized by a medical 3
2268	2268	provider; and 4
2269	2269	(6) Prescription medications and laboratory tests. 5
2270	2270	(e) The secretary of health and human services shall provide enhanced services, as 6
2271	2271	appropriate, to pregnant persons as defined in subsections (a) and (b), as well as to other pregnant 7
2272	2272	persons eligible for medical assistance. These services shall include: care coordination; nutrition 8
2273	2273	and social service counseling; high-risk obstetrical care; childbirth and parenting preparation 9
2274	2274	programs; smoking cessation programs; outpatient counseling for drug-alcohol use; interpreter 10
2275	2275	services; mental health services; and home visitation. The provision of enhanced services is subject 11
2276	2276	to available appropriations. In the event that appropriations are not adequate for the provision of 12
2277	2277	these services, the executive office has the authority to limit the amount, scope, and duration of 13
2278	2278	these enhanced services. 14
2279	2279	(f) The executive office of health and human services shall provide for extended family 15
2280	2280	planning services for up to twenty-four (24) months postpartum. These services shall be available 16
2281	2281	to persons who have been determined eligible for RIte Start or for medical assistance under Title 17
2282	2282	XIX [42 U.S.C. § 1396 et seq.] or Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security 18
2283	2283	Act. 19
2284	2284	(g) Effective October 1, 2022, individuals eligible for RIte Start pursuant to this section or 20
2285	2285	for medical assistance under Title XIX or Title XXI of the Social Security Act while pregnant 21
2286	2286	(including during a period of retroactive eligibility), are eligible for full Medicaid benefits through 22
2287	2287	the last day of the month in which their twelve-month (12) postpartum period ends. This benefit 23
2288	2288	will be provided to eligible Rhode Island residents without regard to the availability of federal 24
2289	2289	financial participation. The executive office of health and human services is directed to ensure that 25
2290	2290	federal financial participation is used to the maximum extent allowable to provide coverage 26
2291	2291	pursuant to this section, and that state-only funds will be used only if federal financial participation 27
2292	2292	is not available. 28
2293	2293	(h) Any person eligible for services under subsections (a) and (b) of this section, or 29
2294	2294	otherwise eligible for medical assistance under Title XIX [42 U.S.C. § 1396 et seq.] and Title XXI 30
2295	2295	[42 U.S.C. § 1397aa et seq.] of the Social Security Act, shall also be entitled to services for any 31
2296	2296	termination of pregnancy permitted under § 23-4.13-2; provided, however, that no federal funds 32
2297	2297	shall be used to pay for such services, except as authorized under federal law. 33
2298	2298	42-12.3-5. Managed care. 34
2299	2299
2300	2300
2301	2301	LC000271 - Page 63 of 93
2302	2302	The delivery and financing of the health care services provided pursuant to §§ 42-12.3-3 1
2303	2303	and 42-12.3-4 shall may be provided through a system of managed care. The delivery and financing 2
2304	2304	of the healthcare services provided under this chapter may be provided through a system of 3
2305	2305	managed care. Beginning July 1, 2029, all payments shall be provided directly by the state without 4
2306	2306	an intermediate payment to a managed care entity or other form of health insurance company, 5
2307	2307	unless the intermediate payor is owned by the Medicaid office or another branch of state 6
2308	2308	government. Beginning July 1, 2025, no new contracts may be entered into between the Medicaid 7
2309	2309	office and an intermediate payor such as a managed care entity or other form of health insurance 8
2310	2310	company for the payment of healthcare services pursuant to this chapter, unless the intermediate 9
2311	2311	payor is owned by the Medicaid office or another branch of state government. 10
2312	2312	A managed care system integrates an efficient financing mechanism with quality service 11
2313	2313	delivery, provides a “medical home” to assure appropriate care and deter unnecessary and 12
2314	2314	inappropriate care, and places emphasis on preventive and primary health care. In developing a 13
2315	2315	managed care system the department of human services shall consider managed care models 14
2316	2316	recognized by the health care financing administration. The department of human services is hereby 15
2317	2317	authorized and directed to seek any necessary approvals or waivers from the U.S. Department of 16
2318	2318	Health and Human Services, Health Care Financing Administration, needed to assure that services 17
2319	2319	are provided through a mandatory managed care system. Certain health services may be provided 18
2320	2320	on an interim basis through a fee for service arrangement upon a finding that there are temporary 19
2321	2321	barriers to implementation of mandatory managed care for a particular population or particular 20
2322	2322	geographic area. Nothing in this section shall prohibit the department of human services from 21
2323	2323	providing enhanced services to medical assistance recipients within existing appropriations. 22
2324	2324	42-12.3-7. Financial contributions. 23
2325	2325	The department of human services may not require the payment of enrollment fees, sliding 24
2326	2326	fees, deductibles, co-payments, and/or other contributions based on ability to pay. These fees shall 25
2327	2327	be established by rules and regulations to be promulgated by the department of human services or 26
2328	2328	the department of health, as appropriate. 27
2329	2329	42-12.3-9. Insurance coverage — Third party insurance. 28
2330	2330	(a) No payment will be made nor service provided in the RIte Start or RIte Track program 29
2331	2331	with respect to any health care that is covered or would be covered, by any employee welfare benefit 30
2332	2332	plan under which a woman or child is either covered or eligible to be covered either as an employee 31
2333	2333	or dependent, whether or not coverage under such plan is elected. 32
2334	2334	(b) A premium may be charged for participation in the RIte Track or RIte Start programs 33
2335	2335	for eligible individuals whose family incomes are in excess of two hundred fifty percent (250%) of 34
2336	2336
2337	2337
2338	2338	LC000271 - Page 64 of 93
2339	2339	the federal poverty level and who have voluntarily terminated health care insurance within one year 1
2340	2340	of the date of application for benefits under this chapter. 2
2341	2341	(c)(b) Every family who is eligible to participate in the RIte Track program, who has an 3
2342	2342	additional child who because of age is not eligible for RIte Track, or whose child becomes ineligible 4
2343	2343	for RIte Track because of his or her age, may be offered by the managed care provider with whom 5
2344	2344	the family is enrolled, the opportunity to enroll such ineligible child or children in the same 6
2345	2345	managed care program on a self-pay basis at the same cost, charge or premium as is being charged 7
2346	2346	to the state under the provisions of this chapter for other covered children within the managed care 8
2347	2347	program. The family may also purchase a package of enhanced services at the same cost or charge 9
2348	2348	to the department. 10
2349	2349	SECTION 17. Section 42-12.3-14 of the General Laws in Chapter 42-12.3 entitled "Health 11
2350	2350	Care for Children and Pregnant Women" is hereby repealed. 12
2351	2351	42-12.3-14. Benefits and coverage — Exclusion. 13
2352	2352	For as long as the United States Department of Health and Human Services, Health Care 14
2353	2353	Financing Administration Project No. 11-W-0004/1-01 entitled “RIte Care” remains in effect, any 15
2354	2354	health care services provided pursuant to this chapter shall be exempt from all mandatory benefits 16
2355	2355	and coverage as may otherwise be provided for in the general laws. 17
2356	2356	SECTION 18. Sections 42-14.5-2 and 42-14.5-3 of the General Laws in Chapter 42-14.5 18
2357	2357	entitled "The Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" are 19
2358	2358	hereby amended to read as follows: 20
2359	2359	42-14.5-2. Purpose. 21
2360	2360	With respect to health insurance as defined in § 42-14-5, the health insurance commissioner 22
2361	2361	shall discharge the powers and duties of office to: 23
2362	2362	(1) Guard the solvency of health insurers Claw back excessive profits, reserves charges, 24
2363	2363	and other monies that health insurers may have accumulated against the public interest of the people 25
2364	2364	of Rhode Island; 26
2365	2365	(2) Protect the interests of consumers; 27
2366	2366	(3) Encourage fair treatment of health care providers; 28
2367	2367	(4) Encourage policies and developments that improve the quality and efficiency of health 29
2368	2368	care service delivery and outcomes; and 30
2369	2369	(5) View the health care system as a comprehensive entity and encourage and direct 31
2370	2370	insurers towards policies that advance the welfare of the public through overall efficiency, 32
2371	2371	improved health care quality, and appropriate access; and 33
2372	2372	(6) Facilitate the transformation of the healthcare payments system to a state-level 34
2373	2373
2374	2374
2375	2375	LC000271 - Page 65 of 93
2376	2376	Medicare-for-All system. 1
2377	2377	42-14.5-3. Powers and duties. 2
2378	2378	The health insurance commissioner shall have the following powers and duties: 3
2379	2379	(a) To conduct quarterly public meetings throughout the state, separate and distinct from 4
2380	2380	rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 5
2381	2381	licensed to provide health insurance in the state; the effects of such rates, services, and operations 6
2382	2382	on consumers, medical care providers, patients, and the market environment in which the insurers 7
2383	2383	operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 8
2384	2384	than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 9
2385	2385	Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 10
2386	2386	general, and the chambers of commerce. Public notice shall be posted on the department’s website 11
2387	2387	and given in the newspaper of general circulation, and to any entity in writing requesting notice. 12
2388	2388	(b) To make recommendations to the governor and the house of representatives and senate 13
2389	2389	finance committees regarding healthcare insurance and the regulations, rates, services, 14
2390	2390	administrative expenses, reserve requirements, and operations of insurers providing health 15
2391	2391	insurance in the state, and to prepare or comment on, upon the request of the governor or 16
2392	2392	chairpersons of the house or senate finance committees, draft legislation to improve the regulation 17
2393	2393	of health insurance. In making the recommendations, the commissioner shall recognize that it is 18
2394	2394	the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 19
2395	2395	of individual administrative expenditures as well as total administrative costs. The commissioner 20
2396	2396	shall make recommendations on the levels of reserves, including consideration of: targeted reserve 21
2397	2397	levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 22
2398	2398	reserves. 23
2399	2399	(c) To establish a consumer/business/labor/medical advisory council to obtain information 24
2400	2400	and present concerns of consumers, business, and medical providers affected by health insurance 25
2401	2401	decisions. The council shall develop proposals to allow the market for small business health 26
2402	2402	insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 27
2403	2403	the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 28
2404	2404	measures to inform small businesses of an insurance complaint process to ensure that small 29
2405	2405	businesses that experience rate increases in a given year may request and receive a formal review 30
2406	2406	by the department. The advisory council shall assess views of the health provider community 31
2407	2407	relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 32
2408	2408	insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 33
2409	2409	an annual report of findings and recommendations to the governor and the general assembly and 34
2410	2410
2411	2411
2412	2412	LC000271 - Page 66 of 93
2413	2413	present its findings at hearings before the house and senate finance committees. The advisory 1
2414	2414	council is to be diverse in interests and shall include representatives of community consumer 2
2415	2415	organizations; small businesses, other than those involved in the sale of insurance products; and 3
2416	2416	hospital, medical, and other health provider organizations. Such representatives shall be nominated 4
2417	2417	by their respective organizations. The advisory council shall be co-chaired by the health insurance 5
2418	2418	commissioner and a community consumer organization or small business member to be elected by 6
2419	2419	the full advisory council. 7
2420	2420	(d) To establish and provide guidance and assistance to a subcommittee (“the professional-8
2421	2421	provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 9
2422	2422	composed of healthcare providers and Rhode Island licensed health plans. This subcommittee The 10
2423	2423	health commissioner shall include provide in its annual report and presentation before the house 11
2424	2424	and senate finance committees the following information: 12
2425	2425	(1) A method whereby health plans shall disclose to contracted providers the fee schedules 13
2426	2426	used to provide payment to those providers for services rendered to covered patients; 14
2427	2427	(2) A standardized provider application and credentials verification process, for the 15
2428	2428	purpose of verifying professional qualifications of participating healthcare providers; 16
2429	2429	(3) The uniform health plan claim form utilized by participating providers; 17
2430	2430	(4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 18
2431	2431	hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make 19
2432	2432	facility-specific data and other medical service-specific data available in reasonably consistent 20
2433	2433	formats to patients regarding quality and costs. This information would help consumers make 21
2434	2434	informed choices regarding the facilities and clinicians or physician practices at which to seek care. 22
2435	2435	Among the items considered would be the unique health services and other public goods provided 23
2436	2436	by facilities and clinicians or physician practices in establishing the most appropriate cost 24
2437	2437	comparisons; 25
2438	2438	(5) All activities related to contractual disclosure to participating providers of the 26
2439	2439	mechanisms for resolving health plan/provider disputes; 27
2440	2440	(6) The uniform process being utilized for confirming, in real time, patient insurance 28
2441	2441	enrollment status, benefits coverage, including copays and deductibles; 29
2442	2442	(7) Information related to temporary credentialing of providers seeking to participate in the 30
2443	2443	plan’s network and the impact of the activity on health plan accreditation; 31
2444	2444	(8) The feasibility of regular contract renegotiations between plans and the providers in 32
2445	2445	their networks; and 33
2446	2446	(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 34
2447	2447
2448	2448
2449	2449	LC000271 - Page 67 of 93
2450	2450	(e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). 1
2451	2451	(f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 2
2452	2452	fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 3
2453	2453	(g) To analyze the impact of changing the rating guidelines and/or merging the individual 4
2454	2454	health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 5
2455	2455	insurance market, as defined in chapter 50 of title 27, in accordance with the following: 6
2456	2456	(1) The analysis shall forecast the likely rate increases required to effect the changes 7
2457	2457	recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 8
2458	2458	health insurance market over the next five (5) years, based on the current rating structure and 9
2459	2459	current products. 10
2460	2460	(2) The analysis shall include examining the impact of merging the individual and small-11
2461	2461	employer markets on premiums charged to individuals and small-employer groups. 12
2462	2462	(3) The analysis shall include examining the impact on rates in each of the individual and 13
2463	2463	small-employer health insurance markets and the number of insureds in the context of possible 14
2464	2464	changes to the rating guidelines used for small-employer groups, including: community rating 15
2465	2465	principles; expanding small-employer rate bonds beyond the current range; increasing the employer 16
2466	2466	group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 17
2467	2467	(4) The analysis shall include examining the adequacy of current statutory and regulatory 18
2468	2468	oversight of the rating process and factors employed by the participants in the proposed, new 19
2469	2469	merged market. 20
2470	2470	(5) The analysis shall include assessment of possible reinsurance mechanisms and/or 21
2471	2471	federal high-risk pool structures and funding to support the health insurance market in Rhode Island 22
2472	2472	by reducing the risk of adverse selection and the incremental insurance premiums charged for this 23
2473	2473	risk, and/or by making health insurance affordable for a selected at-risk population. 24
2474	2474	(6) The health insurance commissioner shall work with an insurance market merger task 25
2475	2475	force to assist with the analysis. The task force shall be chaired by the health insurance 26
2476	2476	commissioner and shall include, but not be limited to, representatives of the general assembly, the 27
2477	2477	business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 28
2478	2478	the individual market in Rhode Island, health insurance brokers, and members of the general public. 29
2479	2479	(7) For the purposes of conducting this analysis, the commissioner may contract with an 30
2480	2480	outside organization with expertise in fiscal analysis of the private insurance market. In conducting 31
2481	2481	its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 32
2482	2482	data shall be subject to state and federal laws and regulations governing confidentiality of health 33
2483	2483	care and proprietary information. 34
2484	2484
2485	2485
2486	2486	LC000271 - Page 68 of 93
2487	2487	(8) The task force shall meet as necessary and include its findings in the annual report, and 1
2488	2488	the commissioner shall include the information in the annual presentation before the house and 2
2489	2489	senate finance committees. 3
2490	2490	(h) To establish and convene a workgroup representing healthcare providers and health 4
2491	2491	insurers for the purpose of coordinating the development of processes, guidelines, and standards to 5
2492	2492	streamline healthcare administration that are to be adopted by payors and providers of healthcare 6
2493	2493	services operating in the state. This workgroup shall include representatives with expertise who 7
2494	2494	would contribute to the streamlining of healthcare administration and who are selected from 8
2495	2495	hospitals, physician practices, community behavioral health organizations, each health insurer, 9
2496	2496	labor union representing healthcare workers, and other affected entities. The workgroup shall also 10
2497	2497	include at least one designee each from the Rhode Island Medical Society, Rhode Island Council 11
2498	2498	of Community Mental Health Organizations, the Rhode Island Health Center Association, and the 12
2499	2499	Hospital Association of Rhode Island. In any year that the workgroup meets and submits 13
2500	2500	recommendations to the office of the health insurance commissioner, the office of the health 14
2501	2501	insurance commissioner shall submit such recommendations to the health and human services 15
2502	2502	committees of the Rhode Island house of representatives and the Rhode Island senate prior to the 16
2503	2503	implementation of any such recommendations and subsequently shall submit a report to the general 17
2504	2504	assembly by June 30, 2024. The report shall include the recommendations the commissioner may 18
2505	2505	implement, with supporting rationale. The workgroup shall consider and make recommendations 19
2506	2506	for: 20
2507	2507	(1) Establishing a consistent standard for electronic eligibility and coverage verification. 21
2508	2508	Such standard shall: 22
2509	2509	(i) Include standards for eligibility inquiry and response and, wherever possible, be 23
2510	2510	consistent with the standards adopted by nationally recognized organizations, such as the Centers 24
2511	2511	for Medicare & Medicaid Services; 25
2512	2512	(ii) Enable providers and payors to exchange eligibility requests and responses on a system-26
2513	2513	to-system basis or using a payor-supported web browser; 27
2514	2514	(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 28
2515	2515	coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 29
2516	2516	requirements for specific services at the specific time of the inquiry; current deductible amounts; 30
2517	2517	accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 31
2518	2518	other information required for the provider to collect the patient’s portion of the bill; 32
2519	2519	(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 33
2520	2520	and benefits information; 34
2521	2521
2522	2522
2523	2523	LC000271 - Page 69 of 93
2524	2524	(v) Recommend a standard or common process to protect all providers from the costs of 1
2525	2525	services to patients who are ineligible for insurance coverage in circumstances where a payor 2
2526	2526	provides eligibility verification based on best information available to the payor at the date of the 3
2527	2527	request of eligibility. 4
2528	2528	(2) Developing implementation guidelines and promoting adoption of the guidelines for: 5
2529	2529	(i) The use of the National Correct Coding Initiative code-edit policy by payors and 6
2530	2530	providers in the state; 7
2531	2531	(ii) Publishing any variations from codes and mutually exclusive codes by payors in a 8
2532	2532	manner that makes for simple retrieval and implementation by providers; 9
2533	2533	(iii) Use of Health Insurance Portability and Accountability Act standard group codes, 10
2534	2534	reason codes, and remark codes by payors in electronic remittances sent to providers; 11
2535	2535	(iv) Uniformity in the processing of claims by payors; and the processing of corrections to 12
2536	2536	claims by providers and payors; 13
2537	2537	(v) A standard payor-denial review process for providers when they request a 14
2538	2538	reconsideration of a denial of a claim that results from differences in clinical edits where no single, 15
2539	2539	common-standards body or process exists and multiple conflicting sources are in use by payors and 16
2540	2540	providers. 17
2541	2541	(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 18
2542	2542	payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 19
2543	2543	detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 20
2544	2544	disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 21
2545	2545	the application of such edits and that the provider have access to the payor’s review and appeal 22
2546	2546	process to challenge the payor’s adjudication decision. 23
2547	2547	(vii) Nothing in this subsection shall be construed to modify the rights or obligations of 24
2548	2548	payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 25
2549	2549	prosecution under applicable law of potentially fraudulent billing activities. 26
2550	2550	(3) Developing and promoting widespread adoption by payors and providers of guidelines 27
2551	2551	to: 28
2552	2552	(i) Ensure payors do not automatically deny claims for services when extenuating 29
2553	2553	circumstances make it impossible for the provider to obtain a preauthorization before services are 30
2554	2554	performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 31
2555	2555	(ii) Require payors to use common and consistent processes and time frames when 32
2556	2556	responding to provider requests for medical management approvals. Whenever possible, such time 33
2557	2557	frames shall be consistent with those established by leading national organizations and be based 34
2558	2558
2559	2559
2560	2560	LC000271 - Page 70 of 93
2561	2561	upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 1
2562	2562	management includes prior authorization of services, preauthorization of services, precertification 2
2563	2563	of services, post-service review, medical-necessity review, and benefits advisory; 3
2564	2564	(iii) Develop, maintain, and promote widespread adoption of a single, common website 4
2565	2565	where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 5
2566	2566	requirements; 6
2567	2567	(iv) Establish guidelines for payors to develop and maintain a website that providers can 7
2568	2568	use to request a preauthorization, including a prospective clinical necessity review; receive an 8
2569	2569	authorization number; and transmit an admission notification; 9
2570	2570	(v) Develop and implement the use of programs that implement selective prior 10
2571	2571	authorization requirements, based on stratification of healthcare providers’ performance and 11
2572	2572	adherence to evidence-based medicine with the input of contracted healthcare providers and/or 12
2573	2573	provider organizations. Such criteria shall be transparent and easily accessible to contracted 13
2574	2574	providers. Such selective prior authorization programs shall be available when healthcare providers 14
2575	2575	participate directly with the insurer in risk-based payment contracts and may be available to 15
2576	2576	providers who do not participate in risk-based contracts; 16
2577	2577	(vi) Require the review of medical services, including behavioral health services, and 17
2578	2578	prescription drugs, subject to prior authorization on at least an annual basis, with the input of 18
2579	2579	contracted healthcare providers and/or provider organizations. Any changes to the list of medical 19
2580	2580	services, including behavioral health services, and prescription drugs requiring prior authorization, 20
2581	2581	shall be shared via provider-accessible websites; 21
2582	2582	(vii) Improve communication channels between health plans, healthcare providers, and 22
2583	2583	patients by: 23
2584	2584	(A) Requiring transparency and easy accessibility of prior authorization requirements, 24
2585	2585	criteria, rationale, and program changes to contracted healthcare providers and patients/health plan 25
2586	2586	enrollees which may be satisfied by posting to provider-accessible and member-accessible 26
2587	2587	websites; and 27
2588	2588	(B) Supporting: 28
2589	2589	(I) Timely submission by healthcare providers of the complete information necessary to 29
2590	2590	make a prior authorization determination, as early in the process as possible; and 30
2591	2591	(II) Timely notification of prior authorization determinations by health plans to impacted 31
2592	2592	health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, 32
2593	2593	and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 33
2594	2594	provider-accessible websites or similar electronic portals or services; 34
2595	2595
2596	2596
2597	2597	LC000271 - Page 71 of 93
2598	2598	(viii) Increase and strengthen continuity of patient care by: 1
2599	2599	(A) Defining protections for continuity of care during a transition period for patients 2
2600	2600	undergoing an active course of treatment, when there is a formulary or treatment coverage change 3
2601	2601	or change of health plan that may disrupt their current course of treatment and when the treating 4
2602	2602	physician determines that a transition may place the patient at risk; and for prescription medication 5
2603	2603	by allowing a grace period of coverage to allow consideration of referred health plan options or 6
2604	2604	establishment of medical necessity of the current course of treatment; 7
2605	2605	(B) Requiring continuity of care for medical services, including behavioral health services, 8
2606	2606	and prescription medications for patients on appropriate, chronic, stable therapy through 9
2607	2607	minimizing repetitive prior authorization requirements; and which for prescription medication shall 10
2608	2608	be allowed only on an annual review, with exception for labeled limitation, to establish continued 11
2609	2609	benefit of treatment; and 12
2610	2610	(C) Requiring communication between healthcare providers, health plans, and patients to 13
2611	2611	facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 14
2612	2612	by posting to provider-accessible websites or similar electronic portals or services; 15
2613	2613	(D) Continuity of care for formulary or drug coverage shall distinguish between FDA 16
2614	2614	designated interchangeable products and proprietary or marketed versions of a medication; 17
2615	2615	(ix) Encourage healthcare providers and/or provider organizations and health plans to 18
2616	2616	accelerate use of electronic prior authorization technology, including adoption of national standards 19
2617	2617	where applicable; and 20
2618	2618	(x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 21
2619	2619	workgroup meeting may be conducted in part or whole through electronic methods. 22
2620	2620	(4) To provide a report to the house and senate, on or before January 1, 2017, with 23
2621	2621	recommendations for establishing guidelines and regulations for systems that give patients 24
2622	2622	electronic access to their claims information, particularly to information regarding their obligations 25
2623	2623	to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 26
2624	2624	(5) No provision of this subsection (h) shall preclude the ongoing work of the office of 27
2625	2625	health insurance commissioner’s administrative simplification task force, which includes meetings 28
2626	2626	with key stakeholders in order to improve, and provide recommendations regarding, the prior 29
2627	2627	authorization process. 30
2628	2628	(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 31
2629	2629	thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 32
2630	2630	committee on health and human services, and the house committee on corporations, with: (1) 33
2631	2631	Information on the availability in the commercial market of coverage for anti-cancer medication 34
2632	2632
2633	2633
2634	2634	LC000271 - Page 72 of 93
2635	2635	options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 1
2636	2636	options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 2
2637	2637	utilization and cost-sharing expense. 3
2638	2638	(j) To monitor the adequacy of each health plan’s compliance with the provisions of the 4
2639	2639	federal Mental Health Parity Act, including a review of related claims processing and 5
2640	2640	reimbursement procedures. Findings, recommendations, and assessments shall be made available 6
2641	2641	to the public. 7
2642	2642	(k) To monitor the prevent by regulation transition from fee-for-service and toward global 8
2643	2643	and other alternative payment methodologies for the payment for healthcare services that the health 9
2644	2644	insurance commissioner shall deem against the interest of public health. The health insurance 10
2645	2645	commissioner shall have no power to impose, encourage, or in any way incentivize any rate caps, 11
2646	2646	global budgets, episode-based payments, or capitation structures in the payment models utilized in 12
2647	2647	contracts between health insurers and providers. Alternative payment methodologies should be 13
2648	2648	assessed for their likelihood to promote damage access to affordable health insurance care, health 14
2649	2649	outcomes, and performance. 15
2650	2650	(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 16
2651	2651	payment variation, including findings and recommendations, subject to available resources. 17
2652	2652	(m) Notwithstanding any provision of the general or public laws or regulation to the 18
2653	2653	contrary, provide a report with findings and recommendations to the president of the senate and the 19
2654	2654	speaker of the house, on or before April 1, 2014, including, but not limited to, the following 20
2655	2655	information: 21
2656	2656	(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 22
2657	2657	27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-23
2658	2658	18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 24
2659	2659	insurance for fully insured employers, subject to available resources; 25
2660	2660	(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 26
2661	2661	the existing standards of care and/or delivery of services in the healthcare system; 27
2662	2662	(3) A state-by-state comparison of health insurance mandates and the extent to which 28
2663	2663	Rhode Island mandates exceed other states benefits; and 29
2664	2664	(4) Recommendations for amendments to existing mandated benefits based on the findings 30
2665	2665	in (m)(1), (m)(2), and (m)(3) above. 31
2666	2666	(n) On or before July 1, 2014, the office of the health insurance commissioner, in 32
2667	2667	collaboration with the director of health and lieutenant governor’s office, shall submit a report to 33
2668	2668	the general assembly and the governor to inform the design of accountable care organizations 34
2669	2669
2670	2670
2671	2671	LC000271 - Page 73 of 93
2672	2672	(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-1
2673	2673	based payment arrangements, that shall include, but not be limited to: 2
2674	2674	(1) Utilization review; 3
2675	2675	(2) Contracting; and 4
2676	2676	(3) Licensing and regulation. 5
2677	2677	(o) On or before February 3, 2015, the office of the health insurance commissioner shall 6
2678	2678	submit a report to the general assembly and the governor that describes, analyzes, and proposes 7
2679	2679	recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 8
2680	2680	to patients with mental health and substance use disorders. 9
2681	2681	(p) To work to ensure the health insurance coverage of behavioral health care under the 10
2682	2682	same terms and conditions as other health care, and to integrate behavioral health parity 11
2683	2683	requirements into the office of the health insurance commissioner insurance oversight and 12
2684	2684	healthcare transformation efforts. 13
2685	2685	(q) To work with other state agencies to seek delivery system improvements that enhance 14
2686	2686	access to a continuum of mental health and substance use disorder treatment in the state; and 15
2687	2687	integrate that treatment with primary and other medical care to the fullest extent possible. 16
2688	2688	(r) To direct insurers toward policies and practices that address the behavioral health needs 17
2689	2689	of the public and greater integration of physical and behavioral healthcare delivery. 18
2690	2690	(s) The office of the health insurance commissioner shall conduct an analysis of the impact 19
2691	2691	of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 20
2692	2692	submit a report of its findings to the general assembly on or before June 1, 2023. 21
2693	2693	(t) To undertake the analyses, reports, and studies contained in this section: 22
2694	2694	(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 23
2695	2695	and competent firm or firms to undertake the following analyses, reports, and studies: 24
2696	2696	(i) The firm shall undertake a comprehensive review of all social and human service 25
2697	2697	programs having a contract with or licensed by the state or any subdivision of the department of 26
2698	2698	children, youth and families (DCYF), the department of behavioral healthcare, developmental 27
2699	2699	disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 28
2700	2700	health (DOH), and Medicaid for the purposes of: 29
2701	2701	(A) Establishing a baseline of the eligibility factors for receiving services; 30
2702	2702	(B) Establishing a baseline of the service offering through each agency for those 31
2703	2703	determined eligible; 32
2704	2704	(C) Establishing a baseline understanding of reimbursement rates for all social and human 33
2705	2705	service programs including rates currently being paid, the date of the last increase, and a proposed 34
2706	2706
2707	2707
2708	2708	LC000271 - Page 74 of 93
2709	2709	model that the state may use to conduct future studies and analyses; 1
2710	2710	(D) Ensuring accurate and adequate reimbursement to social and human service providers 2
2711	2711	that facilitate the availability of high-quality services to individuals receiving home and 3
2712	2712	community-based long-term services and supports provided by social and human service providers; 4
2713	2713	(E) Ensuring the general assembly is provided accurate financial projections on social and 5
2714	2714	human service program costs, demand for services, and workforce needs to ensure access to entitled 6
2715	2715	beneficiaries and services; 7
2716	2716	(F) Establishing a baseline and determining the relationship between state government and 8
2717	2717	the provider network including functions, responsibilities, and duties; 9
2718	2718	(G) Determining a set of measures and accountability standards to be used by EOHHS and 10
2719	2719	the general assembly to measure the outcomes of the provision of services including budgetary 11
2720	2720	reporting requirements, transparency portals, and other methods; and 12
2721	2721	(H) Reporting the findings of human services analyses and reports to the speaker of the 13
2722	2722	house, senate president, chairs of the house and senate finance committees, chairs of the house and 14
2723	2723	senate health and human services committees, and the governor. 15
2724	2724	(2) The analyses, reports, and studies required pursuant to this section shall be 16
2725	2725	accomplished and published as follows and shall provide: 17
2726	2726	(i) An assessment and detailed reporting on all social and human service program rates to 18
2727	2727	be completed by January 1, 2023, including rates currently being paid and the date of the last 19
2728	2728	increase; 20
2729	2729	(ii) An assessment and detailed reporting on eligibility standards and processes of all 21
2730	2730	mandatory and discretionary social and human service programs to be completed by January 1, 22
2731	2731	2023; 23
2732	2732	(iii) An assessment and detailed reporting on utilization trends from the period of January 24
2733	2733	1, 2017, through December 31, 2021, for social and human service programs to be completed by 25
2734	2734	January 1, 2023; 26
2735	2735	(iv) An assessment and detailed reporting on the structure of the state government as it 27
2736	2736	relates to the provision of services by social and human service providers including eligibility and 28
2737	2737	functions of the provider network to be completed by January 1, 2023; 29
2738	2738	(v) An assessment and detailed reporting on accountability standards for services for social 30
2739	2739	and human service programs to be completed by January 1, 2023; 31
2740	2740	(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 32
2741	2741	and unlicensed personnel requirements for established rates for social and human service programs 33
2742	2742	pursuant to a contract or established fee schedule; 34
2743	2743
2744	2744
2745	2745	LC000271 - Page 75 of 93
2746	2746	(vii) An assessment and reporting on access to social and human service programs, to 1
2747	2747	include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 2
2748	2748	(viii) An assessment and reporting of national and regional Medicaid rates in comparison 3
2749	2749	to Rhode Island social and human service provider rates by April 1, 2023; 4
2750	2750	(ix) An assessment and reporting on usual and customary rates paid by private insurers and 5
2751	2751	private pay for similar social and human service providers, both nationally and regionally, by April 6
2752	2752	1, 2023; and 7
2753	2753	(x) Completion of the development of an assessment and review process that includes the 8
2754	2754	following components: eligibility; scope of services; relationship of social and human service 9
2755	2755	provider and the state; national and regional rate comparisons and accountability standards that 10
2756	2756	result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 11
2757	2757	and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 12
2758	2758	requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 13
2759	2759	1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 14
2760	2760	results and findings of this process shall be transparent, and public meetings shall be conducted to 15
2761	2761	allow providers, recipients, and other interested parties an opportunity to ask questions and provide 16
2762	2762	comment beginning in September 2023 and biennially thereafter. 17
2763	2763	(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 18
2764	2764	insurance commissioner shall consult with the Executive Office of Health and Human Services. 19
2765	2765	(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 20
2766	2766	include the corresponding components of the assessment and review (i.e., eligibility; scope of 21
2767	2767	services; relationship of social and human service provider and the state; and national and regional 22
2768	2768	rate comparisons and accountability standards including any changes or substantive issues between 23
2769	2769	biennial reviews) including the recommended rates from the most recent assessment and review 24
2770	2770	with their annual budget submission to the office of management and budget and provide a detailed 25
2771	2771	explanation and impact statement if any rate variances exist between submitted recommended 26
2772	2772	budget and the corresponding recommended rate from the most recent assessment and review 27
2773	2773	process starting October 1, 2023, and biennially thereafter. 28
2774	2774	(v) The general assembly shall appropriate adequate funding as it deems necessary to 29
2775	2775	undertake the analyses, reports, and studies contained in this section relating to the powers and 30
2776	2776	duties of the office of the health insurance commissioner. 31
2777	2777	(w) To approve or deny any compensation of employees of health insurers subject to the 32
2778	2778	laws of the State of Rhode Island in excess of one million dollars ($1,000,000) per employee. 33
2779	2779	(x) To approve or deny dividends of stock buybacks of health insurers subject to the laws 34
2780	2780
2781	2781
2782	2782	LC000271 - Page 76 of 93
2783	2783	of the State of Rhode Island. 1
2784	2784	SECTION 19. Section 44-17-1 of the General Laws in Chapter 44-17 entitled "Taxation of 2
2785	2785	Insurance Companies" is hereby amended to read as follows: 3
2786	2786	44-17-1. Companies required to file — Payment of tax — Retaliatory rates. 4
2787	2787	(a) Every domestic, foreign, or alien insurance company, mutual association, organization, 5
2788	2788	or other insurer, including any health maintenance organization as defined in § 27-41-2, any 6
2789	2789	medical malpractice insurance joint underwriters association as defined in § 42-14.1-1, any 7
2790	2790	nonprofit dental service corporation as defined in § 27-20.1-2 and any nonprofit hospital or medical 8
2791	2791	service corporation as defined in chapters 19 and 20 of title 27, except companies mentioned in § 9
2792	2792	44-17-6 and organizations defined in § 27-25-1, transacting business in this state, shall, on or before 10
2793	2793	April 15 in each year, file with the tax administrator, in the form that he or she may prescribe, a 11
2794	2794	return under oath or affirmation signed by a duly authorized officer or agent of the company, 12
2795	2795	containing information that may be deemed necessary for the determination of the tax imposed by 13
2796	2796	this chapter, and shall at the same time pay an annual tax to the tax administrator of two percent 14
2797	2797	(2%) three percent (3%) of the gross premiums on contracts of insurance and six percent (6%) of 15
2798	2798	all Medicaid payments received by an insurance company, except for ocean marine insurance as 16
2799	2799	referred to in § 44-17-6, covering property and risks within the state, written during the calendar 17
2800	2800	year ending December 31st next preceding. 18
2801	2801	(b) Qualifying insurers for purposes of this section means every domestic, foreign, or alien 19
2802	2802	insurance company, mutual association, organization, or other insurer and excludes: 20
2803	2803	(1) Health maintenance organizations, as defined in § 27-41-2; 21
2804	2804	(2) Nonprofit dental service corporations, as defined in § 27-20.1-2; and 22
2805	2805	(3) Nonprofit hospital or medical service corporations, as defined in §§ 27-19-1 and 27-23
2806	2806	20-1. 24
2807	2807	(c) For tax years 2018 and thereafter, the rate of taxation may be reduced as set forth below 25
2808	2808	and, if so reduced, shall be fully applicable to qualifying insurers instead of the two percent (2%) 26
2809	2809	rate listed in subsection (a). In the case of foreign or alien companies, except as provided in § 27-27
2810	2810	2-17(d), the tax shall not be less in amount than is imposed by the laws of the state or country under 28
2811	2811	which the companies are organized upon like companies incorporated in this state or upon its 29
2812	2812	agents, if doing business to the same extent in the state or country. The tax rate shall not be reduced 30
2813	2813	for gross premiums written on contracts of health insurance as defined in § 42-14-5(c) but shall 31
2814	2814	remain at two percent (2%) three percent (3%) or the appropriate retaliatory tax rate, whichever is 32
2815	2815	higher. 33
2816	2816	(d) For qualifying insurers, the premium tax rate may be decreased based upon Rhode 34
2817	2817
2818	2818
2819	2819	LC000271 - Page 77 of 93
2820	2820	Island jobs added by the industry as detailed below: 1
2821	2821	(1) A committee shall be established for the purpose of implementing tax rates using the 2
2822	2822	framework established herein. The committee shall be comprised of the following persons or their 3
2823	2823	designees: the secretary of commerce, the director of the department of business regulation, the 4
2824	2824	director of the department of revenue, and the director of the office of management and budget. No 5
2825	2825	rule may be issued pursuant to this section without the prior, unanimous approval of the committee; 6
2826	2826	(2) On the timetable listed below, the committee shall determine whether qualifying 7
2827	2827	insurers have added new qualifying jobs in this state in the preceding calendar year. A qualifying 8
2828	2828	job for purposes of this section is any employee with total annual wages equal to or greater than 9
2829	2829	forty percent (40%) of the average annual wages of the Rhode Island insurance industry, as 10
2830	2830	published by the annual employment and wages report of the Rhode Island department of labor and 11
2831	2831	training, in NAICS code 5241; 12
2832	2832	(3) If the committee determines that there has been a sufficient net increase in qualifying 13
2833	2833	jobs in the preceding calendar year(s) to offset a material reduction in the premium tax, it shall 14
2834	2834	calculate a reduced premium tax rate. Such rate shall be determined via a method selected by the 15
2835	2835	committee and designed such that the estimated personal income tax generated by the increase in 16
2836	2836	qualifying jobs is at least one hundred and twenty-five percent (125%) of the anticipated reduction 17
2837	2837	in premium tax receipts resulting from the new rate. For purposes of this calculation, the committee 18
2838	2838	may consider personal income tax withholdings or receipts, but in no event may the committee 19
2839	2839	include for the purposes of determining revenue neutrality income taxes that are subject to 20
2840	2840	segregation pursuant to § 44-48.3-8(f) or that are otherwise available to the general fund; 21
2841	2841	(4) Any reduced rate established pursuant to this section must be established in a 22
2842	2842	rulemaking proceeding pursuant to chapter 35 of title 42, subject to the following conditions: 23
2843	2843	(i) Any net increase in qualifying jobs and the resultant premium tax reduction and revenue 24
2844	2844	impact shall be determined in any rulemaking proceeding conducted under this section and shall 25
2845	2845	be set forth in a report included in the rulemaking record, which report shall also include a 26
2846	2846	description of the data sources and calculation methods used. The first such report shall also include 27
2847	2847	a calculation of the baseline level of employment of qualifying insurers for the calendar year 2015; 28
2848	2848	and 29
2849	2849	(ii) Notwithstanding any provision of the law to the contrary, no rule changing the tax rate 30
2850	2850	shall take effect until one hundred and twenty (120) days after notice of the rate change is provided 31
2851	2851	to the speaker of the house, the president of the senate, the house and senate fiscal advisors, and 32
2852	2852	the auditor general, which notice shall include the report required under the preceding provision. 33
2853	2853	(5) For each of the first three (3) rulemaking proceedings required under this section, the 34
2854	2854
2855	2855
2856	2856	LC000271 - Page 78 of 93
2857	2857	tax rate may remain unchanged or be decreased consistent with the requirements of this section, 1
2858	2858	but may not be increased. These first three (3) rulemaking proceedings shall be conducted by the 2
2859	2859	division of taxation and occur in the following manner: 3
2860	2860	(i) The first rulemaking proceeding shall take place in calendar year 2017. This proceeding 4
2861	2861	shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the requirements 5
2862	2862	of this section, which rate shall take effect in 2018, and (B) A method for calculating the number 6
2863	2863	of jobs at qualifying insurers; 7
2864	2864	(ii) The second rulemaking proceeding shall take place in calendar year 2018. This 8
2865	2865	proceeding shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the 9
2866	2866	requirements of this section, which rate shall take effect in 2019, and (B) The changes, if any, to 10
2867	2867	the method for calculating the number of jobs at qualifying insurers; and 11
2868	2868	(iii) The third rulemaking proceeding shall take place in calendar year 2019. This 12
2869	2869	proceeding shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the 13
2870	2870	requirements of this section, which rate shall take effect in 2020, and (B) The changes, if any, to 14
2871	2871	the method for calculating the number of jobs at qualifying insurers. 15
2872	2872	(6) The tax rate established in the regulation following regulatory proceedings that take 16
2873	2873	place in 2019 shall remain in effect through and including 2023. In calendar year 2023, the 17
2874	2874	department of business regulation will conduct a rulemaking proceeding and issue a rule that sets 18
2875	2875	forth: (A) A new premium tax rate, if allowed under the requirements of this section, which rate 19
2876	2876	shall take effect in 2024, and (B) The changes, if any, to the method for calculating the number of 20
2877	2877	jobs at qualifying insurers. A rule issued by the department of business regulation may decrease 21
2878	2878	the tax rate if the requirements for a rate reduction contained in this section are met, or it may 22
2879	2879	increase the tax rate to the extent necessary to achieve the overall revenue level sought when the 23
2880	2880	then-existing tax rate was established. Any rate established shall be no lower than one percent (1%) 24
2881	2881	and no higher than two percent (2%). This proceeding shall be repeated every three (3) calendar 25
2882	2882	years thereafter, however, the base for determination of job increases or decreases shall remain the 26
2883	2883	number of jobs existing during calendar year 2022; 27
2884	2884	(7) No reduction in the premium tax rate pursuant to this section shall be allowed absent a 28
2885	2885	determination that qualifying insurers have added in this state at least three hundred fifty (350) 29
2886	2886	new, full-time, qualifying jobs above the baseline level of employment of qualifying insurers for 30
2887	2887	the calendar year 2015; 31
2888	2888	(8) Notwithstanding any provision of this section to the contrary, the premium tax rate shall 32
2889	2889	never be set lower than one percent (1%); 33
2890	2890	(9) The division of taxation may adopt implementation guidelines, directives, criteria, rules 34
2891	2891
2892	2892
2893	2893	LC000271 - Page 79 of 93
2894	2894	and regulations pursuant to chapter 35 of title 42 as are necessary to implement this section; and 1
2895	2895	(10) The calculation of revenue impacts under this section is at the sole discretion of the 2
2896	2896	committee established under subsection (d)(1). Notwithstanding any provision of law to the 3
2897	2897	contrary, any administrative action or rule setting a tax rate pursuant to this section or failing or 4
2898	2898	declining to alter a tax rate pursuant to this section shall not be subject to judicial review under 5
2899	2899	chapter 35 of title 42. 6
2900	2900	(d) The department of revenue shall calculate the impacts of changes made to Medicaid 7
2901	2901	taking effect during or after fiscal year two thousand twenty-six (FY2026) on state funds, excluding 8
2902	2902	increased federal reimbursements, hereinafter the "Medicaid adjustment." Should the Medicaid 9
2903	2903	adjustment exceed the revenue impact of raising the gross premiums tax rate from two percent (2%) 10
2904	2904	to three percent (3%), hereinafter the "insurance premium tax rate adjustment revenue bonus," a 11
2905	2905	surtax shall be imposed on gross premiums written on contracts of health insurance as defined in § 12
2906	2906	42-14-5(c) at the rate that shall raise aggregate revenue equal to the Medicaid adjustment minus 13
2907	2907	the insurance premium tax rate adjustment revenue bonus. 14
2908	2908	SECTION 20. Section 44-51-3 of the General Laws in Chapter 44-51 entitled "Nursing 15
2909	2909	Facility Provider Assessment Act" is hereby amended to read as follows: 16
2910	2910	44-51-3. Imposition of assessment — Nursing facilities. 17
2911	2911	(a) For purposes of this section, a “nursing facility” means a person or governmental unit 18
2912	2912	licensed in accordance with chapter 17 of title 23 to establish, maintain, and operate a nursing 19
2913	2913	facility. 20
2914	2914	(b) An assessment is imposed upon the gross patient revenue received by every nursing 21
2915	2915	facility in each month beginning January 1, 2008, at a rate of five and one-half percent (5.5%) six 22
2916	2916	percent (6%) for services provided on or after January 1, 2008. Every provider shall pay the 23
2917	2917	monthly assessment no later than the twenty-fifth (25th) day of each month following the month of 24
2918	2918	receipt of gross patient revenue. 25
2919	2919	(c) The assessment imposed by this section shall be repealed on the effective date of the 26
2920	2920	repeal or a restricted amendment of those provisions of the Medicaid Voluntary Contribution and 27
2921	2921	Provider-Specific Tax Amendments of 1991 (P.L. 102-234) that permit federal financial 28
2922	2922	participation to match state funds generated by taxes. 29
2923	2923	(d) If, after applying the applicable federal law and/or rules, regulations, or standards 30
2924	2924	relating to health care providers, the tax administrator determines that the assessment rate 31
2925	2925	established in subsection (b) of this section exceeds the maximum rate of assessment that federal 32
2926	2926	law will allow without reduction in federal financial participation, then the tax administrator is 33
2927	2927	directed to reduce the assessment to a rate equal to the maximum rate which the federal law will 34
2928	2928
2929	2929
2930	2930	LC000271 - Page 80 of 93
2931	2931	allow without reduction in federal participation. Provided, however, that the authority of the tax 1
2932	2932	administrator to lower the assessment rate established in subsection (b) of this section shall be 2
2933	2933	limited solely to such determination. 3
2934	2934	(e) In order that the tax administrator may properly carry out his/her responsibilities under 4
2935	2935	this section, the director of the department of human services shall notify the tax administrator of 5
2936	2936	any damages in federal law and/or any rules, regulations, or standards which affect any rates for 6
2937	2937	health care provider assessments. 7
2938	2938	SECTION 21. Title 44 of the General Laws entitled "TAXATION" is hereby amended by 8
2939	2939	adding thereto the following chapter: 9
2940	2940	CHAPTER 72 10
2941	2941	PRIVATE HEALTHCARE PROVIDERS ASSESSMENT ACT 11
2942	2942	44-72-1. Short title. 12
2943	2943	This chapter shall be known and may be cited as the "Private HealthCare Providers 13
2944	2944	Assessment Act." 14
2945	2945	44-72-2. Definitions. 15
2946	2946	Except where the context otherwise requires, the following words and phrases as used in 16
2947	2947	this chapter shall have the following meaning: 17
2948	2948	(1) "Administrator" means the tax administrator. 18
2949	2949	(2) "Assessment" means the assessment imposed upon gross patient revenue pursuant to 19
2950	2950	this chapter. 20
2951	2951	(3) "Eligible provider" means a privately operated healthcare facility, which is eligible for 21
2952	2952	taxation up to six percent (6%) of gross patient revenue pursuant to 42 CFR 433.68. Nursing 22
2953	2953	facilities taxed pursuant to § 44-51-3 and hospital facilities taxed pursuant to § 23-17-38.1 shall not 23
2954	2954	be considered providers subject to taxation under this chapter. 24
2955	2955	(4) "Gross patient revenue" means the gross amount received on a cash basis by the 25
2956	2956	provider from all patient care services. Charitable contributions, donated goods and services, fund 26
2957	2957	raising proceeds, endowment support, income from meals on wheels, income from investments, 27
2958	2958	and other nonpatient revenues defined by the tax administrator upon the recommendation of the 28
2959	2959	department of human services shall not be considered as "gross patient revenue". 29
2960	2960	(5) "Person" means any individual, corporation, company, association, partnership, joint 30
2961	2961	stock association, and the legal successor thereof. 31
2962	2962	44-72-3. Imposition of assessment. 32
2963	2963	(a) An assessment is imposed upon the gross patient revenue received by every eligible 33
2964	2964	provider in each month beginning July 1, 2025, at a rate of six percent (6%) for services provided 34
2965	2965
2966	2966
2967	2967	LC000271 - Page 81 of 93
2968	2968	on or after July 1, 2025. Every eligible provider shall pay the monthly assessment no later than the 1
2969	2969	twenty-fifth day of each month following the month of receipt of gross patient revenue. 2
2970	2970	(b) The assessment rate established in subsection (a) of this section shall be reduced by the 3
2971	2971	effective rate of any tax subject to the six percent (6%) limit established pursuant to 42 CFR 433.68 4
2972	2972	imposed on the eligible provider in other chapters of the general laws in order that the total 5
2973	2973	aggregate tax shall be at a rate of six percent (6%). 6
2974	2974	(c) If, after applying the applicable federal law and/or rules, regulations, or standards 7
2975	2975	relating to healthcare providers, the tax administrator determines that the assessment rate 8
2976	2976	established in subsection (a) of this section exceeds the maximum rate of assessment that federal 9
2977	2977	law will allow without reduction in federal financial participation, then the tax administrator is 10
2978	2978	directed to reduce the assessment to a rate equal to the maximum rate which the federal law will 11
2979	2979	allow without reduction in federal participation. Provided, however, that the authority of the tax 12
2980	2980	administrator to lower the assessment rate established in subsection (a) of this section shall be 13
2981	2981	limited solely to such determination. In order that the tax administrator may properly carry out 14
2982	2982	his/her responsibilities under this section, the director of the department of human services shall 15
2983	2983	notify the tax administrator of any changes in federal law and/or any rules, regulations, or standards 16
2984	2984	which affect any rates for healthcare provider assessments. 17
2985	2985	44-72-4. Returns. 18
2986	2986	(a) Every eligible provider shall on or before the twenty-fifth day of the month following 19
2987	2987	the month of receipt of gross patient revenue make a return to the tax administrator. 20
2988	2988	(b) The tax administrator shall adopt rules, pursuant to this chapter, relative to the form of 21
2989	2989	the return and the data which it must contain for the correct computation of gross patient revenue 22
2990	2990	and the assessment upon that amount. All returns shall be signed by the eligible provider or by its 23
2991	2991	authorized representative, subject to the pains and penalties of perjury. If a return shows an 24
2992	2992	overpayment of the assessment due, the tax administrator shall refund or credit the overpayment to 25
2993	2993	the eligible provider. 26
2994	2994	(c) For good cause, the tax administrator may extend the time within which an eligible 27
2995	2995	provider is required to file a return, and if the return is filed during the period of extension, no 28
2996	2996	penalty or late filing charge may be imposed for failure to file the return at the time required by this 29
2997	2997	chapter, but the provider may be liable for interest as prescribed in this chapter. Failure to file the 30
2998	2998	return during the period for the extension shall void the extension. 31
2999	2999	44-72-5. Set-off for delinquent assessments. 32
3000	3000	If an eligible provider shall fail to pay an assessment within thirty (30) days of its due date, 33
3001	3001	the tax administrator may request any agency of state government making payments to the eligible 34
3002	3002
3003	3003
3004	3004	LC000271 - Page 82 of 93
3005	3005	provider to set off the amount of the delinquency against any payment due the provider from the 1
3006	3006	agency of state government and remit the sum to the tax administrator. Upon receipt of the set off 2
3007	3007	request from the tax administrator, any agency of state government is authorized and empowered 3
3008	3008	to set off the amount of the delinquency against any payment or amounts due the eligible provider. 4
3009	3009	The amount of set-off shall be credited against the assessment due from the eligible provider. 5
3010	3010	44-72-6. Assessment on available information -- Interest on delinquencies -- Penalties 6
3011	3011	-- Collection powers. 7
3012	3012	If any eligible provider shall fail to file a return within the time required by this chapter, or 8
3013	3013	shall file an insufficient or incorrect return, or shall not pay the assessment imposed by this chapter 9
3014	3014	when it is due, the tax administrator shall assess upon the information as may be available, which 10
3015	3015	shall be payable upon demand and shall bear interest at the annual rate provided by § 44-1-7 from 11
3016	3016	the date when the assessment should have been paid. If any part of the assessment made is due to 12
3017	3017	negligence or intentional disregard of the provisions of this chapter, a penalty of ten percent (10%) 13
3018	3018	of the amount of the determination shall be added to the assessment. The tax administrator shall 14
3019	3019	collect the assessment with interest in the same manner and with the same powers as are prescribed 15
3020	3020	for collection of taxes in this title. 16
3021	3021	44-72-7. Claims for refund -- Hearing upon denial. 17
3022	3022	(a) Any eligible provider subject to the provisions of this chapter may file a claim for refund 18
3023	3023	with the tax administrator at any time within two (2) years after the assessment has been paid. If 19
3024	3024	the tax administrator shall determine that the assessment has been overpaid, he or she shall make a 20
3025	3025	refund with interest from the date of overpayment. 21
3026	3026	(b) Any eligible provider whose claim for refund has been denied may, within thirty (30) 22
3027	3027	days from the date of the mailing by the tax administrator of the notice of the decision, request a 23
3028	3028	hearing and the tax administrator shall, as soon as practicable, set a time and place for the hearing 24
3029	3029	and shall notify the eligible provider. 25
3030	3030	44-72-8. Hearing by administrator on application. 26
3031	3031	Any eligible provider aggrieved by the action of the tax administrator in determining the 27
3032	3032	amount of any assessment or penalty imposed under the provisions of this chapter may apply to the 28
3033	3033	tax administrator, in writing, within thirty (30) days after the notice of the action is mailed to it, for 29
3034	3034	a hearing relative to the assessment or penalty. The tax administrator shall fix a time and place for 30
3035	3035	the hearing and shall notify the provider. Upon the hearing, the tax administrator shall correct 31
3036	3036	manifest errors, if any, disclosed at the hearing and assess and collect the amount lawfully due 32
3037	3037	together with any penalty or interest. 33
3038	3038	44-72-9. Appeals. 34
3039	3039
3040	3040
3041	3041	LC000271 - Page 83 of 93
3042	3042	Appeals from administrative orders or decisions made pursuant to any provisions of this 1
3043	3043	chapter shall be to the sixth division district court pursuant to §§ 8-8-24 through 8-8-29. The eligible 2
3044	3044	provider's right to appeal under this section shall be expressly made conditional upon prepayment 3
3045	3045	of all assessments, interest, and penalties unless the provider moves for and is granted an exemption 4
3046	3046	from the prepayment requirement pursuant to § 8-8-26. If the court, after appeal, holds that the 5
3047	3047	eligible provider is entitled to a refund, the eligible provider shall also be paid interest on the amount 6
3048	3048	at the rate provided in § 44-1-7.1. 7
3049	3049	44-72-10. Eligible provider records. 8
3050	3050	Every eligible provider shall: 9
3051	3051	(1) Keep records as may be necessary to determine the amount of its liability under this 10
3052	3052	chapter. 11
3053	3053	(2) Preserve those records for the period of three (3) years following the date of filing of 12
3054	3054	any return required by this chapter, or until any litigation or prosecution under this chapter is finally 13
3055	3055	determined. 14
3056	3056	(3) Make those records available for inspection by the tax administrator or the 15
3057	3057	administrator's authorized agents, upon demand, at reasonable times during regular business hours. 16
3058	3058	44-72-11. Method of payment and deposit of assessment. 17
3059	3059	(a) The payments required by this chapter may be made by electronic transfer of monies to 18
3060	3060	the general treasurer and deposited to the general fund. 19
3061	3061	(b) The general treasurer is authorized to establish an account or accounts and to take all 20
3062	3062	steps necessary to facilitate the electronic transfer of monies. The general treasurer shall provide 21
3063	3063	the tax administrator with a record of any monies transferred and deposited. 22
3064	3064	44-72-12. Rules and regulations. 23
3065	3065	The tax administrator shall make and promulgate rules, regulations, and procedures not 24
3066	3066	inconsistent with state law and fiscal procedures as the tax administrator deems necessary for the 25
3067	3067	proper administration of this chapter and to implement the provisions, policy, and purposes of this 26
3068	3068	chapter. 27
3069	3069	44-72-13. Release of assessment information. 28
3070	3070	Notwithstanding any other provisions of the general laws, the tax administrator shall not 29
3071	3071	be prohibited from providing assessment information to the director of the department of human 30
3072	3072	services or his or her designee, with respect to the assessment imposed by this chapter; provided 31
3073	3073	that, the director of human services and the director's agents and employees may use or disclose 32
3074	3074	that information only for purposes directly connected with the administration of the duties and 33
3075	3075	programs of the department of human services. 34
3076	3076
3077	3077
3078	3078	LC000271 - Page 84 of 93
3079	3079	44-72-14. Severability. 1
3080	3080	If any provision of this chapter or the application of this chapter to any person or 2
3081	3081	circumstances is held invalid, that invalidity shall not affect other provisions or applications of the 3
3082	3082	chapter which can be given effect without the invalid provision or application, and to this end the 4
3083	3083	provisions of this chapter are declared to be severable. 5
3084	3084	SECTION 22. Relating to Capital Development Programs - Statewide Referendum. 6
3085	3085	Section 1. Proposition to be submitted to the people. -- At the general election to be held 7
3086	3086	on the Tuesday next after the first Monday in November, 2026, there shall be submitted to the 8
3087	3087	people of the State of Rhode Island, for their approval or rejection, the following proposition: 9
3088	3088	"Shall the action of the general assembly, by an act passed at the January 2023 session, 10
3089	3089	authorizing the issuance of a bond, refunding bond, and/or temporary note of the State of Rhode 11
3090	3090	Island for the local capital projects and in the total amount with respect to the projects listed below 12
3091	3091	be approved, and the issuance of a bond, refunding bond, and/or temporary note authorized in 13
3092	3092	accordance with the provisions of said act? 14
3093	3093	Funding 15
3094	3094	The bond, refunding bond and/or temporary note shall be allocated to the Medicaid office 16
3095	3095	for oversight of the funds. 17
3096	3096	Project 18
3097	3097	(1) Group homes, assisted living facilities, and recovery beds $300,000,000 19
3098	3098	Approval of this question will allow the State of Rhode Island to issue general obligation 20
3099	3099	bonds, refunding bonds, and/or temporary notes in an amount not to exceed three hundred million 21
3100	3100	dollars ($300,000,000) for expansion of and investment in Rhode Island Community Living and 22
3101	3101	Supports. One hundred million dollars ($100,000,000) shall be allocated for investment in and 23
3102	3102	expansion of state group homes operated by Rhode Island Community Living and Supports. One 24
3103	3103	hundred million dollars ($100,000,000) shall be allocated for the construction of assisted living-25
3104	3104	level care facilities for people with mental illnesses and developmental disabilities operated by 26
3105	3105	Rhode Island Community Living and Supports for persons who are eligible for Medicaid. One 27
3106	3106	hundred million dollars ($100,000,000) shall be allocated for the construction of inpatient recovery 28
3107	3107	facilities operated by Rhode Island Community Living and Supports for persons who are eligible 29
3108	3108	for Medicaid and suffering from substance abuse issues in need of inpatient recovery services. 30
3109	3109	None of these funds may be allocated to private facilities. 31
3110	3110	(2) Hospital facilities expansion $50,000,000 32
3111	3111	Approval of this question will allow the State of Rhode Island to issue general obligation 33
3112	3112	bonds, refunding bonds, and/or temporary notes in an amount not to exceed fifty million dollars 34
3113	3113
3114	3114
3115	3115	LC000271 - Page 85 of 93
3116	3116	($50,000,000) for the improvement of state operated hospital facilities. 1
3117	3117	(3) University of Rhode Island Medical School $500,000,000 2
3118	3118	Approval of this question will allow the State of Rhode Island to issue a general obligation 3
3119	3119	bond, refunding bond, and/or temporary note in an amount not to exceed five hundred million 4
3120	3120	dollars ($500,000,000) for the construction of a medical school at the University of Rhode Island. 5
3121	3121	The Medicaid office shall work with the University of Rhode Island Medical School to establish a 6
3122	3122	reasonable annual contribution to fund the debt service on this bond from tuition revenue. While 7
3123	3123	these contributions shall continue until the entire debt service costs are paid, the Medicaid office 8
3124	3124	may allow for an amortization schedule that lasts for up to fifty (50) years." 9
3125	3125	Section 2. Ballot labels and applicability of general election laws. -- The secretary of state 10
3126	3126	shall prepare and deliver to the state board of elections ballot labels for each of the projects provided 11
3127	3127	for in Section 1 hereof with the designations "approve" or "reject" provided next to the description 12
3128	3128	of each such project to enable voters to approve or reject each such proposition. The general 13
3129	3129	election laws, so far as consistent herewith, shall apply to this proposition. 14
3130	3130	Section 3. Approval of projects by people. -- If a majority of the people voting on the 15
3131	3131	proposition in Section 1 hereof shall vote to approve any project stated therein, said project shall 16
3132	3132	be deemed to be approved by the people. The authority to issue bonds, refunding bonds and/or 17
3133	3133	temporary notes of the state shall be limited to the aggregate amount for all such projects as set 18
3134	3134	forth in the proposition, which have been approved by the people. 19
3135	3135	Section 4. Bonds for capital development program. -- The general treasurer is hereby 20
3136	3136	authorized and empowered, with the approval of the governor, and in accordance with the 21
3137	3137	provisions of this act to issue capital development bonds in serial form, in the name of and on behalf 22
3138	3138	of the State of Rhode Island, in amounts as may be specified by the governor in an aggregate 23
3139	3139	principal amount not to exceed the total amount for all projects approved by the people and 24
3140	3140	designated as "capital development loan of 2026 bonds." Provided, however, that the aggregate 25
3141	3141	principal amount of such capital development bonds and of any temporary notes outstanding at any 26
3142	3142	one time issued in anticipation thereof pursuant to Section 7 hereof shall not exceed the total amount 27
3143	3143	for all such projects approved by the people. All provisions in this act relating to "bonds" shall also 28
3144	3144	be deemed to apply to "refunding bonds." 29
3145	3145	Capital development bonds issued under this act shall be in denominations of one thousand 30
3146	3146	dollars ($1,000) each, or multiples thereof, and shall be payable in any coin or currency of the 31
3147	3147	United States which at the time of payment shall be legal tender for public and private debts. 32
3148	3148	These capital development bonds shall bear such date or dates, mature at specified time or 33
3149	3149	times, but not mature beyond the end of the twentieth state fiscal year following the fiscal year in 34
3150	3150
3151	3151
3152	3152	LC000271 - Page 86 of 93
3153	3153	which they are issued; bear interest payable semi-annually at a specified rate or different or varying 1
3154	3154	rates; be payable at designated time or times at specified place or places; be subject to express terms 2
3155	3155	of redemption or recall, with or without premium; be in a form, with or without interest coupons 3
3156	3156	attached; carry such registration, conversion, reconversion, transfer, debt retirement, acceleration 4
3157	3157	and other provisions as may be fixed by the general treasurer, with the approval of the governor, 5
3158	3158	upon each issue of such capital development bonds at the time of each issue. Whenever the 6
3159	3159	governor shall approve the issuance of such capital development bonds, the governor's approval 7
3160	3160	shall be certified to the secretary of state; the bonds shall be signed by the general treasurer and 8
3161	3161	countersigned by the secretary of state and shall bear the seal of the state. The signature approval 9
3162	3162	of the governor shall be endorsed on each bond. 10
3163	3163	Section 5. Refunding bonds for 2026 capital development program. -- The general treasurer 11
3164	3164	is hereby authorized and empowered, with the approval of the governor, and in accordance with 12
3165	3165	the provisions of this act, to issue bonds to refund the 2026 capital development program bonds, in 13
3166	3166	the name of and on behalf of the state, in amounts as may be specified by the governor in an 14
3167	3167	aggregate principal amount not to exceed the total amount approved by the people, to be designated 15
3168	3168	as "capital development program loan of 2026 refunding bonds" (hereinafter "refunding bonds"). 16
3169	3169	The general treasurer with the approval of the governor shall fix the terms and form of any 17
3170	3170	refunding bonds issued under this act in the same manner as the capital development bonds issued 18
3171	3171	under this act, except that the refunding bonds may not mature more than twenty (20) years from 19
3172	3172	the date of original issue of the capital development bonds being refunded. The proceeds of the 20
3173	3173	refunding bonds, exclusive of any premium and accrual interest and net the underwriters' cost, and 21
3174	3174	cost of bond insurance, shall, upon their receipt, be paid by the general treasurer immediately to 22
3175	3175	the paying agent for the capital development bonds which are to be called and prepaid. The paying 23
3176	3176	agent shall hold the refunding bond proceeds in trust until they are applied to prepay the capital 24
3177	3177	development bonds. While the proceeds are held in trust, the proceeds may be invested for the 25
3178	3178	benefit of the state in obligations of the United States of America or the State of Rhode Island. 26
3179	3179	If the general treasurer shall deposit with the paying agent for the capital development 27
3180	3180	bonds the proceeds of the refunding bonds, or proceeds from other sources, amounts that, when 28
3181	3181	invested in obligations of the United States or the State of Rhode Island, are sufficient to pay all 29
3182	3182	principal, interest, and premium, if any, on the capital development bonds until these bonds are 30
3183	3183	called for prepayment, then such capital development bonds shall not be considered debts of the 31
3184	3184	State of Rhode Island for any purpose starting from the date of deposit of such monies with the 32
3185	3185	paying agent. The refunding bonds shall continue to be a debt of the state until paid. 33
3186	3186	The term "bond" shall include "note," and the term "refunding bonds" shall include 34
3187	3187
3188	3188
3189	3189	LC000271 - Page 87 of 93
3190	3190	"refunding notes" when used in this act. 1
3191	3191	Section 6. Proceeds of capital development program. -- The general treasurer is directed to 2
3192	3192	deposit the proceeds from the sale of capital development bonds issued under this act, exclusive of 3
3193	3193	premiums and accrued interest and net the underwriters' cost, and cost of bond insurance, in one or 4
3194	3194	more of the depositories in which the funds of the state may be lawfully kept in special accounts 5
3195	3195	(hereinafter cumulatively referred to as "such capital development bond fund") appropriately 6
3196	3196	designated for each of the projects set forth in Section 1 hereof which shall have been approved by 7
3197	3197	the people to be used for the purpose of paying the cost of all such projects so approved. 8
3198	3198	All monies in the capital development bond fund shall be expended for the purposes 9
3199	3199	specified in the proposition provided for in Section 1 hereof under the direction and supervision of 10
3200	3200	the director of administration (hereinafter referred to as "director"). The director, or designee, shall 11
3201	3201	be vested with all power and authority necessary or incidental to the purposes of this act, including, 12
3202	3202	but not limited to, the following authority: 13
3203	3203	(1) To acquire land or other real property or any interest, estate, or right therein as may be 14
3204	3204	necessary or advantageous to accomplish the purposes of this act; 15
3205	3205	(2) To direct payment for the preparation of any reports, plans and specifications, and 16
3206	3206	relocation expenses and other costs such as for furnishings, equipment designing, inspecting, and 17
3207	3207	engineering, required in connection with the implementation of any projects set forth in Section 1 18
3208	3208	hereof; 19
3209	3209	(3) To direct payment for the costs of construction, rehabilitation, enlargement, provision 20
3210	3210	of service utilities, and razing of facilities, and other improvements to land in connection with the 21
3211	3211	implementation of any projects set forth in Section 1 hereof; and 22
3212	3212	(4) To direct payment for the cost of equipment, supplies, devices, materials, and labor for 23
3213	3213	repair, renovation, or conversion of systems and structures as necessary for the 2023 capital 24
3214	3214	development program bonds or notes hereunder from the proceeds thereof. No funds shall be 25
3215	3215	expended in excess of the amount of the capital development bond fund designated for each project 26
3216	3216	authorized in Section 1 hereof. 27
3217	3217	Section 7. Sale of bonds and notes. --Any bonds or notes issued under the authority of this 28
3218	3218	act shall be sold at not less than the principal amount thereof, in such mode and on such terms and 29
3219	3219	conditions as the general treasurer, with the approval of the governor, shall deem to be in the best 30
3220	3220	interests of the state. 31
3221	3221	Any bonds or notes issued under the provisions of this act and coupons on any capital 32
3222	3222	development bonds, if properly executed by the manual or electronic signatures of officers of the 33
3223	3223	state in office on the date of execution, shall be valid and binding according. to their tenor, 34
3224	3224
3225	3225
3226	3226	LC000271 - Page 88 of 93
3227	3227	notwithstanding that before the delivery thereof and payment therefor, any or all such officers shall 1
3228	3228	for any reason have ceased to hold office. 2
3229	3229	Section 8. Bonds and notes to be tax exempt and general obligations of the state. -- All 3
3230	3230	bonds and notes issued under the authority of this act shall be exempt from taxation in the state and 4
3231	3231	shall be general obligations of the state, and the full faith and credit of the state is hereby pledged 5
3232	3232	for the due payment of the principal and interest on each of such bonds and notes as the same shall 6
3233	3233	become due. 7
3234	3234	Section 9. Investment of monies in fund. -- All monies in the capital development fund not 8
3235	3235	immediately required for payment pursuant to the provisions of this act may be invested by the 9
3236	3236	investment commission, as established by chapter 10 of title 35, entitled "state investment 10
3237	3237	commission," pursuant to the provisions of such chapter; provided, however, that the securities in 11
3238	3238	which the capital development fund is invested shall remain a part of the capital development fund 12
3239	3239	until exchanged for other securities; and provided further, that the income from investments of the 13
3240	3240	capital development fund shall become a part of the general fund of the state and shall be applied 14
3241	3241	to the payment of debt service charges of the state, unless directed by federal law or regulation to 15
3242	3242	be used for some other purpose, or to the extent necessary, to rebate to the United States treasury 16
3243	3243	any income from investments (including gains from the disposition of investments) of proceeds of 17
3244	3244	bonds or notes to the extent deemed necessary to exempt (in whole or in part) the interest paid on 18
3245	3245	such bonds or notes from federal income taxation. 19
3246	3246	Section 10. Appropriation. -- To the extent the debt service on these bonds is not otherwise 20
3247	3247	provided, a sum sufficient to pay the interest and principal due each year on bonds and notes 21
3248	3248	hereunder is hereby annually appropriated out of any money in the treasury not otherwise 22
3249	3249	appropriated. 23
3250	3250	Section 11. Advances from general fund. -- The general treasurer is authorized, with the 24
3251	3251	approval of the director and the governor, in anticipation of the issuance of bonds or notes under 25
3252	3252	the authority of this act, to advance to the capital development bond fund for the purposes specified 26
3253	3253	in Section 1 hereof, any funds of the state not specifically held for any particular purpose; provided, 27
3254	3254	however, that all advances made to the capital development bond fund shall be returned to the 28
3255	3255	general fund from the capital development bond fund forthwith upon the receipt by the capital 29
3256	3256	development fund of proceeds resulting from the issue of bonds or notes to the extent of such 30
3257	3257	advances. 31
3258	3258	Section 12. Federal assistance and private funds. -- In carrying out this act, the director, or 32
3259	3259	designee, is authorized on behalf of the state, with the approval of the governor, to apply for and 33
3260	3260	accept any federal assistance which may become available for the purpose of this act, whether in 34
3261	3261
3262	3262
3263	3263	LC000271 - Page 89 of 93
3264	3264	the form of a loan or grant or otherwise, to accept the provision of any federal legislation therefor, 1
3265	3265	to enter into, act and carry out contracts in connection therewith, to act as agent for the federal 2
3266	3266	government in connection therewith, or to designate a subordinate so to act. Where federal 3
3267	3267	assistance is made available, the project shall be carried out in accordance with applicable federal 4
3268	3268	law, the rules and regulations thereunder and the contract or contracts providing for federal 5
3269	3269	assistance, notwithstanding any contrary provisions of state law. Subject to the foregoing, any 6
3270	3270	federal funds received for the purposes of this act shall be deposited in the capital development 7
3271	3271	bond fund and expended as a part thereof. The director or designee may also utilize any private 8
3272	3272	funds that may be made available for the purposes of this act. 9
3273	3273	Section 13. Effective Date. -- Sections 1, 2, 3, 10, 11 and 12 of this act shall take effect 10
3274	3274	upon passage. The remaining sections of this act shall take effect when and if the state board of 11
3275	3275	elections shall certify to the secretary of state that a majority of the qualified electors voting on the 12
3276	3276	proposition contained in Section 1 hereof have indicated their approval of all or any projects 13
3277	3277	thereunder. 14
3278	3278	SECTION 22. Rhode Island Medicaid Reform Act of 2008 Joint Resolution. 15
3279	3279	WHEREAS, The General Assembly enacted chapter 12.4 of title 42 entitled "The Rhode 16
3280	3280	Island Medicaid Reform Act of 2008"; and 17
3281	3281	WHEREAS, A legislative enactment is required pursuant to Rhode Island General Laws 18
3282	3282	chapter 12.4 of title 42; and 19
3283	3283	WHEREAS, Rhode Island General Laws § 42-7.2-5(3)(i) provides that the Secretary of the 20
3284	3284	Executive Office of Health and Human Services ("Executive Office") is responsible for the 21
3285	3285	implementation of Medicaid policies; and 22
3286	3286	WHEREAS, In pursuit of a higher quality system of care, the General Assembly grants 23
3287	3287	legislative approval of the following proposals and directs the Secretary to implement them; and 24
3288	3288	WHEREAS, If implementation requires changes to rules, regulations, procedures, the 25
3289	3289	Medicaid state plan, and/or the section 1115 waiver, the General Assembly directs and empowers 26
3290	3290	the Secretary to make said changes; further, adoption of new or amended rules, regulations and 27
3291	3291	procedures may also be required: 28
3292	3292	(a) Raising Nursing Facility Personal Needs Allowance. The Executive Office will raise 29
3293	3293	the personal needs allowance for nursing facility residents to two hundred dollars ($200). 30
3294	3294	(b) Medicare Equivalent Rate. The Executive Office will raise all Medicaid rates, except 31
3295	3295	for hospital rates, dental rates, and outpatient behavioral health rates to equal the Medicare 32
3296	3296	equivalent rate. Specific to early intervention services, a payment of fifty dollars ($50.00) per 33
3297	3297	member per month payment shall be established in addition to these rates, and a floor of fifty 34
3298	3298
3299	3299
3300	3300	LC000271 - Page 90 of 93
3301	3301	percent (50%) rate increase shall be established within the calculation of the Medicare equivalent 1
3302	3302	rate. 2
3303	3303	(c) Setting Outpatient Behavioral Healthcare Rates at one hundred fifty percent (150%) of 3
3304	3304	Medicare Equivalent Rates. The Executive Office will set outpatient behavioral health rates at one 4
3305	3305	hundred fifty percent (150%) of the Medicare equivalent rate. The Executive Office will maximize 5
3306	3306	federal financial participation if and when available, though state-only funds will be used if federal 6
3307	3307	financial participation is not available. 7
3308	3308	(d) FQHC APM Modernization. The Executive Office will make certain modifications to 8
3309	3309	modernize and standardize the alternative payment methodology option for federally qualified 9
3310	3310	health centers. 10
3311	3311	(e) Hospital Payment Modernization. The Executive Office will make changes to hospital 11
3312	3312	payment rates to modernize payment methodologies to encourage utilization and quality. Inpatient 12
3313	3313	FFS DRG rates will be set at ninety percent (90%) of the Medicare equivalent rate, inpatient non-13
3314	3314	DRG FFS rates will be established at ninety-five percent (95%) of the Medicare equivalent rate, 14
3315	3315	inpatient managed care rates will be set at one hundred five percent (105%) of FFS rates, and 15
3316	3316	outpatient rates will be set at one hundred percent (100%) of Medicare rates. 16
3317	3317	(f) RIteShare Freedom of Choice. The Executive Office will make employee participation 17
3318	3318	in the RIteShare program voluntary. 18
3319	3319	(g) Elderly and Disabled Eligibility Expansion. The Executive Office will expand 19
3320	3320	Medicaid eligibility for elderly and disabled residents to one hundred thirty-three percent (133%) 20
3321	3321	of the federal poverty level. 21
3322	3322	(h) Payments Streamlining. The Executive Office will conduct a multifaceted initiative to 22
3323	3323	begin the phase-out of intermediary payers such as managed care entities, streamlining payments 23
3324	3324	and reducing wasteful expenditures on intermediary payers. 24
3325	3325	(i) Medicaid Office Expansion. The Executive Office will expand Medicaid office staffing 25
3326	3326	to improve administrative capacities. 26
3327	3327	(j) End to Health System Transformation Project. The Executive Office will end the Health 27
3328	3328	System Transformation Project to reduce risk exposure to providers and increase the efficiency of 28
3329	3329	the payments system. 29
3330	3330	(k) Rhode Island Mental Health Nursing Facility. The Executive Office will open a state 30
3331	3331	nursing facility to serve patients with significant mental health needs. 31
3332	3332	(l) Raising Nursing Facility Assessment Rate. The Executive Office will raise the nursing 32
3333	3333	facility assessment rate to six percent (6%). 33
3334	3334	(m) Universal Provider Assessment. Consistent with overall goals of transitioning all 34
3335	3335
3336	3336
3337	3337	LC000271 - Page 91 of 93
3338	3338	services to a model where rates are at the Medicare equivalent rate, the Executive Office will extend 1
3339	3339	the existing nursing facility assessment model to cover all providers eligible for taxation under 2
3340	3340	federal regulations to help defray the costs of the state component. 3
3341	3341	(n) Dental Optimization. The Executive Office will make an array of changes to dental 4
3342	3342	benefits offered under Medicaid. Rates will be the rates utilized in § 27-18-54; § 27-19-30.1 § 27-5
3343	3343	20-25.2; and § 27-41-27.2; billing will be extended to teledentistry services, Silver Diamine 6
3344	3344	Fluoride (code D1354), and denture billing (codes D5130, D5140, D5221, D5222, D5213, and 7
3345	3345	D5214); the mobile dentistry encounter rate will be raised to the FQHC rate; and a fifty percent 8
3346	3346	(50%) payment shall be established for undeliverable dentures. 9
3347	3347	(o) Transition to State-Level Medicare for All. The Executive Office is empowered to 10
3348	3348	begin the process of negotiating the necessary waivers for a transition to a state-level Medicare for 11
3349	3349	All health care payments system for Rhode Island. These waivers shall include the combining of 12
3350	3350	all federal health care funding streams into the system financing including, but not limited to, 13
3351	3351	Medicaid, Medicare, federal health care tax exemptions, and exchange subsides established 14
3352	3352	pursuant to the U.S. Patient Protection and Affordable Care Act of 2010. The Executive Office 15
3353	3353	plans to begin the transition process after the completion of the raising of the Medicaid system to 16
3354	3354	a Medicare standard of care and the associated stabilization of the Rhode Island health care 17
3355	3355	workforce and provider network; provided, however, that the Executive Office, understanding the 18
3356	3356	complexity of the proposed waiver application, reserves the right to begin the waiver negotiation 19
3357	3357	process before the transition of Medicaid to a Medicare standard is complete. The Executive Office 20
3358	3358	shall only proceed with the waiver and transition should waiver conditions be favorable to the state 21
3359	3359	as a whole, in the judgment of the Executive Office. In the event that a full waiver cannot be 22
3360	3360	complete, and health insurers have been acquired by the Medicaid Office due to insolvency and the 23
3361	3361	Medicaid Office's goal of payer system stabilization, the Executive Office is empowered to seek 24
3362	3362	limited waivers for the streamlining and integration of acquired health insurers with the Medicaid 25
3363	3363	system. The Executive Office shall submit the final approved waiver and transition plan to the 26
3364	3364	general assembly for final approval. 27
3365	3365	Now, therefore, be it: 28
3366	3366	RESOLVED, That the General Assembly hereby approves the proposals stated above in 29
3367	3367	the recitals; and be it further; 30
3368	3368	RESOLVED, That the Secretary of the Executive Office of Health and Human Services is 31
3369	3369	authorized to pursue and implement any waiver amendments, state plan amendments, and/or 32
3370	3370	changes to the applicable department's rules, regulations and procedures approved herein and as 33
3371	3371	authorized by chapter 12.4 of title 42; and be it further; 34
3372	3372
3373	3373
3374	3374	LC000271 - Page 92 of 93
3375	3375	RESOLVED, That this Joint Resolution shall take effect upon passage. 1
3376	3376	SECTION 23. This act shall take effect upon passage; however, the RICHIP program shall 2
3377	3377	not come into operation until the necessary waivers are obtained, and the final financing proposal 3
3378	3378	is approved by the general assembly. 4
3379	3379	========
3380	3380	LC000271
3381	3381	========
3382	3382
3383	3383
3384	3384	LC000271 - Page 93 of 93
3385	3385	EXPLANATION
3386	3386	BY THE LEGISLATIVE COUNCIL
3387	3387	OF
3388	3388	A N A C T
3389	3389	RELATING TO HEALTH AND SAFETY -- THE RHODE ISLAND COMPREHENS IVE
3390	3390	HEALTH INSURANCE PRO GRAM
3391	3391	***
3392	3392	This act would establish a universal, comprehensive, affordable single-payer health care 1
3393	3393	insurance program and help control health care costs, which would be referred to as, "the Rhode 2
3394	3394	Island Comprehensive Health Insurance Program" (RICHIP). The program would be paid for by 3
3395	3395	consolidating government and private payments to multiple insurance carriers into a more 4
3396	3396	economical and efficient improved Medicare-for-all style single-payer program and substituting 5
3397	3397	lower progressive taxes for higher health insurance premiums, co-pays, deductibles and costs due 6
3398	3398	to caps. This program would save Rhode Islanders from the current overly expensive, inefficient 7
3399	3399	and unsustainable multi-payer health insurance system that unnecessarily prevents access to 8
3400	3400	medically necessary health care. 9
3401	3401	This act would take effect upon passage; however, the RICHIP program would not come 10
3402	3402	into operation until the necessary waivers are obtained, and the final financing proposal is approved 11
3403	3403	by the general assembly. 12
3404	3404	========
3405	3405	LC000271
3406	3406	========
3407	3407