2012 -- H 7933

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STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2012

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A N A C T

RELATING TO HUMAN SERVICES -- DISABLED CHILDREN'S MEDICAID BUY-IN

     Introduced By: Representatives Naughton, Morrison, Slater, E Coderre, and Gallison

     Date Introduced: March 13, 2012

     Referred To: House Finance

It is enacted by the General Assembly as follows:

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     SECTION 1. Title 40 of the General Laws entitled "HUMAN SERVICES" is hereby

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amended by adding thereto the following chapter:

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     CHAPTER 8.11

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MEDICAID BUY-IN FOR CHILDREN WITH DISABILITIES ACT

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     40-8.11-1. Short title. – This chapter shall be known and may be cited as the “Medicaid

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Buy-In for Children with Disabilities Act.”

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     40-8.11-2. Legislative findings. – The general assembly hereby finds and declares:

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     WHEREAS, The National Health Interview Survey (NHIS) census data shows that eight

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percent (8%) of children in this country have significant disabilities, many of whom do not have

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access to critical healthcare services they need.

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     WHEREAS, In order for these families to get needed health services for their children,

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many are forced to stay impoverished, become impoverished, put their children in out-of-home

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placements, or simply give up custody of their children so that their child can maintain eligibility

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for health coverage through Medicaid.

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     WHEREAS, Children must not have health insurance coverage for six (6) months to

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become eligible for the Children Health Insurance Program (CHIP).

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     WHEREAS, The six (6) month lack of health insurance coverage causes children with

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disabilities deterioration of their health status.

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     WHEREAS, Families with children with disabilities report they are turning down jobs,

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turning down raises, turning down overtime, and are unable to save money for the future of their

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children and family so that they can stay in the income bracket that qualifies their child for social

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security income and/or Medicaid.

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     WHEREAS, The Family Opportunity Act of 2005 was intended to address the two (2)

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greatest barriers preventing families from staying together and staying employed.

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     WHEREAS, The Family Opportunity Act, signed into law by congress as part of the

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Deficit Reduction Act of 2005, allows states to offer a Medicaid buy-in program to children with

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disabilities who are not eligible for supplemental security income (SSI) disability benefits due to

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family income requirements, but who do meet the social security childhood disability

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determination qualifications.

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     WHEREAS, Through implementation of the Family Opportunity Act, children with

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special healthcare needs may access comprehensive health insurance coverage who are now

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uninsured, and fill in some of the gaps in their coverage through the Medicaid Buy-in program.

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     WHEREAS, Only Medicaid can provide these comprehensive services.

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     WHEREAS, Through the Medicaid buy-in program disabled children can “buy-in” to

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Medicaid either as their only source of health coverage, or as supplement to private health

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insurance.

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     WHEREAS, The state can offer Medicaid buy-in programs and receive federal matching

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funds for the cost of these services.

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     WHEREAS, A majority of these children covered by the Family Opportunity Act will

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have private coverage as their primary payer, the Medicaid program will not have to cover

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services such as hospitalization and pharmaceuticals, which are typically the most expensive. The

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majority of costs, as is seen in other states with buy-in programs, rest on copayments, deductibles

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and other out-of-pocket costs currently borne by families of children with disabilities.

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     WHEREAS, A Medicaid buy-in program means savings in state spending on other

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sources of coverage for children and youth with disabilities such as uncompensated care, bad debt

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at public hospitals and clinics, as well as education, juvenile justice and social services.

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     WHEREAS, Families that are currently forced to limit their income in order to qualify

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for Medicaid may take pay raises, overtime, and promotions without losing their child's health

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coverage. Families who earn too much to qualify for Medicaid, but not enough for private

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insurance may have access to coverage for their children with disabilities. Most significantly,

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fewer families will face the choice of giving up custody or placing their children in institutions in

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order to obtain the healthcare coverage they require.

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     40-8.11-3. Definitions. – For the purposes of this section, the following terms are defined

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as:

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     (1) “Family Opportunity Act” means the federal law enacted as a part of the Deficit

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Reduction Act of 2005, Public Law 109-171; Stat. 442 U.S.C. 1396.

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     (2) “Children with disabilities” means having a physical and/or mental impairment that is

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disabling under the social security administration's childhood disability definition.

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     (3) “Disability determinations” means one made by the medical eligibility determination

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team (MEDT) unless disability has already been established by the social security administration.

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     40-8.11-4. Legislative purpose and policy. – It shall be the goal and purpose of this

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chapter to require the office of health and human services (OHHS) and its Medicaid office to

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provide access to children that meet the social security administration's definition of disability.

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     (a) The OHHS and its Medicaid office are hereby authorized and directed to amend its

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title XIX state plan to initiate a Medicaid buy-in program for children with disabilities.

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     (b) The OHHS and its Medicaid office are hereby authorized and directed to amend its

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title XIX state plan to initiate community choice first (Section 2401 in the Affordable Care Act

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Section 1915 (k) in the Social Security Act). This provision provides states with an additional

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federal medical assistance program (FMAP) for personal care services for individuals with

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disabilities in order that parents can be employed and continues employment.

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     40-8.11-5. Implementation. – (a) Medicaid coverage to children less than nineteen (19)

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years of age for families with incomes up to three hundred percent (300%) of the federal poverty

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level receive federal match. This coverage may be a child's only health care coverage or

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supplemental to private insurance.

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     (b) The state may require families to pay monthly premiums based on a sliding scale. If

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parents have employer-provided health plans, they are required to apply for, enroll in, and pay

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these premiums (which will reduce the state costs) when the employer contributes at least fifty

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percent (50%) of the annual premium costs. Participation in such an employer-sponsored health

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plan, when available, is a condition of continuing Medicaid coverage.

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     (d) The aggregate amount of all premiums paid must not exceed five percent (5%) of a

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family's income for families below two hundred percent (200%) of the federal poverty level and

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seven and one-half percent (7.5%) of a family's income for families between two hundred percent

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(200%) and three hundred percent (300%) of the federal poverty level. The state has the option of

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waiving premiums in the case of undue hardship for families.

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     40-8.11-6. Regulations and commencement of program. – (a) The OHHS and its

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Medicaid office shall promulgate the rules and regulations necessary to implement the provisions

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of this act by October 30, 2012, and enrollment of children with disabilities in the Medicaid buy-

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in program shall commence on March 1, 2013.

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     (b) The department shall report to the governor and the general assembly on or before

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December 31, 2013 and annually thereafter, with regard to the effectiveness of this chapter in

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achieving its purpose which report shall include, but not be limited to:

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     (1) The number of applications for the children's Medicaid buy-in, the number of

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beneficiaries approved who are new to Medicaid, the number of beneficiaries who were in

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another Medicaid eligibility category just prior to the children's Medicaid buy-in, and

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beneficiaries who have or have access to employer-based health insurance coverage;

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     (2) Demographics including: age; sex; employment supports provided; and primary

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disabling condition, as permissible under the health insurance portability and accountability act of

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1996 (HIPAA) privacy and security rules; prior and current participation in other public programs

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including Medicare, social security disability insurance (SSDI), supplemental security income

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(SSI), including the 1619 (b) provision; statistics regarding the number of beneficiaries employed,

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and the average wage of those beneficiaries prior to and post Medicaid buy-in eligibility;

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Statistics regarding the amounts of premiums collected; Medicaid claims data including pre-buy-

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in, while on the buy-in, and if disenrolled, after buy-in; and

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     (3) Findings and recommendations with regard to any improvements, amendments, or

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changes that should be considered to make the act more effective in achieving its purposes or

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which may be necessary in order to encourage more Medicaid beneficiaries parents to seek and

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retain employment;

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     40-8.11-7. Application and appeals process. – (a) The director, or his or her designee,

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shall review each application for benefits filed in accordance with regulations, and shall make a

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determination of whether the application will be honored and the extent of the benefits to be made

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available to the applicant, and shall within thirty (30) days after the filing notify the applicant, in

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writing, of the determination. If the application is rejected, the notice to the applicant shall set

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forth therein the reason therefor. The director may at any time reconsider any determination.

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     (b) Any applicant aggrieved because of a decision, or delay in making a decision, shall be

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entitled to an appeal and shall be afforded reasonable notice and opportunity for a fair hearing

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conducted by the director.

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     (c) Findings of fact by the director shall be final and his or her decision shall be subject to

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judicial review only by certiorari if the decision is arbitrary, capricious, or unreasonable or

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inconsistent with law.

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     40-8.11-8. Annual program evaluation report. – (a) The office of health and human

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services shall annually prepare a report for the state senate and house of representatives finance

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committees which evaluates the Medicaid buy-in program.

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     (b) The report shall include, but not be limited to, the following:

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     (1) Comparison of employment incomes for the buy-in participants who enrolled in

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Medicaid change after they enrolled in the buy-in.

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     (2) The demographic information:

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     (i) Primary disabling condition;

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     (ii) Prior and current participation in other programs such as social security disability

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insurance; supplemental security income (including the 1819(b) provision) and Medicare;

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     (iii) Pre buy-in earned income;

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     (iv) Family earnings while participating in this buy-in;

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     (v) Hours worked; and

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     (vi) Availability of employer-provided health insurance coverage.

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     (3) The comparison of expenditures between primary disability for new Medicaid buy-in

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participants and participants who transferred from another Medicaid eligibility pursuant to this

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buy-in program.

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     (4) Disenrollment information as to why participants leave this program and what other

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Medicaid medical coverage they acquire.

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     (5) Whether disenrollees return to this buy-in program after a period of time off.

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     (6) Findings and recommendations based upon the best practices used in New England

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and throughout the nation concerning:

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     (i) The best practices to increase employment opportunities for the parents of disabled

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Medicaid children beneficiaries;

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     (ii) The best ways to support the working parents of disabled children;

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     (iii) The best strategies to ensure that supportive employment policies are integrated into

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the state’s design and implementation of the following:

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     (A) Long-term affordable care act;

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     (B) Balancing incentive payments plan (BIPP);

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     (C) Section 1915(i) State plan amendment;

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     (D) Section 2400 community first choice (CFC);

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     (E) Section 2703 health homes for individuals with chronic conditions;

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     (F) Money follows the person; and

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     (G) The dual eligible integrated care plan.

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     SECTION 2. This act shall serve as a joint resolution required pursuant to Rhode Island

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general laws section 42-12-12.4-1, et seq.

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     WHEREAS, The General Assembly enacted Chapter 12.4 of Title 42 entitled “The

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Rhode Island Medicaid Reform Act of 2008”; and

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     WHEREAS, Rhode Island General Law section 42-12.4-7 provides that any change that

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requires the implementation of a rule or regulation or modification or a rule or regulation in

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existence prior to the implementation of the global consumer choice section 1115 demonstration

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(“the demonstration”) shall require prior approval of the general assembly; and further provides

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that any category II change or category III change as defined in the demonstration shall also

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require prior approval to the general assembly; and

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     WHEREAS, Rhode Island General Law section 42-7.2-5 states that the secretary of the

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office of health and human services is responsible for the “review and coordination of any global

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consumer choice and human services is responsible for the review and coordination of any global

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consumer choice compact waiver requests and renewals as well as any initiatives and proposals

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requiring amendments to the Medicaid state plan or category I or II changes” as described in the

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demonstration, with “the potential to affect the scope, amount, or duration of publicly-funded

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health care services, provider payments or reimbursements, or access to or the availability of

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benefits and services provided by Rhode Island general and public laws”; and

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     WHEREAS, In pursuit of a more cost-effective consumer choice system of care that is

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fiscally sound and sustainable, the secretary requests that the following proposal to amend the

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demonstration be approved by the general assembly: The OHHS proposes determination of

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eligibility and premiums for families of children with disabilities enrolled in the Medicaid buy-in

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program; now, therefore, be it

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     RESOLVED, That the general assembly hereby approves the changes set forth in the

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proposal listed above to amend the demonstration; and be it further

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     RESOLVED, That the secretary of the office of health and human services is authorized

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to pursue and implement any such necessary waiver amendments, category II or category III

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changes, state plan amendments and/or changes to the applicable department's rules, regulations

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and procedures approved herein and as authorized by section 42-12.4-7.

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     SECTION 3. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO HUMAN SERVICES -- DISABLED CHILDREN'S MEDICAID BUY-IN

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     This would establish a framework for disabled children to buy into the federal Medicaid

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program.

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     This act would take effect upon passage.

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