2012 -- S 2755

=======

LC02089

=======

STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2012

____________

A N A C T

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

     Introduced By: Senators DiPalma, Pichardo, Tassoni, Sosnowski, and Felag

     Date Introduced: March 08, 2012

     Referred To: Senate Finance

It is enacted by the General Assembly as follows:

1-1

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

1-2

amended by adding thereto the following chapter:

1-3

     CHAPTER 8.11

1-4

MEDICAID BUY-IN FOR CHILDREN WITH DISABILITIES ACT

1-5

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

1-6

Buy-In for Children with Disabilities Act.”

1-7

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

1-8

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

1-9

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

1-10

access to critical healthcare services they need.

1-11

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

1-12

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

1-13

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

1-14

for health coverage through Medicaid.

1-15

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

1-16

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

1-17

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

1-18

disabilities deterioration of their health status.

1-19

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

1-20

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

2-1

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

2-2

security income and/or Medicaid.

2-3

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

2-4

greatest barriers preventing families from staying together and staying employed.

2-5

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

2-6

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

2-7

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

2-8

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

2-9

determination qualifications.

2-10

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

2-11

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

2-12

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

2-13

     WHEREAS, Only Medicaid can provide these comprehensive services.

2-14

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

2-15

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

2-16

insurance.

2-17

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

2-18

funds for the cost of these services.

2-19

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

2-20

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

2-21

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

2-22

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

2-23

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

2-24

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

2-25

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

2-26

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

2-27

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

2-28

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

2-29

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

2-30

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

2-31

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

2-32

order to obtain the healthcare coverage they require.

2-33

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

2-34

as:

3-1

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

3-2

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

3-3

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

3-4

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

3-5

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

3-6

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

3-7

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

3-8

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

3-9

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

3-10

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

3-11

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

3-12

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

3-13

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

3-14

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

3-15

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

3-16

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

3-17

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

3-18

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

3-19

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

3-20

supplemental to private insurance.

3-21

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

3-22

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

3-23

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

3-24

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

3-25

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

3-26

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

3-27

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

3-28

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

3-29

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

3-30

waiving premiums in the case of undue hardship for families.

3-31

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

3-32

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

3-33

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

3-34

in program shall commence on March 1, 2013.

4-1

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

4-2

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

4-3

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

4-4

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

4-5

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

4-6

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

4-7

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

4-8

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

4-9

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

4-10

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

4-11

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

4-12

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

4-13

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

4-14

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

4-15

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

4-16

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

4-17

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

4-18

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

4-19

retain employment;

4-20

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

4-21

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

4-22

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

4-23

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

4-24

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

4-25

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

4-26

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

4-27

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

4-28

conducted by the director.

4-29

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

4-30

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

4-31

inconsistent with law.

4-32

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

4-33

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

4-34

committees which evaluates the Medicaid buy-in program.

5-1

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

5-2

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

5-3

Medicaid change after they enrolled in the buy-in.

5-4

     (2) The demographic information:

5-5

     (i) Primary disabling condition;

5-6

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

5-7

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

5-8

     (iii) Pre buy-in earned income;

5-9

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

5-10

     (v) Hours worked; and

5-11

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

5-12

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

5-13

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

5-14

buy-in program.

5-15

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

5-16

Medicaid medical coverage they acquire.

5-17

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

5-18

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

5-19

and throughout the nation concerning:

5-20

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

5-21

Medicaid children beneficiaries;

5-22

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

5-23

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

5-24

the state’s design and implementation of the following:

5-25

     (A) Long-term affordable care act;

5-26

     (B) Balancing incentive payments plan (BIPP);

5-27

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

5-28

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

5-29

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

5-30

     (F) Money follows the person; and

5-31

     (G) The dual eligible integrated care plan.

5-32

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

5-33

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

6-34

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

6-35

Rhode Island Medicaid Reform Act of 2008”; and

6-36

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

6-37

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

6-38

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

6-39

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

6-40

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

6-41

require prior approval to the general assembly; and

6-42

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

6-43

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

6-44

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

6-45

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

6-46

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

6-47

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

6-48

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

6-49

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

6-50

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

6-51

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

6-52

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

6-53

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

6-54

program; now, therefore, be it

6-55

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

6-56

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

6-57

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

6-58

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

6-59

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

6-60

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

6-61

     SECTION 3. This act shall take effect upon passage.

=======

LC02089

========

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

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

***

7-1

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

7-2

program.

7-3

     This act would take effect upon passage.

=======

LC02089

=======