2014 -- H 7527

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LC004660

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2014

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A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL ASSISTANCE

     Introduced By: Representatives Serpa, and Fellela

     Date Introduced: February 26, 2014

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

     SECTION 1. Chapter 40-8 of the General Laws entitled "Medical Assistance" is hereby

amended by adding thereto the following section:

     40-8-16.1. Managed care arrangements for long-term care. – (a) Definitions. For

purposes of this section, the following terms shall have the following :

     (1) “Beneficiary” means an individual who is eligible for medical assistance under the

Rhode Island Medicaid state plan established in accordance with 42 U.S.C. 1396, and includes

individuals who are additionally eligible for benefits under the Medicare program (42 U.S.C. Sec.

1395, et seq.) or other health plan.

     (2) “Duals demonstration project” means a demonstration project established pursuant to

the financial alignment demonstration established under § 2602 of the Patient Protection and

Affordable Care Act (Pub. L. 111-148), involving a three way contract between Rhode Island, the

federal Centers for Medicare and Medicaid Services (“CMS”) and qualified health plans, and

covering health care services provided to beneficiaries.

     (3) “EOHHS” means the Rhode Island executive office of health and human services.

     (4) “EOHHS level of care tool” means to a set of criteria established by EOHHS and used

in January 2014 to determine the long-term care needs of a beneficiary as well as the appropriate

setting for delivery of that care.

     (5) “Long-term care services and supports” means a spectrum of services covered by the

Rhode Island Medicaid program and/or the Medicare program, that are required by individuals

with post acute care needs, functional impairments and/or chronic illness, and includes skilled or

custodial nursing facility care, as well as various home and community based services.

     (6) “Managed long-term care arrangement” means any arrangement under which a

managed care organization is granted some or all of the responsibility for providing and/or paying

for long-term care services and supports that would otherwise be provided or paid under the

Rhode Island Medicaid program. The term includes, but is not limited to, a duals demonstration

project, and/or phase I and phase II of the integrated care initiative established by the executive

office of health and human services.

     (7) "Managed care organization" means any health plan, health maintenance

organization, managed care plan, or other person or entity that enters into a contract with the state

under which it is granted the authority to arrange for the provision of, and/or payment for, long-

term care supports and services to eligible beneficiaries under a managed long-term care

arrangement.

     (8) "Plan of care" means a care plan established by a nursing facility in accordance with

state and federal regulations, and which identifies specific problems, goals, interventions and time

frames for care and services provided to a beneficiary.

     (b) Beneficiary choice. Any managed long-term care arrangement shall offer

beneficiaries the option to decline participation and remain in traditional Medicaid and, if a duals

demonstration project, traditional Medicare. Beneficiaries must be provided with sufficient

information to make an informed choice regarding enrollment, including:

     (1) Any changes in the beneficiary's payment or other financial obligations with respect

to long-term care services and supports as a result of enrollment;

     (2) Any changes in the nature of the long-term care services and supports available to the

beneficiary as a result of enrollment, including specific descriptions of new services that will be

available or existing services that will be curtailed or terminated;

     (3) A contact person who can assist the beneficiary in making decisions about

enrollment;

     (4) Individualized information regarding whether the managed care organization's

network includes the health care providers with whom beneficiaries have established provider

relationships. Directing beneficiaries to a website identifying the plan's provider network shall not

be sufficient to satisfy this requirement; and

     (5) The deadline by which the beneficiary must make a choice regarding enrollment, and

the length of time a beneficiary must remain enrolled in a managed care organization before

being permitted to change plans or opt out of the arrangement.

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     (c) Ombudsman process. EOHHS shall designate an ombudsperson to advocate for

beneficiaries enrolled in a managed long-term care arrangement. The ombudsperson shall

advocate for beneficiaries through complaint and appeal processes and ensure that necessary

health care services are provided. At the time of enrollment, a managed care organization must

inform enrollees of the availability of the ombudsperson, including contact information.

     (d) Provider/plan liaison. EOHHS shall designate an individual, not employed by or

otherwise under contract with a participating managed care organization, who shall act as liaison

between health care providers and managed care organizations, for the purpose of facilitating

communications and assuring that issues and concerns are promptly addressed.

     (e) Financial savings under managed care. To the extent that financial savings are a goal

under any managed long-term care arrangement, it is the intent of the legislature to achieve such

savings through administrative efficiencies, care coordination, and improvements in care

outcomes, rather than through reduced reimbursement rates to providers or limiting access to

medically necessary care and services. Therefore:

     (1) Any managed long-term care arrangement shall include a requirement that

participating managed care organizations reimburse providers for services in accordance with the

following:

     (i) The annual adjustment to rates by the change in a recognized national nursing home

inflation index as described in § 40-8-19(a)(2)(vi) or successor statute shall be applied to rates of

payment to nursing facilities for Medicaid-covered services.

     (ii) For a duals demonstration project, the managed care organization:

     (A) Shall not combine the rates of payment for post-acute skilled and rehabilitation care

provided by a nursing facility and long-term and chronic care provided by a nursing facility in

order to establish a single payment rate for dual eligible beneficiaries requiring skilled nursing

services;

     (B) Shall pay nursing facilities providing post-acute skilled and rehabilitation care or

long-term and chronic care rates that reflect the different level of services and intensity required

to provide these services; and

     (C) For purposes of determining the appropriate rate for the type of care identified in

subsection (e)(l)(ii)(B), the managed care organization shall pay no less than the rates which

would be paid for that care under Medicare and Rhode Island Medicaid for these service types.

     (iii) For a managed long-term care arrangement that is not a duals demonstration project,

the managed care organization shall reimburse providers in an amount no less than the rate that

would be paid for the same care by EOHHS under the Medicaid program.

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     (2) Any managed long-term care arrangement shall include a requirement that

participating managed care organizations use only the EOHHS level of care tool in determining

coverage of long-term care supports and services for beneficiaries. EOHHS may amend the level

of care tool provided that any changes are established upon public notice and comment; in

consultation with beneficiaries and providers of Medicaid-covered long-term care supports and

services; and are based upon reasonable medical evidence or consensus, in consideration of the

specific needs of Rhode Island beneficiaries. Notwithstanding anything else herein, however, in

the case of a duals demonstration project a managed care organization may use a different level of

care tool for determining coverage of services that would otherwise be covered by Medicare,

since the criteria established by EOHHS are directed towards Medicaid-covered services;

provided that such level of care tool is established upon public notice and comment; in

consultation with beneficiaries and providers of Medicaid-covered long-term care supports and

services; and is based upon reasonable medical evidence or consensus, in consideration of the

specific needs of Rhode Island beneficiaries.

     (3) Any managed long-term care arrangement shall include a requirement that

participating managed care organizations establish a mechanism under which providers furnish

input into the managed care organization's long-term care policies and procedures, including case

management; nursing care; quality management and reporting; and claims processing and

payment, as well as a mechanism under which beneficiaries furnish input into the managed care

organization's policies and procedures regarding the delivery of long-term care services and

supports.

     (e) Payment incentives. In order to encourage quality improvement and promote

appropriate utilization incentives for providers in a managed long-term care arrangement a

managed care organization may use incentive or bonus payment programs that are in addition to

the rates identified in subsection (e)(1).

     (f) Any willing provider. A managed care organization must contract with and cover

services furnished by any nursing facility licensed under chapter 23-17, and certified by CMS that

provides Medicaid-covered nursing facility services pursuant to a provider agreement with the

state, provided that the nursing facility is not disqualified under the managed care organization's

quality standards that are applicable to all nursing facilities; and the nursing facility is willing to

accept the reimbursement rates described in subsection (e) of this section.

     (g) Case management/plan of care. No managed care organization acting under a

managed long-term care arrangement may require a provider to change a plan of care if the

provider reasonably believes that such an action would conflict with the provider's responsibility

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to develop an appropriate care plan under state and federal regulations.

     (i) Care transitions. In the event that a beneficiary: (1) Has been determined to meet level

of care requirements for nursing facility coverage as of the date of his or her enrollment in a

managed care organization; or (2) Been determined to meet level of care requirements for nursing

facility coverage by a managed care organization after enrollment; and there is a change in

condition whereby the managed care organization determines that the beneficiary no longer meets

such level of care requirements, the nursing facility shall promptly arrange for an appropriate and

safe discharge (with the assistance of the managed care organization if the facility requests it),

and the managed care organization shall continue to pay for the beneficiary's nursing facility care

at the same rate until the beneficiary is discharged.

     (j) Reporting requirements. EOHHS shall report to the general assembly and shall make

available to interested persons a separate accounting of state expenditures for long-term care

supports and services under any managed long-term care arrangement, specifically and separately

identifying expenditures for home and community based services, assisted living services,

hospice services within nursing facilities, hospice services outside of nursing facilities, and

nursing facility services. Such reports shall be made twice annually, six (6) months apart,

beginning six (6) months following the implementation of any managed long-term care

arrangement, and shall include a detailed report of utilization of each such service. In order to

facilitate such reporting, any managed long-term care arrangement shall include a requirement

that a participating managed care organization make timely reports of the data necessary to

compile such reports.

     SECTION 2. 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 - MEDICAL ASSISTANCE

***

     This act would provide a choice for beneficiaries to decline participation in any managed

long-term care arrangement, and to remain in traditional Medicaid and/or traditional Medicare,

designate an ombudsperson to advocate on their behalf, provide an individual to act as a liaison

between health care providers and managed care organizations, and realize financial savings

whenever possible without any detrimental effect on the quality of care afforded beneficiaries

with reports required by the executive office of health and human services every six (6) months.

     This act would take effect upon passage.

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