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art.005/4/005/3/005/2/005/1

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     ARTICLE 5 AS AMENDED

THE REINVENTING MEDICAID ACT OF 2015

     Preamble: The following Act shall be known as "The Reinventing Medicaid Act of

2015", which achieves significant Medicaid savings while improving quality, controlling costs

and putting Rhode Island on a path toward closing a $190 million structural deficit.

     The Rhode Island Medicaid program is an integral component of the State’s health care

system. Medicaid provides services and supports to as many as one out of four Rhode Islanders,

including low-income children and families, developmentally-disabled residents, elders and

individuals with severe and persistent mental illness.

     Rhode Island currently spends more than 30 cents of every state revenue dollar on

Medicaid, much of it on fee-for-service payments to hospitals and nursing homes. As the

program’s reach expands, the costs of Medicaid have continued to rise, the delivery of care has

become more fragmented and uncoordinated and funding for Medicaid has crowded out

investments for important economic development priorities like education, skills training and

infrastructure.

     Given the crucial role of the Medicaid program to the state, it is of compelling

importance that the state conduct a fundamental restructuring of its Medicaid program that

achieves measurable improvement in health outcomes for the people of Rhode Island and

transforms the health care system to one that pays for outcomes and quality at a sustainable,

predictable and affordable cost for Rhode Island taxpayers and employers.

     Rhode Island cannot build a foundation for economic growth unless the state addresses

its structural deficit. Nor can it tackle the structural deficit without reforming Medicaid. Rhode

Island needs a strong Medicaid system that functions as a safety net for the most vulnerable

Rhode Islanders, but it also needs a sustainable model that works for patients, providers, and

taxpayers.

     The Reinventing Medicaid Act of 2015 makes a number of statutory changes to the state

Medicaid program, including the creation of incentive models that reward better hospitals and

nursing homes for better quality and better coordination, a pilot coordinated care program that

establishes person-centered care and payment methods, targeted community-based programs for

individuals who need intensive services and managed care for Rhode Islanders with severe and

persistent mental illness.

     This Act shall be known as the "Reinventing Medicaid Act of 2015."

     SECTION 1. Chapter 15-10 of the General Laws entitled "Support of Parents" is hereby

amended by adding thereto the following section:

     15-10-8. Support for certain patients of nursing facilities. -- The uncompensated costs

of care provided by a licensed nursing facility to any person may be recovered by the nursing

facility from any child of that person who is above the age of eighteen (18) years, to the extent

that the child previously received a transfer of any interests or assets from the person receiving

such care, which transfer resulted in a period of Medicaid ineligibility imposed pursuant to 42

USC 1396p(c), as amended from time to time, on a person whose assets have been transferred for

less than fair market value.

     Recourse hereunder shall be limited to the fair market value of the interests or assets

transferred at the time of transfer. For the purposes of this section "the costs of care" shall mean

the costs of providing care, including nursing care, personal care, meals, transportation and any

other costs, charges, and expenses incurred by the facility. Costs of care shall not exceed the

customary rate the nursing facility charges to a patient who pays for his or her care directly rather

than through a governmental or other third party payor. Nothing contained in this section shall

prohibit or otherwise diminish any other causes of action possessed by any such nursing facility.

The death of the person receiving nursing facility care shall not nullify or otherwise affect the

liability of the person or persons charged with the costs of care hereunder.

     SECTION 2. Section 23-17-38.1 of the General Laws in Chapter 23-17 entitled

"Licensing of Health Care Facilities" is hereby amended to read as follows:

     23-17-38.1 Hospitals - Licensing fee. -- (a) There is imposed a hospital licensing fee at

the rate of five and four hundred eighteen thousandths percent (5.418%) upon the net patient

services revenue of every hospital for the hospital's first fiscal year ending on or after January 1,

2012, except that the license fee for all hospitals located in Washington County, Rhode Island,

shall be discounted by thirty-seven percent (37%). The discount for Washington County hospitals

is subject to approval by the Secretary of the US Department of Health and Human Services of a

state plan amendment submitted by the executive office of health and human services for the

purpose of pursuing a waiver of the uniformity requirement for the hospital license fee. This

licensing fee shall be administered and collected by the tax administrator, division of taxation

within the department of revenue, and all the administration, collection, and other provisions of

chapter 51 of title 44 shall apply. Every hospital shall pay the licensing fee to the tax

administrator on or before July 14, 2014, and payments shall be made by electronic transfer of

monies to the general treasurer and deposited to the general fund. Every hospital shall, on or

before June 16, 2014, make a return to the tax administrator containing the correct computation of

net patient services revenue for the hospital fiscal year ending September 30, 2012, and the

licensing fee due upon that amount. All returns shall be signed by the hospital's authorized

representative, subject to the pains and penalties of perjury.

     (b)(a) There is also imposed a hospital licensing fee at the rate of five and seven hundred

three forty-five thousandths percent (5.703%) (5.745%) upon the net patient services revenue of

every hospital for the hospital's first fiscal year ending on or after January 1, 2013, except that the

license fee for all hospitals located in Washington County, Rhode Island shall be discounted by

thirty-seven percent (37%). The discount for Washington County hospitals is subject to approval

by the Secretary of the US Department of Health and Human Services of a state plan amendment

submitted by the executive office of health and human services for the purpose of pursuing a

waiver of the uniformity requirement for the hospital license fee. This licensing fee shall be

administered and collected by the tax administrator, division of taxation within the department of

revenue, and all the administration, collection and other provisions of chapter 51 of title 44 shall

apply. Every hospital shall pay the licensing fee to the tax administrator on or before July 13,

2015 and payments shall be made by electronic transfer of monies to the general treasurer and

deposited to the general fund. Every hospital shall, on or before June 15, 2015, make a return to

the tax administrator containing the correct computation of net patient services revenue for the

hospital fiscal year ending September 30, 2013, and the licensing fee due upon that amount. All

returns shall be signed by the hospital's authorized representative, subject to the pains and

penalties of perjury.

     (b) There is also imposed a hospital licensing fee at the rate of five and eight hundred

sixty-two thousandths percent (5.862%) upon the net patient services revenue of every hospital

for the hospital's first fiscal year ending on or after January 1, 2014, except that the license fee for

all hospitals located in Washington County, Rhode Island shall be discounted by thirty-seven

percent (37%). The discount for Washington County hospitals is subject to approval by the

Secretary of the US Department of Health and Human Services of a state plan amendment

submitted by the executive office of health and human services for the purpose of pursuing a

waiver of the uniformity requirement for the hospital license fee. This licensing fee shall be

administered and collected by the tax administrator, division of taxation within the department of

revenue, and all the administration, collection and other provisions of chapter 51 of title 44 shall

apply. Every hospital shall pay the licensing fee to the tax administrator on or before July 11,

2016 and payments shall be made by electronic transfer of monies to the general treasurer and

deposited to the general fund. Every hospital shall, on or before June 13, 2016, make a return to

the tax administrator containing the correct computation of net patient services revenue for the

hospital fiscal year ending September 30, 2014, and the licensing fee due upon that amount. All

returns shall be signed by the hospital's authorized representative, subject to the pains and

penalties of perjury.

     (c) For purposes of this section the following words and phrases have the following

meanings:

     (1) "Hospital" means a person or governmental unit duly licensed in accordance with this

chapter to establish, maintain, and operate a hospital, except a hospital whose primary service and

primary bed inventory are psychiatric. the actual facilities and buildings in existence in Rhode

Island, licensed pursuant to § 23-17-1 et seq. on June 30, 2010, and thereafter any premises

included on that license, regardless of changes in licensure status pursuant to § 23-17.14 (hospital

conversions) and §23-17-6 (b) (change in effective control), that provides short-term acute

inpatient and/or outpatient care to persons who require definitive diagnosis and treatment for

injury, illness, disabilities, or pregnancy. Notwithstanding the preceding language, the negotiated

Medicaid managed care payment rates for a court-approved purchaser that acquires a hospital

through receivership, special mastership or other similar state insolvency proceedings (which

court-approved purchaser is issued a hospital license after January 1, 2013) shall be based upon

the newly negotiated rates between the court-approved purchaser and the health plan, and such

rates shall be effective as of the date that the court-approved purchaser and the health plan

execute the initial agreement containing the newly negotiated rate. The rate-setting methodology

for inpatient hospital payments and outpatient hospital payments set for the §§ 40-8-

13.4(b)(1)(B)(iii) and 40-8-13.4(b)(2), respectively, shall thereafter apply to negotiated increases

for each annual twelve (12) month period as of July 1 following the completion of the first full

year of the court-approved purchaser's initial Medicaid managed care contract.

     (2) "Gross patient services revenue" means the gross revenue related to patient care

services.

     (3) "Net patient services revenue" means the charges related to patient care services less

(i) charges attributable to charity care; (ii) bad debt expenses; and (iii) contractual allowances.

     (d) The tax administrator shall make and promulgate any rules, regulations, and

procedures not inconsistent with state law and fiscal procedures that he or she deems necessary

for the proper administration of this section and to carry out the provisions, policy, and purposes

of this section.

     (e) The licensing fee imposed by this section shall apply to hospitals as defined herein

that are duly licensed on July 1, 2014 2015, and shall be in addition to the inspection fee imposed

by § 23-17-38 and to any licensing fees previously imposed in accordance with § 23-17-38.1.

     SECTION 3. Section 23-17.5-17 of the General Laws in Chapter 23-17.5 entitled "Rights

of Nursing Home Patients" is hereby amended to read as follows:

     23-17.5-17. Transfer to another facility. -- (a) Before transferring a patient to another

facility or level of care within a facility, the patient shall be informed of the need for the transfer

and of any alternatives to the transfer.

      (b) A patient shall be transferred or discharged only for medical reasons, or for the

patient's welfare or that of other patients or for nonpayment of the patient's stay. A facility

seeking to discharge a patient for nonpayment of the patient’s stay must, if the patient has been a

patient of the facility for thirty (30) days or longer, provide the patient and, if known, a family

member or legal representative of the patient, with written notice of the proposed discharge thirty

(30) days in advance of the discharge.

     (c) The patient may file an appeal of the proposed discharge with the state agency

designated for hearing such appeals, and if the appeal is received by that agency within ten days

after the date of written notice, the patient may remain in the facility until the decision of the

hearing officer. For appeals where the patient remains in the facility:

     (i) Any hearing on the appeal shall be scheduled no later than thirty (30) days after the

receipt by the state agency of the request for appeal;

     (ii) No more than one request for continuance by the patient shall be permitted and, if

granted, the hearing on the appeal must be rescheduled for a date and time no later than forty (40)

days after the receipt by the state agency of the request for appeal; and

     (iii) The decision of the hearing officer shall be rendered as soon as possible, but in any

event within five (5) days after the date of the hearing.

      (c)(d) Reasonable advance notice of transfers to health care facilities other than hospitals

shall be given to ensure orderly transfer or discharge and those actions shall be documented in the

medical record.

      (d)(e) In the event that a facility seeks a variance from the required thirty (30) day notice

of closure of the facility, reasonable advance notice of the hearing for the variance shall be given

by the facility to the patient, his or her guardian, or relative so appointed or elected to be his or

her decision-maker, and an opportunity to be present at the hearing shall be granted to the

designated person.

      (e)(f) In the event of the voluntary closure of a facility, which closure is the result of a

variance from the required thirty (30) day notice of closure, granted by the director of the

department of health, reasonable advance notice of the closure shall be given by the facility to the

patient, his or her guardian, or relative so appointed or elected to be his or her decision-maker.

     (g) Nothing herein shall be construed to relieve a patient from any obligation to pay for

the patient’s stay in a facility.

     SECTION 4. Section 27-18-64 of the General Laws in Chapter 27-18 entitled "Accident

and Sickness Insurance Policies" is hereby amended to read as follows:

     27-18-64. Coverage for early intervention services. -- (a) Every individual or group

hospital or medical expense insurance policy or contract providing coverage for dependent

children, delivered or renewed in this state on or after July 1, 2004, shall include coverage of

early intervention services which coverage shall take effect no later than January 1, 2005. Such

coverage shall be limited to a benefit of five thousand dollars ($5,000) per dependent child per

policy or calendar year and shall not be subject to deductibles and coinsurance factors. Any

amount paid by an insurer under this section for a dependent child shall not be applied to any

annual or lifetime maximum benefit contained in the policy or contract. For the purpose of this

section, "early intervention services" means, but is not limited to, speech and language therapy,

occupational therapy, physical therapy, evaluation, case management, nutrition, service plan

development and review, nursing services, and assistive technology services and devices for

dependents from birth to age three (3) who are certified by the department of human services

executive office of health and human services as eligible for services under part C of the

Individuals with Disabilities Education Act (20 U.S.C. § 1471 et seq.).

     (b) Subject to the annual limits provided in this section, insurers Insurers shall reimburse

certified early intervention providers, who are designated as such by the Department of Human

Services executive office, for early intervention services as defined in this section at rates of

reimbursement equal to or greater than the prevailing integrated state/Medicaid rate for early

intervention services as established by the Department of Human Services.

     (c) This section shall not apply to insurance coverage providing benefits for: (1) hospital

confinement indemnity; (2) disability income; (3) accident only; (4) long-term care; (5) Medicare

supplement; (6) limited benefit health; (7) specified disease indemnity; (8) sickness or bodily

injury or death by accident or both; and (9) other limited benefit policies.

     SECTION 5. Section 27-20.11-3 of the General Laws in Chapter 27-20.11 entitled

"Autism Spectrum Disorders" is hereby amended to read as follows:

     27-20.11-3. Scope of coverage. -- (a) Benefits under this section shall include coverage

for pharmaceuticals, applied behavior analysis, physical therapy, speech therapy, psychology,

psychiatric and occupational therapy services for the treatment of Autism spectrum disorders, as

defined in the most recent edition of the DSM. Provided, however:

     (1) Coverage for physical therapy, speech therapy and occupational therapy and

psychology, psychiatry and pharmaceutical services shall be, to the extent such services are a

covered benefit for other diseases and conditions under such policy ; and

     (2) Applied behavior analysis .shall be limited to thirty-two thousand dollars ($32,000)

per person per year.

     (b) Benefits under this section shall continue until the covered individual reaches age

fifteen (15).

     (c) The health care benefits outlined in this chapter apply only to services delivered

within the State of Rhode Island; provided, that all health insurance carriers shall be required to

provide coverage for those benefits mandated by this chapter outside of the State of Rhode Island

where it can be established through a pre-authorization process that the required services are not

available in the State of Rhode Island from a provider in the health insurance carrier's network.

     SECTION 6: Section 35-17-1 of the General Laws in Chapter 35-17 entitled "Medical

Assistance and Public Assistance Caseload Estimating Conferences" is hereby amended to read

as follows:

     35-17-1. Purpose and membership. -- (a) In order to provide for a more stable and

accurate method of financial planning and budgeting, it is hereby declared the intention of the

legislature that there be a procedure for the determination of official estimates of anticipated

medical assistance expenditures and public assistance caseloads, upon which the executive budget

shall be based and for which appropriations by the general assembly shall be made.

     (b) The state budget officer, the house fiscal advisor, and the senate fiscal advisor shall

meet in regularly scheduled caseload estimating conferences (C.E.C.). These conferences shall be

open public meetings.

     (c) The chairpersonship of each regularly scheduled C.E.C. will rotate among the state

budget officer, the house fiscal advisor, and the senate fiscal advisor, hereinafter referred to as

principals. The schedule shall be arranged so that no chairperson shall preside over two (2)

successive regularly scheduled conferences on the same subject.

     (d) Representatives of all state agencies are to participate in all conferences for which

their input is germane.

     (e) The department of human services shall provide monthly data to the members of the

caseload estimating conference by the fifteenth day of the following month. Monthly data shall

include, but is not limited to, actual caseloads and expenditures for the following case assistance

programs: Rhode Island Works, SSI state program, general public assistance, and child care. The

executive office of health and human services shall report relevant caseload information and

expenditures for the following medical assistance categories: hospitals, long-term care, managed

care, pharmacy, and other medical services. In the category of managed care, caseload

information and expenditures for the following populations shall be separately identified and

reported: children with disabilities, children in foster care, and children receiving adoption

assistance. The information shall include the number of Medicaid recipients whose estate may be

subject to a recovery and the anticipated amount to be collected from those subject to recovery

estate, and the total recoveries collected each month and number of estates attached to the

collections and each month, the number of open cases and the number of cases that have been

open longer than three months.

     SECTION 7. Section 40-5-13 of the General Laws in Chapter 40-5 entitled "Support of

the Needy" is hereby amended to read as follows:

     40-5-13. Obligation of kindred for support. – (a) The kindred of any poor person, if

any he or she shall have in the line or degree of father or grandfather, mother or grandmother,

children or grandchildren, by consanguinity, or children by adoption, living within this state and

of sufficient ability, shall be holden to support the pauper in proportion to their ability.

     (b) The uncompensated costs of care provided by a licensed nursing facility to any person

may be recovered by the nursing facility from any person who is obligated to provide support to

that patient under subsection (a) hereof, to the extent that the individual so obligated received a

transfer of any interests or assets from the patient receiving such care, which transfer resulted in a

period of Medicaid ineligibility imposed pursuant to 42 USC 1396p(c), as amended from time to

time, on a person whose assets have been transferred for less than fair market value.

     Recourse hereunder shall be limited to the fair market value of the interests or assets

transferred at the time of transfer. For the purposes of this section "the costs of care" shall mean

the costs of providing care, including nursing care, personal care, meals, transportation and any

other costs, charges, and expenses incurred by the facility. Costs of care shall not exceed the

customary rate the nursing facility charges to a patient who pays for his or her care directly rather

than through a governmental or other third party payor. Nothing contained in this section shall

prohibit or otherwise diminish any other causes of action possessed by any such nursing facility.

The death of the person receiving nursing facility care shall not nullify or otherwise affect the

liability of the person or persons charged with the costs of care hereunder.

     SECTION 8. Sections 40-6-27 and 40-6-27.2 of the General Laws in Chapter 40-6

entitled General Public Assistance are hereby amended to read as follows:

     40-6-27. Supplemental security income. -- (a)(1) The director of the department is

hereby authorized to enter into agreements on behalf of the state with the secretary of the U.S.

Department of Health and Human Services or other appropriate federal officials, under the

supplementary and security income (SSI) program established by title XVI of the Social Security

Act, 42 U.S.C. § 1381 et seq., concerning the administration and determination of eligibility for

SSI benefits for residents of this state, except as otherwise provided in this section. The state's

monthly share of supplementary assistance to the supplementary security income program shall

be as follows:

     (i) Individual living alone: $39.92

     (ii) Individual living with others: $51.92

     (iii) Couple living alone: $79.38

     (iv) Couple living with others: $97.30

     (v) Individual living in state licensed assisted living residence: $332.00

     (vi) Individual eligible to receive Medicaid-funded long-term services and supports and

living in a Medicaid certified state licensed assisted living residence or adult supportive housing

care residence, as defined in §23-17.24, participating in the program authorized under § 40-8.13-

2.1:

     (a) with countable income above one hundred and twenty (120) percent of poverty: up to

$465.00;

     (b) with countable income at or below one hundred and twenty (120) percent of poverty:

up to the total amount established in (v) and $465: $797

     (vi)(vii) Individual living in state licensed supportive residential care settings that,

depending on the population served, meet the standards set by the department of human services

in conjunction with the department(s) of children, youth and families, elderly affairs and/or

behavioral healthcare, developmental disabilities and hospitals: $300.00.

     Provided, however, that the department of human services shall by regulation reduce,

effective January 1, 2009, the state's monthly share of supplementary assistance to the

supplementary security income program for each of the above listed payment levels, by the same

value as the annual federal cost of living adjustment to be published by the federal social security

administration in October 2008 and becoming effective on January 1, 2009, as determined under

the provisions of title XVI of the federal social security act [42 U.S.C. § 1381 et seq.]; and

provided further, that it is the intent of the general assembly that the January 1, 2009 reduction in

the state's monthly share shall not cause a reduction in the combined federal and state payment

level for each category of recipients in effect in the month of December 2008; provided further,

that the department of human services is authorized and directed to provide for payments to

recipients in accordance with the above directives.

     (2) As of July 1, 2010, state supplement payments shall not be federally administered and

shall be paid directly by the department of human services to the recipient.

     (3) Individuals living in institutions shall receive a twenty dollar ($20.00) per month

personal needs allowance from the state which shall be in addition to the personal needs

allowance allowed by the Social Security Act, 42 U.S.C. § 301 et seq.

     (4) Individuals living in state licensed supportive residential care settings and assisted

living residences who are receiving SSI supplemental payments under this section who are

participating in the program under §40-8.13-2.1 or otherwise shall be allowed to retain a

minimum personal needs allowance of fifty-five dollars ($55.00) per month from their SSI

monthly benefit prior to payment of any monthly fees in addition to any amounts established in

an administrative rule promulgated by the secretary of the executive office of health and human

services for persons eligible to receive Medicaid-funded long-term services and supports in the

settings identified in subsection (a)(1)(v) and (a)(1)(vi).

     (5) Except as authorized for the program authorized under §40-8.13-2.1, To to ensure that

supportive residential care or an assisted living residence is a safe and appropriate service setting,

the department is authorized and directed to make a determination of the medical need and

whether a setting provides the appropriate services for those persons who:

     (i) Have applied for or are receiving SSI, and who apply for admission to supportive

residential care setting and assisted living residences on or after October 1, 1998; or

     (ii) Who are residing in supportive residential care settings and assisted living residences,

and who apply for or begin to receive SSI on or after October 1, 1998.

     (6) The process for determining medical need required by subsection (4) (5) of this

section shall be developed by the office of health and human services in collaboration with the

departments of that office and shall be implemented in a manner that furthers the goals of

establishing a statewide coordinated long-term care entry system as required pursuant to the

Global Consumer Choice Compact Waiver Medicaid section 1115 waiver demonstration.

     (7) To assure access to high quality coordinated services, the department executive office

of health and human services is further authorized and directed to establish rules specifying the

payment certification or contract standards that must be met by those state licensed supportive

residential care settings, including adult supportive care homes and assisted living residences

admitting or serving any persons eligible for state-funded supplementary assistance under this

section or the program established under §40-8.13-2.1. Such payment certification or contract

standards shall define:

     (i) The scope and frequency of resident assessments, the development and

implementation of individualized service plans, staffing levels and qualifications, resident

monitoring, service coordination, safety risk management and disclosure, and any other related

areas;

     (ii) The procedures for determining whether the payment certifications or contract

standards have been met; and

     (iii) The criteria and process for granting a one time, short-term good cause exemption

from the payment certification or contract standards to a licensed supportive residential care

setting or assisted living residence that provides documented evidence indicating that meeting or

failing to meet said standards poses an undue hardship on any person eligible under this section

who is a prospective or current resident.

     (8) The payment certification or contract standards required by this section or § 40-8.13-

2.1 shall be developed in collaboration by the departments, under the direction of the executive

office of health and human services, so as to ensure that they comply with applicable licensure

regulations either in effect or in development.

     (b) The department is authorized and directed to provide additional assistance to

individuals eligible for SSI benefits for:

     (1) Moving costs or other expenses as a result of an emergency of a catastrophic nature

which is defined as a fire or natural disaster; and

     (2) Lost or stolen SSI benefit checks or proceeds of them; and

     (3) Assistance payments to SSI eligible individuals in need because of the application of

federal SSI regulations regarding estranged spouses; and the department shall provide such

assistance in a form and an amount in which the department shall by regulation determine.

     40-6-27.2. Supplementary cash assistance payment for certain supplemental security

income recipients. -- There is hereby established a $206 monthly payment for disabled and

elderly individuals who, on or after July 1, 2012, receive the state supplementary assistance

payment for an individual in state licensed assisted living residence under § 40-6-27 and further

reside in an assisted living facility that is not eligible to receive funding under Title XIX of the

Social Security Act, 42 U.S.C. § 1381 et seq., including through the program authorized under

§40-8.13-2.1 or reside in any assisted living facility financed by the Rhode Island housing and

mortgage finance corporation prior to January 1, 2006, and receive a payment under § 40-6-27.

Such a monthly payment shall not be made on behalf of persons participating in the program

authorized under §40-8.13-2.

     SECTION 9. Sections 40-8-4 and 40-8-13.4 of the General Laws in Chapter 40-8 entitled

"Medical Assistance" is hereby amended to read as follows:

     40-8-4. Direct vendor payment plan. -- (a) The department shall furnish medical care

benefits to eligible beneficiaries through a direct vendor payment plan. The plan shall include, but

need not be limited to, any or all of the following benefits, which benefits shall be contracted for

by the director:

     (1) Inpatient hospital services, other than services in a hospital, institution, or facility for

tuberculosis or mental diseases;

     (2) Nursing services for such period of time as the director shall authorize;

     (3) Visiting nurse service;

     (4) Drugs for consumption either by inpatients or by other persons for whom they are

prescribed by a licensed physician;

     (5) Dental services; and

     (6) Hospice care up to a maximum of two hundred and ten (210) days as a lifetime

benefit.

     (b) For purposes of this chapter, the payment of federal Medicare premiums or other

health insurance premiums by the department on behalf of eligible beneficiaries in accordance

with the provisions of Title XIX of the federal Social Security Act, 42 U.S.C. § 1396 et seq., shall

be deemed to be a direct vendor payment.

     (c) With respect to medical care benefits furnished to eligible individuals under this

chapter or Title XIX of the federal Social Security Act, the department is authorized and directed

to impose:

     (i) Nominal co-payments or similar charges upon eligible individuals for non-emergency

services provided in a hospital emergency room; and

     (ii) Co-payments for prescription drugs in the amount of one dollar ($1.00) for generic

drug prescriptions and three dollars ($3.00) for brand name drug prescriptions in accordance with

the provisions of 42 U.S.C. § 1396, et seq.

     (d) The department is authorized and directed to promulgate rules and regulations to

impose such co-payments or charges and to provide that, with respect to subdivision (ii) above,

those regulations shall be effective upon filing.

     (e) No state agency shall pay a vendor for medical benefits provided to a recipient of

assistance under this chapter until and unless the vendor has submitted a claim for payment to a

commercial insurance plan, Medicare, and/or a Medicaid managed care plan, if applicable for that

recipient, in that order. This includes payments for skilled nursing and therapy services

specifically outlined in Chapter 7, 8 and 15 of the Medicare Benefit Policy Manual.

     SECTION 10. Chapter 40-8 of the General Laws entitled "Medical Assistance" is hereby

amended by adding thereto the following section:

     40-8-6.1. Nursing facility care during pendency of application. -- (a) Definitions. or

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

     "Applied Income" – The amount of income a Medicaid beneficiary is required to

contribute to the cost of his or her care.

     "Authorized Representative" – An individual who signs an application for Medicaid

benefits on behalf of a Medicaid Applicant

     "Complete Application" – An application for Medicaid benefits filed by or on behalf of

an individual receiving care and services from a nursing facility, including attachments and

supplemental information as necessary, which provides sufficient information for the director or

designee to determine the applicant’s eligibility for coverage. An application shall not be

disqualified from status as a complete application hereunder except for failure on the part of the

Medicaid applicant, or his or her authorized representative, to provide necessary information or

documentation, or to take any other action necessary to make the application a complete

application.

     "Medicaid Applicant" – An individual who is receiving care in a nursing facility during

the pendency of an application for Medicaid benefits.

     "Nursing Facility" – A nursing facility licensed under Chapter 17 of Title 23, which is a

participating provider in the Rhode Island Medicaid program.

     "Uncompensated Care" – Care and services provided by a nursing facility to a Medicaid

applicant without receiving compensation therefore from Medicaid, Medicare, the Medicaid

applicant, or other source. The acceptance of any payment representing actual or estimated

applied income shall not disqualify the care and services provided from qualifying as

uncompensated care.

     (b) Uncompensated Care During Pendency of an Application for Benefits. A nursing

facility may not discharge a Medicaid applicant for non-payment of the facility’s bill during the

pendency of a complete application; nor may a nursing facility charge a Medicaid applicant for

care provided during the pendency of a complete application, except for an amount representing

the estimated applied income. A nursing facility may discharge a Medicaid applicant for non-

payment of the facility’s bill during the pendency of an application for Medicaid coverage that is

not a complete application, but only if the nursing facility has provided the patient (and his or her

authorized representative, if known) with thirty (30) days’ written notice of its intention to do so,

and the application remains incomplete during that thirty (30) day period.

     (c) Notice Of Application Status. When a nursing facility is providing uncompensated

care to a Medicaid applicant, then the nursing facility may inform the director or designee of its

status, and the director or designee shall thereafter inform the nursing facility of any decision on

the application at the time the decision is rendered and, if coverage is approved, of the date that

coverage will begin. In addition, a nursing facility providing uncompensated care to a Medicaid

applicant may inquire of the director or designee as to the status of that individual’s application,

and the director or designee shall respond within five business days as follows:

     (i) Without Release – If the nursing facility has not obtained a signed release authorizing

disclosure of information to the facility, the director or designee must provide the following

information only, in writing: (a) whether or not the application has been approved; (b) the identity

of any authorized representative; and (c) if the application has not yet been decided, whether or

not the application is a complete application.

     (ii) With Release – If the nursing facility has obtained a signed release, the director or

designee must additionally provide any further information requested by the nursing facility, to

the extent that the release permits its disclosure.

     40-8-13.4. Rate methodology for payment for in state and out of state hospital

services. -- (a) The executive office of health and human services shall implement a new

methodology for payment for in state and out of state hospital services in order to ensure access

to and the provision of high quality and cost-effective hospital care to its eligible recipients.

     (b) In order to improve efficiency and cost effectiveness, the executive office of health

and human services shall:

     (1)(A) With respect to inpatient services for persons in fee for service Medicaid, which is

non-managed care, implement a new payment methodology for inpatient services utilizing the

Diagnosis Related Groups (DRG) method of payment, which is, a patient classification method

which provides a means of relating payment to the hospitals to the type of patients cared for by

the hospitals. It is understood that a payment method based on Diagnosis Related Groups may

include cost outlier payments and other specific exceptions. The executive office will review the

DRG payment method and the DRG base price annually, making adjustments as appropriate in

consideration of such elements as trends in hospital input costs, patterns in hospital coding,

beneficiary access to care, and the Center for Medicare and Medicaid Services national CMS

Prospective Payment System (IPPS) Hospital Input Price index. For the twelve (12) month period

beginning July 1, 2015, the DRG base rate for Medicaid fee-for-service inpatient hospital services

shall not exceed ninety-seven and one-half percent (97.5%) of the payment rates in effect as of

July 1, 2014.

     (B) With respect to inpatient services, (i) it is required as of January 1, 2011 until

December 31, 2011, that the Medicaid managed care payment rates between each hospital and

health plan shall not exceed ninety and one tenth percent (90.1%) of the rate in effect as of June

30, 2010. Negotiated increases in inpatient hospital payments for each annual twelve (12) month

period beginning January 1, 2012 may not exceed the Centers for Medicare and Medicaid

Services national CMS Prospective Payment System (IPPS) Hospital Input Price index for the

applicable period; (ii) provided, however, for the twenty-four (24) month period beginning July 1,

2013 the Medicaid managed care payment rates between each hospital and health plan shall not

exceed the payment rates in effect as of January 1, 2013 and for the twelve (12) month period

beginning July 1, 2015, the Medicaid managed care payment inpatient rates between each

hospital and health plan shall not exceed ninety-seven and one-half percent (97.5%) of the

payment rates in effect as of January 1, 2013; (iii) negotiated increases in inpatient hospital

payments for each annual twelve (12) month period beginning July 1, 2015 2016 may not exceed

the Centers for Medicare and Medicaid Services national CMS Prospective Payment System

(IPPS) Hospital Input Price Index, less Productivity Adjustment, for the applicable period; (iv)

The Rhode Island executive office of health and human services will develop an audit

methodology and process to assure that savings associated with the payment reductions will

accrue directly to the Rhode Island Medicaid program through reduced managed care plan

payments and shall not be retained by the managed care plans; (v) All hospitals licensed in Rhode

Island shall accept such payment rates as payment in full; and (vi) for all such hospitals,

compliance with the provisions of this section shall be a condition of participation in the Rhode

Island Medicaid program.

     (2) With respect to outpatient services and notwithstanding any provisions of the law to

the contrary, for persons enrolled in fee for service Medicaid, the executive office will reimburse

hospitals for outpatient services using a rate methodology determined by the executive office and

in accordance with federal regulations. Fee-for-service outpatient rates shall align with Medicare

payments for similar services. Notwithstanding the above, there shall be no increase in the

Medicaid fee-for-service outpatient rates effective on July 1, 2013 or, July 1, 2014, or July 1,

2015. For the twelve (12) month period beginning July 1, 2015, Medicaid fee-for-service

outpatient rates shall not exceed ninety-seven and one-half percent (97.5%) of the rates in effect

as of July 1, 2014. Thereafter, changes to outpatient rates will be implemented on July 1 each

year and shall align with Medicare payments for similar services from the prior federal fiscal

year. With respect to the outpatient rate, (i) it is required as of January 1, 2011 until December 31,

2011, that the Medicaid managed care payment rates between each hospital and health plan shall

not exceed one hundred percent (100%) of the rate in effect as of June 30, 2010. Negotiated

increases in hospital outpatient payments for each annual twelve (12) month period beginning

January 1, 2012 may not exceed the Centers for Medicare and Medicaid Services national CMS

Outpatient Prospective Payment System (OPPS) hospital price index for the applicable period;

(ii) provided, however, for the twenty-four (24) month period beginning July 1, 2013 the

Medicaid managed care outpatient payment rates between each hospital and health plan shall not

exceed the payment rates in effect as of January 1, 2013 and for the twelve (12) month period

beginning July 1, 2015, the Medicaid managed care outpatient payment rates between each

hospital and health plan shall not exceed ninety-seven and one-half percent (97.5%) of the

payment rates in effect as of January 1, 2013; (iii) negotiated increases in outpatient hospital

payments for each annual twelve (12) month period beginning July 1, 2015 2016 may not exceed

the Centers for Medicare and Medicaid Services national CMS Outpatient Prospective Payment

System (OPPS) Hospital Input Price Index, less Productivity Adjustment, for the applicable

period.

     (3) "Hospital" as used in this section shall mean the actual facilities and buildings in

existence in Rhode Island, licensed pursuant to § 23-17-1 et seq. on June 30, 2010, and thereafter

any premises included on that license, regardless of changes in licensure status pursuant to § 23-

17.14 (hospital conversions) and § 23-17-6 (b) (change in effective control), that provides short-

term acute inpatient and/or outpatient care to persons who require definitive diagnosis and

treatment for injury, illness, disabilities, or pregnancy. Notwithstanding the preceding language,

the negotiated Medicaid managed care payment rates for a court-approved purchaser that acquires

a hospital through receivership, special mastership or other similar state insolvency proceedings

(which court-approved purchaser is issued a hospital license after January 1, 2013) shall be based

upon the newly negotiated rates between the court-approved purchaser and the health plan, and

such rates shall be effective as of the date that the court-approved purchaser and the health plan

execute the initial agreement containing the newly negotiated rate. The rate-setting methodology

for inpatient hospital payments and outpatient hospital payments set for the §§ 40-8-

13.4(b)(1)(B)(iii) and 40-8-13.4(b)(2), respectively, shall thereafter apply to negotiated increases

for each annual twelve (12) month period as of July 1 following the completion of the first full

year of the court-approved purchaser's initial Medicaid managed care contract.

     (c) It is intended that payment utilizing the Diagnosis Related Groups method shall

reward hospitals for providing the most efficient care, and provide the executive office the

opportunity to conduct value based purchasing of inpatient care.

     (d) The secretary of the executive office of health and human services is hereby

authorized to promulgate such rules and regulations consistent with this chapter, and to establish

fiscal procedures he or she deems necessary for the proper implementation and administration of

this chapter in order to provide payment to hospitals using the Diagnosis Related Group payment

methodology. Furthermore, amendment of the Rhode Island state plan for medical assistance

(Medicaid) pursuant to Title XIX of the federal Social Security Act is hereby authorized to

provide for payment to hospitals for services provided to eligible recipients in accordance with

this chapter.

     (e) The executive office shall comply with all public notice requirements necessary to

implement these rate changes.

     (f) As a condition of participation in the DRG methodology for payment of hospital

services, every hospital shall submit year-end settlement reports to the executive office within one

year from the close of a hospital's fiscal year. Should a participating hospital fail to timely submit

a year-end settlement report as required by this section, the executive office shall withhold

financial cycle payments due by any state agency with respect to this hospital by not more than

ten percent (10%) until said report is submitted. For hospital fiscal year 2010 and all subsequent

fiscal years, hospitals will not be required to submit year-end settlement reports on payments for

outpatient services. For hospital fiscal year 2011 and all subsequent fiscal years, hospitals will not

be required to submit year-end settlement reports on claims for hospital inpatient services.

Further, for hospital fiscal year 2010, hospital inpatient claims subject to settlement shall include

only those claims received between October 1, 2009 and June 30, 2010.

     (g) The provisions of this section shall be effective upon implementation of the

amendments and new payment methodology pursuant to this section and § 40-8-13.3, which shall

in any event be no later than March 30, 2010, at which time the provisions of §§ 40-8-13.2, 27-

19-14, 27-19-15, and 27-19-16 shall be repealed in their entirety.

     40-8-13.5. Hospital Incentive Program (HIP). -- The secretary of the executive office

of health and human services is authorized to seek the federal authorities required to implement a

hospital incentive program (HIP). The HIP shall provide the participating licensed hospitals the

ability to obtain certain payments for achieving performance goals established by the secretary.

HIP payments shall commence no earlier than July 1, 2016.

     SECTION 11. Section 40-8-19 of the General Laws in Chapter 40-8 entitled "Medical

Assistance" is hereby amended to read as follows:

     40-8-19. Rates of payment to nursing facilities. -- (a) Rate reform. (1) The rates to be

paid by the state to nursing facilities licensed pursuant to chapter 17 of title 23, and certified to

participate in the Title XIX Medicaid program for services rendered to Medicaid-eligible

residents, shall be reasonable and adequate to meet the costs which must be incurred by

efficiently and economically operated facilities in accordance with 42 U.S.C. § 1396a(a)(13). The

executive office of health and human services shall promulgate or modify the principles of

reimbursement for nursing facilities in effect as of July 1, 2011 to be consistent with the

provisions of this section and Title XIX, 42 U.S.C. § 1396 et seq., of the Social Security Act.

     (2) The executive office of health and human services ("Executive Office") shall review

the current methodology for providing Medicaid payments to nursing facilities, including other

long-term care services providers, and is authorized to modify the principles of reimbursement to

replace the current cost based methodology rates with rates based on a price based methodology

to be paid to all facilities with recognition of the acuity of patients and the relative Medicaid

occupancy, and to include the following elements to be developed by the executive office:

     (i) A direct care rate adjusted for resident acuity;

     (ii) An indirect care rate comprised of a base per diem for all facilities;

     (iii) A rearray of costs for all facilities every three (3) years beginning October, 2015,

which may or may not result in automatic per diem revisions;

     (iv) Application of a fair rental value system;

     (v) Application of a pass-through system; and

     (vi) Adjustment of rates by the change in a recognized national nursing home inflation

index to be applied on October 1st of each year, beginning October 1, 2012. This adjustment will

not occur on October 1, 2013 or October 1, 2015 but will resume occur on April 1, 2015. Said

inflation index shall be applied without regard for the transition factor in subsection (b)(2) below.

     (b) Transition to full implementation of rate reform. For no less than four (4) years after

the initial application of the price-based methodology described in subdivision (a)(2) to payment

rates, the executive office of health and human services shall implement a transition plan to

moderate the impact of the rate reform on individual nursing facilities. Said transition shall

include the following components:

     (1) No nursing facility shall receive reimbursement for direct care costs that is less than

the rate of reimbursement for direct care costs received under the methodology in effect at the

time of passage of this act; and

     (2) No facility shall lose or gain more than five dollars ($5.00) in its total per diem rate

the first year of the transition. The An adjustment to the per diem loss or gain may be phased out

by twenty-five percent (25%) each year; except, however, for the year beginning October 1, 2015,

there shall be no adjustment to the per diem gain or loss, gain during state fiscal year 2016, but it

may resume the phase out shall resume thereafter; and

     (3) The transition plan and/or period may be modified upon full implementation of

facility per diem rate increases for quality of care related measures. Said modifications shall be

submitted in a report to the general assembly at least six (6) months prior to implementation.

     (4) Notwithstanding any law to the contrary, for the twelve (12) month period beginning

July 1, 2015, Medicaid payment rates for nursing facilities established pursuant to this section

shall not exceed ninety-eight percent (98%) of the rates in effect on April 1, 2015.

     40-8-19.2. Nursing Facility Incentive Program (NFIP). -- The secretary of the

executive office of health and human services is authorized to seek the federal authority required

to implement a nursing facility incentive program (NFIP). The NFIP shall provide the

participating licensed nursing facilities the ability to obtain certain payments for achieving

performance goals established by the secretary. NFIP payments shall commence no earlier than

July 1, 2016.

     SECTION 12. Sections 40-8.2-2 to 40-8.2-4, 40-8.2-10 to 40-8.2-12, and 40-8.2-14 to

40-8.2-22 of the General Laws in Chapter 40-8.2 entitled "Medical Assistance Fraud " are

hereby amended to read as follows:

     40-8.2-1. Short title. -- This chapter shall be known as the "Rhode Island Medical

Assistance Fraud Law".

     40-8.2-2. Definitions. -- Whenever used in this chapter:

     (1) "Benefit" means pecuniary benefit as defined herein.

     (2) "Claim" means any request for payment, electronic or otherwise, and shall also

include any data commonly known as encounter data, which is used or is to be used for the

development of a capitation fee payable to a provider of managed health care goods, merchandise

or services.

     (3) "Department" means the Rhode Island department of human services "Executive

Office" means the executive office of health and human services, the agency designated by state

law and the Medicaid state plan as the Medicaid single state agency.

     (4) "Fee schedule" means a list of goods or services to be recognized as properly

compensable under the Rhode Island Medicaid program and applicable rates of reimbursement.

     (5) "Kickback" means a return in any form by any individual of a part of an expenditure

made by a provider:

     (i) To the same provider;

     (ii) To an entity controlled by the provider; or

     (iii) To an entity, which the provider intends to benefit whenever the expenditure is

reimbursed, or reimbursable, or claimed by a provider as being reimbursable by the Rhode Island

Medicaid program and when the sum or value returned is not credited to the benefit of the Rhode

Island Medicaid program.

     (6) "Medicaid fraud control unit" means a duly certified Medicaid fraud control unit

under federal regulation authorized to perform those functions as described by § 1903(q) of the

Social Security Act, 42 U.S.C. § 1396b(q).

     (7) "Medically unnecessary services or merchandise" means services or merchandise

provided to recipients intentionally without any expectation that the services or merchandise will

alleviate or aid the recipient's medical condition.

     (8) "Office of Program Integrity or OPI" means the unit division within the executive

office of health and human services authorized pursuant to §42-7.2-18 to coordinate state and

local agencies, law enforcement entities, and investigative units in order to increase the

effectiveness of programs and initiatives dealing with the prevention, detection, and prosecution

of Medicaid and public assistance fraud; to develop cooperative strategies to investigate and

eliminate Medicaid and public assistance fraud and to recover state and federal funds; and to

represent the executive office and act on the secretary’s behalf in any matters related to the

prevention, detection , and prosecution of Medicaid fraud under this chapter.

     (8)(9) "Pecuniary benefit" means benefit in the form of money, property, commercial

interests, or anything else the primary significance of which is economic gain.

     (9)(10) "Person" means any person or individual, natural or otherwise and includes those

person(s) or entities defined by the term "provider".

     (10)(11) "Provider" means any individual, individual medical vendor, firm, corporation,

professional association, partnership, organization, or other legal entity that provides goods or

services under the Rhode Island Medicaid program or the employee of any person or entity who,

on his or her own behalf or on the behalf of his or her employer, knowingly performs any act or is

knowingly responsible for an omission prohibited by this chapter.

     (11)(12) "Recipient" means any person receiving medical assistance under the Rhode

Island Medicaid program.

     (12)(13) "Records" means all documents developed by a provider and related to the

provision of services reimbursed or claimed as reimbursable by the Rhode Island Medicaid

program.

     (13)(14) "Rhode Island Medicaid program" means a state administered, medical

assistance health care program which is funded by the state and federal governments under Title

XIX and Title XXI of the U.S., Social Security Act, 42 U.S.C. § 1396 et seq and any general or

public laws and administered by the executive office of health and human services.

     40-8.2-3. Prohibited acts. -- (a) It shall be unlawful for any person intentionally to:

     (1) Present or cause to be presented for preauthorization or payment to the Rhode Island

Medicaid program:

     (i) Any materially false or fraudulent claim or cost report for the furnishing of services or

merchandise; or

     (ii) Present or cause to be presented for preauthorization or payment, any claim or cost

report for medically unnecessary services or merchandise; or

     (iii) To submit or cause to be submitted materially false or fraudulent information, for the

intentional purpose(s) of obtaining greater compensation than that to which the provider is legally

entitled for the furnishing of services or merchandise; or

     (iv) Submit or cause to be submitted materially false information for the purpose of

obtaining authorization for furnishing services or merchandise; or

     (v) Submit or cause to be submitted any claim or cost report or other document which

fails to make full disclosure of material information.

     (2) (i) Solicit, receive, offer, or pay any remuneration, including any kickback, bribe, or

rebate, directly or indirectly, in cash or in kind, to induce referrals from or to any person in return

for furnishing of services or merchandise or in return for referring an individual to a person for

the furnishing of any services or merchandise for which payment may be made, in whole or in

part, under the Rhode Island Medicaid program.

     (ii) Provided, however, that in any prosecution under this subsection, it shall not be

necessary for the state to prove that the remuneration returned was taken from any particular

expenditure made by a person.

     (3) Submit or cause to be submitted a duplicate claim for services, supplies, or

merchandise to the Rhode Island Medicaid program for which the provider has already received

or claimed reimbursement from any source, unless the duplicate claim is filed

     (i) For payment of more than one type of service or merchandise furnished or rendered to

a recipient for which the use of more than one type of claim is necessary; or

     (ii) Because of a lack of a response from or a request by the Rhode Island Medicaid

program; provided, however, in such instance a duplicate claim will clearly be identified as such,

in writing, by the provider; or

     (iii) Simultaneous with a claim submission to another source of payment when the

provider has knowledge that the other payor will not pay the claim.

     (4) Submit or cause to be submitted to the Rhode Island Medicaid program a claim for

service or merchandise which was not rendered to a recipient.

     (5) Submit or cause to be submitted to the Rhode Island Medicaid program a claim for

services or merchandise which includes costs or charges not related to the provision or rendering

of services or merchandise to the recipient.

     (6) Submit or cause to be submitted a claim or refer a recipient to a person for services or

merchandise under the Rhode Island Medicaid program which are intentionally not documented

in the provider's record and/or are medically unnecessary as that term is defined by § 40-8.2-

2(7).

     (7) Submit or cause to be submitted to the Rhode Island Medicaid program a claim which

materially misrepresents:

     (i) The description of services or merchandise rendered or provided to a recipient;

     (ii) The cost of the services or merchandise rendered or provided to a recipient;

     (iii) The dates that the services or merchandise were rendered or provided to a recipient;

     (iv) The identity of the recipient(s) of the services or merchandise; or

     (v) The identity of the attending, prescribing, or referring practitioner or the identity of

the actual provider.

     (8) Submit a claim for reimbursement to the Rhode Island Medicaid program for

service(s) or merchandise at a fee or charge, which exceeds the provider's lowest fee or charge for

the provision of the service or merchandise to the general public.

     (9) Submit or cause to be submitted to the Rhode Island Medicaid program a claim for a

service or merchandise which was not rendered by the provider, unless the claim is submitted on

behalf of:

     (i) A bona fide provider employee of such provider; or

     (ii) An affiliated provider entity owned or controlled by the provider; or

     (iii) Is submitted on behalf of a provider by a third party billing service under a written

agreement with the provider, and the claims are submitted in a manner which does not otherwise

violate the provisions of this chapter.

     (10) Render or provide services or merchandise under the Rhode Island Medicaid

program unless otherwise authorized by the regulations of the Rhode Island Medicaid program

without a provider's written order and the recipient's consent, or submit or cause to be submitted a

claim for services or merchandise, except in emergency situations or when the recipient is a

minor or is incompetent to give consent. The type of consent to be required hereunder can include

verbal acquiescence of the recipient and need not require a signed consent form or the recipient's

signature, except where otherwise required by the regulations of the Rhode Island Medicaid

program.

     (11) Charge any recipient or person acting on behalf of a recipient, money or other

consideration in addition to, or in excess of the rates of remuneration established under the Rhode

Island Medicaid program.

     (12) Enter into an agreement, combination or conspiracy with any party other than the

Rhode Island Medicaid program to obtain or aid another to obtain reimbursement or payments

from the Rhode Island Medicaid program to which the person, recipient, or provider seeking

reimbursement or payment is not entitled.

     (13) Make a material false statement in the application for enrollment as a provider under

the Rhode Island Medicaid program.

     (14) Refuse to provide representatives of the Medicaid fraud control unit and/or the office

of program integrity upon reasonable request, access to information and data pertaining to

services or merchandise rendered to eligible recipients, and/or former recipients while recipients

under the Rhode Island Medicaid program.

     (15) Obtain any monies by false pretenses through the use of any artifice, scheme, or

design prohibited by this section.

     (16) Seek or obtain employment with or as a provider after having actual or constructive

knowledge of a then existing exclusion issued under the authority of 42 U.S.C. § 1320a-7.

     (17) Grant or offer to grant employment in violation of a then existing exclusion issued

under the authority of 42 U.S.C. § 1320a-7, having actual or constructive knowledge of the

existence of such exclusion.

     (18) File a false document to gain employment in a Medicaid funded facility or with a

provider.

     (b) (1) A provider or person who violates any provision of subsection (a), excepting

subsection (a)(14), (a)(16), or (a)(18), is guilty of a felony for each violation, and upon conviction

therefor, shall be sentenced to a term of imprisonment not exceeding ten (10) years, nor fined

more than ten thousand dollars ($10,000), or both.

     (2) A provider or person who violates the provisions of subsection (a)(14), (a)(16), or

(a)(18), shall be guilty of a misdemeanor for each violation and, upon conviction, be fined not

more than five hundred dollars ($500).

     (3) Any provider who knowingly and willfully participates in any offense either as a

principal or as an accessory, or conspirator shall be subject to the same penalty as if the provider

had committed the substantive offense.

     (c) The provisions of subsection (a)(2) shall not apply to:

     (1) A discount or other reduction in price obtained by a person or provider of services or

merchandise under the Rhode Island Medicaid program, if the reduction in price is properly

disclosed and appropriately reflected in the costs claimed or charges made by the person or

provider under the Rhode Island Medicaid program.

     (2) Any amount paid by an employer to an employee, who has a bona fide employment

relationship with the employer, for employment in the provision of covered services or

merchandise furnished under the Rhode Island Medicaid program.

     (3) Any amounts paid by a vendor of services or merchandise to a person authorized to

act as a purchasing agent for a group of individuals or entities who are furnishing services or

merchandise which are reimbursed by the Rhode Island Medicaid program, as long as:

     (i) The purchasing agent has a written agreement with each individual or entity in the

group that specifies the amount the agent will be paid by each vendor (where the sum may be a

fixed sum or a fixed percentage of the value of the purchases made from the vendor by the group

under the contract between the vendor and the purchasing agent); and

     (ii) In the case of an entity that is a provider of services to the Rhode Island Medicaid

program, the agent discloses in writing to the individual or entity in accordance with regulations

to be promulgated by the department executive office, and to the department office of program

integrity upon request, the amount received from each vendor with respect to purchases made by

or on behalf of the entity.

     40-8.2-4. Statute of limitations. -- The statute of limitations for any violation of the

provisions of this chapter shall be ten (10) years.

     40-8.2-5. Civil remedy. -- Any person, including the Rhode Island Medicaid program

secretary of the executive office of health and human services or the office of program integrity

acting on behalf of the secretary of the office, injured by any violation of the provisions of § 40-

8.2-3 or § 40-8.2-4 may recover through a civil action from the persons inflicting the injury three

(3) times the amount of the injury.

     40-8.2-6. Civil actions brought by attorney general on behalf of persons injured by

violations of chapter. -- (a) The attorney general may bring a civil action in superior court in the

name of the state, as parens patriae on behalf of persons residing in this state, to secure monetary

relief as provided in this section for injuries sustained by such persons by reason of any violation

of this chapter. The court shall exclude from the amount of monetary relief awarded in an action

any amount of monetary relief:

     Which duplicates amounts which have been awarded for the same injury, or

     Which is properly allocable to persons who have excluded their claims pursuant to

subsection (c)(1) of this section.

     (b) The court shall award the state as monetary relief threefold the total damage sustained

as described in subsection (a) of this section and the costs of bringing suit, including reasonable

attorney's fees.

     (c) In any action brought under subsection (a) of this section, the attorney general shall, at

such times, in such manner, and with such content as the court may direct, cause notice thereof to

be given by publication.

     (1) Any person on whose behalf an action is brought under subsection (a), may elect to

exclude from adjudication the portion of the state claim for monetary relief attributable to him or

her by filing notice of the election with the court within such time as specified in the notice given

pursuant to this subsection.

     (2) The final judgment in an action under subsection (a) shall be res judicata as to any

claim under § 40-8.2-5 by any person on behalf of whom the action was brought and who fails to

give notice within the period specified in the notice given pursuant to this subsection.

     (d) An action under subsection (a) shall not be dismissed or compromised without the

approval of the court, and notice of any proposed dismissal or compromise shall be given by

publication at such times, in such manner, and with such content as the court may direct.

     (e) In any action under subsection (a):

     (1) The amount of the plaintiff's attorney's fees, if any, shall be determined by the court,

and any attorney's fees awarded to the attorney general shall be deposited with the state as general

revenues; and

     (2) The court may, in its discretion, award a reasonable attorney's fee to a prevailing

defendant upon a finding that the attorney general has acted in bad faith, vexatiously, wantonly,

or for oppressive reasons.

     (f) Monetary relief recovered in an action under this section shall:

     (1) Be distributed in such manner as the court, in its discretion, may authorize; or

     (2) Be deemed a civil penalty by the court and deposited with the state as general

revenues; subject in either case to the requirement that any distribution procedure adopted afford

each person a reasonable opportunity to secure his or her appropriate portion of the net monetary

relief.

     (g) In any action under this section the fact that a person or public body has not dealt

directly with the defendant shall not bar or otherwise limit recovery. Provided, however, that the

court shall exclude from the amount of monetary relief which duplicates amounts which have

been awarded for the same injury.

     40-8.2-10. Other civil remedies and criminal penalties. -- The penalties and remedies

under this statute are not exclusive and shall not preclude the use of any other civil remedy or the

application of any other criminal penalty deemed appropriate by the attorney general in

accordance with federal law or regulations governing Title XIX or Title XXI or the general or

public laws of this state.

     40-8.2-11. Barring or suspending participation in program. -- Whenever a provider is

sentenced or placed on probation for an offense under this chapter, the trial judge may, in his or

her discretion, order that the provider be permanently barred from further participation in the

program, that the provider's participation in the program be suspended for a definite period of

time not exceeding two (2) years, or that the provider conform to applicable federal regulations.

For the purposes of this section, the Rhode Island Medicaid program office of program integrity

may submit a recommendation to the trial judge as to whether the provider should be suspended

or barred from the Medicaid program. Nothing contained herein shall be construed to prevent the

Rhode Island Medicaid program executive office of health and human services from imposing its

own administrative sanctions.

     40-8.2-17. Stays and review of revocation orders. -- An order of the Rhode Island

Medicaid program executive office of health and human services revoking a provider's

certification may, in the discretion of the program, go into immediate effect or may be stayed.

Review of any order may be had in accordance with the Rhode Island administrative procedures

law, §§ 42-35-1 -42-35-18. If an administrative hearing is claimed, the program may, in its

discretion, stay the effect of a revocation until a hearing is had held and a decision is rendered,

and for a period not to exceed ten (10) days after the administrative decision is rendered.

     40-8.2-18. Filing and enforcement of administrative decision. -- An administrative

decision, not appealed, or which has been affirmed after judicial review under the Rhode Island

administrative procedures law, §§ 42-35-1 - 42-35-18, determining any amounts due to the

Rhode Island Medicaid program executive office of health and human services or to a provider,

may be filed with the clerk of the superior court for Providence County and shall be enforceable

as a judgment of that court.

     40-8.2-19. Certification as a provider. -- Revocation or suspension of certification.-

Before any provider of medical services receives payment from the Rhode Island Medicaid

program, and as a condition of receipt of payment, the provider must have in effect a valid

certification of eligibility from the Rhode Island department of human services executive office

of health and human services. This certification of eligibility will take the form of either a

separate provider agreement or language as required by federal regulations imprinted on the

medical assistance billing form, which must be signed by the provider. This certification may be

revoked or suspended, in accordance with administrative rules to be promulgated by the

department executive office, if a provider fails to meet professional licensure requirements,

violates any administrative regulations of the Rhode Island Medicaid program executive office of

health and human services, does not provide proper professional services, is the subject of a

suspension of payments order, is convicted of Medicaid fraud, or otherwise violates any provision

of this chapter.

     40-8.2-21. Suspension of payments to a provider. -- (a) The Rhode Island Medicaid

program executive office of health and human services may issue a suspension of payments order

if:

     (1) The provider does not meet certification requirements of the Rhode Island Medicaid

program; or

     (2) The Rhode Island Medicaid program has been unable to collect (or make satisfactory

arrangements for the collection of ) amounts due on account of overpayments to any provider; or

     (3) The Rhode Island Medicaid program office of program integrity and/or the Medicaid

fraud control unit of the attorney general's office has been unable to obtain, from a provider, the

data and information necessary to enable it to determine the existence or amount (if any) of the

overpayments made to a provider; or

     (4) The office of program integrity or the Medicaid fund control unit of the attorney

general's office has been denied reasonable access to information by a provider which pertains to

a patient or resident of a long term residential care facility or to a former patient or resident of a

long term residential care facility; or

     (5) The Rhode Island Medicaid program office of program integrity and/or the Medicaid

fraud control unit of the attorney general's office has been denied reasonable access to data and

information by the provider for the purpose of conducting activities as described in § 1903(g) of

the Social Security Act, 42 U.S.C. § 1396b(g); or

     (6) The Rhode Island Medicaid program office of program integrity has been presented

with reliable evidence that the provider has engaged in fraud or willful misrepresentation under

the Medicaid program.

     (b) Any such order of the Rhode Island Medicaid program executive office of health and

human services may cease to be effective at such time as the program office of program integrity

is satisfied that the provider is participating in substantial negotiations which seek to remedy the

conditions which gave rise to its order of suspension of payments, or that amounts are no longer

due from the provider or that a satisfactory arrangement has been made for the payment of the

provider or that a satisfactory arrangement has been made for the payment by the provider of any

such amounts.

     40-8.2-22. Interest on overcharges. -- Any provider of services or goods contracting

with the department of human services executive office of health and human services pursuant to

Title XIX or Title XXI of the Social Security Act., 42 U.S.C. § 1396 et seq., who, without intent

to defraud, obtains payments under this chapter in excess of the amount to which the provider is

entitled, thereby becomes liable for payment of the amount of the excess with payment of interest

allowable by law, under § 6-26-2, as was in effect on the date payment was made to the provider.

The interest period will commence on the date upon which payment was made and will extend to

the date upon which repayment is made to the state of Rhode Island.

     SECTION 13. Chapter 40-8 of the General Laws entitled "Medical Assistance" is hereby

amended by adding thereto the following section:

     40-8-32. Support for certain patients of nursing facilities. -- (a) Definitions. For

purposes of this section,

     "Applied Income" shall mean the amount of income a Medicaid beneficiary is required to

contribute to the cost of his or her care.

     "Authorized Individual" shall mean a person who has authority over the income of a

patient of a Nursing Facility such as a person who has been given or has otherwise obtained

authority over a patient’s bank account, has been named as or has rights as a joint account holder,

or is a fiduciary as defined below.

     "Costs of Care" shall mean the costs of providing care to a patient of a nursing facility,

including nursing care, personal care, meals, transportation and any other costs, charges, and

expenses incurred by a nursing facility in providing care to a patient. Costs of care shall not

exceed the customary rate the nursing facility charges to a patient who pays for his or her care

directly rather than through a governmental or other third party payor.

     "Fiduciary" shall mean a person to whom power or property has been formally entrusted

for the benefit of another such as an attorney-in-fact, legal guardian, trustee, or representative

payee.

      "Nursing Facility" shall mean a nursing facility licensed under Chapter 17 of Title 23,

which is a participating provider in the Rhode Island Medicaid program.

     "Penalty Period" means the period of Medicaid ineligibility imposed pursuant to 42 USC

1396p(c), as amended from time to time, on a person whose assets have been transferred for less

than fair market value;

     "Uncompensated Care" – Care and services provided by a nursing facility to a Medicaid

applicant without receiving compensation therefore from Medicaid, Medicare, the Medicaid

Applicant, or other source. The acceptance of any payment representing actual or estimated

Applied Income shall not disqualify the care and services provided from qualifying as

uncompensated care.

     (b) Penalty Period Resulting from Transfer. Any transfer or assignment of assets

resulting in the establishment or imposition of a penalty period shall create a debt that shall be

due and owing to a nursing facility for the unpaid costs of care provided during the penalty period

to a patient of that facility who has been subject to the penalty period. The amount of the debt

established shall not exceed the fair market value of the transferred assets at the time of transfer

that are the subject of the penalty period. A nursing facility may bring an action to collect a debt

for the unpaid costs of care given to a patient who has been subject to a penalty period, against

either the transferor or the transferee, or both. The provisions of this section shall not affect

other rights or remedies of the parties.

     (c) Applied Income. A nursing facility may provide written notice to a patient who is a

Medicaid recipient and any authorized individual of that patient of:

     (1) Of the amount of applied income due;

     (2) Of the recipient's legal obligation to pay the applied income to the nursing facility;

and

     (3) That the recipient's failure to pay applied income due to a nursing facility not later

than thirty days after receiving such notice from the Nursing Facility may result in a court action

to recover the amount of applied income due.

     A nursing facility that is owed applied income may, in addition to any other remedies

authorized under law, bring a claim to recover the applied income against a patient and any

authorized individual. If a court of competent jurisdiction determines, based upon clear and

convincing evidence, that a defendant willfully failed to pay or withheld applied income due and

owing to a Nursing Facility for more than thirty days after receiving notice pursuant to this

subsection (d), the court may award the amount of the debt owed, court costs and reasonable

attorneys' fees to the nursing facility.

     (d) Effects. Nothing contained in this section shall prohibit or otherwise diminish any

other causes of action possessed by any such nursing facility. The death of the person receiving

nursing facility care shall not nullify or otherwise affect the liability of the person or persons

charged with the costs of care rendered or the applied income amount as referenced in this

section.

     SECTION 14. Sections 40-8.3-2 and 40-8.3-3 of the General Laws in Chapter 40-8.3

entitled "Uncompensated Care" are hereby amended to read as follows:

     40-8.3-2. Definitions. -- As used in this chapter:

     (1) "Base year" means for the purpose of calculating a disproportionate share payment for

any fiscal year ending after September 30, 2013 2014, the period from October 1, 2011 2012

through September 30, 2012 2013, and for any fiscal year ending after September 30, 2014 2015,

the period from October 1, 2012 2013 through September 30, 2013 2014.

      (2) "Medical assistance Medicaid inpatient utilization rate for a hospital" means a

fraction (expressed as a percentage) the numerator of which is the hospital's number of inpatient

days during the base year attributable to patients who were eligible for medical assistance during

the base year and the denominator of which is the total number of the hospital's inpatient days in

the base year.

     (3) "Participating hospital" means any nongovernment and nonpsychiatric hospital that:

(i) was licensed as a hospital in accordance with chapter 17 of title 23 during the base year; and

shall mean the actual facilities and buildings in existence in Rhode Island, licensed pursuant to §

23-17-1 et seq. on June 30, 2010, and thereafter any premises included on that license, regardless

of changes in licensure status pursuant to § 23-17.14 (hospital conversions) and §23-17-6 (b)

(change in effective control), that provides short-term acute inpatient and/or outpatient care to

persons who require definitive diagnosis and treatment for injury, illness, disabilities, or

pregnancy. Notwithstanding the preceding language, the negotiated Medicaid managed care

payment rates for a court-approved purchaser that acquires a hospital through receivership,

special mastership or other similar state insolvency proceedings (which court-approved purchaser

is issued a hospital license after January 1, 2013) shall be based upon the newly negotiated rates

between the court-approved purchaser and the health plan, and such rates shall be effective as of

the date that the court-approved purchaser and the health plan execute the initial agreement

containing the newly negotiated rate. The rate-setting methodology for inpatient hospital

payments and outpatient hospital payments set for the §§ 40-8-13.4(b)(1)(B)(iii) and 40-8-

13.4(b)(2), respectively, shall thereafter apply to negotiated increases for each annual twelve (12)

month period as of July 1 following the completion of the first full year of the court-approved

purchaser's initial Medicaid managed care contract.

     (ii) achieved a medical assistance inpatient utilization rate of at least one percent (1%)

during the base year; and

     (iii) continues to be licensed as a hospital in accordance with chapter 17 of title 23 during

the payment year.

     (4) "Uncompensated care costs" means, as to any hospital, the sum of: (i) the cost

incurred by such hospital during the base year for inpatient or outpatient services attributable to

charity care (free care and bad debts) for which the patient has no health insurance or other third-

party coverage less payments, if any, received directly from such patients; and (ii) the cost

incurred by such hospital during the base year for inpatient or out-patient services attributable to

Medicaid beneficiaries less any Medicaid reimbursement received therefor; multiplied by the

uncompensated care index.

     (5) "Uncompensated care index" means the annual percentage increase for hospitals

established pursuant to § 27-19-14 for each year after the base year, up to and including the

payment year, provided, however, that the uncompensated care index for the payment year ending

September 30, 2007 shall be deemed to be five and thirty-eight hundredths percent (5.38%), and

that the uncompensated care index for the payment year ending September 30, 2008 shall be

deemed to be five and forty-seven hundredths percent (5.47%), and that the uncompensated care

index for the payment year ending September 30, 2009 shall be deemed to be five and thirty-eight

hundredths percent (5.38%), and that the uncompensated care index for the payment years ending

September 30, 2010, September 30, 2011, September 30, 2012, September 30, 2013, September

30, 2014 and, September 30, 2015, and September 30, 2016 shall be deemed to be five and thirty

hundredths percent (5.30%).

     40-8.3-3. Implementation. -- (a) For federal fiscal year 2013, commencing on October 1,

2012 and ending September 30, 2013, the executive office of health and human services shall

submit to the Secretary of the U.S. Department of Health and Human Services a state plan

amendment to the Rhode Island Medicaid state plan for disproportionate share hospital payments

(DSH Plan) to provide:

     (1) That the disproportionate share hospital payments to all participating hospitals, not to

exceed an aggregate limit of $128.3 million, shall be allocated by the executive office of health

and human services to the Pool A, Pool C and Pool D components of the DSH Plan; and,

     (2) That the Pool D allotment shall be distributed among the participating hospitals in

direct proportion to the individual participating hospital's uncompensated care costs for the base

year, inflated by the uncompensated care index to the total uncompensated care costs for the base

year inflated by uncompensated care index for all participating hospitals. The disproportionate

share payments shall be made on or before July 15, 2013 and are expressly conditioned upon

approval on or before July 8, 2013 by the Secretary of the U.S. Department of Health and Human

Services, or his or her authorized representative, of all Medicaid state plan amendments necessary

to secure for the state the benefit of federal financial participation in federal fiscal year 2013 for

the disproportionate share payments.

      (b)(a) For federal fiscal year 2014, commencing on October 1, 2013 and ending

September 30, 2014, the executive office of health and human services shall submit to the

Secretary of the U.S. Department of Health and Human Services a state plan amendment to the

Rhode Island Medicaid state plan for disproportionate share hospital payments (DSH Plan) to

provide:

     (1) That the disproportionate share hospital payments to all participating hospitals, not to

exceed an aggregate limit of $136.8 million, shall be allocated by the executive office of health

and human services to the Pool A, Pool C and Pool D components of the DSH Plan; and,

     (2) That the Pool D allotment shall be distributed among the participating hospitals in

direct proportion to the individual participating hospital's uncompensated care costs for the base

year, inflated by the uncompensated care index to the total uncompensated care costs for the base

year inflated by uncompensated care index for all participating hospitals. The disproportionate

share payments shall be made on or before July 14, 2014 and are expressly conditioned upon

approval on or before July 7, 2014 by the Secretary of the U.S. Department of Health and Human

Services, or his or her authorized representative, of all Medicaid state plan amendments necessary

to secure for the state the benefit of federal financial participation in federal fiscal year 2014 for

the disproportionate share payments.

     (c)(b) For federal fiscal year 2015, commencing on October 1, 2014 and ending

September 30, 2015, the executive office of health and human services shall submit to the

Secretary of the U.S. Department of Health and Human Services a state plan amendment to the

Rhode Island Medicaid state plan for disproportionate share hospital payments (DSH Plan) to

provide:

     (1) That the disproportionate share hospital payments to all participating hospitals, not to

exceed an aggregate limit of $136.8 $140.0 million, shall be allocated by the executive office of

health and human services to the Pool A, Pool C and Pool D components of the DSH Plan; and,

     (2) That the Pool D allotment shall be distributed among the participating hospitals in

direct proportion to the individual participating hospital's uncompensated care costs for the base

year, inflated by the uncompensated care index to the total uncompensated care costs for the base

year inflated by uncompensated care index for all participating hospitals. The disproportionate

share payments shall be made on or before July 13, 2015 and are expressly conditioned upon

approval on or before July 6, 2015 by the Secretary of the U.S. Department of Health and Human

Services, or his or her authorized representative, of all Medicaid state plan amendments necessary

to secure for the state the benefit of federal financial participation in federal fiscal year 2015 for

the disproportionate share payments.

     (c) For federal fiscal year 2016, commencing on October 1, 2015 and ending September

30, 2016, the executive office of health and human services shall submit to the Secretary of the

U.S. Department of Health and Human Services a state plan amendment to the Rhode Island

Medicaid state plan for disproportionate share hospital payments (DSH Plan) to provide:

     (1) That the disproportionate share hospital payments to all participating hospitals, not to

exceed an aggregate limit of $138.2 million, shall be allocated by the executive office of health

and human services to the Pool A, Pool C and Pool D components of the DSH Plan; and,

     (2) That the Pool D allotment shall be distributed among the participating hospitals in

direct proportion to the individual participating hospital's uncompensated care costs for the base

year, inflated by the uncompensated care index to the total uncompensated care costs for the base

year inflated by uncompensated care index for all participating hospitals. The disproportionate

share payments shall be made on or before July 11, 2016 and are expressly conditioned upon

approval on or before July 5, 2016 by the Secretary of the U.S. Department of Health and Human

Services, or his or her authorized representative, of all Medicaid state plan amendments necessary

to secure for the state the benefit of federal financial participation in federal fiscal year 2016 for

the disproportionate share payments.

     (d) No provision is made pursuant to this chapter for disproportionate share hospital

payments to participating hospitals for uncompensated care costs related to graduate medical

education programs.

     (e) The executive office of health and human services is directed, on at least a monthly

basis, to collect patient level uninsured information, including, but not limited to, demographics,

services rendered, and reason for uninsured status from all hospitals licensed in Rhode Island.

     (f) Beginning with federal FY 2016, Pool D DSH payments will be recalculated by the

state based on actual hospital experience. The final Pool D payments will be based on the data

from the final DSH audit for each federal fiscal year. Pool D DSH payments will be redistributed

among the qualifying hospitals in direct proportion to the individual qualifying hospital's

uncompensated care to the total uncompensated care costs for all qualifying hospitals as

determined by the DSH audit. No hospital will receive an allocation that would incur funds

received in excess of audited uncompensated care costs.

     SECTION 15. Section 5 of Article 18 of Chapter 145 of the Public Laws of 2014 is

hereby amended to read as follows:

     A pool is hereby established of up to $1.5 million $2.5 million to support Medicaid

Graduate Education funding for Academic Medical Centers with level I Trauma Centers who

provide care to the state's critically ill and indigent populations. The office of Health and Human

Services shall utilize this pool to provide up to $3 million $5 million per year in additional

Medicaid payments to support Graduate Medical Education programs to hospitals meeting all of

the following criteria:

     (a) Hospital must have a minimum of 25,000 inpatient discharges per year for all patients

regardless of coverage.

     (b) Hospital must be designated as Level I Trauma Center.

     (c) Hospital must provide graduate medical education training for at least 250 interns and

residents per year.

     The Secretary of the Executive Office of Health and Human Services shall determine the

appropriate Medicaid payment mechanism to implement this program and amend any state plan

documents required to implement the payments.

     Payments for Graduate Medical Education programs shall be effective July 1, 2014 made

annually.

     SECTION 16. Section 40-8.9-9 of the General Laws in Chapter 40-8.9 entitled "Medical

Assistance – Long-Term Care Service and Finance Reform" is hereby amended to read as

follows:

     40-8.9-9. Long-term care re-balancing system reform goal. -- (a) Notwithstanding any

other provision of state law, the department of human services executive office of health and

human services is authorized and directed to apply for and obtain any necessary waiver(s), waiver

amendment(s) and/or state plan amendments from the secretary of the United States department

of health and human services, and to promulgate rules necessary to adopt an affirmative plan of

program design and implementation that addresses the goal of allocating a minimum of fifty

percent (50%) of Medicaid long-term care funding for persons aged sixty-five (65) and over and

adults with disabilities, in addition to services for persons with developmental disabilities and

mental disabilities, to home and community-based care on or before December 31, 2013;

provided, further, the executive office of health and human services executive office shall report

annually as part of its budget submission, the percentage distribution between institutional care

and home and community-based care by population and shall report current and projected waiting

lists for long-term care and home and community-based care services. The department executive

office is further authorized and directed to prioritize investments in home and community-based

care and to maintain the integrity and financial viability of all current long-term care services

while pursuing this goal.

     (b) The reformed long-term care system re-balancing goal is person-centered and

encourages individual self-determination, family involvement, interagency collaboration, and

individual choice through the provision of highly specialized and individually tailored home-

based services. Additionally, individuals with severe behavioral, physical, or developmental

disabilities must have the opportunity to live safe and healthful lives through access to a wide

range of supportive services in an array of community-based settings, regardless of the

complexity of their medical condition, the severity of their disability, or the challenges of their

behavior. Delivery of services and supports in less costly and less restrictive community settings,

will enable children, adolescents and adults to be able to curtail, delay or avoid lengthy stays in

long-term care institutions, such as behavioral health residential treatment facilities, long-term

care hospitals, intermediate care facilities and/or skilled nursing facilities.

     (c) Pursuant to federal authority procured under § 42-7.2-16 of the general laws, the

department of human services executive office of health and human services is directed and

authorized to adopt a tiered set of criteria to be used to determine eligibility for services. Such

criteria shall be developed in collaboration with the state's health and human services departments

and, to the extent feasible, any consumer group, advisory board, or other entity designated for

such purposes, and shall encompass eligibility determinations for long-term care services in

nursing facilities, hospitals, and intermediate care facilities for the mentally retarded persons with

intellectual disabilities as well as home and community-based alternatives, and shall provide a

common standard of income eligibility for both institutional and home and community-based

care. The department executive office is, subject to prior approval of the general assembly,

authorized to adopt clinical and/or functional criteria for admission to a nursing facility, hospital,

or intermediate care facility for the mentally retarded persons with intellectual disabilities that are

more stringent than those employed for access to home and community-based services. The

department executive office is also authorized to promulgate rules that define the frequency of re-

assessments for services provided for under this section. Legislatively approved levels Levels of

care may be applied in accordance with the following:

     (1) The department executive office shall continue to apply pre-waiver the level of care

criteria in effect on June 30, 2015 for any recipient determined eligible for and receiving

Medicaid recipient eligible for Medicaid-funded long-term services in supports in a nursing

facility, hospital, or intermediate care facility for the mentally retarded persons with intellectual

disabilities as of June 30, 2009 on or before that date, unless: (a) the recipient transitions to home

and community based services because he or she: (a) Improves to a level where he/she would no

longer meet the pre- waiver level of care criteria in effect on June 30, 2015; or (b) The individual

the recipient chooses home and community based services over the nursing facility, hospital, or

intermediate care facility for the mentally retarded persons with intellectual disabilities. For the

purposes of this section, a failed community placement, as defined in regulations promulgated by

the department executive office, shall be considered a condition of clinical eligibility for the

highest level of care. The department executive office shall confer with the long-term care

ombudsperson with respect to the determination of a failed placement under the ombudsperson's

jurisdiction. Should any Medicaid recipient eligible for a nursing facility, hospital, or

intermediate care facility for the mentally retarded persons with intellectual disabilities as of June

30, 2009 2015 receive a determination of a failed community placement, the recipient shall have

access to the highest level of care; furthermore, a recipient who has experienced a failed

community placement shall be transitioned back into his or her former nursing home, hospital, or

intermediate care facility for the mentally retarded persons with intellectual disabilities whenever

possible. Additionally, residents shall only be moved from a nursing home, hospital, or

intermediate care facility for the mentally retarded persons with intellectual disabilities in a

manner consistent with applicable state and federal laws.

     (2) Any Medicaid recipient eligible for the highest level of care who voluntarily leaves a

nursing home, hospital, or intermediate care facility for the mentally retarded persons with

intellectual disabilities shall not be subject to any wait list for home and community based

services.

     (3) No nursing home, hospital, or intermediate care facility for the mentally retarded

persons with intellectual disabilities shall be denied payment for services rendered to a Medicaid

recipient on the grounds that the recipient does not meet level of care criteria unless and until the

department of human services executive office has: (i) performed an individual assessment of the

recipient at issue and provided written notice to the nursing home, hospital, or intermediate care

facility for the mentally retarded persons with intellectual disabilities that the recipient does not

meet level of care criteria; and (ii) the recipient has either appealed that level of care

determination and been unsuccessful, or any appeal period available to the recipient regarding

that level of care determination has expired.

     (d) The department of human services executive office is further authorized and directed

to consolidate all home and community-based services currently provided pursuant to § 1915(c)

of title XIX of the United States Code into a single system of home and community-based

services that include options for consumer direction and shared living. The resulting single home

and community-based services system shall replace and supersede all §1915(c) programs when

fully implemented. Notwithstanding the foregoing, the resulting single program home and

community-based services system shall include the continued funding of assisted living services

at any assisted living facility financed by the Rhode Island housing and mortgage finance

corporation prior to January 1, 2006, and shall be in accordance with chapter 66.8 of title 42 of

the general laws as long as assisted living services are a covered Medicaid benefit.

     (e) The department of human services executive office is authorized to promulgate rules

that permit certain optional services including, but not limited to, homemaker services, home

modifications, respite, and physical therapy evaluations to be offered to persons at risk for

Medicaid-funded long-term care subject to availability of state-appropriated funding for these

purposes.

     (f) To promote the expansion of home and community-based service capacity, the

department of human services executive office is authorized and directed to pursue rate payment

methodology reforms that increase access to for homemaker, personal care (home health aide),

assisted living, adult supportive care homes, and adult day care services, as follows:

     (1) A prospective base adjustment effective, not later than July 1, 2008, across all

departments and programs, of ten percent (10%) of the existing standard or average rate,

contingent upon a demonstrated increase in the state-funded or Medicaid caseload by June 30,

2009;

     (2) (1) Development, not later than September 30, 2008, of revised or new Medicaid

certification standards supporting and defining targeted rate increments to encourage that increase

access to service specialization and scheduling accommodations including but not limited to,

medication and pain management, wound management, certified Alzheimer's Syndrome

treatment and support programs, and work and shift differentials for night and week-end services;

and by using payment strategies designed to achieve specific quality and health outcomes.

     (3) Development and submission to the governor and the general assembly, not later than

December 31, 2008, of a proposed rate-setting methodology for home and community-based

services to assure coverage of the base cost of service delivery as well as reasonable coverage of

changes in cost caused by wage inflation.

     (2) Development of Medicaid certification standards for state authorized providers of

adult day services, excluding such providers of services authorized under § 40.1-24-1(3), assisted

living, and adult supportive care (as defined under § 23-17.24) that establish for each, an acuity-

based, tiered service and payment methodology tied to: licensure authority, level of beneficiary

needs; the scope of services and supports provided; and specific quality and outcome measures.

The standards for adult day services for persons eligible for Medicaid-funded long-term services

may differ from those who do not meet the clinical/functional criteria set forth in § 40-8.10-3.

     (g) The department, in collaboration with the executive office of human services,

executive office shall implement a long-term care options counseling program to provide

individuals or their representatives, or both, with long-term care consultations that shall include,

at a minimum, information about: long-term care options, sources and methods of both public and

private payment for long-term care services and an assessment of an individual's functional

capabilities and opportunities for maximizing independence. Each individual admitted to or

seeking admission to a long-term care facility regardless of the payment source shall be informed

by the facility of the availability of the long-term care options counseling program and shall be

provided with long-term care options consultation if they so request. Each individual who applies

for Medicaid long-term care services shall be provided with a long-term care consultation.

     (h) The department of human services executive office is also authorized, subject to

availability of appropriation of funding, and federal Medicaid-matching funds, to pay for certain

expenses services and supports necessary to transition residents back to the community or divert

beneficiaries from institutional or restrictive settings and optimize their health and safety when

receiving care in a home or the community. The secretary is authorized to obtain any state plan

or waiver authorities required to maximize the federal funds available to support expanded access

to such home and community transition and stabilization services; provided, however, payments

shall not exceed an annual or per person amount.

     (j)(i) To ensure persons with long-term care needs who remain living at home have

adequate resources to deal with housing maintenance and unanticipated housing related costs, the

department of human services secretary is authorized to develop higher resource eligibility limits

for persons on or obtain any state plan or waiver authorities necessary to change the financial

eligibility criteria for long-term services and supports to enable beneficiaries receiving home and

community waiver services to have the resources to continue who are living in their own homes

or rental units or other home-based settings.

     (j) The executive office shall implement, no later than January 1, 2016, the following

home and community-based service and payment reforms:

     (1) Community-based supportive living program established in § 40-8.13-2.1;

     (2) Adult day services level of need criteria and acuity-based, tiered payment

methodology; and

     (3) Payment reforms that encourage home and community-based providers to provide the

specialized services and accommodations beneficiaries need to avoid or delay institutional care.

     (k) The secretary is authorized to seek any Medicaid section 1115 waiver or state plan

amendments and take any administrative actions necessary to ensure timely adoption of any new

or amended rules, regulations, policies, or procedures and any system enhancements or changes,

for which appropriations have been authorized, that are necessary to facilitate implementation of

the requirements of this section by the dates established. The secretary shall reserve the discretion

to exercise the authority established under §§ 42-7.2-5(6)(v) and 42-7.2-6.1, in consultation with

the governor, to meet the legislative directives established herein.

     SECTION 17: Sections 40-8.10-1, 40-8.10-2, 40-8.10-3, 40-8.10-4, 40-8.10-5, and 40-

8.10-6 of the General Laws in Chapter 40-8.10 entitled "Long Term Care Service Reform for

Medicaid Eligible Individuals" are hereby amended to read as follows:

     40-8.10-1. Purpose. -- (a) In order to ensure that all Medicaid recipients eligible for long-

term care have access to the full continuum of services they need, the secretary of the executive

office of health and human services, in collaboration with the director of the department of human

services and the directors of the departments of children youth and families, elderly affairs,

health, and mental health, retardation and hospitals, directors of EOHHS departments, shall offer

eligible Medicaid recipients the full range of services as allowed under the terms and conditions

of the Rhode Island Global Consumer Choice Compact 1115a Demonstration Waiver Medicaid

section 1115 demonstration waiver, including institutional services and the home and community

based services provided for under the previous Medicaid Section 1915(c) waivers, as well as

additional services for medication management, transition services and other authorized services

as defined in this chapter, in order to meet the individual needs of the Medicaid recipient.

     40-8.10-2. Definitions. -- As used in this chapter,

     (a) "Core services" mean homemaker services, environmental modifications (home

accessibility adaptations, special medical equipment (minor assistive devices), meals on wheels

(home delivered meals), personal emergency response (PERS), licensed practical nurse services,

community transition services, residential supports, day supports, supported employment,

supported living arrangements, private duty nursing, supports for consumer direction (supports

facilitation), participant directed goods and services, case management, senior companion

services, assisted living, personal care assistance services and respite.

     (b) "Preventive services" mean homemaker services, minor environmental modifications,

physical therapy evaluation and services and respite services.

     40-8.10-3. Levels of care. -- (a) The secretary of the executive office of health and

human services shall coordinate responsibilities for long-term care assessment in accordance with

the provisions of this chapter within the department of human services, and with the cooperation

of the directors of the department of elderly affairs, the department of children, youth and

families, and the department of mental health, retardation and hospitals. Assessments conducted

by each department's staff shall be coordinated through the Assessment Coordination Unit

(ACU). Members of each department's staff responsible for assessing level of care, developing

care plans, and determining budgets will meet on a regular basis in order to ensure that services

are provided in a uniform and consistent manner. Importance shall be placed upon the proper and

consistent determination of levels of care across the state departments for each long-term care

setting, including behavioral health residential treatment facilities, long-term care hospitals,

intermediate care facilities, and/or skilled nursing facilities. Three (3) appropriate Specialized

plans of care that meet the needs of the individual Medicaid recipients shall be coordinated and

consistent across all state departments. The development of care plans shall be person-centered

and shall support individual self-determination, family involvement, when appropriate, individual

choice and interdepartmental collaboration.

     (b) Levels of care for long-term care institutions (behavioral health residential treatment

facilities, long-term care hospitals, intermediate care facilities and/or skilled nursing facilities),

for which alternative community-based services and supports are available, shall be established

pursuant to the § 40-8.9-9. The structure of the three (3) levels of care is as follows:

     (i) Highest level of care. Individuals who are determined, based on medical need, to

require the institutional level of care will have the choice to receive services in a long-term care

institution or in a home and community-based setting.

     (ii) High level of care. Individuals who are determined, based on medical need, to benefit

from home and community-based services.

     (iii) Preventive level of care. Individuals who do not presently need an institutional level

of care but who need services targeted at preventing admission, re-admissions or reducing lengths

of stay in an institution.

     (c) Determinations of levels of care and the provision of long term care health services

shall be determined in accordance with this section and shall be in accordance with the applicable

provisions of § 40-8.9-9.

     40-8.10-4. Long-term Care Assessment and Coordination Assessment and

Coordination Unit (ACU). -- (a) The department of human services, in collaboration with the

The executive office of health and human services, shall implement a long-term care options

counseling program to provide individuals or their representative, or both, with long-term care

consultations that shall include, at a minimum, information about long-term care options, sources

and methods of both public and private payment for long term care services, information on

caregiver support services, including respite care, and an assessment of an individual's functional

capabilities and opportunities for maximizing independence. Each individual admitted to or

seeking admission to a long-term care facility, regardless of the payment source, shall be

informed by the facility of the availability of the long-term care options counseling program and

shall be provided with a long-term care options consultation, if he or she so requests. Each

individual who applies for Medicaid long-term care services shall be provided with a long-term

care consultation.

     (b) Core and preventative home and community based services defined and delineated in