2015 -- H 5515

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LC000992

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2015

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A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL ASSISTANCE

     Introduced By: Representatives Slater, Serpa, Diaz, Hull, and Bennett

     Date Introduced: February 12, 2015

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

     SECTION 1. 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 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 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 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 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 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 is, subject to prior approval of the general assembly, authorized to

adopt criteria for admission to a nursing facility, hospital, or intermediate care facility for the

mentally retarded that are more stringent than those employed for access to home and

community-based services. The department is also authorized to promulgate rules that define the

frequency of re-assessments for services provided for under this section. Legislatively approved

levels of care may be applied in accordance with the following:

      (1) The department shall apply pre-waiver level of care criteria for any Medicaid

recipient eligible for a nursing facility, hospital, or intermediate care facility for the mentally

retarded as of June 30, 2009, unless 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; or (b) The individual chooses home and community based services

over the nursing facility, hospital, or intermediate care facility for the mentally retarded. For the

purposes of this section, a failed community placement, as defined in regulations promulgated by

the department, shall be considered a condition of clinical eligibility for the highest level of care.

The department 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

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recipient eligible for a nursing facility, hospital, or intermediate care facility for the mentally

retarded as of June 30, 2009 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 whenever possible.

Additionally, residents shall only be moved from a nursing home, hospital, or intermediate care

facility for the mentally retarded 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 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

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

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 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 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 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 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 is and executive office of health and human services is authorized

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and directed to pursue rate reform for homemaker, personal care (home health aide) 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) Development, not later than September 30, 2008, of certification standards

supporting and defining targeted rate increments to encourage 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 shift

differentials for night and week-end services; and

      (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) A prospective base adjustment effective not later than October 1, 2015 across all

departments and programs of ten percent (10%) of the existing base rate.

     (3) Development of rate enhancements for complex adult day participants to reflect

participant acuity, dementia care, and other criteria as determined by the department of human

services and executive office of health and human services, to be implemented on January 1,

2016.

     (4) Annual adjustments to the provider reimbursement rates by a percentage amount

equal to the change in a recognized national long-term care inflation index to begin on October 1,

2016.

     (g) The department, in collaboration with the executive office of human services, 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.

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      (h) The department of human services is also authorized, subject to availability of

appropriation of funding, to pay for certain expenses necessary to transition residents back to the

community; provided, however, payments shall not exceed an annual or per person amount.

      (i) To assure the continued financial viability of nursing facilities, the department of

human services is authorized and directed to develop a proposal for revisions to § 40-8-19 that

reflect the changes in cost and resident acuity that result from implementation of this re-balancing

goal. Said proposal shall be submitted to the governor and the general assembly on or before

January 1, 2010.

      (j) 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 is authorized to develop higher resource eligibility limits for

persons on home and community waiver services who are living in their own homes or rental

units.

     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HUMAN SERVICES - MEDICAL ASSISTANCE

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     This act would provide for annual adjustments to the provider reimbursement rates and

development of rate enhancements for complex adult day participants.

     This act would take effect upon passage.

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