2016 -- H 7728

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LC004645

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2016

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A N   A C T

RELATING TO HUMAN SERVICES -- MEDICAL ASSISTANCE--LONG-TERM CARE

SERVICE AND FINANCE REFORM

     Introduced By: Representative K. Joseph Shekarchi

     Date Introduced: February 24, 2016

     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 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, to home and

community-based care; provided, further, the 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 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

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 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 executive office is authorized to

adopt clinical and/or functional criteria for admission to a nursing facility, hospital, or

intermediate care facility for persons with intellectual disabilities that are more stringent than

those employed for access to home and community-based services. The executive office is also

authorized to promulgate rules that define the frequency of re-assessments for services provided

for under this section. Levels of care may be applied in accordance with the following:

      (1) The executive office shall continue to apply the level of care criteria in effect on June

30, 2015 for any recipient determined eligible for and receiving Medicaid-funded long-term

services in supports in a nursing facility, hospital, or intermediate care facility for persons with

intellectual disabilities on or before that date, unless (a) the recipient transitions to home and

community based services because he or she would no longer meet the level of care criteria in

effect on June 30, 2015; or (b) the recipient chooses home and community based services over

the nursing facility, hospital, or intermediate care facility for persons with intellectual disabilities.

For the purposes of this section, a failed community placement, as defined in regulations

promulgated by the executive office, shall be considered a condition of clinical eligibility for the

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highest level of care. The 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 persons with intellectual disabilities as of June 30, 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 persons with

intellectual disabilities whenever possible. Additionally, residents shall only be moved from a

nursing home, hospital, or intermediate care facility for 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 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 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 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 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 executive office is further authorized 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 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

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subject to availability of state-appropriated funding for these purposes.

      (f) To promote the expansion of home and community-based service capacity, the

executive office is authorized to pursue payment methodology reforms that increase access to

homemaker, personal care (home health aide), assisted living, adult supportive care homes, and

adult day services, as follows:

      (1) Development, of revised or new Medicaid certification standards that increase access

to service specialization and scheduling accommodations by using payment strategies designed to

achieve specific quality and health outcomes.

      (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.

     (3) A prospective base adjustment effective not later than October 1, 2016, of forty

percent (40%) of the existing base rate for home care providers, home nursing care providers, and

hospice providers contracted with the executive office of health and human services, its

subordinate agencies, and contactors to deliver Medicaid services.

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

equal to the change in cost inflation and compliance with all federal and state laws, regulations,

and rules, and all national accreditation program requirements through cost reports submitted by

home care providers, home nursing care providers, and hospice providers on all Medicaid

services, managed directly through the executive office of health and human services, its

subordinate agencies, and contractors, to the executive office of health and human services. The

executive office of health and human services shall design and implement a cost reporting system

to begin not later than June 30, 2017. Annual adjustments shall begin not later than October 1,

2017.

      (g) The 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

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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 executive office is also authorized, subject to availability of appropriation of

funding, and federal Medicaid-matching funds, to pay for certain services and supports necessary

to transition 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.

      (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

secretary is authorized to develop higher resource eligibility limits for persons 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 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.

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     SECTION 2. This act shall take effect upon passage.

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LC004645

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HUMAN SERVICES -- MEDICAL ASSISTANCE--LONG-TERM CARE

SERVICE AND FINANCE REFORM

***

     This act would provide for a Medicaid rate adjustment in parity with Massachusetts and

Connecticut for health care services provided in the home and would develop annual adjustments

to home care providers, home nursing care providers, and hospice provider reimbursement rates

based on transparent cost reporting to the executive office of health and human services.

     This act would take effect upon passage.

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