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:

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     SECTION 1. Section 40-8.9-9 of the General Laws in Chapter 40-8.9 entitled "Medical

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Assistance - Long-Term Care Service and Finance Reform" is hereby amended to read as

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follows:

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     40-8.9-9. Long-term care re-balancing system reform goal. -- (a) Notwithstanding any

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other provision of state law, the executive office of health and human services is authorized and

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directed to apply for and obtain any necessary waiver(s), waiver amendment(s) and/or state plan

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amendments from the secretary of the United States department of health and human services,

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and to promulgate rules necessary to adopt an affirmative plan of program design and

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implementation that addresses the goal of allocating a minimum of fifty percent (50%) of

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Medicaid long-term care funding for persons aged sixty-five (65) and over and adults with

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disabilities, in addition to services for persons with developmental disabilities, to home and

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community-based care; provided, further, the executive office shall report annually as part of its

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budget submission, the percentage distribution between institutional care and home and

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community-based care by population and shall report current and projected waiting lists for long-

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term care and home and community-based care services. The executive office is further

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authorized and directed to prioritize investments in home and community-based care and to

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maintain the integrity and financial viability of all current long-term care services while pursuing

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this goal.

 

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      (b) The reformed long-term care system re-balancing goal is person-centered and

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encourages individual self-determination, family involvement, interagency collaboration, and

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individual choice through the provision of highly specialized and individually tailored home-

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based services. Additionally, individuals with severe behavioral, physical, or developmental

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disabilities must have the opportunity to live safe and healthful lives through access to a wide

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range of supportive services in an array of community-based settings, regardless of the

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complexity of their medical condition, the severity of their disability, or the challenges of their

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behavior. Delivery of services and supports in less costly and less restrictive community settings,

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will enable children, adolescents and adults to be able to curtail, delay or avoid lengthy stays in

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long-term care institutions, such as behavioral health residential treatment facilities, long-term

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care hospitals, intermediate care facilities and/or skilled nursing facilities.

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      (c) Pursuant to federal authority procured under § 42-7.2-16 of the general laws, the

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executive office of health and human services is directed and authorized to adopt a tiered set of

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criteria to be used to determine eligibility for services. Such criteria shall be developed in

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collaboration with the state's health and human services departments and, to the extent feasible,

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any consumer group, advisory board, or other entity designated for such purposes, and shall

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encompass eligibility determinations for long-term care services in nursing facilities, hospitals,

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and intermediate care facilities for persons with intellectual disabilities as well as home and

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community-based alternatives, and shall provide a common standard of income eligibility for

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both institutional and home and community-based care. The executive office is authorized to

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

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

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

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

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

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

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

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

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

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

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

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

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

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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

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with respect to the determination of a failed placement under the ombudsperson's jurisdiction.

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Should any Medicaid recipient eligible for a nursing facility, hospital, or intermediate care

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facility for persons with intellectual disabilities as of June 30, 2015 receive a determination of a

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failed community placement, the recipient shall have access to the highest level of care;

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furthermore, a recipient who has experienced a failed community placement shall be transitioned

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back into his or her former nursing home, hospital, or intermediate care facility for persons with

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

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nursing home, hospital, or intermediate care facility for persons with intellectual disabilities in a

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manner consistent with applicable state and federal laws.

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      (2) Any Medicaid recipient eligible for the highest level of care who voluntarily leaves a

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nursing home, hospital, or intermediate care facility for persons with intellectual disabilities shall

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not be subject to any wait list for home and community based services.

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      (3) No nursing home, hospital, or intermediate care facility for persons with intellectual

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disabilities shall be denied payment for services rendered to a Medicaid recipient on the grounds

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that the recipient does not meet level of care criteria unless and until the executive office has: (i)

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performed an individual assessment of the recipient at issue and provided written notice to the

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nursing home, hospital, or intermediate care facility for persons with intellectual disabilities that

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the recipient does not meet level of care criteria; and (ii) the recipient has either appealed that

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level of care determination and been unsuccessful, or any appeal period available to the recipient

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regarding that level of care determination has expired.

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      (d) The executive office is further authorized to consolidate all home and community-

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based services currently provided pursuant to § 1915(c) of title XIX of the United States Code

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into a single system of home and community-based services that include options for consumer

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direction and shared living. The resulting single home and community-based services system

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shall replace and supersede all § 1915(c) programs when fully implemented. Notwithstanding the

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foregoing, the resulting single program home and community-based services system shall include

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the continued funding of assisted living services at any assisted living facility financed by the

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Rhode Island housing and mortgage finance corporation prior to January 1, 2006, and shall be in

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accordance with chapter 66.8 of title 42 of the general laws as long as assisted living services are

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a covered Medicaid benefit.

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      (e) The executive office is authorized to promulgate rules that permit certain optional

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services including, but not limited to, homemaker services, home modifications, respite, and

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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.

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

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

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

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adult day services, as follows:

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

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

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achieve specific quality and health outcomes.

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      (2) Development of Medicaid certification standards for state authorized providers of

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adult day services, excluding such providers of services authorized under § 40.1-24-1(3), assisted

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living, and adult supportive care (as defined under § 23-17.24) that establish for each, an acuity-

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based, tiered service and payment methodology tied to: licensure authority, level of beneficiary

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needs; the scope of services and supports provided; and specific quality and outcome measures.

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The standards for adult day services for persons eligible for Medicaid-funded long-term services

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may differ from those who do not meet the clinical/functional criteria set forth in § 40-8.10-3.

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

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

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

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subordinate agencies, and contactors to deliver Medicaid services.

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

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

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

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

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

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

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

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

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2017.

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      (g) The executive office shall implement a long-term care options counseling program

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to provide individuals or their representatives, or both, with long-term care consultations that

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shall include, at a minimum, information about: long-term care options, sources and methods of

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both public and private payment for long-term care services and an assessment of an individual's

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functional capabilities and opportunities for maximizing independence. Each individual admitted

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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

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shall be provided with long-term care options consultation if they so request. Each individual

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who applies for Medicaid long-term care services shall be provided with a long-term care

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consultation.

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      (h) The executive office is also authorized, subject to availability of appropriation of

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

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to transition or divert beneficiaries from institutional or restrictive settings and optimize their

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health and safety when receiving care in a home or the community. The secretary is authorized to

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obtain any state plan or waiver authorities required to maximize the federal funds available to

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support expanded access to such home and community transition and stabilization services;

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

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      (i) To ensure persons with long-term care needs who remain living at home have

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adequate resources to deal with housing maintenance and unanticipated housing related costs, the

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secretary is authorized to develop higher resource eligibility limits for persons or obtain any state

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plan or waiver authorities necessary to change the financial eligibility criteria for long-term

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services and supports to enable beneficiaries receiving home and community waiver services to

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have the resources to continue living in their own homes or rental units or other home-based

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settings.

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      (j) The executive office shall implement, no later than January 1, 2016, the following

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home and community-based service and payment reforms:

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      (1) Community-based supportive living program established in § 40-8.13-2.1;

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      (2) Adult day services level of need criteria and acuity-based, tiered payment

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methodology; and

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      (3) Payment reforms that encourage home and community-based providers to provide

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the specialized services and accommodations beneficiaries need to avoid or delay institutional

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care.

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      (k) The secretary is authorized to seek any Medicaid section 1115 waiver or state plan

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amendments and take any administrative actions necessary to ensure timely adoption of any new

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or amended rules, regulations, policies, or procedures and any system enhancements or changes,

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for which appropriations have been authorized, that are necessary to facilitate implementation of

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the requirements of this section by the dates established. The secretary shall reserve the discretion

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to exercise the authority established under §§ 42-7.2-5(6)(v) and 42-7.2-6.1, in consultation with

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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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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

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

SERVICE AND FINANCE REFORM

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

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

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

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

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     This act would take effect upon passage.

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