2018 -- S 2610

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LC004712

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2018

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A N   A C T

RELATING TO INSURANCE - PRIMARY CARE TRUST ACT

     

     Introduced By: Senators Sosnowski, and Crowley

     Date Introduced: March 01, 2018

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

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     SECTION 1. Title 27 of the General Laws entitled "INSURANCE" is hereby amended

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by adding thereto the following chapter:

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CHAPTER 27-82

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PRIMARY CARE TRUST ACT

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     27-82-1. Short title.

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     This chapter shall be known and may be cited as the "Primary Care Trust Act".

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     27-82-2. Definitions.

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     As used in this chapter:

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     (1) "Essential health services" means primary care services (medical, pediatric, and

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maternity), and those coordinated and integrated services which support the health of patients in a

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community health region, such as mental health services, substance use disorder services,

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physical therapy, dental and oral services, eye care services, emergency medical services not

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provided by a hospital-controlled organization, same-day access to urgent essential health

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services, and other services identified by the primary care trust and approved by the office.

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     (2) "Health insurer" means:

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     (i) A health insurance company;

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     (ii) A nonprofit hospital and medical service corporation;

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     (iii) A health maintenance organization;

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     (iv) The state Medicaid program, and any other health care benefit plan administered by

 

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the state for eligible individuals and families;

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     (v) A health care plan administered by the state and any agency or instrumentality of the

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state for the benefit of their employees and dependents; and

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     (vi) To the extent permitted under federal law, Medicare, and any administrator of an

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insured, self-insured, or publicly funded health care benefit plan offered by public and private

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entities.

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     (3) "Neighborhood health station" means a single clinical entity that provides primary

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medical care, urgent care, primary dental care, mental and behavioral health and substance use

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disorder treatment to the entire population of a specific geographic area without regard to method

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of payment, and actively works to improve the measured population health of that population.

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     (4) "Office" means the office of the health insurance commissioner pursuant to chapter

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14.5 of title 42.

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     (5) "Primary care" means health care services delivered by health care providers:

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     (i) Who are specifically trained for and skilled in first-contact and continuing care for

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individuals with sign, symptoms, or health concerns, not limited by problem origin, organ system,

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or diagnosis;

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     (ii) Who provide services that are comprehensive, including those of more than a single

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discipline;

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     (iii) Who provide such services in a coordinated manner, so that they focus on the health

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goals of individual patients; and

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     (iv) Who provide such services in a manner that ensures each service is effective at

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achieving those individual health goals.

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     (6) "Primary care provider" means a physician, nurse practitioner, physician's assistant,

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primary care medical practice, neighborhood health station, federally qualified community health

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center, or other provider of primary care services who contracts with, and is paid by the primary

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care trust to provide primary care services.

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     (7) "Primary care trust" means one or more nonprofit organizations designated by the

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office to provide primary care and essential health services in one or more geographical regions

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of the state.

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     (8) "Primary care trust program" means the program administered by the office to provide

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primary care services to all residents of this state.

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     27-82-3. Responsibilities of the office of the health insurance commissioner.

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     The office shall:

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     (1) Ensure that affordable and quality primary care services are available and accessible

 

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to all residents of this state;

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     (2) Identify one or more geographic regions of the state as primary care community

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health districts;

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     (3) Designate one or more nonprofit organizations as a primary care trust responsible for

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the delivery of primary care and essential health services in each primary care community health

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district;

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     (4) In consultation with the department of health, establish program and administrative

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standards for a primary care trust;

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     (5) Monitor the capacity and ability of each primary care trust to fulfill their

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responsibilities to residents of the community health district; and

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     (6) Establish standards and procedures to fund the primary care trusts by annual primary

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care trust assessments paid by health insurers.

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     (b) The office shall establish, annually, through the rate-setting process, a primary care

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trust assessment to fund the primary care trust program. The assessment shall be equal to ten and

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seven-tenths percent (10.7%) of total projected medical spending by each health insurer doing

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business in this state. At the conclusion of the rate-setting process, the office shall issue an

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allocation order apportioning each insurer's assessment among designated primary care trusts

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based on the population of the community health region and the essential health needs of the

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community health region. The office may permit variations from the ten and seven tenths percent

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(10.7%) assessment not to exceed plus or minus five-tenths percent (+/- 0.5%) to account for

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changed circumstances, and the primary care and essential health care needs of residents. The

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office shall have jurisdiction over all health insurers in this state for purposes of imposing the

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primary trust fund assessment.

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     (c) The primary care trust assessment shall constitute a health care service funding

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contribution under chapter 7.4 of title 42. The primary care trust assessment shall be

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administered, collected, and enforced as a health care services funding contribution in accordance

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with chapter 7.4 of title 42, except that each health insurer shall pay its assessment directly to one

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or more primary care trusts in accordance with the allocation order issued by the office at the

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conclusion of the annual rate-setting process.

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     (d) The office may:

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     (1) Promulgate rules and regulations necessary to establish standards and procedures as

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are required or desirable to carry out the purposes of this chapter; and

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     (2) Re-designate another nonprofit organization as the primary care trust for a community

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health district, if, after consultation with the board of directors of a primary care trust, the office

 

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determines that the primary care trust has failed to propose or implement an adequate community

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health plan.

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     27-82-4. The primary care trust - Establishment and duties.

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     (a) A primary care trust shall be governed by a board of directors. One-half (1/2) of the

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board shall be composed of primary care providers and providers of essential health services in

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the community health district. One-half (1/2) of the board shall be composed of community

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members residing in the community health district. The articles of association or other governing

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document of a primary care trust must be approved by the office. The appointment of initial

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directors shall be made by the office within ninety (90) days following the effective date of this

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act for a term not to exceed twelve (12) months. The articles shall include a mechanism for

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subsequent directors to be elected by providers and community members for two (2) year terms.

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     (b) The primary care trust shall:

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     (1) Be responsible for the delivery of primary care services within its community health

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district; and

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     (2) Develop and implement a community health plan, approved annually by the office.

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The community health plan shall describe how the primary care trust shall:

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     (i) Provide primary care services to all residents of the community health district;

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     (ii) Provide essential health services, and expand the availability of essential health

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services to all residents of the community health district;

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     (iii) Improve the health of residents in the community health district as measured by not

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more than four (4) population health indicators including, but not limited to, smoking, body mass

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index, and vaccination rates. Such measures shall be adopted by rule or regulation by the office,

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in consultation with the director of the department of health;

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     (iv) Ensure patient access to primary care during evenings and weekends; and

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     (v) Include other elements as are designed to maintain and improve the health of all

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residents of the community health district.

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     (c) The primary care trust shall reimburse primary care providers on a per capita, or on a

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fee-for-service basis.

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     (d) Primary care providers and other providers of essential health services who enter into

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an agreement with the primary care trust to provide coordinated essential health services shall be

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reimbursed with per capita payments. Per capita payments shall provide a financial incentive for

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primary care providers to offer essential health services, and to increase the percentage of

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residents in the community health region that receive essential health services.

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     (e) Primary care providers who do not enter into an agreement with the primary care trust

 

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to provide coordinated essential health services shall be reimbursed on a fee for service basis, in

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accordance with a fee schedule established by the primary care trust.

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     (f) The primary care trust may establish per capita payments or fee schedules with or

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without patient cost sharing.

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     (g) Primary care services provided to Medicare beneficiaries and beneficiaries of other

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health plans offered by the federal government shall be reimbursed by Medicare or such other

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health plans until such time as an agreement with the federal government can be reached to

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incorporate the primary care trust as the reimbursement mechanism for such patients.

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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 INSURANCE - PRIMARY CARE TRUST ACT

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     This act would create the "Primary Care Trust Act" to:

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     (1) Create a single payment and universal health care delivery system for primary care

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health services in this state;

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     (2) Require health insurers to allocate a fair portion of their medical spending for the

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delivery of primary care services;

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     (3) Designate one or more primary care trusts to ensure the delivery of primary care and

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essential health services to all residents of this state;

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     (4) Authorize a primary care trust to pay for primary care from a portion of health

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insurers' annual medical spending, with financial incentives for providers that provide essential

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health services in each community health district; and

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     (5) Lower the growth of state health care spending by empowering primary care

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providers to focus care delivery for their patients at the least intensive and most affordable level

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of care, when clinically appropriate.

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     This act would take effect upon passage.

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