2019 -- H 5403

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LC001414

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2019

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A N   A C T

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

SERVICES AND FINANCE REFORMS

     

     Introduced By: Representatives Bennett, Edwards, and Diaz

     Date Introduced: February 14, 2019

     Referred To: House Finance

     (Dept. of Administration)

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 rebalancing system reform goal.

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     (a) Notwithstanding any other provision of state law, the executive office of health and

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human services is authorized and directed to apply for, and obtain, any necessary waiver(s),

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waiver amendment(s), and/or state-plan amendments from the secretary of the United States

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Department of Health and Human Services, and to promulgate rules necessary to adopt an

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affirmative plan of program design and implementation that addresses the goal of allocating a

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minimum of fifty percent (50%) of Medicaid long-term-care funding for persons aged sixty-five

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(65) and over and adults with disabilities, in addition to services for persons with developmental

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disabilities, to home- and community-based care; provided, further, the executive office shall

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report annually as part of its budget submission, the percentage distribution between institutional

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care and home- and community-based care by population and shall report current and projected

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waiting lists for long-term-care and home- and community-based care services. The executive

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office is further authorized and directed to prioritize investments in home- and community-based

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

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while pursuing this goal.

 

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     (b) The reformed long-term-care system rebalancing 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, the executive office of

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health and human services is directed and authorized to adopt a tiered set of criteria to be used to

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determine eligibility for services. Such criteria shall be developed in collaboration with the state's

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health and human services departments and, to the extent feasible, any consumer group, advisory

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board, or other entity designated for such purposes, and shall encompass eligibility

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determinations for long-term-care services in nursing facilities, hospitals, and intermediate-care

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facilities for persons with intellectual disabilities, as well as home- and community-based

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alternatives, and shall provide a common standard of income eligibility for both institutional and

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home- and community-based care. The executive office is authorized to adopt clinical and/or

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functional criteria for admission to a nursing facility, hospital, or intermediate-care facility for

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persons with intellectual disabilities that are more stringent than those employed for access to

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home- and community-based services. The executive office is also authorized to promulgate rules

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that define the frequency of re-assessments for services provided for under this section. Levels of

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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:

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     (a) The recipient transitions to home- and community-based services because he or she

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would no longer meet the level of care criteria in effect on June 30, 2015; or

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     (b) The recipient chooses home- and community-based services over the nursing facility,

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hospital, or intermediate-care facility for persons with intellectual disabilities. For the purposes of

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

 

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

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The executive office shall confer with the long-term-care ombudsperson with respect to the

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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 persons with

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intellectual disabilities as of June 30, 2015, receive a determination of a failed community

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placement, the recipient shall have access to the highest level of care; furthermore, a recipient

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who has experienced a failed community placement shall be transitioned back into his or her

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former nursing home, hospital, or intermediate-care facility for persons with intellectual

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

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hospital, or intermediate-care facility for persons with intellectual disabilities in a manner

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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:

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     (i) Performed an individual assessment of the recipient at issue and provided written

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notice to the nursing home, hospital, or intermediate-care facility for persons with intellectual

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disabilities that the recipient does not meet level of care criteria; and

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     (ii) The recipient has either appealed that level of care determination and been

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unsuccessful, or any appeal period available to the recipient regarding that level of care

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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 42 U.S.C. § 1396n into a single system of home-

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and community-based services that include options for consumer direction and shared living. The

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resulting single home- and community-based services system shall replace and supersede all 42

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U.S.C. § 1396n programs when fully implemented. Notwithstanding the foregoing, the resulting

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single program home- and community-based services system shall include the continued funding

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of assisted-living services at any assisted-living facility financed by the Rhode Island housing and

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mortgage finance corporation prior to January 1, 2006, and shall be in accordance with chapter

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66.8 of title 42 as long as assisted-living services are 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 chapter 17.24 of title 23) that establish for

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each, an acuity-based, tiered service and payment methodology tied to: licensure authority; level

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of beneficiary needs; the scope of services and supports provided; and specific quality and

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outcome measures.

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

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

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8.10-3.

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     (3) As the state's Medicaid program seeks to assist more beneficiaries requiring long-term

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services and supports in home- and community-based settings, the demand for home care workers

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has increased, and wages for these workers has not kept pace with neighboring states, leading to

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high turnover and vacancy rates in the state's home-care industry, the executive office shall

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institute a one-time increase in the base-payment rates for home-care service providers to

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promote increased access to and an adequate supply of highly trained home health care

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professionals, in amount to be determined by the appropriations process, for the purpose of

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raising wages for personal care attendants and home health aides to be implemented by such

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providers.

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     (4) A prospective base adjustment, effective not later than July 1, 2018, of ten percent

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(10%) of the current base rate for home care providers, home nursing care providers, and hospice

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

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agencies to deliver Medicaid fee-for-service personal care attendant services.

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     (5) A prospective base adjustment, effective not later than July l, 2018, of twenty percent

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(20%) of the current base rate for home care providers, home nursing care providers, and hospice

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

 

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agencies to deliver Medicaid fee-for-service skilled nursing and therapeutic services and hospice

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care.

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     (6) The rate for hospice providers delivering hospice care in a skilled nursing facility

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shall not exceed ninety-five percent (95%) of the rate paid for non-hospice care in a skilled

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nursing facility.

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     (6)(7) On the first of July in each year, beginning on July l, 2019, the executive office of

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health and human services will initiate an annual inflation increase to the base rate by a

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percentage amount equal to the New England Consumer Price Index card as determined by the

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United States Department of Labor for medical care and for compliance with all federal and state

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laws, regulations, and rules, and all national accreditation program requirements.

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

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

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

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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 § 40-8.13-12;

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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

SERVICES AND FINANCE REFORMS

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     This act would require that the rate for hospice providers, delivering hospice care in a

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skilled nursing facility, not exceed ninety-five percent (95%) of the rate paid for non-hospice care

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in a skilled nursing facility.

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     This act would take effect upon passage.

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