2023 -- H 6332

========

LC002859

========

     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2023

____________

A N   A C T

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

SERVICE AND FINANCE REFORM

     

     Introduced By: Representatives Spears, Donovan, Abney, Speakman, Craven, O'Brien,
Shanley, McEntee, Morales, and Tanzi

     Date Introduced: April 26, 2023

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

1

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

2

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

3

     40-8.9-9. Long-term-care rebalancing system reform goal.

4

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

5

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

6

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

7

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

8

program design and implementation that addresses the goal of allocating a minimum of fifty percent

9

(50%) of Medicaid long-term-care funding for persons aged sixty-five (65) and over and adults

10

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

11

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

12

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

13

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

14

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

15

and directed to prioritize investments in home- and community-based care and to maintain the

16

integrity and financial viability of all current long-term-care services while pursuing this goal.

17

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

18

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

 

1

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

2

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

3

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

4

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

5

medical condition, the severity of their disability, or the challenges of their behavior. Delivery of

6

services and supports in less-costly and less-restrictive community settings will enable children,

7

adolescents, and adults to be able to curtail, delay, or avoid lengthy stays in long-term-care

8

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

9

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

10

     (c) Pursuant to federal authority procured under § 42-7.2-16, the executive office of health

11

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

12

eligibility for services. The criteria shall be developed in collaboration with the state’s health and

13

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

14

other entity designated for these purposes, and shall encompass eligibility determinations for long-

15

term-care services in nursing facilities, hospitals, and intermediate-care facilities for persons with

16

intellectual disabilities, as well as home- and community-based alternatives, and shall provide a

17

common standard of income eligibility for both institutional and home- and community-based care.

18

The executive office is authorized to adopt clinical and/or functional criteria for admission to a

19

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

20

are more stringent than those employed for access to home- and community-based services. The

21

executive office is also authorized to promulgate rules that define the frequency of re-assessments

22

for services provided for under this section. Levels of care may be applied in accordance with the

23

following:

24

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

25

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

26

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

27

intellectual disabilities on or before that date, unless:

28

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

29

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

30

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

31

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

32

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

33

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

34

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

 

LC002859 - Page 2 of 8

1

determination of a failed placement under the ombudsperson’s jurisdiction. Should any Medicaid

2

recipient eligible for a nursing facility, hospital, or intermediate-care facility for persons with

3

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

4

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

5

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

6

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

7

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

8

intermediate-care facility for persons with intellectual disabilities in a manner consistent with

9

applicable state and federal laws.

10

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

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

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

20

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

21

determination has expired.

22

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

23

based services currently provided pursuant to 42 U.S.C. § 1396n into a single system of home- and

24

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

25

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

26

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

27

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

28

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

29

mortgage finance corporation prior to January 1, 2006, and shall be in accordance with chapter 66.8

30

of title 42 as long as assisted-living services are a covered Medicaid benefit.

31

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

32

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

33

physical therapy evaluations to be offered to persons at risk for Medicaid-funded long-term care

34

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

 

LC002859 - Page 3 of 8

1

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

2

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

3

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

4

adult day services, as follows:

5

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

6

service specialization and scheduling accommodations by using payment strategies designed to

7

achieve specific quality and health outcomes.

8

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

9

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

10

adult supportive care (as defined under chapter 17.24 of title 23) that establish for each, an acuity-

11

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

12

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

13

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

14

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

15

8.10-3.

16

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

17

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

18

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

19

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

20

a one-time increase in the base-payment rates for FY 2019, as described below, for home-care

21

service providers to promote increased access to and an adequate supply of highly trained home-

22

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

23

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

24

providers.

25

     (i) A prospective base adjustment, effective not later than July 1, 2018, of ten percent (10%)

26

of the current base rate for home-care providers, home nursing care providers, and hospice

27

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

28

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

29

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

30

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

31

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

32

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

33

care.

34

     (iii) Effective upon passage of this section, hospice provider reimbursement, exclusively

 

LC002859 - Page 4 of 8

1

for room and board expenses for individuals residing in a skilled nursing facility, shall revert to the

2

rate methodology in effect on June 30, 2018, and these room and board expenses shall be exempted

3

from any and all annual rate increases to hospice providers as provided for in this section.

4

     (iv) On the first of July in each year, beginning on July 1, 2019, the executive office of

5

health and human services will initiate an annual inflation increase to the base rate for home-care

6

providers, home nursing care providers, and hospice providers contracted with the executive office

7

and its subordinate agencies to deliver Medicaid fee-for-service personal care attendant services,

8

skilled nursing and therapeutic services and hospice care. The base rate increase shall be a

9

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

10

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

11

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

12

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

13

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

14

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

15

high turnover and vacancy rates in the state’s home-care industry. To promote increased access to

16

and an adequate supply of direct-care workers, the executive office shall institute a payment

17

methodology change, in Medicaid fee-for-service and managed care, for FY 2022, that shall be

18

passed through directly to the direct-care workers’ wages who are employed by home nursing care

19

and home-care providers licensed by the Rhode Island department of health, as described below:

20

     (1) Effective July 1, 2021, increase the existing shift differential modifier by $0.19 per

21

fifteen (15) minutes for personal care and combined personal care/homemaker.

22

     (i) Employers must pass on one hundred percent (100%) of the shift differential modifier

23

increase per fifteen-minute (15) unit of service to the CNAs who rendered such services. This

24

compensation shall be provided in addition to the rate of compensation that the employee was

25

receiving as of June 30, 2021. For an employee hired after June 30, 2021, the agency shall use not

26

less than the lowest compensation paid to an employee of similar functions and duties as of June

27

30, 2021, as the base compensation to which the increase is applied.

28

     (ii) Employers must provide to EOHHS an annual compliance statement showing wages

29

as of June 30, 2021, amounts received from the increases outlined herein, and compliance with this

30

section by July 1, 2022. EOHHS may adopt any additional necessary regulations and processes to

31

oversee this subsection.

32

     (2) Effective January 1, 2022, establish a new behavioral healthcare enhancement of $0.39

33

per fifteen (15) minutes for personal care, combined personal care/homemaker, and homemaker

34

only for providers who have at least thirty percent (30%) of their direct-care workers (which

 

LC002859 - Page 5 of 8

1

includes certified nursing assistants (CNA) and homemakers) certified in behavioral healthcare

2

training.

3

     (i) Employers must pass on one hundred percent (100%) of the behavioral healthcare

4

enhancement per fifteen (15) minute unit of service rendered by only those CNAs and homemakers

5

who have completed the thirty (30) hour behavioral health certificate training program offered by

6

Rhode Island College, or a training program that is prospectively determined to be compliant per

7

EOHHS, to those CNAs and homemakers. This compensation shall be provided in addition to the

8

rate of compensation that the employee was receiving as of December 31, 2021. For an employee

9

hired after December 31, 2021, the agency shall use not less than the lowest compensation paid to

10

an employee of similar functions and duties as of December 31, 2021, as the base compensation to

11

which the increase is applied.

12

     (ii) By January 1, 2023, employers must provide to EOHHS an annual compliance

13

statement showing wages as of December 31, 2021, amounts received from the increases outlined

14

herein, and compliance with this section, including which behavioral healthcare training programs

15

were utilized. EOHHS may adopt any additional necessary regulations and processes to oversee

16

this subsection.

17

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

18

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

19

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

20

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

21

functional capabilities and opportunities for maximizing independence. Each individual admitted

22

to, or seeking admission to, a long-term-care facility, regardless of the payment source, shall be

23

informed by the facility of the availability of the long-term-care-options counseling program and

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

expanded access to home- and community-transition and stabilization services; provided, however,

32

payments shall not exceed an annual or per-person amount.

33

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

34

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

 

LC002859 - Page 6 of 8

1

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

2

waiver authorities necessary to change the financial eligibility criteria for long-term services and

3

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

4

resources to continue living in their own homes or rental units or other home-based settings.

5

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

6

home- and community-based service and payment reforms:

7

     (1) [Deleted by P.L. 2021, ch. 162, art. 12, § 6.]

8

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

9

methodology; and

10

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

11

specialized services and accommodations beneficiaries need to avoid or delay institutional care.

12

     (l) For federal fiscal year 2024, commencing on October 1, 2023, and ending September

13

30, 2024, the executive office of health and human services shall submit to the Secretary of the

14

United States Department of Health and Human Services a state plan amendment to provide that:

15

     (1) Chiropractic rates shall be as follows: exam - one hundred fifteen dollars ($115),

16

manipulation - fifty-five dollars ($55.00), physiotherapy/electric muscle stimulation - thirty-five

17

dollars ($35.00) and therapeutic exercises - forty-five dollars ($45.00).

18

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

19

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

20

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

21

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

22

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

23

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

24

the governor, to meet the legislative directives established herein.

25

     SECTION 2. This act shall take effect upon passage.

========

LC002859

========

 

LC002859 - Page 7 of 8

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

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

SERVICE AND FINANCE REFORM

***

1

     This act would provide that for federal fiscal year 2024, commencing on October 1, 2023,

2

and ending September 30, 2024, the executive office of health and human services would submit

3

to the Secretary of the United States Department of Health and Human Services a state plan

4

amendment to provide set rates related to chiropractic services.

5

     This act would take effect upon passage.

========

LC002859

========

 

LC002859 - Page 8 of 8