ARTICLE 25 SUBSTITUTE A AS AMENDED

RELATING TO MEDICAL ASSISTANCE -- MANAGED CARE

SECTION 1. Sections 40-8.4-4 and 40-8.4-12 of the General Laws in Chapter 40-8.4 entitled “Health Care for Families” are hereby amended to read as follows:

§ 40-8.4-4.  Eligibility. – (a) Medical assistance for families. There is hereby established a category of medical assistance eligibility pursuant to § 1931 of title XIX of the Social Security Act [42 U.S.C. § 1396u-1] for families whose income and resources are no greater than the standards in effect in the aid to families with dependent children program on July 16, 1996 or such increased standards as the department may determine. The department of human services is directed to amend the medical assistance title XIX state plan and to submit to the U.S. Department of Health and Human Services an amendment to the RIte Care waiver project to provide for medical assistance coverage to families under this chapter in the same amount, scope and duration as coverage provided to comparable groups under the waiver. The department is further authorized and directed to submit such amendments and/or requests for waivers to the title XXI state plan as may be necessary to maximize federal contribution for provision of medical assistance coverage under this chapter. However, implementation of expanded coverage under this chapter shall not be delayed pending federal review of any title XXI amendment or waiver.

(b) Income. The director of the department of human services is authorized and directed to amend the medical assistance title XIX state plan or RIte Care waiver to provide medical assistance coverage through expanded income disregards or other methodology for families parents or relative caretakers whose income levels are below one hundred eighty-five percent (185%) of the federal poverty level.

   (c) Resources. Resources shall be disregarded in determining eligibility under this chapter. Except as provided herein, no family or child shall be eligible for medical assistance coverage provided under this section if the combined value of the child’s or the family’s liquid resources exceed ten thousand dollars ($10,000); provided, however, that this subsection shall not apply to:

(1) children with disabilities who are otherwise eligible for medical assistance coverage as categorically needy under Section 134(a) of the Tax Equity and Fiscal Responsibility Act of 1982 [federal P.L. 97-248], commonly known as Katie Beckett eligible, upon meeting the requirements established in Section 1902 (e)(3) of the federal Social Security Act; and

(2) pregnant women.

Liquid Resources are defined as any interest(s) in property in the form of cash or other financial instruments or accounts which are readily convertible to cash or cash equivalents. These include, but are not limited to: cash, bank, credit union or other financial institution savings, checking and money market accounts, certificates of deposit or other time deposits, stocks, bonds, mutual funds, and other similar financial instruments or accounts. These do not include educational savings accounts, plans, or programs; retirement accounts, plans, or programs; or accounts held jointly with another adult, not including a spouse, living outside the same household but only to the extent the applicant/recipient family documents the funds are from sources owned by the other adult living outside the household, plus the proportionate share of any interest, dividend or capital gains thereon. The department is authorized to promulgate rules and regulations to determine the ownership and source of the funds in the joint account.

(d) Waiver. The department of human services is authorized and directed to apply for and obtain appropriate waivers from the Secretary of the U.S. Department of Health and Human Services, including, but not limited to, a waiver of the appropriate provisions of title XIX, to require that individuals with incomes equal to or greater than one hundred fifty percent (150%) of the federal poverty level pay a share of the costs of their medical assistance coverage provided through enrollment in either the RIte Care Program or under the premium assistance program under § 40-8.4-12, in a manner and at an amount consistent with comparable cost-sharing provisions under § 40-8.4-12, provided that such cost sharing shall not exceed five percent (5%) of annual income; and provided, further, that cost-sharing shall not be required for pregnant women or children under age one.

§ 40-8.4-12. RIte Share Health Insurance Premium Assistance Program. – (a) Basic RIte Share Health Insurance Premium Assistance Program.

(1) The department of human services is authorized and directed to amend the medical assistance Title XIX state plan to implement the provisions of § 1906 of Title XIX of the Social Security Act [42 U.S.C. § 1396e] and establish the Rhode Island health insurance premium assistance program for RIte Care eligible parents with incomes up to one hundred eighty-five percent (185%) of the federal poverty level who have access to employer-based health insurance. The state plan amendment shall require eligible individuals with access to employer-based health insurance to enroll themselves and/or their family in the employer-based health insurance plan as a condition of participation in the RIte Share program under this chapter and as a condition of retaining eligibility for medical assistance under chapters 5.1 and 8.4 of this title and/or chapter 12.3 of title 42 and/or premium assistance under this chapter, provided that doing so meets the criteria established in § 1906 of Title XIX for obtaining federal matching funds and the department has determined that the individual's and/or the family's enrollment in the employer-based health insurance plan is cost-effective and the department has determined that the employer-based health insurance plan meets the criteria set forth in subsection (d). The department shall provide premium assistance by paying all or a portion of the employee's cost for covering the eligible individual or his or her family under the employer-based health insurance plan, subject to the cost sharing provisions in subsection (b), and provided that the premium assistance is cost-effective in accordance with Title XIX [42 U.S.C. § 1396 et seq.].

(2) Resources. Except as provided herein, no family, individual, or child shall be eligible for medical assistance coverage provided under this section if the combined value of the child’s or family’s liquid resources exceeds ten thousand dollars ($10,000); provided, however, that this subsection shall not apply to:

(i) children with disabilities who are otherwise eligible for medical assistance coverage as categorically needy under Section 134(a) of the Tax Equity and Fiscal Responsibility Act of 1982 [federal P.L. 97-248], commonly known as Katie Beckett eligible, upon meeting the requirements established in Section 1902 (e)(3) of the federal Social Security Act, and

(ii) pregnant women.

(b) Individuals who can afford it shall share in the cost. The department of human services is authorized and directed to apply for and obtain any necessary waivers from the secretary of the United States department of health and human services, including, but not limited to a waiver of the appropriate sections of Title XIX [42 U.S.C. § 1396 et seq.], to require that individuals eligible for RIte Care under this chapter or chapter 12.3 of title 42 with incomes equal to or greater than one hundred fifty percent (150%) of the federal poverty level pay a share of the costs of health insurance based on the individual's ability to pay, provided that the cost sharing shall not exceed five percent (5%) of the individual's annual income. The department of human services shall implement the cost-sharing by regulation, and shall consider co-payments, premium shares or other reasonable means to do so. 

(c) Current RIte Care enrollees with access to employer-based health insurance. The department of human services shall require any individual who receives RIte Care or whose family receives RIte Care on the effective date of the applicable regulations adopted in accordance with subsection (f) to enroll in an employer-based health insurance plan at the individual's eligibility redetermination date or at an earlier date determined by the department, provided that doing so meets the criteria established in the applicable sections of Title XIX [42 U.S.C. § 1396 et seq.] for obtaining federal matching funds and the department has determined that the individual's and/or the family's enrollment in the employer-based health insurance plan is cost-effective and has determined that the health insurance plan meets the criteria in subsection (d). The insurer shall accept the enrollment of the individual and/or the family in the employer-based health insurance plan without regard to any enrollment season restrictions.

(d) Approval of health insurance plans for premium assistance. The department of human services shall adopt regulations providing for the approval of employer-based health insurance plans for premium assistance and shall approve employer-based health insurance plans based on these regulations. In order for an employer-based health insurance plan to gain approval, the department must determine that the benefits offered by the employer-based health insurance plan are substantially similar in amount, scope, and duration to the benefits provided to RIte Care eligible persons by the RIte Care program, when the plan is evaluated in conjunction with available supplemental benefits provided by the department. The department shall obtain and make available to persons otherwise eligible for RIte Care as supplemental benefits those benefits not reasonably available under employer-based health insurance plans which are required for RIte Care eligible persons by state law or federal law or regulation.

(e) Maximization of federal contribution. The department of human services is authorized and directed to apply for and obtain federal approvals and waivers necessary to maximize the federal contribution for provision of medical assistance coverage under this section.

(f) Implementation by regulation. The department of human services is authorized and directed to adopt regulations to ensure the establishment and implementation of the premium assistance program in accordance with the intent and purpose of this section, the requirements of Title XIX and any approved federal waivers.

SECTION 2. Section 42-12.3-4 of the General Laws in Chapter 42-12.3 entitled “Health Care for Children and Pregnant Women” is hereby amended to read as follows:

§ 42-12.3-4. "RIte track" program. - (a) There is hereby established a payor of last resort program for comprehensive health care for children until they reach nineteen (19) years of age, to be known as "RIte track". The department of human services is hereby authorized to amend its title XIX state plan pursuant to title XIX [42 U.S.C. § 1396 et seq.] of the Social Security Act to provide for expanded Medicaid coverage through expanded family income disregards for children, until they reach nineteen (19) years of age, whose family income levels are up to two hundred fifty percent (250%) of the federal poverty level; provided, however, that health care coverage under this section shall also be provided without regard to the availability of federal financial participation to a noncitizen child lawfully residing in the United States and to a noncitizen child residing in Rhode Island, provided that the child satisfies all other eligibility requirements. The department is further authorized to promulgate any regulations necessary, and in accord with title XIX [42 U.S.C. § 1396 et seq.] of the Social Security Act to implement the state plan amendment. For those children who lack health insurance, and whose family incomes are in excess of two hundred fifty percent (250%) of the federal poverty level, the department of human services shall promulgate necessary regulations to implement the program. The department of human services is further directed to ascertain and promulgate the scope of services that will be available to those children whose family income exceeds the maximum family income specified in the approved title XIX [42 U.S.C. section 1396 et seq.] state plan amendment.

(b) Resources. Except as provided herein, no child shall be eligible for medical assistance coverage provided under this section if the combined value of the child’s or the family’s liquid resources exceeds ten thousand dollars ($10,000); provided, however, that this subsection shall not apply to children with disabilities who are otherwise eligible for medical assistance coverage as categorically needy under Section 134(a) of the Tax Equity and Fiscal Responsibility Act of 1982 [federal P.L. 97-248], commonly known as Katie Beckett eligible, upon meeting the requirements established in Section 1902 (e)(3) of the federal Social Security Act.

SECTION 3. This article shall take effect on July 1, 2006.