ARTICLE 10 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 section 1931 of Title XIX of the Social Security Act, 42 U.S.C. section 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 parents or relative caretakers whose income levels are below one hundred eighty-five percent (185%) one hundred seventy-five percent (175%) of the federal poverty level.

 (c) Resources. - 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) (c) 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%) one hundred thirty-three percent (133%) 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 section 40-8.4-12, in a manner and at an amount consistent with comparable cost-sharing provisions under section 40-8.4-12, provided that such cost sharing shall not exceed five percent (5%) of annual income for those with annual income in excess of one hundred thirty-three percent (133%); 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. – (1)(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 section 1906 of Title XIX of the Social Security Act, 42 U.S.C. section 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%) one hundred seventy-five percent (175%) 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 section 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. section 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. section 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%) one hundred thirty-three percent (133%) 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. section 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 40-21-1 of the General Laws in Chapter 40-21 entitled "Medical Assistance - Prescription Drugs" is hereby amended to read as follows:

 

40-21-1. Prescription drug program. -- The department of human services is hereby authorized and directed to amend its practices, procedures, regulations and the Rhode Island state plan for medical assistance (Medicaid) pursuant to title XIX of the Federal Social Security Act [42 U.S.C. section 1396 et seq.]to modify the prescription drug program:

 (1) To establish a preferred drug list (PDL);

 (2) To enter into supplemental rebate, discount or other agreements with pharmaceutical companies; and

 (3) To negotiate either state-specific supplemental rebates or to participate in a multi-state pooling supplemental rebate program.

 Determinations of drugs included on the PDL will be made by the State Department of Human Services, and a listing of such drugs shall be maintained on a public website. In making these determinations, the department shall consider the recommendations of the Medicaid Pharmaceutical and Therapeutics Committee, whose membership shall include practicing pharmacists and physicians, faculty members of the University of Rhode Island's College of Pharmacy, and consumers or consumer representatives. Drugs exempt from the PDL shall include: (1) antipsychotics; (2) anti-retrovirals; and (3) organ transplant medications. Physicians will be informed about prior authorization procedures for medications not on the PDL, and seventy-two (72) hour emergency supplies may be dispensed if authorizations cannot be obtained.

(4) To mandate the dispensing of generic-only drugs with the exception of limited brand drug coverage for certain therapeutic classes as approved by the Department of Human Services to individuals eligible for medical assistance (Medicaid) under sections 40-8.4-4, 42-12.3-4 and 42-12.3-15.

 

SECTION 3. This article shall take effect as of July 1, 2008.