ARTICLE 22 SUBSTITUTE A AS AMENDED
RELATING TO
CENTERS FOR MEDICARE AND MEDICAID SERVICES WAIVER AND EXPENDITURE AUTHORITY
SECTION
1. Chapter 42-12.4 of the General Laws entitled "The Rhode Island Medicaid
Reform Act of 2008" is
hereby amended by adding thereto the following sections:
42-12.4-7.
Demonstration implementation - Restrictions. -- The executive office
of
health and human services and the department of human
services may implement the global
consumer choice section 1115 demonstration ("the
demonstration"), project number 11W-
00242/1, subject to the following restrictions:
(1) Notwithstanding
the provisions of the demonstration, any change that requires the
implementation of a rule or regulation or modification
of a rule or regulation in existence prior to
the demonstration shall require prior approval of the
general assembly;
(2) Notwithstanding
the provisions of the demonstration, any Category II change or
Category III change, as defined in the demonstration,
shall require the prior approval of the
general assembly.
42-12.4-8.
Demonstration termination. -- In the event the demonstration is
suspended
or terminated for any reason, or in the event that the
demonstration expires, the department of
human services, in conjunction with the executive
office of health and human services, is directed
and authorized to apply for and obtain all waivers in
existence prior to the acceptance of the
demonstration. The department of human services and the
executive office of health and human
services to the extent possible shall ensure that said
waivers are reinstated prior to any
suspension, termination, or expiration of the
demonstration.
42-12.4-9.
Demonstration implementation taskforce. -- (a) Purpose. The general
assembly is committed to a public participatory
process to implement Medicaid reform through
the demonstration. To assure such a process, following
final acceptance of the demonstration by
the state, the executive office of health and human
service and the department of human services
shall establish a demonstration implementation
taskforce. The taskforce shall work
collaboratively with the executive office of health
and human services and the department of
human services to plan, design, and implement changes
to the Medicaid program under the
demonstration and to evaluate the impact of such
changes and of the demonstration.
(b) Chair. The
taskforce shall be co-chaired by a senior state official of EOHHS/DHS and
a member of the community who is knowledgeable about
the Medicaid program and the
populations and services it funds in
demonstration.
(c) Taskforce
composition. There are distinct populations that receive services funded
through the Medicaid program including: children and
youth with special health care needs,
adults and children with developmental disabilities,
adults with serious and persistent mental
illness and/or addiction disorders and children with
severe emotional disturbance, adults with
disabilities, adults age sixty-five (65) and older and
low-income children and families. It is the
intent of the general assembly that the taskforce
includes members who are knowledgeable about
the needs of these populations and the services
currently provided to them.
Members of the
taskforce shall be appointed by director of the department of human
services. The membership shall include: for each
distinct population two (2) consumers or family
members of consumers, one member of an advocacy
organization and one member of a policy
organization; a representative from organizations that
either provide or represent entities that
provide services to Medicaid beneficiaries including,
but not limited to, health plans, hospitals
community health centers, community mental health
organizations, licensed substance abuse
treatment providers, licensed health care
practitioners, nursing facilities, and home and
community-based service providers.
Total membership
shall not exceed forty-five (45) individuals. The executive office of
health and human services/department of human services
shall provide necessary staff support to
effectively operate the taskforce.
(d) Duration. The
taskforce shall remain in effect so long as the demonstration is in
effect.
(e) Meeting frequency
and relationship to the permanent joint committee of the
demonstration compact:
The taskforce shall
meet no less than monthly and shall report on its activities to the
permanent joint committee of the global waiver compact
established pursuant to section 42-12.4-
5. The permanent joint committee of the global waiver
compact shall appoint a member to serve
as a liaison to the taskforce.
SECTION
2. Section 40-8.4-19 of the General Laws in Chapter 40-8.4 entitled
"Health
Care For Families" is
hereby amended to read as follows:
40-8.4-19. Managed
health care delivery systems for families. -- (a) Notwithstanding
any other provision of state law, the delivery and
financing of the health care services provided
under this chapter shall be provided through a system
of managed care. "Managed care" is
defined as systems that: integrate an efficient
financing mechanism with quality service delivery;
provide a "medical home" to assure
appropriate care and deter unnecessary services; and place
emphasis on preventive and primary care. For the
purposes of Medical Assistance, managed care
systems are defined to include a primary care case
management model in which ancillary services
are provided under the direction of a physician in a
practice that meets standards established by
the department of human services, including standards
pertaining to certification as an "advanced
medical home".
(b) Enrollment in
managed care health delivery systems is mandatory for individuals
eligible for medical assistance under this chapter.
This includes children in substitute care,
children receiving Medical Assistance through an adoption
subsidy, and children eligible for
medical assistance based on their disability.
Beneficiaries with third-party medical coverage or
insurance may be exempt from mandatory managed care in
accordance with rules and regulations
promulgated by the department of human services for
such purposes.
(c) Individuals who can
afford to contribute shall share in the cost. - The department of
human services is authorized and directed to apply for
and obtain any necessary waivers and/or
state plan amendments from the secretary of the
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 beneficiaries eligible
under this chapter or chapter 12.3 of title 42,
with incomes equal to or greater than one hundred
thirty-three percent (133%) one hundred fifty
percent (150%)
of the federal poverty level, pay a share of the costs of health coverage based
on
the ability to pay. The department of human services
shall implement this cost-sharing obligation
by regulation, and shall consider co-payments, premium
shares, or other reasonable means to do
so in accordance with approved provisions of
appropriate waivers and/or state plan amendments
approved by the secretary of the
(d) All children and
families receiving Medical Assistance under title 40 of the Rhode
Island general laws shall also be subject to
co-payments for certain medical services as approved
in the waiver and/or the applicable state plan
amendment, and in accordance with rules and
regulations promulgated by the department.
(e) The department
of human services may provide health benefits, similar to those
available through commercial health plans, to parents
or relative caretakers with an income above
one hundred percent (100%) of the federal poverty
level who are not receiving cash assistance
under the Rhode Island Temporary Assistance to Needy
Families (TANF program).
(f) The department
of human services is authorized to create consumer directed health
care accounts, including but not limited to health
opportunity accounts or health savings accounts,
in order to increase and encourage personal responsibility,
wellness and healthy decision-making,
disease management, and to provide tangible incentives
for beneficiaries who meet designated
wellness initiatives.
SECTION
3. Section 40-8.5-1.1 of the General Laws in Chapter 40-8.5 entitled "Health
Care for Elderly and
Disabled Residents Act" is hereby amended to read as follows:
40-8.5-1.1.
Managed health care delivery systems. -- (a) To ensure that all medical
assistance beneficiaries, including the elderly and
all individuals with disabilities, have access to
quality and affordable health care, the department of
human services is authorized to implement
mandatory managed care health systems.
(b) "Managed
care" is defined as systems that: integrate an efficient financing
mechanism with quality service delivery; provides a
"medical home" to assure appropriate care
and deter unnecessary services; and place emphasis on
preventive and primary care. For purposes
of Medical Assistance, managed care systems are also
defined to include a primary care case
management model in which ancillary services are
provided under the direction of a physician in
a practice that meets standards established by the
department of human services. Those medical
assistance recipients who have third-party medical
coverage or insurance may be exempt from
mandatory managed care in accordance with rules and
regulations promulgated by the department
of human services. The department is further
authorized to redesign benefit packages for medical
assistance beneficiaries subject to appropriate
federal approval.
(c) The department is
authorized to obtain any approval through waiver(s) and/or state
plan amendments, from the secretary of the
services, that are necessary to implement mandatory
managed health care delivery systems for all
medical assistance recipients, including the primary
case management model in which ancillary
services are provided under the direction of a
physician in a practice that meets standards
established by the department of human services. The
waiver(s) and/or state plan amendments
shall include the authorization to exempt
beneficiaries with third-party medical coverage or
insurance from mandatory managed care in accordance
with rules and regulations promulgated by
the department of human services. The department
may also redesign benefit packages for
medical assistance beneficiaries in accordance with
rules and regulations promulgated by the
department.
(d) To ensure the
delivery of timely and appropriate services to persons who become
eligible for Medicaid by virtue of their eligibility
for a
program, the department of human services is
authorized to seek any and all data sharing
agreements or other agreements with the social
security administration as may be necessary to
receive timely and accurate diagnostic data and
clinical assessments. Such information shall be
used exclusively for the purpose of service planning,
and shall be held and exchanged in
accordance with all applicable state and federal
medical record confidentiality laws and
regulations.
(e) The department
of human services and/or the executive office of health and human
services is authorized and directed to apply for and
obtain any necessary waiver(s) and/or state
plan amendments from the secretary of the
services, including, but not limited to, a waiver of
the appropriate sections of law for the purpose
of administering and implementing the goals of the
Medicaid Reform Act 2008 as described in
section 42-7.2-16 of the
purchasing to maximize the available service options
and to promote accountability and
transparency in the delivery of services for all
Medical Assistance beneficiaries.
SECTION
4. Section 40-8-29 of the General Laws in Chapter 40-8 entitled "Medical
Assistance" is hereby
amended to read as follows:
40-8-29. Selective
contracting. -- (a) Notwithstanding any other provision of state law,
the department of human services is authorized to
utilize selective contracting with prior general
assembly approval to assure that all service expenditures under this chapter have the
maximum
benefit of competition, and afford Rhode Islanders the
overall best value, optimal quality, and the
most cost-effective care possible. Beneficiaries
will be limited to using the services/products of
only those providers determined in a competitive
bidding process to meet the standards for best
quality, performance and price set by the department
in accordance with applicable federal and
state laws.
(b) Any approved
medical assistance provider who declines to participate in contracting
for benefits in any one of the department's medical
assistance programs, including, but not limited
to any and all managed care programs, may be suspended
as a participating provider and denied
participation in all state operated medical assistance
programs at the discretion of the department.
(b) For purposes of
this section "selective contracting" shall mean the process for
choosing providers to serve Medicaid beneficiaries
based on their ability to deliver the best
quality products or services, at the best value or
price.
(c) To ensure all
services allowable for Medicare reimbursement for beneficiaries who
are dually eligible, selective contractors must be
willing and able to accept Medicare.
SECTION
5. Chapter 40-8 of the General Laws entitled "Medical Assistance" is
hereby
amended by adding thereto
the following section:
40-8-30.
Suspension of participating providers. -- Any approved medical
assistance
provider who declines to participate in contracting
for benefits in any one of the department's
medical assistance programs, including, but not
limited to, any and all managed care programs,
may be suspended as a participating provider and
denied participation in all state operated
medical assistance programs at the discretion of the
department. Prior to suspension, a
participating provider shall have the right to appeal
such suspension to a state administrative
hearing officer, in accordance with the rules of the
department of human services.
SECTION
6. Section 40-8.9-9 of the General Laws in Chapter 40-8.9 entitled
"Medical
Assistance - Long-Term Care
Service and Finance Reform" is hereby amended to read as
follows:
40-8.9-9.
Long-term care re-balancing system reform goal. -- (a) Notwithstanding
any
other provision of state law, the department of human
services is authorized and directed to apply
for and obtain any necessary waiver(s), waiver
amendment(s) and/or state plan amendments from
the secretary of the
rules necessary to adopt an affirmative plan of
program design and implementation that addresses
the goal of allocating a minimum of fifty percent
(50%) of Medicaid long-term care funding for
persons aged sixty-five (65) and over and adults with
disabilities in addition to services for
persons with developmental disabilities and mental
disabilities to home and
community-based
care on or before December 31, 2012 2013;
provided, further, the executive office of health and
human services shall report annually as part of its
budget submission, the percentage distribution
between institutional care and home and
community-based care by population and shall report
current and projected waiting lists for long-term care
and home and community-based care
services.
The department is further authorized and directed to prioritize investments in
home and
community-based care and to maintain the integrity and
financial viability of all current long-
term care services while pursuing this goal.
(b) The long-term care
re-balancing goal is person-centered and encourages individual
self-determination, family involvement, interagency
collaboration, and individual choice through
the provision of highly specialized and individually
tailored home-based services. Additionally,
individuals with severe behavioral, physical, or
developmental disabilities must have the
opportunity to live safe and healthful lives through
access to a wide range of supportive services
in an array of community-based settings, regardless of
the complexity of their medical condition,
the severity of their disability, or the challenges of
their behavior. Delivery of services and
supports in less costly and less restrictive community
settings, will enable children, adolescents
and adults to be able to curtail, delay or avoid
lengthy stays in residential treatment facilities,
juvenile detention centers, psychiatric facilities,
and/or intermediate care or skilled nursing
facilities.
(c) Pursuant to federal
authority procured under section 42-7.2-16 of the general laws,
the department of human services is directed and
authorized to adopt a tiered set of criteria to be
used to determine eligibility for services. Such
criteria shall be developed in collaboration with
the state's health and human services departments and
shall encompass eligibility determinations
for services in nursing facilities, hospitals, and
intermediate care facilities for the mentally
retarded as well as home and community-based
alternatives, and shall provide a common
standard of income eligibility for both institutional
and home and community-based care. The
department is, subject to prior approval of the
general assembly, authorized to adopt criteria for
admission to a nursing facility, hospital, or
intermediate care facility for the mentally retarded that
are more stringent than those employed for access to
home and community-based services. The
department is also authorized to promulgate rules that
define the frequency of re-assessments for
services provided for under this section. Legislatively
approved levels of care may be applied in
accordance with the following:
(1) Any Medicaid
recipient deemed eligible for nursing facility, hospital, or intermediate
care facility for the mentally retarded as of January
15, 2009, shall continue, throughout that
individual's life, to be assessed utilizing the level
of care criteria in place for that care as of
January 15, 2009;
(2) Any Medicaid
recipient deemed eligible for home and community services prior to
January 15, 2009, shall continue to be assessed for
that care utilizing the level of care criteria in
place as of January 15, 2009;
(3) Persons meeting
or who would have met the level of care criteria for nursing facility
care as of January 15, 2009, shall continue to be
deemed to meet the institutional level of care and
shall only be transitioned to home and community
services on a voluntary basis, and shall not be
subject to any wait list for home and community
services; and
(4) No resident of a
nursing facility, hospital, or intermediate care facility for the
mentally retarded shall be removed involuntarily from
said facility even if the condition of the
resident improves.
(5) No nursing home,
hospital, or intermediate care facility for the mentally retarded shall
be denied payment for services rendered to a Medicaid
recipient on the grounds that the recipient
does not meet level of care criteria unless and until
the department of human services has: (i)
performed an individual assessment of the recipient at
issue and provided written notice to the
nursing home, hospital, or intermediate care facility
for the mentally retarded that the recipient
does not meet level of care criteria; and (ii) the
recipient has either appealed that level of care
determination and been unsuccessful, or any appeal
period available to the recipient regarding
that level of care determination has expired.
(d) The department of
human services is further authorized and directed to consolidate
all home and community-based services currently
provided pursuant to section 1915(c) of title
XIX of the Untied United States Code
into a single program of home and community-based
services that include options for consumer direction
and shared living. The resulting single home
and community-based services program shall replace and
supersede all section 1915(c) programs
when fully implemented. Notwithstanding the foregoing,
the resulting single program home and
community-based services program shall include the
continued funding of assisted living services
at any assisted living facility financed by the
corporation prior to January 1, 2006, and shall be in
accordance with chapter 66.8 of title 42 of
the general laws as long as assisted living services
are a covered Medicaid benefit.
(e) The department of
human services is authorized to promulgate rules that permit
certain optional services including, but not limited
to, homemaker services, home modifications,
respite, and physical therapy evaluations to be
offered subject to availability of state-appropriated
funding for these purposes.
(f) To promote the
expansion of home and community-based service capacity, the
department of human services is authorized and
directed to pursue rate reform for homemaker,
personal care (home health aide) and adult day care
services, as follows:
(1) A prospective base
adjustment effective, not later than July 1, 2008, across all
departments and programs, of ten percent (10%) of the
existing standard or average rate,
contingent upon a demonstrated increase in the
state-funded or Medicaid caseload by June 30,
2009;
(2) Development, not
later than September 30, 2008, of certification standards
supporting and defining targeted rate increments to
encourage service specialization and
scheduling accommodations including, but not limited
to, medication and pain management,
wound management, certified Alzheimer's Syndrome
treatment and support programs, and shift
differentials for night and week-end services; and
(3) Development and
submission to the governor and the general assembly, not later than
December 31, 2008, of a proposed rate-setting
methodology for home and community-based
services to assure coverage of the base cost of
service delivery as well as reasonable coverage of
changes in cost caused by wage inflation.
(h) The department of
human services is also authorized, subject to availability of
appropriation of funding, to pay for certain
non-Medicaid reimbursable expenses necessary to
transition residents back to the community; provided,
however, payments shall not exceed an
annual or per person amount.
(i)
To assure the continued financial viability of nursing facilities, the
department of
human services is authorized and directed to develop a
proposal for revisions to section 40-8-19
that reflect the changes in cost and resident acuity
that result from implementation of this re-
balancing goal. Said proposal shall be submitted to
the governor and the general assembly on or
before January 1, 2010.
SECTION
7. This article shall take effect upon passage.