Human Services

Medical Assistance

SECTION 40-8-4

§ 40-8-4. Direct vendor payment plan.

(a) The department shall furnish medical care benefits to eligible beneficiaries through a direct vendor payment plan. The plan shall include, but need not be limited to, any or all of the following benefits, which benefits shall be contracted for by the director:

(1) Inpatient hospital services, other than services in a hospital, institution, or facility for tuberculosis or mental diseases;

(2) Nursing services for such period of time as the director shall authorize;

(3) Visiting nurse service;

(4) Drugs for consumption either by inpatients or by other persons for whom they are prescribed by a licensed physician;

(5) Dental services; and

(6) Hospice care up to a maximum of two hundred and ten (210) days as a lifetime benefit.

(b) For purposes of this chapter, the payment of federal Medicare premiums or other health insurance premiums by the department on behalf of eligible beneficiaries in accordance with the provisions of Title XIX of the federal Social Security Act, 42 U.S.C. § 1396 et seq., shall be deemed to be a direct vendor payment.

(c) With respect to medical care benefits furnished to eligible individuals under this chapter or Title XIX of the federal Social Security Act, the department is authorized and directed to impose:

(i) Nominal co-payments or similar charges upon eligible individuals for non-emergency services provided in a hospital emergency room; and

(ii) Co-payments for prescription drugs in the amount of one dollar ($1.00) for generic drug prescriptions and three dollars ($3.00) for brand name drug prescriptions in accordance with the provisions of 42 U.S.C. § 1396, et seq.

(d) The department is authorized and directed to promulgate rules and regulations to impose such co-payments or charges and to provide that, with respect to subdivision (ii) above, those regulations shall be effective upon filing.

(e) No state agency shall pay a vendor for medical benefits provided to a recipient of assistance under this chapter until and unless the vendor has submitted a claim for payment to a commercial insurance plan, Medicare, and/or a Medicaid managed care plan, if applicable for that recipient, in that order. This includes payments for skilled nursing and therapy services specifically outlined in Chapter 7, 8 and 15 of the Medicare Benefit Policy Manual.

History of Section.
(P.L. 1966, ch. 266, § 2; P.L. 1968, ch. 189, § 2; G.L. 1956, § 40-10.1-4; Reorg. Plan No. 1, 1970; P.L. 1977, ch. 269, § 1; P.L. 1988, ch. 356, § 1; P.L. 1989, ch. 53, § 1; P.L. 1991, ch. 6, art. 13, § 1; P.L. 1993, ch. 138, art. 21, § 2; P.L. 2007, ch. 73, art. 17, § 1; P.L. 2007, ch. 230, § 1; P.L. 2011, ch. 151, art. 23, § 2; P.L. 2015, ch. 141, art. 5, § 9.)