HEALTH AND SAFETY -- THE RHODE ISLAND COMPREHENSIVE HEALTH INSURANCE PROGRAM, the official text

H8126 2026 -- H 8126 ======== LC005672 ======== STATE OF RHODE ISLAND IN GENERAL ASSEMBLY JANUARY SESSION, A.D. 2026 ____________ A N A C T RELATING TO HEALTH AND SAFETY -- THE RHODE ISLAND COMPREHENSIVE HEALTH INSURANCE PROGRAM Introduced By: Representatives Morales, Sanchez, Cruz, Voas, Giraldo, Potter, Tanzi, and Cotter Date Introduced: February 27, 2026 Referred To: House Corporations It is enacted by the General Assembly as follows: 1 SECTION 1. Title 23 of the General Laws entitled HEALTH AND SAFETY is hereby 2 amended by adding thereto the following chapter: 3 CHAPTER 106 4 THE RHODE ISLAND COMPREHENSIVE HEALTH INSURANCE PROGRAM 5 23-106-1. Legislative findings. 6 The general assembly hereby finds and declares as follows: 7 (1) Health care is a human right, not a commodity available only to those who can afford 8 it; 9 (2) Although the federal Affordable Care Act (“ACA”) allowed states to offer more people 10 taxpayer subsidized private health insurance, the ACA has not provided universal, comprehensive, 11 affordable coverage for all Rhode Islanders: 12 (i) In 2019, about four and three-tenths percent (4.3%) of Rhode Islanders had no health 13 insurance, causing about forty-three (43) (1 per 1,000 uninsured) unnecessary deaths each year; 14 (ii) An estimated forty-five percent (45%) of Rhode Islanders are underinsured (e.g., not 15 seeking health care because of high deductibles and co-pays); 16 (3) COVID-19 exacerbated and highlighted problems with the status quo health insurance 17 system including: 18 (i) Coverage is too easily lost when health insurance is tied to jobs - between February and 1 May, 2020, about twenty-one thousand (21,000) more Rhode Islanders lost their jobs and their 2 health insurance; 3 (ii) Systemic racism is reinforced - Black and Hispanic/Latinx Rhode Islanders, who are 4 more likely to be uninsured or underinsured, have suffered the highest rates of COVID-19 mortality 5 and morbidity; 6 (iii) The fear of out-of-pocket costs for uninsured and underinsured puts everyone at risk 7 because they avoid testing and treatment; 8 (4) In 2016, sixty million (60,000,000) people separated from their job at some point during 9 the year (i.e., about forty-two percent (42%) of the American workforce) and although this chapter 10 may cause some job loss, on balance, a single-payer would increase employment in Rhode Island 11 by nearly three percent (3%); 12 (5) The existing US health insurance system has failed to control the cost of health care 13 and to provide universal access to health care in a system which is widely accepted to waste thirty 14 percent (30%) of its revenues on activities that do not improve the health of Americans; 15 (6) Every industrialized nation in the world, except the United States, offers universal 16 health care to its citizens and enjoys better health outcomes for less than two thirds (2/3) to one- 17 half (1/2) the cost; 18 (7) Health care is rationed under our current multi-payer system, despite the fact that Rhode 19 Island patients, businesses and taxpayers already pay enough to have comprehensive and universal 20 health insurance under a single-payer system; 21 (8) About one-third (1/3) of every healthcare dollar spent in the U.S. is wasted on 22 unnecessary administrative costs and excessive pharmaceutical company profits due to laws 23 preventing Medicare from negotiating prices and private health insurance companies lacking 24 adequate market share to effectively negotiate prices; 25 (9) Private health insurance companies are incentivized to let the cost of health care rise 26 because higher costs require health insurance companies to charge higher health insurance 27 premiums, increasing companies revenue and stock price; 28 (10) The healthcare marketplace is not an efficient market and because it represents only 29 eighteen percent (18%) of the US domestic market, significantly restricts economic growth and 30 thus the financial well-being of every American, including every Rhode Islander; 31 (11) Rhode Islanders cannot afford to keep the current multi-payer health insurance system: 32 (i) Between 1991 and 2014, healthcare spending in Rhode Island per person rose by over 33 two hundred fifty percent (250%) rising much faster than income and greatly reducing disposable 34 income; LC005672 - Page 2 of 79 1 (ii) It was estimated that by 2025, the cost of health insurance for an average family of four 2 (4) will equal about one-half (1/2) of their annual income; 3 (iii) In the U.S., about two-thirds (2/3) of personal bankruptcies are medical cost-related 4 and of these, about three-fourths (3/4) had health insurance at the onset of their medical problems. 5 In no other industrialized country do people worry about going bankrupt over medical costs; 6 (12) Rhode Island private businesses bear most of the costs of employee health insurance 7 coverage and spend significant time and money choosing from a confusing array of increasingly 8 expensive plans which do not provide comprehensive coverage; 9 (13) Rhode Island employees and retirees lose significant wages and pensions as they are 10 forced to pay higher amounts of health insurance and healthcare costs; 11 (14) Rhode Island s hospitals are under increasing financial distress i.e., closing, sold to 12 out-of-state entities, attempting mergers largely due to health insurance reimbursement problems 13 that other nations do not face and are fixed by a single-payer system; 14 (15) The state and its municipalities face enormous other post-employment benefits 15 (OPEB) unfunded liabilities due mostly to health insurance costs; 16 (16) An improved Medicare-for-all style single-payer program would, based on the 17 performance of existing Medicare, eliminate fifty percent (50%) of the administrative waste in the 18 current system of private insurance before other savings achieved through meaningful negotiation 19 of prices and other savings are considered; 20 (17) The high costs of medical care could be lowered significantly if the state could 21 negotiate on behalf of all its residents for bulk purchasing, as well as gain access to usage and price 22 information currently kept confidential by private health insurers as proprietary information; 23 (18) Single-payer healthcare would establish a true free market system where doctors 24 compete for patients rather than health insurance companies dictating which patients are able to see 25 which doctors and setting reimbursement rates; 26 (19) Healthcare providers would spend significantly less time with administrative work 27 caused by multiple health insurance company requirements and barriers to care delivery and would 28 spend significantly less for overhead costs because of streamlined billing; 29 (20) Rhode Island must act because there are currently no effective state or federal laws 30 that can provide universal coverage and adequately control rising premiums, co-pays, deductibles 31 and medical costs, or prevent private insurance companies from continuing to limit available 32 providers and coverage; 33 (21) In 1962, Canada s successful single-payer program began in the province of 34 Saskatchewan (with approximately the same population as Rhode Island) and became a national LC005672 - Page 3 of 79 1 program within ten (10) years; and 2 (v) The proposed Rhode Island single-payer program was studied by Professor Gerald 3 Friedman at UMass Amherst in 2015 and he concluded that: 4 Single-payer in Rhode Island will finance medical care with substantial savings compared 5 with the existing multi-payer system of public and private insurers and would improve access to 6 health care by extending coverage to the four percent (4%) of Rhode Island residents still without 7 insurance under the Affordable Care Act and expanding coverage for the growing number with 8 inadequate healthcare coverage. Single-payer would improve the economic health of Rhode Island 9 by: increasing real disposable income for most residents; reducing the burden of health care on 10 businesses and promoting increased employment; and shifting the costs of health care away from 11 working and middle-class residents . 12 23-106-2. Legislative purpose. 13 It is the intent of the general assembly that this chapter establish a universal, 14 comprehensive, affordable single-payer healthcare insurance program that will help control 15 healthcare costs which shall be referred to as, the Rhode Island comprehensive health insurance 16 program (“RICHIP”). The program will be paid for by consolidating government and private 17 payments to multiple insurance carriers into a more economical and efficient improved Medicare- 18 for-all style single-payer program and substituting lower progressive taxes for higher health 19 insurance premiums, co-pays, deductibles and costs in excess of caps. This program will save 20 Rhode Islanders from the current overly expensive, inefficient and unsustainable multi-payer health 21 insurance system that unnecessarily prevents access to medically necessary health care. The 22 program will be established after the standard of care funded by Medicaid has been raised to a 23 Medicare standard. 24 23-106-3. Definitions. 25 As used in this chapter: 26 (1) Affordable Care Act or ACA means the Federal Patient Protection and Affordable 27 Care Act (Pub. L. 111-148), as amended by the Federal Health Care and Education Reconciliation 28 Act of 2010 (Pub. L. 111-152), and any amendments to, or regulations or guidance issued under, 29 those acts. 30 (2) Carrier means either a private health insurer authorized to sell health insurance in 31 Rhode Island or a healthcare service plan, i.e., any person who undertakes to arrange for the 32 provision of healthcare services to subscribers or enrollees, or to pay for or to reimburse any part 33 of the cost for those services, in return for a prepaid or periodic charge paid by or on behalf of the 34 subscribers or enrollees, or any person, whether located within or outside of this state, who solicits LC005672 - Page 4 of 79 1 or contracts with a subscriber or enrollee in this state to pay for or reimburse any part of the cost 2 of, or who undertakes to arrange or arranges for, the provision of healthcare services that are to be 3 provided, wholly or in part, in a foreign country in return for a prepaid or periodic charge paid by 4 or on behalf of the subscriber or enrollee. 5 (3) Dependent has the same definition as set forth in federal tax law (26 U.S.C. § 152). 6 (4) Emergency and urgently needed services has the same definition as set forth in the 7 federal Medicare law (42 CFR 422.113). 8 (5) Federally matched public health program means the state s Medicaid program under 9 Title XIX of the Social Security Act (42 U.S.C. § 1396 et seq.) and the state s Children s Health 10 Insurance Program (CHIP) under Title XXI of the Social Security Act (42 U.S.C. § 1397aa et seq.). 11 (6) For-profit provider means any healthcare professional or healthcare institution that 12 provides payments, profits or dividends to investors or owners who do not directly provide health 13 care. 14 (7) Health insurance company means any entity subject to the insurance laws and 15 regulations of this state, or subject to the jurisdiction of the health insurance commissioner, that 16 contracts or offers to contract, to provide and/or insuring health services on a prepaid basis 17 including, but not limited to, policies of accident and sickness insurance, as defined by chapter 18 18 of title 27, nonprofit hospital service corporation as defined by chapter 19 of title 27, and nonprofit 19 medical service corporation as defined in chapter 20 of title 27, a health maintenance organizations, 20 as defined in chapter 41 of title 27 and also includes a nonprofit dental service corporation, as 21 defined in chapter 20.1 of title 27, all nonprofit optometric service corporations, as defined in 22 chapter 20.2 of title 27, a domestic insurance company subject to chapter 1 of title 27 that offers or 23 provides health insurance coverage in the state, and a foreign insurance company, subject to chapter 24 2 of title 27, all pharmacy benefit managers (“PBMs”) that contracts to administer or manage 25 prescription drug benefits, any plan preempted by ERISA, but subject to state control (specifically 26 state government, local government, and quasi-public agency ERISA plans). 27 (8) Medicaid or medical assistance means a program that is one of the following: 28 (i) The state s Medicaid program under Title XIX of the Social Security Act (42 U.S.C. § 29 1396 et seq.); or 30 (ii) The state s Children s Health Insurance Program under Title XXI of the Social Security 31 Act (42 U.S.C. § 1397aa et seq.). 32 (9) Medically necessary means medical, surgical or other services or goods (including 33 prescription drugs) required for the prevention, diagnosis, cure, or treatment of a health-related 34 condition including any such services that are necessary to prevent a detrimental change in either LC005672 - Page 5 of 79 1 medical or mental health status. Medically necessary services shall be provided in a cost-effective 2 and appropriate setting and shall not be provided solely for the convenience of the patient or service 3 provider. Medically necessary does not include services or goods that are primarily for cosmetic 4 purposes; and does not include services or goods that are experimental, unless approved pursuant 5 to § 23-106-6(b). 6 (10) Medicare means Title XVIII of the Social Security Act (42 U.S.C. § 1395 et seq.) 7 and the programs thereunder. 8 (11) Qualified healthcare provider means any individual who meets requirements set 9 forth in § 23-106-7(a)(1). 10 (12) Qualified Rhode Island resident means any individual who is a resident as defined 11 by §§ 44-30-5(a)(1) and (a)(2) or a dependent of that resident. 12 (13) Rhode Island comprehensive health insurance program or ( RICHIP ) means the 13 affordable, comprehensive and effective health insurance program as set forth in this chapter. 14 (14) RICHIP participant means a qualified Rhode Island resident who is enrolled in 15 RICHIP (and not disenrolled or disqualified) at the time they seek health care. 16 (15) “State-owned health insurance company” means a health insurance company owned 17 by RICHIP. 18 23-106-4. Rhode Island comprehensive health insurance program. 19 (a) Organization. This chapter creates the Rhode Island comprehensive health insurance 20 program (“RICHIP”) as an independent state government agency. 21 (b) Board. There shall be a RICHIP board composed of nine (9) members serving terms of 22 four (4) years. Members shall be appointed by the governor with the advice and consent of the 23 senate. 24 (c) Director. A director shall be appointed by the governor, with the advice and consent of 25 the senate, to lead RICHIP and serve a term of four (4) years, subject to oversight by an executive 26 board. The director shall be compensated in accordance with the job title and job classification 27 established by the division of human resources and approved by the general assembly. 28 (d) Phase one. The board shall have the power to acquire or launch a health insurance 29 company, which shall be managed by the board. Such an acquisition will initiate phase one. 30 (1) The state-owned health insurance company shall be exempt from any reserve 31 requirements. 32 (2) The State of Rhode Island shall be responsible for funding any costs of the state-owned 33 health insurance company that may exceed the available reserves. 34 (3) The director shall be responsible for daily management of the state-owned health LC005672 - Page 6 of 79 1 insurance company, and the duties, powers, and responsibilities of the director shall be determined 2 by the board. 3 (4) The state-owned health insurance company shall not be exempt from taxation. 4 (e) Phase two. The board shall vote to initiate phase two. In phase two, the state-owned 5 health insurance company and federal healthcare programs such as Medicare and Medicaid shall 6 be merged into a comprehensive program, RICHIP, which shall aim to cover all residents of the 7 State of Rhode Island. 8 (1) Under phase two, the duties of the director shall include: 9 (i) Employ staff and authorize reasonable expenditures, as necessary, from the RICHIP 10 trust fund, to pay program expenses and to administer the program, including creation and oversight 11 of RICHIP budgets; 12 (ii) Oversee management of the RICHIP trust fund set forth in § 23-106-11(a) to ensure 13 the operational well-being and fiscal solvency of the program, including ensuring that all available 14 funds from all appropriate sources are collected and placed into the trust fund; 15 (iii) Take any actions necessary and proper to implement the provisions of this chapter; 16 (iv) Implement standardized claims and reporting procedures; 17 (v) Provide for timely payments to participating providers through a structure that is well 18 organized and that eliminates unnecessary administrative costs, i.e., coordinate with the state 19 comptroller to facilitate billing from and payments to providers using the state s computerized 20 financial system, the Rhode Island financial and accounting network system (“RIFANS”); 21 (vi) Coordinate with federal healthcare programs, including Medicare and Medicaid, to 22 obtain necessary waivers and streamline federal funding and reimbursement; 23 (vii) Monitor billing and reimbursements to detect inappropriate behavior by providers and 24 patients and create prohibitions and penalties regarding bad faith or criminal RICHIP participation, 25 and procedures by which they will be enforced; 26 (viii) Support the development of an integrated healthcare database for healthcare planning 27 and quality assurance and ensure the legally required confidentiality of all health records it 28 contains; 29 (ix) Determine eligibility for RICHIP and establish procedures for enrollment, 30 disenrollment and disqualification from RICHIP, as well as procedures for handling complaints 31 and appeals from affected individuals, as set forth in § 29-106-5; 32 (x) Create RICHIP expenditure, status, and assessment reports including, but not limited 33 to, annual reports with the following: 34 (A) Performance of the program; LC005672 - Page 7 of 79 1 (B) Fiscal condition of the program; 2 (C) Recommendations for statutory changes; 3 (D) Receipt of payments from the federal government; 4 (E) Whether current year goals and priorities were met; and 5 (F) Future goals and priorities; 6 (xi) Review RICHIP collections and disbursements on at least a quarterly basis and 7 recommend adjustments needed to achieve budgetary targets and permit adequate access to care; 8 (xii) Develop procedures for accommodating: 9 (A) Employer retiree health benefits for people who have been members of RICHIP but 10 leave to live as retirees out of the state; 11 (B) Employer retiree health benefits for people who earned or accrued those benefits while 12 residing in the state prior to the implementation of RICHIP and live as retirees out of the state; and 13 (C) RICHIP coverage of healthcare services currently covered under the workers 14 compensation system, including whether and how to continue funding for those services under that 15 system and whether and how to incorporate an element of experience rating; and 16 (xiii) No later than two (2) years after the initiation of phase two, develop a proposal, 17 consistent with the principles of this chapter, for provision and funding by the program of long- 18 term care coverage. 19 (2) Under phase two, the duties of the board shall include: 20 (i) Annually establish a RICHIP benefits package for participants, including a formulary 21 and a list of other medically necessary goods, as well as a procedure for handling complaints and 22 appeals relating to the benefits package, pursuant to § 23-106-6. 23 (ii) Establish RICHIP provider reimbursement and a procedure for handling provider 24 complaints and appeals as set forth in § 23-106-9; 25 (iii) Review budget proposals from providers pursuant to § 23-106-11(b); and 26 (iv) The board shall be subject to chapter 46 of title 42 ( open meetings ). 27 23-106-5. Coverage. 28 (a) All qualified Rhode Island residents may participate in RICHIP. The director shall 29 establish procedures to determine eligibility, enrollment, disenrollment and disqualification, 30 including criteria and procedures by which RICHIP can: 31 (1) Identify, automatically enroll, and provide a RICHIP card to qualified Rhode Island 32 residents; 33 (2) Process applications from individuals seeking to obtain RICHIP coverage for 34 dependents after the implementation date; LC005672 - Page 8 of 79 1 (3) Ensure eligible residents are knowledgeable and aware of their rights to health care; 2 (4) Determine whether an individual should be disenrolled (e.g., for leaving the state); 3 (5) Determine whether an individual should be disqualified (e.g., for fraudulent receipt of 4 benefits or reimbursements); 5 (6) Determine appropriate actions that should be taken with respect to individuals who are 6 disenrolled or disqualified (including civil and criminal penalties); and 7 (7) Permit individuals to request review and appeal decisions to disenroll or disqualify 8 them. 9 (b) Medicare and Medicaid eligible coverage under RICHIP shall be as follows: 10 (1) If all necessary federal waivers are obtained, qualified Rhode Island residents eligible 11 for federal Medicare ( Medicare eligible residents ) shall continue to pay required fees to the 12 federal government. RICHIP shall establish procedures to ensure that Medicare eligible residents 13 shall have such amounts deducted from what they owe to RICHIP under § 23-106-12(h). RICHIP 14 shall become the equivalent of qualifying coverage under Medicare part D and Medicare advantage 15 programs, and as such shall be the vendor for coverage to RICHIP participants. RICHIP shall 16 provide Medicare eligible residents benefits equal to those available to all other RICHIP 17 participants and equal to or greater than those available through the federal Medicare program. To 18 streamline the process, RICHIP shall seek to receive federal reimbursements for services and goods 19 to Medicare eligible residents and administer all Medicare funds. 20 (2) If all necessary federal waivers are obtained, RICHIP shall become the state s sole 21 Medicaid provider. RICHIP shall create procedures to enroll all qualified Rhode Island residents 22 eligible for Medicaid ( Medicaid eligible residents ) in the federal Medicaid program to ensure a 23 maximum amount of federal Medicaid funds go to the RICHIP trust fund. RICHIP shall provide 24 benefits to Medicaid eligible residents equal to those available to all other RICHIP participants. 25 (3) If all necessary federal waivers are not granted from the Medicaid or Medicare 26 programs operated under Title XVIII or XIX of the Social Security Act, the Medicaid or Medicare 27 program for which a waiver is not granted shall act as the primary insurer for those eligible for such 28 coverage, and RICHIP shall serve as the secondary or supplemental plan of health insurance 29 coverage. Until such time as a waiver is granted, the plan shall not pay for services for persons 30 otherwise eligible for the same healthcare benefits under the Medicaid or Medicare program. The 31 director shall establish procedures for determining amounts owed by Medicare and Medicaid 32 eligible residents for supplemental RICHIP coverage and the extent of such coverage. 33 (4) The director may require Rhode Island residents to provide information necessary to 34 determine whether the resident is eligible for a federally matched public health program or for LC005672 - Page 9 of 79 1 Medicare, or any program or benefit under Medicare. 2 (5) As a condition of eligibility or continued eligibility for healthcare services under 3 RICHIP, a qualified Rhode Island resident who is eligible for benefits under Medicare shall enroll 4 in Medicare, including Parts A, B, and D. 5 (c) Veterans. RICHIP shall serve as the secondary or supplemental plan of health insurance 6 coverage for military veterans. The director shall establish procedures for determining amounts 7 owed by military veterans who are qualified residents for such supplemental RICHIP coverage and 8 the extent of such coverage. 9 (d) This chapter does not create any employment benefit, nor require, prohibit, or limit the 10 providing of any employment benefit. 11 (e) This chapter does not affect or limit collective action or collective bargaining on the 12 part of a healthcare provider with their employer or any other lawful collective action or collective 13 bargaining. 14 (f) This section shall take effect when the RICHIP board votes to initiate phase two. 15 23-106-6. Benefits. 16 (a) This chapter shall provide insurance coverage for services and goods (including 17 prescription drugs) deemed medically necessary by a qualified healthcare provider and that is 18 currently covered under: 19 (1) Services and goods currently covered by the federal Medicare program (Social Security 20 Act title XVIII) parts A, B and D; 21 (2) Services and goods covered by Medicaid as of January 1, 2027; 22 (3) Services and goods currently covered by the state s Children s Health Insurance 23 Program; 24 (4) Essential health benefits mandated by the Affordable Care Act; and 25 (5) Services and goods within the following categories: 26 (i) Primary and preventive care; 27 (ii) Approved dietary and nutritional therapies; 28 (iii) Inpatient care; 29 (iv) Outpatient care; 30 (v) Emergency and urgently needed care; 31 (vi) Prescription drugs and medical devices; 32 (vii) Laboratory and diagnostic services; 33 (viii) Palliative care; 34 (ix) Mental health services; LC005672 - Page 10 of 79 1 (x) Oral health, including dental services, periodontics, oral surgery, and endodontics; 2 (xi) Substance abuse treatment services; 3 (xii) Physical therapy and chiropractic services; 4 (xiii) Vision care and vision correction; 5 (xiv) Hearing services, including coverage of hearing aids; 6 (xv) Podiatric care; 7 (xvi) Comprehensive family planning, reproductive, maternity, and newborn care; 8 (xvii) Short-term rehabilitative services and devices; 9 (xviii) Durable medical equipment; 10 (xix) Gender affirming health care; and 11 (xx) Diagnostic and routine medical testing. 12 (b) Additional coverage. The director shall create a procedure that may permit additional 13 medically necessary goods and services beyond that provided by federal laws cited herein and 14 within the areas set forth in § 23-106-4, if the coverage is for services and goods deemed medically 15 necessary based on credible scientific evidence published in peer-reviewed medical literature 16 generally recognized by the relevant medical community, physician specialty society 17 recommendations, and the views of physicians practicing in relevant clinical areas and any other 18 relevant factors. The director shall create procedures for handling complaints and appeals 19 concerning the benefits package. 20 (c) Restrictions shall not apply. In order for RICHIP participants to be able to receive 21 medically necessary goods and services, this chapter shall override any state law that restricts the 22 provision or use of state funds for any medically necessary goods or services, including those 23 related to family planning and reproductive healthcare. 24 (d) Medically necessary goods: 25 (1) Prescription drug formulary: 26 (i) In general. The director shall establish a prescription drug formulary system, to be 27 approved by the board, and encourage best-practices in prescribing and discourage the use of 28 ineffective, dangerous, or excessively costly medications when better alternatives are available. 29 (ii) Promotion of generics. The formulary under this subsection shall promote the use of 30 generic medications to the greatest extent possible. 31 (iii) Formulary updates and petition rights. The formulary under this subsection shall be 32 updated frequently and the director shall create a procedure for patients and providers to make 33 requests and appeal denials to add new pharmaceuticals or to remove ineffective or dangerous 34 medications from the formulary. LC005672 - Page 11 of 79 1 (iv) Use of off-formulary medications. The director shall promulgate rules and regulations 2 regarding the use of off-formulary medications which allow for patient access but do not 3 compromise the formulary. 4 (v) Approved devices and equipment. The director shall present a list of medically 5 necessary devices and equipment that shall be covered by RICHIP, subject to final approval by the 6 board. 7 (vi) Bulk purchasing. The director shall seek and implement ways to obtain goods at the 8 lowest possible cost, including bulk purchasing agreements. 9 (e) This section shall take effect when the RICHIP board votes to initiate phase two. 10 23-106-7. Providers. 11 (a) Rhode Island providers. 12 (1) Licensing. Participating providers shall meet state licensing requirements in order to 13 participate in RICHIP. No provider whose license is under suspension or has been revoked shall 14 participate in the program. 15 (2) Participation. All providers may participate in RICHIP by providing items on the 16 RICHIP benefits list for which they are licensed. Providers may elect either to participate fully, or 17 not at all, in the program. 18 (3) For-profit providers. For-profit providers may continue to offer services and goods in 19 Rhode Island, but are prohibited from charging patients more than RICHIP reimbursement rates 20 for covered services and goods and shall notify qualified Rhode Island residents when the services 21 and goods they offer will not be reimbursed fully under RICHIP. 22 (b) Out-of-state providers. Except for emergency and urgently needed service, as set forth 23 in § 23-106-7(d), RICHIP shall not pay for healthcare services obtained outside of Rhode Island 24 unless the following requirements are met: 25 (1) The out-of-state provider agrees to accept the RICHIP rate for out-of-state providers; 26 and 27 (2) The services are medically necessary care. 28 (c) Out-of-state provider reimbursement. The program shall pay out-of-state healthcare 29 providers at a rate equal to the average rate paid by commercial insurers or Medicare for the services 30 rendered, whichever is higher. 31 (d) Out-of-state residents. 32 (1) In general. Rhode Island providers who provide any services to individuals who are not 33 RICHIP participants shall not be reimbursed by RICHIP and shall seek reimbursement from those 34 individuals or other sources. LC005672 - Page 12 of 79 1 (2) Emergency care exception. Nothing in this chapter shall prevent any individual from 2 receiving or any provider from providing emergency healthcare services and goods in Rhode 3 Island. The director shall adopt rules and regulations to provide reimbursement; however, the rules 4 shall reasonably limit reimbursement to protect the fiscal integrity of RICHIP. The director shall 5 implement procedures to secure reimbursement from any appropriate third-party funding source or 6 from the individual to whom the emergency services were rendered. 7 (e) This section shall take effect when the RICHIP board votes to initiate phase two. 8 23-106-8. Cross border employees. 9 (a) State residents employed out-of-state. If an individual is employed out-of-state by an 10 employer that is subject to Rhode Island state law, the employer and employee shall be required to 11 pay the payroll taxes as to that employee as if the employment were in the state. If an individual is 12 employed out-of-state by an employer that is not subject to Rhode Island state law, the employee 13 health coverage provided by the out-of-state employer to a resident working out-of-state shall serve 14 as the employee s primary plan of health coverage, and RICHIP shall serve as the employee s 15 secondary plan of health coverage. The director shall establish procedures for determining amounts 16 owed by residents employed out-of-state for such supplemental secondary RICHIP coverage and 17 the extent of such coverage. 18 (b) Out-of-state residents employed in the state. The payroll tax set forth in § 23-106-12(i) 19 shall apply to any out-of-state resident who is employed or self-employed in the state. However, 20 such out-of-state residents shall be able to take a credit for amounts they spend on health benefits 21 for themselves that would otherwise be covered by RICHIP if the individual were a RICHIP 22 participant. The out-of-state resident s employer shall be able to take a credit against such payroll 23 taxes regardless of the form of the health benefit (e.g., health insurance, a self-insured plan, direct 24 services, or reimbursement for services), to ensure that the revenue proposal does not relate to 25 employment benefits in violation of the Federal Employee Retirement Income Security Act 26 ( ERISA ) law. For non-employment-based spending by individuals, the credit shall be available 27 for and limited to spending for health coverage (not out-of-pocket health spending). The credit shall 28 be available without regard to how little is spent or how sparse the benefit. The credit may only be 29 taken against the payroll taxes set forth in § 23-106-12(i). Any excess amount may not be applied 30 to other tax liability. For employment-based health benefits, the credit shall be distributed between 31 the employer and employee in the same proportion as the spending by each for the benefit. The 32 employer and employee may each apply their respective portion of the credit to their respective 33 portion of the payroll taxes set forth in § 23-106-12(i). If any provision of this clause or any 34 application of it shall be ruled to violate ERISA, the provision or the application of it shall be null LC005672 - Page 13 of 79 1 and void and the ruling shall not affect any other provision or application of this section or this 2 chapter. 3 (c) This section shall take effect when the RICHIP board votes to initiate phase two. 4 23-106-9. Provider reimbursement. 5 (a) Rates for services and goods. RICHIP reimbursement rates to providers shall be 6 determined by the RICHIP board. These rates shall be equal to or greater than the federal Medicare 7 rates available to Rhode Island qualified residents that are in effect at the time services and goods 8 are provided. For outpatient behavioral health services, the minimum rate shall equal one hundred 9 fifty percent (150%) of federal Medicare rates. If the director determines that there are no such 10 federal Medicare reimbursement rates, the director shall set the minimum rate. The director shall 11 review the rates at least annually, recommend changes to the board, and establish procedures by 12 which complaints about reimbursement rates may be reviewed by the board. 13 (b) Billing and payments. Providers shall submit billing for services to RICHIP participants 14 in the form of electronic invoices entered into RIFANS, the state s computerized financial system. 15 The director shall coordinate the manner of processing and payment with the office of accounts and 16 control and the RIFANS support team within the division of information technology. Payments 17 shall be made by check or electronic funds transfer in accordance with terms and procedures 18 coordinated by the director and the office of accounts and control and consistent with the fiduciary 19 management of the RICHIP trust fund. 20 (c) Provider restrictions. In-state providers who accept any payment from RICHIP shall 21 not bill any patient for any covered benefit. In-state providers cannot use any of their operating 22 budgets for expansion, profit, excessive executive income, including bonuses, marketing, or major 23 capital purchases or leases. 24 (d) This section shall take effect when the RICHIP board votes to initiate phase two. 25 23-106-10. Private insurance companies. 26 (a) Non-duplication. It is unlawful for a private health insurer to sell health insurance 27 coverage to qualified Rhode Island residents that duplicates the benefits provided under this 28 chapter. Nothing in this chapter shall be construed as prohibiting the sale of health insurance 29 coverage for any additional benefits not covered by this chapter, including additional benefits that 30 an employer may provide to employees or their dependents, or to former employees or their 31 dependents (e.g., multiemployer plans can continue to provide wrap-around coverage for any 32 benefits not provided by RICHIP). 33 (b) Displaced employees. Re-education and job placement of persons employed in Rhode 34 Island-located enterprises who have lost their jobs as a result of this chapter shall be managed by LC005672 - Page 14 of 79 1 the Rhode Island department of labor and training or an appropriate federal retraining program. The 2 director may provide funds from RICHIP or funds otherwise appropriated for this purpose for 3 retraining and assisting job transition for individuals employed or previously employed in the fields 4 of health insurance, healthcare service plans, and other third-party payments for health care or those 5 individuals providing services to healthcare providers to deal with third-party payers for health 6 care, whose jobs may be or have been ended as a result of the implementation of the program, 7 consistent with applicable laws. 8 (c) This section shall take effect when the RICHIP board votes to initiate phase two. 9 23-106-11. Budgeting. 10 (a) Operating budget. Annually, the director shall create an operating budget for the 11 program that includes the costs for all benefits set forth in § 23-106-6 and the costs for RICHIP 12 administration. The director shall determine appropriate reimbursement rates for benefits pursuant 13 to § 23-106-9(a). The operating budget shall be approved by the executive board prior to 14 submission to the governor and general assembly. 15 (b) Capital expenditures. The director shall work with representatives from state entities 16 involved with provider capital expenditures including, but not limited to, the Rhode Island 17 department of administration office of capital projects, the Rhode Island health and educational 18 building corporation as well as providers to help ensure that capital expenditures proposed by 19 providers, including amounts to be spent on construction and renovation of health facilities and 20 major equipment purchases, will address healthcare needs of RICHIP participants. To the extent 21 that providers are seeking to use RICHIP funds for capital expenditures, the director shall have the 22 authority to approve or deny such expenditures. 23 (c) Prohibition against co-mingling operations and capital improvement funds. It is 24 prohibited to use funds under this chapter that are earmarked: 25 (1) For operations for capital expenditures; or 26 (2) For capital expenditures for operations. 27 (d) This section shall take effect when the RICHIP board votes to initiate phase two. 28 23-106-12. Financing. 29 (a) RICHIP trust fund. There shall be established a RICHIP trust fund into which funds 30 collected pursuant to this chapter are deposited and from which funds are distributed. All money 31 collected and received shall be used exclusively to finance RICHIP. The governor or general 32 assembly may provide funds to the RICHIP trust fund, but may not remove or borrow funds from 33 the RICHIP trust fund. 34 (b) Revenue proposal. After approval of the RICHIP executive board, the director shall LC005672 - Page 15 of 79 1 submit to the governor and the general assembly a revenue plan and, if required, legislation 2 (referred to collectively in this section as the revenue proposal ) to provide the revenue necessary 3 to finance RICHIP. The initial revenue proposal shall be submitted once waiver negotiations have 4 proceeded to a level deemed sufficient by the director and annually, thereafter. The basic structure 5 of the initial revenue proposal will be based on a consideration of: 6 (1) Anticipated savings from a single-payer program; 7 (2) Government funds available for health care; 8 (3) Private funds available for health care; and 9 (4) Replacing current regressive health insurance payments made to multiple health 10 insurance carriers with progressive contributions to a single payer (RICHIP) in order to make 11 healthcare insurance affordable and remove unnecessary barriers to healthcare access. 12 (i) Subsequent proposals shall adjust the RICHIP contributions, based on projections from 13 the total RICHIP costs in the previous year, and shall include a five (5) year plan for adjusting 14 RICHIP contributions to best meet the goals set forth in this section and § 23-106-2. 15 (c) Anticipated savings. It is anticipated that RICHIP will lower healthcare costs by: 16 (1) Eliminating payments to private health insurance carriers; 17 (2) Reducing paperwork and administrative expenses for both providers and payers created 18 by the marketing, sales, eligibility checks, network contract management, issues associated 19 multiple benefit packages, and other administrative waste associated with the current multi-payer 20 private health insurance system; 21 (3) Allowing the planning and delivery of a public health strategy for the entire population 22 of Rhode Island; 23 (4) Improving access to preventive healthcare; and 24 (5) Negotiating on behalf of the state for bulk purchasing of medical supplies and 25 pharmaceuticals. 26 (d) Federal funds. The executive office of health and human services, in collaboration with 27 the director, the board and the Medicaid office, shall seek and obtain waivers and other approvals 28 relating to Medicaid, the Children s Health Insurance Program, Medicare, federal tax exemptions 29 for health care, the ACA, and any other relevant federal programs in order that: 30 (1) Federal funds and other subsidies for health care that would otherwise be paid to the 31 state and its residents and healthcare providers, would be paid by the federal government to the 32 state and deposited into the RICHIP trust fund; 33 (2) Programs would be waived and such funding from federal programs in Rhode Island 34 would be replaced or merged into RICHIP in order that it can operate as a single-payer program; LC005672 - Page 16 of 79 1 (3) Maximum federal funding for health care is sought even if any necessary waivers or 2 approvals are not obtained and multiple sources of funding with RICHIP trust fund monies are 3 pooled, in order that RICHIP can act as much as possible like a single-payer program to maximize 4 benefits to Rhode Islanders; and 5 (4) Federal financial participation in the programs that are incorporated into RICHIP are 6 not jeopardized. 7 (e) State funds. State funds that would otherwise be appropriated to any governmental 8 agency, office, program, instrumentality, or institution for services and benefits covered under 9 RICHIP shall be directed into the RICHIP trust fund. Payments to the fund pursuant to this section 10 shall be in an amount equal to the money appropriated for those purposes in the fiscal year 11 beginning immediately preceding the effective date of this chapter. 12 (f) Private funds. Private grants including, but not limited to, from nonprofit corporations 13 and other funds specifically ear-marked for health care including, but not limited to, from litigation 14 against tobacco companies, opioid manufacturers, shall also be put into the RICHIP trust fund. 15 (g) Assignments from RICHIP participants. Receipt of healthcare services under the plan 16 shall be deemed an assignment by the RICHIP participant of any right to payment for services from 17 a policy of insurance, a health benefit plan or other source. The other source of healthcare benefits 18 shall pay to the fund all amounts it is obligated to pay to, or on behalf of, the RICHIP participant 19 for covered healthcare services. The director shall commence any action necessary to recover the 20 amounts due. 21 (h) Replacing current health insurance payments with progressive contributions. Instead of 22 making health insurance payments to multiple carriers including, but not limited to, for premiums, 23 co-pays deductibles, and costs in excess of caps for limited coverage, individuals and entities 24 subject to Rhode Island taxation pursuant to § 44-30-1 shall pay progressive contributions to the 25 RICHIP trust fund (referred to collectively in this section as the RICHIP contributions ) for 26 comprehensive coverage. These RICHIP contributions shall be set and adjusted over time to an 27 appropriate level to: 28 (1) Cover the actual cost of the program; 29 (2) Ensure that higher brackets of income subject to specified taxes shall be assessed at a 30 higher marginal rate than lower brackets; and 31 (3) Protect the economic welfare of small businesses, low-income earners and working 32 families through tax credits or exemptions. 33 (i) Contributions based on earned income. The amounts currently paid by employers and 34 employees for health insurance shall initially be replaced by a ten percent (10%) payroll tax, based LC005672 - Page 17 of 79 1 on the projected average payroll of employees over three (3) previous calendar years. The employer 2 shall pay eighty percent (80%) and the employee shall pay twenty percent (20%) of this payroll 3 tax, except that an employer may agree to pay all or part of the employee s share. Self- employed 4 individuals shall initially pay one-hundred percent (100%) of the payroll tax. The ten percent (10%) 5 initial rate will be adjusted by the director in order that higher brackets of income subject to these 6 taxes shall be assessed at a higher marginal rate than lower brackets and in order that small 7 businesses and lower income earners receive a credit or exemption. 8 (j) Contributions based on unearned income. There shall be a progressive contribution 9 based on unearned income including, but not limited to, capital gains, dividends, interest, profits, 10 and rents. Initially, the unearned income RICHIP contributions shall be equal to ten percent (10%) 11 of such unearned income. The ten percent (10%) initial rate may be adjusted by the director to 12 allow for a graduated progressive exemption or credit for individuals with lower unearned income 13 levels. 14 (e) This section shall take effect when the RICHIP board votes to initiate phase two. 15 23-106-12. Implementation. 16 (a) State laws and regulations. 17 (1) In general. The director shall work with the RICHIP board and receive such assistance 18 as may be necessary from other state agencies and entities to examine state laws and regulations 19 and to make recommendations necessary to conform such laws and regulations to properly 20 implement the RICHIP program. The director shall report any recommendations to the governor 21 and the general assembly. 22 (2) Anti-trust laws. The intent of this chapter is to exempt activities provided for under this 23 chapter from state antitrust laws and to provide immunity from federal antitrust laws through the 24 state action doctrine. 25 (b) Severability. If any provision or application of this chapter shall be held to be invalid, 26 or to violate or be inconsistent with any applicable federal law or regulation, that shall not affect 27 other provisions or applications of this chapter which can be given effect without that provision or 28 application; and to that end, the provisions and applications of this chapter are severable. 29 SECTION 2. Chapter 22-11 of the General Laws entitled Joint Committee on Legislative 30 Services is hereby amended by adding thereto the following section: 31 22-11-4.1. Health policy staffing. 32 The joint committee on legislative services shall fund five (5) new full-time employees 33 (FTEs) for the senate fiscal office and five (5) new FTEs for the house fiscal office exclusively 34 devoted to health policy. LC005672 - Page 18 of 79 1 SECTION 3. Section 27-34.3-7 of the General Laws in Chapter 27-34.3 entitled Rhode 2 Island Life and Health Insurance Guaranty Association Act is hereby amended to read as follows: 3 27-34.3-7. Board of directors. 4 (a) The board of directors of the association shall consist of: 5 (1) Not less than five (5) nor more than nine (9) member insurers serving terms as 6 established in the plan of operation Nine (9) members appointed by the governor with advice and 7 consent of the senate ; and 8 (2) The commissioner or the commissioner’s designee shall chair the board in a non-voting 9 ex officio capacity . Only member insurers shall be eligible to vote. The members of the board shall 10 be selected by member insurers subject to the approval of the commissioner. The board of directors, 11 previously established under § 27-34.1-8 [repealed], shall continue to operate in accordance with 12 the provision of this section. Vacancies on the board shall be filled for the remaining period of the 13 term by a majority vote of the remaining board members, subject to the approval of the 14 commissioner. 15 (b) In approving selections to the board, the commissioner shall consider, among other 16 things, whether all member insurers are fairly represented. 17 (c) Members of the board may be reimbursed from the assets of the association for expenses 18 incurred by them as members of the board of directors but members of the board shall not be 19 compensated by the association for their services. 20 SECTION 4. Section 27-66-24 of the General Laws in Chapter 27-66 entitled The Health 21 Insurance Conversions Act is hereby amended to read as follows: 22 27-66-24. Exceptions — Rehabilitation, liquidation, or conservation. 23 No proposed conversion shall be subject to this chapter in In the event that the a health 24 insurance corporation, health maintenance corporation, pharmacy benefit manager, nonprofit 25 dental service corporation, managed care organization, nonprofit optometric service corporation, a 26 nonprofit hospital service corporation, nonprofit medical service corporation, or affiliate or 27 subsidiary of them , hereinafter the insurer , is subject to an order from the superior court directing 28 the director to rehabilitate, liquidate, or conserve, as provided in §§ 27-19-28, 27-20-24, 27-41-18, 29 or chapter 14.1, 14.2, 14.3, or 14.4 of this title , certain additional conditions shall apply to the 30 insurer: 31 (1) The insolvency, financial condition, or default of the insurer at any time shall not permit 32 the insurer to fail to pay claims in a timely manner . 33 (2) Should the insurer fail to pay claims in a timely manner, those claims shall become a 34 temporary obligation of the state, who shall pay them in a timely manner. Should the state be LC005672 - Page 19 of 79 1 compelled to pay claims for this reason, the insurer shall owe the state a fine ten (10) times the 2 value of all claims paid. 3 (3) The insolvency, financial condition, or default of the insurer at any time shall not permit 4 the insurer to fail to pay state taxes on time. Should the insurer fail to pay taxes on time, the size of 5 the tax obligation owed shall increase by a factor of ten (10). 6 (4) The RICHIP board and its state-owned health insurance company shall be guaranteed 7 a right of first refusal to acquire the insurer before alternate buyers are considered. Any obligations 8 due to the state by the insurer shall be counted towards the purchase price of the insurer. The Rhode 9 Island life and health insurance guaranty association, created pursuant to § 27-34.3-6, shall pay the 10 costs of an acquisition by the RICHIP board or its state-owned health insurance company pursuant 11 to this section. 12 SECTION 5. Title 27 of the General Laws entitled INSURANCE is hereby amended by 13 adding thereto the following chapter: 14 CHAPTER 84 15 PRIOR AUTHORIZATION OF CERTAIN HEALTH INSURANCE POLICY CHANGES 16 27-84-1. Definitions. 17 For purposes of this chapter: 18 Health insurer means any entity subject to the insurance laws and regulations of this state, 19 or subject to the jurisdiction of the health insurance commissioner, that contracts or offers to 20 contract, to provide and/or insuring health services on a prepaid basis including, but not limited to, 21 policies of accident and sickness insurance subject to chapter 18 of title 27; any nonprofit hospital 22 service corporation subject to chapter 19 of title 27; any nonprofit medical service corporation 23 subject to chapter 20 of title 27; any health maintenance organization subject to chapter 41 of title 24 27; any nonprofit dental service corporation subject to chapter 20.1 of title 27; any nonprofit 25 optometric service corporation subject to chapter 20.2 of title 27; any pharmacy benefit manager; 26 or any health benefit plan issued by the State of Rhode Island, a municipality, a quasi-public 27 agency, or any other political subdivision of the State of Rhode Island to cover employees. 28 27-84-2. Prior authorization of general assembly. 29 (a) Prior authorization of the general assembly shall be required for certain policy changes 30 by health insurers: 31 (1) Any change that increases the average amount charged annually to consumers on a per 32 beneficiary basis; 33 (2) Any change that in any way reduces any benefits offered to plan beneficiaries; 34 (3) Any change that increases any premiums, deductibles, or copays; LC005672 - Page 20 of 79 1 (4) Ceasing offering any plan a health insurer offers within the State of Rhode Island; or 2 (5) Any other change that the health insurance commissioner or attorney general shall, 3 through regulation, determine to require prior authorization of the general assembly. 4 (b) No rate reviews pursuant to those utilized in §§ 27-18-54, 27-19-30.1, 27-20-25.2, 27- 5 41-27.2, and 42-62-13 shall be construed to exempt any health insurer from the prior authorization 6 requirements of this chapter. 7 SECTION 6. Section 28-57-5 of the General Laws in Chapter 28-57 entitled Healthy and 8 Safe Families and Workplaces Act is hereby amended to read as follows: 9 28-57-5. Accrual of paid sick and safe leave time. 10 (a) All employees employed by an employer of eighteen (18) or more employees in Rhode 11 Island shall accrue a minimum of one hour of paid sick and safe leave time for every thirty five 12 (35) hours worked up to a maximum of twenty-four (24) hours during calendar year 2018, thirty- 13 two (32) hours during calendar year 2019, and up to a maximum of forty (40) hours per year from 14 calendar year 2020 through calendar year 2027, and one hundred sixty (160) hours per year 15 thereafter, unless the employer chooses to provide a higher annual limit in both accrual and use. In 16 determining the number of employees who are employed by an employer for compensation, all 17 employees defined in § 28-57-3(7) shall be counted. 18 (b) Employees who are exempt from the overtime requirements under 29 U.S.C. § 19 213(a)(1) of the federal Fair Labor Standards Act, 29 U.S.C. § 201 et seq., will be assumed to work 20 forty (40) hours in each workweek for purposes of paid sick and safe leave time accrual unless their 21 normal workweek is less than forty (40) hours, in which case paid sick and safe leave time accrues 22 based upon that normal workweek. 23 (c) Paid sick and safe leave time as provided in this chapter shall begin to accrue at the 24 commencement of employment or pursuant to the law’s effective date [July 1, 2018], whichever is 25 later. An employer may provide all paid sick and safe leave time that an employee is expected to 26 accrue in a year at the beginning of the year. 27 (d) An employer may require a waiting period for newly hired employees of up to ninety 28 (90) days. During this waiting period, an employee shall accrue earned sick time pursuant to this 29 section or the employer’s policy, if exempt under § 28-57-4(b), but shall not be permitted to use 30 the earned sick time until after he or she has completed the waiting period. 31 (e) Paid sick and safe leave time shall be carried over to the following calendar year; 32 however, an employee’s use of paid sick and safe leave time provided under this chapter in each 33 calendar year shall not exceed twenty-four (24) hours during calendar year 2018, and thirty-two 34 (32) hours during calendar year 2019, and forty (40) hours per year thereafter. Alternatively, in lieu LC005672 - Page 21 of 79 1 of carryover of unused earned paid sick and safe leave time from one year to the next, an employer 2 may pay an employee for unused earned paid sick and safe leave time at the end of a year and 3 provide the employee with an amount of paid sick and safe leave that meets or exceeds the 4 requirements of this chapter that is available for the employee’s immediate use at the beginning of 5 the subsequent year. 6 (f) Nothing in this chapter shall be construed as requiring financial or other reimbursement 7 to an employee from an employer upon the employee’s termination, resignation, retirement, or 8 other separation from employment for accrued paid sick and safe leave time that has not been used. 9 (g) If an employee is transferred to a separate division, entity, or location within the state, 10 but remains employed by the same employer as defined in 29 C.F.R. § 791.2 of the federal Fair 11 Labor Standards Act, 29 U.S.C. § 201 et seq., the employee is entitled to all paid sick and safe leave 12 time accrued at the prior division, entity, or location and is entitled to use all paid sick and safe 13 leave time as provided in this act. When there is a separation from employment and the employee 14 is rehired within one hundred thirty-five (135) days of separation by the same employer, previously 15 accrued paid sick and safe leave time that had not been used shall be reinstated. Further, the 16 employee shall be entitled to use accrued paid sick and safe leave time and accrue additional sick 17 and safe leave time at the re-commencement of employment. 18 (h) When a different employer succeeds or takes the place of an existing employer, all 19 employees of the original employer who remain employed by the successor employer within the 20 state are entitled to all earned paid sick and safe leave time they accrued when employed by the 21 original employer, and are entitled to use earned paid sick and safe leave time previously accrued. 22 (i) At its discretion, an employer may loan sick and safe leave time to an employee in 23 advance of accrual by such employee. 24 (j) Temporary employees shall be entitled to use accrued paid sick and safe leave time 25 beginning on the one hundred eightieth (180) calendar day following commencement of their 26 employment, unless otherwise permitted by the employer. On and after the one hundred eightieth 27 (180) calendar day of employment, employees may use paid sick and safe leave time as it is 28 accrued. During this waiting period, an employee shall accrue earned sick time pursuant to this 29 chapter, but shall not be permitted to use the earned sick time until after he or she has completed 30 the waiting period. 31 (k) Seasonal employees shall be entitled to use accrued paid sick and safe leave time 32 beginning on the one hundred fiftieth (150) calendar day following commencement of their 33 employment, unless otherwise permitted by the employer. On and after the one hundred fiftieth 34 (150) calendar day of employment, employees may use paid sick and safe leave time as it is LC005672 - Page 22 of 79 1 accrued. During this waiting period, an employee shall accrue earned sick time pursuant to this 2 chapter, but shall not be permitted to use the earned sick time until after he or she has completed 3 the waiting period. 4 SECTION 7. Sections 40-8-2, 40-8-6, 40-8-10, 40-8-13, 40-8-16, 40-8-26 and 40-8-32 of 5 the General Laws in Chapter 40-8 entitled Medical Assistance are hereby amended to read as 6 follows: 7 40-8-2. Definitions. 8 As used in this chapter, unless the context shall otherwise require: 9 (1) “Dental service” means and includes emergency care, X-rays for diagnoses, extractions, 10 palliative treatment, and the refitting and relining of existing dentures and prosthesis. 11 (2) “Department” means the department of human services. 12 (3) “Director” means the director of human services Medicaid director . 13 (4) “Drug” means and includes only drugs and biologicals prescribed by a licensed dentist 14 or physician as are either included in the United States pharmacopoeia, national formulary, or are 15 new and nonofficial drugs and remedies. 16 (5) “Inpatient” means a person admitted to and under treatment or care of a physician or 17 surgeon in a hospital or nursing facility that meets standards of and complies with rules and 18 regulations promulgated by the director. 19 (6) “Inpatient hospital services” means the following items and services furnished to an 20 inpatient in a hospital other than a hospital, institution, or facility for tuberculosis or mental 21 diseases: 22 (i) Bed and board; 23 (ii) Nursing services and other related services as are customarily furnished by the hospital 24 for the care and treatment of inpatients and drugs, biologicals, supplies, appliances, and equipment 25 for use in the hospital, as are customarily furnished by the hospital for the care and treatment of 26 patients; 27 (iii)(A) Other diagnostic or therapeutic items or services, including, but not limited to, 28 pathology, radiology, and anesthesiology furnished by the hospital or by others under arrangements 29 made by the hospital, as are customarily furnished to inpatients either by the hospital or by others 30 under such arrangements, and services as are customarily provided to inpatients in the hospital by 31 an intern or resident-in-training under a teaching program having the approval of the Council on 32 Medical Education and Hospitals of the American Medical Association or of any other recognized 33 medical society approved by the director. 34 (B) The term “inpatient hospital services” shall be taken to include medical and surgical LC005672 - Page 23 of 79 1 services provided by the inpatient’s physician, but shall not include the services of a private-duty 2 nurse or services in a hospital, institution, or facility maintained primarily for the treatment and 3 care of patients with tuberculosis or mental diseases. Provided, further, it shall be taken to include 4 only the following organ transplant operations: kidney, liver, cornea, pancreas, bone marrow, lung, 5 heart, and heart/lung, and other organ transplant operations as may be designated by the director 6 after consultation with medical advisory staff or medical consultants; and provided that any such 7 transplant operation is determined by the director or his or her designee to be medically necessary. 8 Prior written approval of the director, or his or her designee, shall be required for all covered organ 9 transplant operations. 10 (C) In determining medical necessity for organ transplant procedures, the state plan shall 11 adopt a case-by-case approach and shall focus on the medical indications and contra-indications in 12 each instance; the progressive nature of the disease; the existence of any alternative therapies; the 13 life-threatening nature of the disease; the general state of health of the patient apart from the 14 particular organ disease; and any other relevant facts and circumstances related to the applicant and 15 the particular transplant procedure. 16 (7) Medicare equivalent rate means the amount that would be paid for the relevant 17 services as furnished by the relevant group of facilities under Medicare payment principles 18 delineated in subchapter B of 42 CFR Chapter IV. Should no direct Medicare rates be available for 19 the particular service and facility group, the Medicaid director will estimate the rate. Providers will 20 have standing to bring an action in superior court for a higher rate, but intermediary insurers such 21 as managed care entities shall have no standing to bring an action for a lower rate. 22 (7) (8) “Nursing services” means the following items and services furnished to an inpatient 23 in a nursing facility: 24 (i) Bed and board; 25 (ii) Nursing care and other related services as are customarily furnished to inpatients 26 admitted to the nursing facility, and drugs, biologicals, supplies, appliances, and equipment for use 27 in the facility, as are customarily furnished in the facility for the care and treatment of patients; 28 (iii) Other diagnostic or therapeutic items or services, legally furnished by the facility or 29 by others under arrangements made by the facility, as are customarily furnished to inpatients either 30 by the facility or by others under such arrangement; 31 (iv) Medical services provided in the facility by the inpatient’s physician, or by an intern 32 or resident-in-training of a hospital with which the facility is affiliated or that is under the same 33 control, under a teaching program of the hospital approved as provided in subsection (6); and 34 (v) A personal-needs allowance of seventy-five dollars ($75.00) two hundred dollars LC005672 - Page 24 of 79 1 ($200) per month. 2 (8) (9) “Relative with whom the dependent child is living” means and includes the father, 3 mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, 4 uncle, aunt, first cousin, nephew, or niece of any dependent child who maintains a home for the 5 dependent child. 6 (9) (10) “Visiting nurse service” means part-time or intermittent nursing care provided by 7 or under the supervision of a registered professional nurse other than in a hospital or nursing home. 8 40-8-6. Review of application for benefits. 9 The director, or someone designated by him or her, shall review each application for 10 benefits filed in accordance with regulations, and shall make a determination of whether the 11 application will be honored and the extent of the benefits to be made available to the applicant, and 12 shall, within thirty (30) fifteen (15) days after the filing, notify the applicant, in writing, of the 13 determination. If the application is rejected, the notice to the applicant shall set forth therein the 14 reason therefor. The director may at any time reconsider any determination. 15 40-8-10. Recovery of benefits paid in error. 16 Any person, who through error or mistake of himself or herself or another willful and 17 knowing fraudulent misrepresentation , receives medical care benefits to which he or she is not 18 entitled or with respect to which he or she was ineligible, shall be required to reimburse the state 19 for the benefits paid through error or mistake that were paid out during a time period, not to exceed 20 three (3) years, where the person was not entitled to benefits but received them as a result of the 21 willful and knowing fraudulent misrepresentation . 22 40-8-13. Rules, regulations, and fee schedules. 23 The director shall make and promulgate rules, regulations, and fee schedules not 24 inconsistent with state law and fiscal procedures as he or she deems necessary for the proper 25 administration of this chapter and to carry out the policy and purposes thereof, and to make the 26 department’s plan conform to the provisions of the federal Social Security Act, 42 U.S.C. § 1396 27 et seq., and any rules or regulations promulgated pursuant thereto. Except where explicitly 28 authorized by this title, the director shall have no power to set any fee schedule below the Medicare 29 equivalent rate; provided, however, that the director shall be empowered to provide a lower rate 30 equal to the maximum rate where federal reimbursement can be obtained in the event that federal 31 reimbursement cannot be obtained for the Medicare equivalent rate. For outpatient behavioral 32 health services, the minimum fee schedule shall be set at one hundred fifty percent (150%) of the 33 Medicare equivalent rate. The director shall attempt to obtain federal reimbursement for billing 34 outpatient behavioral health services at one hundred fifty percent (150%) of the Medicare LC005672 - Page 25 of 79 1 equivalent rate, but the state shall bear the costs of this higher rate for outpatient behavioral health 2 services even if federal reimbursement cannot be obtained. Should federal financial participation 3 be impossible to obtain for the outpatient behavioral health services rate of one hundred fifty 4 percent (150%) of the Medicare equivalent rate, the director shall impose a surtax on the tax 5 imposed on health insurers pursuant to chapter 17 of title 44 in the amount necessary to defray the 6 costs of the inability to obtain federal reimbursement for an outpatient behavioral health services 7 rate of one hundred fifty percent (150%) of the Medicare equivalent rate. 8 40-8-16. Notification of long-term care alternative. 9 (a) The department of human services, before authorizing care in a nursing home or 10 intermediate-care facility for a person who is eligible to receive benefits pursuant to Title XIX of 11 the federal Social Security Act, 42 U.S.C. § 1396 et seq., and who is being discharged from a 12 hospital to a nursing home, shall notify the person, in writing, of the provisions of the long-term- 13 care alternative, a home- and a community-based program. 14 (b) If a person, eligible to receive benefits pursuant to Title XIX of the federal Social 15 Security Act, requires services in a nursing home and desires to remain in his or her own home or 16 the home of a responsible relative or other adult, the person or his or her representative shall so 17 inform the department. 18 (c) The department shall not make payments pursuant to Title XIX of the federal Social 19 Security Act for benefits until written notification documenting the person’s choice as to a nursing 20 home or home- and community-based services has been filed with the department. 21 40-8-26. Community health centers. 22 (a) For the purposes of this section, the term community health centers refers to federally 23 qualified health centers and rural health centers. 24 (b) To support the ability of community health centers to provide high-quality medical care 25 to patients, the executive office of health and human services (“executive office”) may adopt and 26 implement an alternative payment methodology (APM) for determining a Medicaid per-visit 27 reimbursement for community health centers that is compliant with the prospective payment system 28 (PPS) provided for in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection 29 Act of 2000 . The following principles are to ensure that the APM PPS rate determination 30 methodology is part of the executive office overall value purchasing approach. For community 31 health centers that do not agree to the principles of reimbursement that reflect the APM PPS , 32 EOHHS shall reimburse such community health centers at the federal PPS rate, as required per 33 section 1902(bb)(3) of the Social Security Act, 42 U.S.C. § 1396a(bb)(3). For community health 34 centers that are reimbursed at the federal PPS rate, subsections (d) through (f) of this section apply. LC005672 - Page 26 of 79 1 (c) The APM PPS rate determination methodology will (i) Fairly recognize the reasonable 2 costs of providing services. Recognized reasonable costs will be those appropriate for the 3 organization, management, and direct provision of services and (ii) Provide assurances to the 4 executive office that services are provided in an effective and efficient manner, consistent with 5 industry standards. Except for demonstrated cause and at the discretion of the executive office, the 6 maximum reimbursement rate for a service (e.g., medical, dental) provided by an individual 7 community health center shall not exceed one hundred twenty-five percent (125%) of the median 8 rate for all community health centers within Rhode Island. not only bill the community health center 9 on a fee-for-service basis at the Medicare equivalent rate but also make a series of quality incentive 10 payments if the community health center meets certain quality incentives. Quality incentive 11 payments shall be set at a percentage of the aggregate monthly billing. The quality incentive 12 payments shall be as follows: 13 (1) Ten percent (10%) for meeting benchmarks set by the Medicaid director for screening 14 patients for Medicaid eligibility. 15 (2) Five percent (5%) for meeting benchmarks set by the Medicaid director for enrolling 16 patients who regularly smoke tobacco in smoking cessation programs. 17 (3) Ten percent (10%) for meeting benchmarks set by the director of human services for 18 screening patients for supplemental nutrition assistance program eligibility. 19 (4) Ten percent (10%) for ensuring that no more than one percent of patients are ever not 20 offered an appointment within a month if they request one. 21 (5) Up to fifteen percent (15%) for meeting benchmarks set by the Medicaid director for 22 the improvement of air quality in patients homes through directly funding interventions including, 23 but not limited: air quality inspections, the installation of air filters, the installation of ventilation, 24 and the replacement of gas stoves with electric stoves. 25 (6) Up to fifteen percent (15%) for meeting benchmarks set by the Medicaid director for 26 the removal or mitigation of environmental toxins in patients homes through the direct funding of 27 removal or mitigation of environmental toxins. These toxins shall include, but shall not be limited 28 to, lead, radon, asbestos, and carbon monoxide. 29 (d) Community health centers will cooperate fully and timely with reporting requirements 30 established by the executive office. 31 (e) Reimbursement rates established through this methodology shall be incorporated into 32 the PPS reconciliation for services provided to Medicaid-eligible persons who are enrolled in a 33 health plan on the date of service. Monthly payments by the executive office related to PPS for 34 persons enrolled in a health plan shall be made directly to the community health centers. LC005672 - Page 27 of 79 1 (f) Reimbursement rates established through this the APM methodology shall not be 2 incorporated into the actuarially certified capitation rates paid to a health plan. The health plan shall 3 be responsible for paying the full amount of the reimbursement rate to the community health center 4 for each service eligible for reimbursement under the Medicare, Medicaid, and SCHIP Benefits 5 Improvement and Protection Act of 2000. If the health plan has an alternative payment arrangement 6 with the community health center opts to utilize the APM methodology, the health plan may 7 establish a PPS reconciliation process for eligible services and make monthly payments related to 8 PPS for persons enrolled in the health plan on the date of service shall bear the full upside and 9 downside risk of decreased or increased costs from the APM methodology . The executive office 10 will review, at least annually, the Medicaid reimbursement rates and reconciliation methodology 11 used by the health plans for community health centers to ensure payments to each are made in 12 compliance with the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 13 2000. 14 40-8-32. Support for certain patients of nursing facilities. 15 (a) Definitions. For purposes of this section: 16 (1) “Applied income” shall mean the amount of income a Medicaid beneficiary is required 17 to contribute to the cost of his or her care. 18 (2) “Authorized individual” shall mean a person who has authority over the income of a 19 patient of a nursing facility, such as a person who has been given or has otherwise obtained 20 authority over a patient’s bank account; has been named as or has rights as a joint account holder; 21 or is a fiduciary as defined below. 22 (3) “Costs of care” shall mean the costs of providing care to a patient of a nursing facility, 23 including nursing care, personal care, meals, transportation, and any other costs, charges, and 24 expenses incurred by a nursing facility in providing care to a patient. Costs of care shall not exceed 25 the customary rate the nursing facility charges to a patient who pays for his or her care directly 26 rather than through a governmental or other third-party payor. 27 (4) “Fiduciary” shall mean a person to whom power or property has been formally 28 entrusted for the benefit of another, such as an attorney-in-fact, legal guardian, trustee, or 29 representative payee. 30 (5) “Nursing facility” shall mean a nursing facility licensed under chapter 17 of title 23, 31 that is a participating provider in the Rhode Island Medicaid program. 32 (6) “Penalty period” means the period of Medicaid ineligibility imposed pursuant to 42 33 U.S.C. § 1396p(c), as amended from time to time, on a person whose assets have been transferred 34 for less than fair market value. LC005672 - Page 28 of 79 1 (7) “Uncompensated care” — Care and services provided by a nursing facility to a 2 Medicaid applicant without receiving compensation therefore from Medicaid, Medicare, the 3 Medicaid applicant, or other source. The acceptance of any payment representing actual or 4 estimated applied income shall not disqualify the care and services provided from qualifying as 5 uncompensated care. 6 (b) Penalty period resulting from transfer. Any transfer or assignment of assets resulting in 7 the establishment or imposition of a penalty period shall create a debt that shall be due and owing 8 to a nursing facility for the unpaid costs of care provided during the penalty period to a patient of 9 that facility who has been subject to the penalty period. The amount of the debt established shall 10 not exceed the fair market value of the transferred assets at the time of transfer that are the subject 11 of the penalty period. A nursing facility may bring an action to collect a debt for the unpaid costs 12 of care given to a patient who has been subject to a penalty period, against either the transferor or 13 the transferee, or both . The provisions of this section shall not affect other rights or remedies of the 14 parties. 15 (c) Applied income. A nursing facility may provide written notice to a patient who is a 16 Medicaid recipient and any authorized individual of that patient: 17 (1) Of the amount of applied income due; 18 (2) Of the recipient’s legal obligation to pay the applied income to the nursing facility; and 19 (3) That the recipient’s failure to pay applied income due to a nursing facility not later than 20 thirty (30) days after receiving notice from the nursing facility may result in a court action to 21 recover the amount of applied income due. 22 A nursing facility that is owed applied income may, in addition to any other remedies 23 authorized under law, bring a claim to recover the applied income against a patient and any 24 authorized individual. If a court of competent jurisdiction determines, based upon clear and 25 convincing evidence, that a defendant willfully failed to pay or withheld applied income due and 26 owing to a nursing facility for more than thirty (30) days after receiving notice pursuant to 27 subsection (c), the court may award the amount of the debt owed , court costs, and reasonable 28 attorney’s fees to the nursing facility. 29 (d) Effects. Nothing contained in this section shall prohibit or otherwise diminish any other 30 causes of action possessed by any such nursing facility. The death of the person receiving nursing 31 facility care shall not nullify or otherwise affect the liability of the person or persons charged with 32 the costs of care rendered or the applied income amount as referenced in this section. 33 SECTION 8. Sections 40-8-3.1, 40-8-9.1, 40-8-13.5, 40-8-15, 40-8-19.2 and 40-8-27 of 34 the General Laws in Chapter 40-8 entitled Medical Assistance are hereby repealed. LC005672 - Page 29 of 79 1 40-8-3.1. Life estate in property — Retained powers. 2 When an applicant or recipient of Medicaid owns a life estate in property that is his or her 3 principal place of residence with the reserved power and authority, during his or her lifetime, to 4 sell, convey, mortgage, or otherwise dispose of the real property without the consent or joinder by 5 the holder(s) of the remainder interest, the principal place of residence shall not be regarded as an 6 excluded resource for the purpose of Medicaid eligibility, unless the applicant or recipient 7 individually, or through his or her guardian, conservator, or attorney in fact, conveys all outstanding 8 remainder interest to him or herself. 9 An applicant or recipient who, by a deed created, executed and recorded on or before June 10 30, 2014, has reserved a life estate in property that is his or her principal place of residence with 11 the reserved power and authority, during his or her lifetime, to sell, convey, mortgage, or otherwise 12 dispose of the real property without the consent or joinder by the holder(s) of the remainder interest, 13 shall not be ineligible for Medicaid on the basis of the deed, regardless of whether the transferee of 14 the remainder interest is a person or persons, trust, or entity. 15 40-8-9.1. Notice. 16 Whenever an individual who is receiving medical assistance under this chapter transfers 17 an interest in real or personal property, the individual shall notify the executive office of health and 18 human services within ten (10) days of the transfer. The notice shall be sent to the individual’s local 19 office and the legal office of the executive office of health and human services and include, at a 20 minimum, the individual’s name, social security number or, if different, the executive office of 21 health and human services identification number, the date of transfer, and the dollar value, if any, 22 paid or received by the individual who received benefits under this chapter. In the event an 23 individual fails to provide notice required by this section to the executive office of health and human 24 services and in the event an individual has received medical assistance, any individual and/or entity, 25 who knew or should have known that the individual failed to provide the notice and who receives 26 any distribution of value as a result of the transfer, shall be liable to the executive office of health 27 and human services to the extent of the value of the transfer. Moreover, any such individual shall 28 be subject to the provisions of § 40-6-15 and any remedy provided by applicable state and federal 29 laws and rules and regulations. Failure to comply with the notice requirements set forth in the 30 section shall not affect the marketability of title to real estate transferred while the transferor is 31 receiving medical assistance. 32 40-8-13.5. Hospital Incentive Program (HIP). 33 The secretary of the executive office of health and human services is authorized to seek the 34 federal authorities required to implement a hospital incentive program (HIP). The HIP shall provide LC005672 - Page 30 of 79 1 the participating licensed hospitals the ability to obtain certain payments for achieving performance 2 goals established by the secretary. HIP payments shall commence no earlier than July 1, 2016. 3 40-8-15. Lien on deceased recipient’s estate for assistance. 4 (a)(1) Upon the death of a recipient of Medicaid under Title XIX of the federal Social 5 Security Act (42 U.S.C. § 1396 et seq. and referred to hereinafter as the “Act”), the total sum for 6 Medicaid benefits so paid on behalf of a beneficiary who was fifty-five (55) years of age or older 7 at the time of receipt shall be and constitute a lien upon the estate, as defined in subsection (a)(2), 8 of the beneficiary in favor of the executive office of health and human services (“executive office”). 9 The lien shall not be effective and shall not attach as against the estate of a beneficiary who is 10 survived by a spouse, or a child who is under the age of twenty-one (21), or a child who is blind or 11 permanently and totally disabled as defined in Title XVI of the federal Social Security Act, 42 12 U.S.C. § 1381 et seq. The lien shall attach against property of a beneficiary, which is included or 13 includable in the decedent’s probate estate, regardless of whether or not a probate proceeding has 14 been commenced in the probate court by the executive office or by any other party. Provided, 15 however, that such lien shall only attach and shall only be effective against the beneficiary’s real 16 property included or includable in the beneficiary’s probate estate if such lien is recorded in the 17 land evidence records and is in accordance with subsection (e). Decedents who have received 18 Medicaid benefits are subject to the assignment and subrogation provisions of §§ 40-6-9 and 40-6- 19 10. 20 (2) For purposes of this section, the term “estate” with respect to a deceased individual 21 shall include all real and personal property and other assets included or includable within the 22 individual’s probate estate. 23 (b) The executive office is authorized to promulgate regulations to implement the terms, 24 intent, and purpose of this section and to require the legal representative(s) and/or the heirs-at-law 25 of the decedent to provide reasonable written notice to the executive office of the death of a 26 beneficiary of Medicaid benefits who was fifty-five (55) years of age or older at the date of death, 27 and to provide a statement identifying the decedent’s property and the names and addresses of all 28 persons entitled to take any share or interest of the estate as legatees or distributees thereof. 29 (c) The amount of reimbursement for Medicaid benefits imposed under this section shall 30 also become a debt to the state from the person or entity liable for the payment thereof. 31 (d) Upon payment of the amount of reimbursement for Medicaid benefits imposed by this 32 section, the secretary of the executive office, or his or her designee, shall issue a written discharge 33 of lien. 34 (e) Provided, however, that no lien created under this section shall attach nor become LC005672 - Page 31 of 79 1 effective upon any real property unless and until a statement of claim is recorded naming the 2 debtor/owner of record of the property as of the date and time of recording of the statement of 3 claim, and describing the real property by a description containing all of the following: (1) Tax 4 assessor’s plat and lot; and (2) Street address. The statement of claim shall be recorded in the 5 records of land evidence in the town or city where the real property is situated. Notice of the lien 6 shall be sent to the duly appointed executor or administrator, the decedent’s legal representative, if 7 known, or to the decedent’s next of kin or heirs at law as stated in the decedent’s last application 8 for Medicaid benefits. 9 (f) The executive office shall establish procedures, in accordance with the standards 10 specified by the Secretary, United States Department of Health and Human Services, under which 11 the executive office shall waive, in whole or in part, the lien and reimbursement established by this 12 section if the lien and reimbursement would cause an undue hardship, as determined by the 13 executive office, on the basis of the criteria established by the secretary in accordance with 42 14 U.S.C. § 1396p(b)(3). 15 (g) Upon the filing of a petition for admission to probate of a decedent’s will or for 16 administration of a decedent’s estate, when the decedent was fifty-five (55) years or older at the 17 time of death, a copy of the petition and a copy of the death certificate shall be sent to the executive 18 office. Within thirty (30) days of a request by the executive office, an executor or administrator 19 shall complete and send to the executive office a form prescribed by that office and shall provide 20 such additional information as the office may require. In the event a petitioner fails to send a copy 21 of the petition and a copy of the death certificate to the executive office and a decedent has received 22 Medicaid benefits for which the executive office is authorized to recover, no distribution and/or 23 payments, including administration fees, shall be disbursed. Any person and/or entity that receives 24 a distribution of assets from the decedent’s estate shall be liable to the executive office to the extent 25 of such distribution. 26 (h) Compliance with the provisions of this section shall be consistent with the requirements 27 set forth in § 33-11-5 and the requirements of the affidavit of notice set forth in § 33-11-5.2. Nothing 28 in these sections shall limit the executive office from recovery, to the extent of the distribution, in 29 accordance with all state and federal laws. 30 (i) To ensure the financial integrity of the Medicaid eligibility determination, benefit 31 renewal, and estate recovery processes in this and related sections, the secretary of health and 32 human services is authorized and directed to, by no later than August 1, 2018: (1) Implement an 33 automated asset verification system, as mandated by § 1940 of the Act, that uses electronic data 34 sources to verify the ownership and value of countable resources held in financial institutions and LC005672 - Page 32 of 79 1 any real property for applicants and beneficiaries subject to resource and asset tests pursuant to the 2 Act in § 1902(e)(14)(D); (2) Apply the provisions required under §§ 1902(a)(18) and 1917(c) of 3 the Act pertaining to the disposition of assets for less than fair market value by applicants and 4 beneficiaries for Medicaid long-term services and supports and their spouses, without regard to 5 whether they are subject to or exempted from resources and asset tests as mandated by federal 6 guidance; and (3) Pursue any state plan or waiver amendments from the United States Centers for 7 Medicare and Medicaid Services and promulgate such rules, regulations, and procedures he or she 8 deems necessary to carry out the requirements set forth herein and ensure the state plan and 9 Medicaid policy conform and comply with applicable provisions of Title XIX. 10 40-8-19.2. Nursing Facility Incentive Program (NFIP). 11 The secretary of the executive office of health and human services is authorized to seek the 12 federal authority required to implement a nursing facility incentive program (NFIP). The NFIP 13 shall provide the participating licensed nursing facilities the ability to obtain certain payments for 14 achieving performance goals established by the secretary. NFIP payments shall commence no 15 earlier than July 1, 2016. 16 40-8-27. Cooperation by providers. 17 Medicaid providers who employ individuals applying for benefits under any chapter of this 18 title shall comply in a timely manner with requests made by the department for any documents 19 describing employer-sponsored health insurance coverage or benefits the provider offers that are 20 necessary to determine eligibility for the state’s premium assistance program pursuant to § 40-8.4- 21 12. Documents requested by the department may include, but are not limited to, certificates of 22 coverage or a summary of benefits and employee obligations. Upon receiving notification that the 23 department has determined that the employee is eligible for premium assistance under § 40-8.4-12, 24 the provider shall accept the enrollment of the employee and his or her family in the employer- 25 based health insurance plan without regard to any seasonal enrollment restrictions, including open- 26 enrollment restrictions, and/or the impact on the employee’s wages. Additionally, the Medicaid 27 provider employing such persons shall not offer “pay in lieu of benefits.” Providers who do not 28 comply with the provisions set forth in this section shall be subject to suspension as a participating 29 Medicaid provider. 30 SECTION 9. Sections 40-8.4-5, 40-8.4-10, 40-8.4-12, 40-8.4-15 and 40-8.4-19 of the 31 General Laws in Chapter 40-8.4 entitled Health Care for Families are hereby amended to read as 32 follows: 33 40-8.4-5. Managed care. 34 The delivery and financing of the healthcare services provided under this chapter shall may LC005672 - Page 33 of 79 1 be provided through a system of managed care. A managed care system integrates an efficient 2 financing mechanism with quality service delivery; provides a “medical home” to ensure 3 appropriate care and deter unnecessary and inappropriate care; and places emphasis on preventive 4 and primary health care. Beginning July 1, 2030, all payments shall be provided directly by the 5 state without an intermediate payment to a managed care entity or other form of health insurance 6 company, unless it is owned by the state. Beginning July 1, 2026, no new contracts may be entered 7 into between the Medicaid office and an intermediate payor such as a managed care entity or other 8 form of health insurance company for the payment of healthcare services pursuant to this chapter, 9 unless it is owned by the state. 10 40-8.4-10. Regulations. 11 (a) The department of human services Medicaid director is authorized to promulgate any 12 regulations necessary to implement this chapter. 13 (b) When promulgating any rule or regulation necessary to implement this chapter, or any 14 rule or regulation related to RIte Care, the department Medicaid director shall send the notice 15 referred to in § 42-35-3 and a true copy of the rule referred to in § 42-35-4 of the Rhode Island 16 administrative procedures act to each of the co-chairpersons of the permanent joint committee on 17 health care oversight established by § 40-8.4-14. 18 40-8.4-12. RIte Share health insurance premium assistance program. 19 (a) Basic RIte Share health insurance premium assistance program. Under the terms 20 of Section 1906 of Title XIX of the U.S. Social Security Act, 42 U.S.C. § 1396e, states are permitted 21 to pay a Medicaid-eligible person’s share of the costs for enrolling in employer-sponsored health 22 insurance (ESI) coverage if it is cost-effective to do so. Pursuant to the general assembly’s direction 23 in the Rhode Island health reform act of 2000, the Medicaid agency requested and obtained federal 24 approval under § 1916, 42 U.S.C. § 1396o, to establish the RIte Share premium assistance program 25 to subsidize the costs of enrolling Medicaid-eligible persons and families in employer-sponsored 26 health insurance plans that have been approved as meeting certain cost and coverage requirements. 27 The Medicaid agency also obtained, at the general assembly’s direction, federal authority to require 28 any such persons with access to ESI coverage to enroll as a condition of retaining eligibility 29 providing that doing so meets the criteria established in Title XIX for obtaining federal matching 30 funds. 31 (b) Definitions. For the purposes of this section, the following definitions apply: 32 (1) “Cost-effective” means that the portion of the ESI that the state would subsidize, as 33 well as wrap-around costs, would on average cost less to the state than enrolling that same 34 person/family in a managed-care delivery system. LC005672 - Page 34 of 79 1 (2) “Cost sharing” means any co-payments, deductibles, or co-insurance associated with 2 ESI. 3 (3) “Employee premium” means the monthly premium share a person or family is required 4 to pay to the employer to obtain and maintain ESI coverage. 5 (4) “Employer-sponsored insurance” or “ESI” means health insurance or a group health 6 plan offered to employees by an employer. This includes plans purchased by small employers 7 through the state health insurance marketplace, healthsource, RI (HSRI). 8 (5) “Policy holder” means the person in the household with access to ESI, typically the 9 employee. 10 (6) “RIte Share-approved employer-sponsored insurance (ESI)” means an employer- 11 sponsored health insurance plan that meets the coverage and cost-effectiveness criteria for RIte 12 Share. 13 (7) “RIte Share buy-in” means the monthly amount an Medicaid-ineligible policy holder 14 must pay toward RIte Share-approved ESI that covers the Medicaid-eligible children, young adults, 15 or spouses with access to the ESI. The buy-in only applies in instances when household income is 16 above one hundred fifty percent (150%) of the FPL. 17 (8) “RIte Share premium assistance program” means the Rhode Island Medicaid premium 18 assistance program in which the State pays the eligible Medicaid member’s share of the cost of 19 enrolling in a RIte Share-approved ESI plan. This allows the state to share the cost of the health 20 insurance coverage with the employer. 21 (9) “RIte Share unit” means the entity within the executive office of health and human 22 services (EOHHS) responsible for assessing the cost-effectiveness of ESI, contacting employers 23 about ESI as appropriate, initiating the RIte Share enrollment and disenrollment process, handling 24 member communications, and managing the overall operations of the RIte Share program. 25 (10) “Third-party liability (TPL)” means other health insurance coverage. This insurance 26 is in addition to Medicaid and is usually provided through an employer. Since Medicaid is always 27 the payer of last resort, the TPL is always the primary coverage. 28 (11) “Wrap-around services or coverage” means any healthcare services not included in 29 the ESI plan that would have been covered had the Medicaid member been enrolled in a RIte Care 30 or Rhody Health Partners plan. Coverage of deductibles and co-insurance is included in the wrap. 31 Co-payments to providers are not covered as part of the wrap-around coverage. 32 (c) RIte Share populations. Medicaid beneficiaries subject to eligible for RIte Share 33 include: children, families, parent and caretakers eligible for Medicaid or the children’s health 34 insurance program (CHIP) under this chapter or chapter 12.3 of title 42; and adults between the LC005672 - Page 35 of 79 1 ages of nineteen (19) and sixty-four (64) who are eligible under chapter 8.12 of this title, not 2 receiving or eligible to receive Medicare, and are enrolled in managed care delivery systems. The 3 following conditions apply: 4 (1) The income of Medicaid beneficiaries shall affect whether and in what manner they 5 must may participate in RIte Share as follows: 6 (i) Income at or below one hundred fifty percent (150%) of FPL — Persons and families 7 determined to have household income at or below one hundred fifty percent (150%) of the federal 8 poverty level (FPL) guidelines based on the modified adjusted gross income (MAGI) standard or 9 other standard approved by the secretary are required to participate in RIte Share if a Medicaid- 10 eligible adult or parent/caretaker has access to cost-effective ESI. Enrolling in ESI through RIte 11 Share shall be a condition of maintaining Medicaid health coverage for any eligible adult with 12 access to such coverage. 13 (ii) Income above one hundred fifty percent (150%) of FPL and policy holder is not 14 Medicaid-eligible — Premium assistance is available when the household includes Medicaid- 15 eligible members, but the ESI policy holder (typically a parent/caretaker, or spouse) is not eligible 16 for Medicaid. Premium assistance for parents/caretakers and other household members who are not 17 Medicaid-eligible may be provided in circumstances when enrollment of the Medicaid-eligible 18 family members in the approved ESI plan is contingent upon enrollment of the ineligible policy 19 holder and the executive office of health and human services (executive office) determines, based 20 on a methodology adopted for such purposes, that it is cost-effective to provide premium assistance 21 for family or spousal coverage. 22 (d) RIte Share enrollment as not a condition of eligibility. RIte Share enrollment shall 23 be purely voluntary and shall never be a condition of eligibility for Medicaid. For Medicaid 24 beneficiaries over the age of nineteen (19), enrollment in RIte Share shall be a condition of 25 eligibility except as exempted below and by regulations promulgated by the executive office. 26 (1) Medicaid-eligible children and young adults up to age nineteen (19) shall not be 27 required to enroll in a parent/caretaker relative’s ESI as a condition of maintaining Medicaid 28 eligibility if the person with access to RIte Share-approved ESI does not enroll as required. These 29 Medicaid-eligible children and young adults shall remain eligible for Medicaid and shall be 30 enrolled in a RIte Care plan. 31 (2) There shall be a limited six-month (6) exemption from the mandatory enrollment 32 requirement for persons participating in the RI works program pursuant to chapter 5.2 of this title. 33 (e) Approval of health insurance plans for premium assistance. The executive office of 34 health and human services shall adopt regulations providing for the approval of employer-based LC005672 - Page 36 of 79 1 health insurance plans for premium assistance and shall approve employer-based health insurance 2 plans based on these regulations. In order for an employer-based health insurance plan to gain 3 approval, the executive office must determine that the benefits offered by the employer-based 4 health insurance plan are substantially similar in amount, scope, and duration to the benefits 5 provided to Medicaid-eligible persons enrolled in a Medicaid managed care plan, when the plan is 6 evaluated in conjunction with available supplemental benefits provided by the office. The office 7 shall obtain and make available to persons otherwise eligible for Medicaid identified in this section 8 as supplemental benefits those benefits not reasonably available under employer-based health 9 insurance plans that are required for Medicaid beneficiaries by state law or federal law or 10 regulation. Once it has been determined by the Medicaid agency that the ESI offered by a particular 11 employer is RIte Share-approved, all Medicaid members with access to that employer’s plan are 12 required to participate in RIte Share. Failure to meet the mandatory enrollment requirement shall 13 result in the termination of the Medicaid eligibility of the policy holder and other Medicaid 14 members nineteen (19) or older in the household who could be covered under the ESI until the 15 policy holder complies with the RIte Share enrollment procedures established by the executive 16 office. 17 (f) Premium assistance. The executive office shall provide premium assistance by paying 18 all or a portion of the employee’s cost for covering the eligible person and/or his or her family 19 under such a RIte Share-approved ESI plan subject to the buy-in provisions in this section. 20 (g) Buy-in. Persons who can afford it shall share in the cost. — The executive office is 21 authorized and directed to apply for and obtain any necessary state plan and/or waiver amendments 22 from the Secretary of the United States Department of Health and Human Services (DHHS) to 23 require that persons enrolled in a RIte Share-approved employer-based health plan who have 24 income equal to or greater than one hundred fifty percent (150%) of the FPL to buy-in to pay a 25 share of the costs based on the ability to pay, provided that the buy-in cost shall not exceed five 26 percent (5%) of the person’s annual income. The executive office shall implement the buy-in by 27 regulation, and shall consider co-payments, premium shares, or other reasonable means to do so. 28 (h) Maximization of federal contribution. The executive office of health and human 29 services is authorized and directed to apply for and obtain federal approvals and waivers necessary 30 to maximize the federal contribution for provision of medical assistance coverage under this 31 section, including the authorization to amend the Title XXI state plan and to obtain any waivers 32 necessary to reduce barriers to provide premium assistance to recipients as provided for in Title 33 XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. 34 (i) Implementation by regulation. The executive office of health and human services is LC005672 - Page 37 of 79 1 authorized and directed to adopt regulations to ensure the establishment and implementation of the 2 premium assistance program in accordance with the intent and purpose of this section, the 3 requirements of Title XIX, Title XXI, and any approved federal waivers. 4 (j) Outreach and reporting. The executive office of health and human services shall 5 develop a plan to identify Medicaid-eligible individuals who have access to employer-sponsored 6 insurance and increase the use of RIte Share benefits. Beginning October 1, 2019, the executive 7 office shall submit the plan to be included as part of the reporting requirements under § 35-17-1. 8 Starting January 1, 2020, the executive office of health and human services shall include the number 9 of Medicaid recipients with access to employer-sponsored insurance, the number of plans that did 10 not meet the cost-effectiveness criteria for RIte Share, and enrollment in the premium assistance 11 program as part of the reporting requirements under § 35-17-1. 12 (k) Employer-sponsored insurance. The executive office of health and human services 13 shall dedicate staff and resources to reporting monthly as part of the requirements under § 35-17-1 14 which employer-sponsored insurance plans meet the cost-effectiveness criteria for RIte Share. 15 Information in the report shall be used for screening for Medicaid enrollment to encourage Rite 16 Share participation. By October 1, 2021, the report shall include any employers with 300 or more 17 employees. By January 1, 2022, the report shall include employers with 100 or more employees. 18 The January report shall also be provided to the chairperson of the house finance committee; the 19 chairperson of the senate finance committee; the house fiscal advisor; the senate fiscal advisor; and 20 the state budget officer. 21 40-8.4-15. Advisory commission on health care. 22 (a) There is hereby established an advisory commission to be known as the “advisory 23 commission on health care” to advise the director of the department of human services on all 24 matters relating to the RIte Care and RIte Share programs, and other matters concerning access for 25 all Rhode Islanders to quality health care in the most affordable, economical manner. The director 26 of the department of human services shall serve ex officio as chairperson. The director shall appoint 27 the eighteen (18) members: 28 (1) Three (3) of whom shall represent the healthcare providers; 29 (2) Three (3) of whom shall represent the healthcare insurers; 30 (3) Three (3) of whom shall represent healthcare consumers or consumer organizations; 31 (4) Two (2) of whom shall represent organized labor; 32 (5) One of whom shall be the health care advocate in the office of the attorney general; and 33 (6) Three (3) of whom shall represent employers; and 34 (7) Three (3) Nine (9) of whom shall be other members of the public. LC005672 - Page 38 of 79 1 (b) The commission may study all aspects of the provisions of the RIte Care and RIte Share 2 programs involving purchasers of health care, including employers, consumers, and the state, health 3 insurers, providers of health care, and healthcare facilities, and all matters related to the interaction 4 among these groups, including methods to achieve more effective and timely resolution of disputes, 5 better communication, speedier, more reliable and less-costly administrative processes, claims, 6 payments, and other reimbursement matters, and the application of new processes or technologies 7 to such issues. 8 (c) Members of the commission shall be appointed in the month of July, each to hold office 9 until the last day of June in the second year of his or her appointment or until his or her successor 10 is appointed by the director. 11 (d) The commission shall meet at least quarterly, and the initial meeting of the commission 12 shall take place on or before September 15, 2000. The commission may meet more frequently than 13 quarterly at the call of the chair or at the call of any three (3) members of the commission. 14 (e) Members of the permanent joint committee on health care oversight established 15 pursuant to § 40-8.4-14 shall be notified of each meeting of the commission and shall be invited to 16 participate. 17 40-8.4-19. Managed healthcare delivery systems for families Cost sharing. 18 (a) Notwithstanding any other provision of state law, the delivery and financing of the 19 healthcare services provided under this chapter shall be provided through a system of managed 20 care. “Managed care” is defined as systems that: integrate an efficient financing mechanism with 21 quality service delivery; provide a “medical home” to ensure appropriate care and deter 22 unnecessary services; and place emphasis on preventive and primary care. 23 (b) Enrollment in managed care health delivery systems is mandatory for individuals 24 eligible for medical assistance under this chapter. This includes children in substitute care, children 25 receiving medical assistance through an adoption subsidy, and children eligible for medical 26 assistance based on their disability. Beneficiaries with third-party medical coverage or insurance 27 may be exempt from mandatory managed care in accordance with rules and regulations 28 promulgated by the department of human services for such purposes. 29 (c) Individuals who can afford to contribute shall share in the cost. The department of 30 human services is authorized and directed to apply for and obtain any necessary waivers and/or 31 state plan amendments from the Secretary of the United States Department of Health and Human 32 Services, including, but not limited to, a waiver of the appropriate sections of Title XIX, 42 U.S.C. 33 § 1396 et seq., to require that beneficiaries eligible under this chapter or chapter 12.3 of title 42, 34 with incomes equal to or greater than one hundred fifty percent (150%) of the federal poverty level, LC005672 - Page 39 of 79 1 pay a share of the costs of health coverage based on the ability to pay. The department of human 2 services shall implement this cost-sharing obligation by regulation, and shall consider co-payments, 3 premium shares, or other reasonable means to do so in accordance with approved provisions of 4 appropriate waivers and/or state plan amendments approved by the Secretary of the United States 5 Department of Health and Human Services. 6 SECTION 10. Section 40-8.4-13 of the General Laws in Chapter 40-8.4 entitled Health 7 Care for Families is hereby repealed. 8 40-8.4-13. Utilization of available employer-based health insurance. 9 To the extent permitted under Titles XIX and XXI of the Social Security Act, 42 U.S.C. § 10 1396 et seq. and 42 U.S.C. § 1397aa et seq., or by waiver from the Secretary of the United States 11 Department of Health and Human Services, the department of human services shall adopt 12 regulations to restrict eligibility for RIte Care under this chapter and/or chapter 12.3 of title 42, or 13 the RIte Share program under § 40-8.4-12, for certain periods of time for certain individuals or 14 families who have access to, or have refused or terminated employer-based health insurance and 15 for certain periods of time for certain individuals but not including children whose employer has 16 terminated their employer-based health insurance. The department is authorized and directed to 17 amend the medical assistance Title XIX and XXI state plans, and/or to seek and obtain appropriate 18 federal approvals or waivers to implement this section. 19 SECTION 11. Sections 40-8.5-1 and 40-8.5-1.1 of the General Laws in Chapter 40-8.5 20 entitled Health Care for Elderly and Disabled Residents Act are hereby amended to read as 21 follows: 22 40-8.5-1. Categorically needy medical assistance coverage. 23 The department of human services is hereby authorized and directed to amend its Title XIX 24 state plan to provide for categorically needy medical assistance coverage as permitted pursuant to 25 Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., as amended, to individuals who are 26 sixty-five (65) years or older or are disabled, as determined under § 1614(a)(3) of the Social 27 Security Act, 42 U.S.C. § 1382c(a)(3), as amended, whose income does not exceed one hundred 28 percent (100%) one hundred thirty-three percent (133%) of the federal poverty level (as revised 29 annually) applicable to the individual’s family size, and whose resources do not exceed four 30 thousand dollars ($4,000) per individual, or six thousand dollars ($6,000) per couple. The 31 department shall provide medical assistance coverage to such elderly or disabled persons in the 32 same amount, duration, and scope as provided to other categorically needy persons under the state’s 33 Title XIX state plan. 34 40-8.5-1.1. Managed healthcare delivery systems. LC005672 - Page 40 of 79 1 (a) The delivery and financing of the healthcare services provided under this chapter may 2 be provided through a system of managed care. Beginning July 1, 2030, all payments shall be 3 provided directly by the state without an intermediate payment to a managed care entity or other 4 form of health insurance company. Beginning July 1, 2026, no new contracts may be entered into 5 between the Medicaid office and an intermediate payor such as a managed care entity or other form 6 of health insurance company for the payment of healthcare services pursuant to this chapter. To 7 ensure that all medical assistance beneficiaries, including the elderly and all individuals with 8 disabilities, have access to quality and affordable health care, the executive office of health and 9 human services (“executive office”) is authorized to implement mandatory managed-care health 10 systems. 11 (b) “Managed care” is defined as systems that: integrate an efficient financing mechanism 12 with quality service delivery; provide a “medical home” to ensure appropriate care and deter 13 unnecessary services; and place emphasis on preventive and primary care. For purposes of this 14 section, managed care systems may also be defined to include a primary care case-management 15 model, community health teams, and/or other such arrangements that meet standards established 16 by the executive office and serve the purposes of this section. Managed care systems may also 17 include services and supports that optimize the health and independence of beneficiaries who are 18 determined to need Medicaid-funded long-term care under chapter 8.10 of this title or to be at risk 19 for the care under applicable federal state plan or waiver authorities and the rules and regulations 20 promulgated by the executive office. Any Medicaid beneficiaries who have third-party medical 21 coverage or insurance may be provided such services through an entity certified by, or in a 22 contractual arrangement with, the executive office or, as deemed appropriate, exempt from 23 mandatory managed care in accordance with rules and regulations promulgated by the executive 24 office. 25 (c) In accordance with § 42-12.4-7, the executive office is authorized to obtain any approval 26 through waiver(s), category II or III changes, and/or state-plan amendments, from the Secretary of 27 the United States Department of Health and Human Services, that are necessary to implement 28 mandatory, managed healthcare delivery systems for all Medicaid beneficiaries. The waiver(s), 29 category II or III changes, and/or state-plan amendments shall include the authorization to extend 30 managed care to cover long-term-care services and supports. Authorization shall also include, as 31 deemed appropriate, exempting certain beneficiaries with third-party medical coverage or 32 insurance from mandatory managed care in accordance with rules and regulations promulgated by 33 the executive office. 34 (d) To ensure the delivery of timely and appropriate services to persons who become LC005672 - Page 41 of 79 1 eligible for Medicaid by virtue of their eligibility for a United States Social Security Administration 2 program, the executive office is authorized to seek any and all data-sharing agreements or other 3 agreements with the Social Security Administration as may be necessary to receive timely and 4 accurate diagnostic data and clinical assessments. This information shall be used exclusively for 5 the purpose of service planning, and shall be held and exchanged in accordance with all applicable 6 state and federal medical record confidentiality laws and regulations. 7 SECTION 12. Sections 40-8.12-2 and 40-8.12-3 of the General Laws in Chapter 40-8.12 8 entitled Health Care for Adults are hereby amended to read as follows: 9 40-8.12-2. Eligibility. 10 (a) Medicaid coverage for nonpregnant adults without children. There is hereby 11 established, effective January 1, 2014, a category of Medicaid eligibility pursuant to Title XIX of 12 the Social Security Act, as amended by the U.S. Patient Protection and Affordable Care Act (ACA) 13 of 2010, 42 U.S.C. § 1396u-1, for adults ages nineteen (19) to sixty-four (64) who do not have 14 dependent children and do not qualify for Medicaid under Rhode Island general laws applying to 15 families with children and adults who are blind, aged, or living with a disability. The executive 16 office of health and human services is directed to make any amendments to the Medicaid state plan 17 and waiver authorities established under Title XIX necessary to implement this expansion in 18 eligibility and ensure the maximum federal contribution for health insurance coverage provided 19 pursuant to this chapter. 20 (b) Income. The secretary of the executive office of health and human services is authorized 21 and directed to amend the Medicaid Title XIX state plan and, as deemed necessary, any waiver 22 authority to effectuate this expansion of coverage to any Rhode Islander who qualifies for Medicaid 23 eligibility under this chapter with income at or below one hundred and thirty-three percent (133%) 24 of the federal poverty level, based on modified adjusted-gross income. 25 (c) Delivery system. The executive office of health and human services is authorized and 26 directed to apply for and obtain any waiver authorities necessary to provide persons eligible under 27 this chapter with managed, coordinated healthcare coverage consistent with the principles set forth 28 in chapter 12.4 of title 42, pertaining to a healthcare home. Beginning July 1, 2030, all payments 29 shall be provided directly by the state without an intermediate payment to a managed care entity or 30 other form of health insurance company. Beginning July 1, 2026, no new contracts may be entered 31 into between the Medicaid office and an intermediate payor such as a managed care entity or other 32 form of health insurance company for the payment of healthcare services pursuant to this chapter. 33 40-8.12-3. Premium assistance program. 34 (a) The executive office of health and human services is directed to amend its rules and LC005672 - Page 42 of 79 1 regulations to implement a premium assistance program for adults with dependent children, 2 enrolled in the state’s health-benefits exchange, whose annual income and resources meet the 3 guidelines established in § 40-8.4-4 in effect on December 1, 2013. The premium assistance will 4 pay one-half of the cost of a commercial plan that a parent may incur after subtracting the cost- 5 sharing requirement under § 40-8.4-4 as of December 31, 2013, and any applicable federal tax 6 credits available. The office is also directed to amend the 1115 waiver demonstration extension and 7 the medical assistance Title XIX state plan for this program if it is determined that it is eligible for 8 funding pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. 9 (b) The executive office of health and human services shall require any individual receiving 10 benefits under a state-funded, healthcare assistance program to apply for any health insurance for 11 which he or she is eligible, including health insurance available through the health benefits 12 exchange. Nothing shall preclude the state from using funds appropriated for Affordable Care Act 13 transition expenses to reduce the impact on an individual who has been transitioned from a state 14 program to a health insurance plan available through the health benefits exchange. It shall not be 15 deemed cost-effective for the state if it would result in a loss of benefits or an increase in the cost 16 of healthcare services for the person above an amount deemed de minimus as determined by state 17 regulation. 18 SECTION 13. Chapter 40-8.13 of the General Laws entitled Long-Term Managed Care 19 Arrangements is hereby repealed in its entirety. 20 CHAPTER 40-8.13 21 Long-Term Managed Care Arrangements 22 40-8.13-1. Definitions. 23 For purposes of this section the following terms shall have the meanings indicated: 24 (1) “Beneficiary” means an individual who is eligible for medical assistance under the 25 Rhode Island Medicaid state plan established in accordance with 42 U.S.C. § 1396, and includes 26 individuals who are additionally eligible for benefits under the Medicare program (42 U.S.C. § 27 1395 et seq.) or other health plan. 28 (2) “Duals demonstration project” means a demonstration project established pursuant to 29 the financial alignment demonstration established under section 2602 of the Patient Protection and 30 Affordable Care Act (Pub. L. No. 111-148) [42 U.S.C. § 1315b], involving a three-way contract 31 between Rhode Island, the federal Centers for Medicare and Medicaid Services (“CMS”), and 32 qualified health plans, and covering healthcare services provided to beneficiaries. 33 (3) “EOHHS” means the Rhode Island executive office of health and human services. 34 (4) “EOHHS level-of-care tool” refers to a set of criteria established by EOHHS and used LC005672 - Page 43 of 79 1 in January, 2014 to determine the long-term-care needs of a beneficiary as well as the appropriate 2 setting for delivery of that care. 3 (5) “Long-term-care services and supports” means a spectrum of services covered by the 4 Rhode Island Medicaid program and/or the Medicare program, that are required by individuals with 5 functional impairments and/or chronic illness, and includes skilled or custodial nursing facility 6 care, as well as various home- and community-based services. 7 (6) “Managed care organization” means any health plan, health-maintenance organization, 8 managed care plan, or other person or entity that enters into a contract with the state under which 9 it is granted the authority to arrange for the provision of, and/or payment for, long-term-care 10 supports and services to eligible beneficiaries under a managed long-term-care arrangement. 11 (7) “Managed long-term-care arrangement” means any arrangement under which a 12 managed care organization is granted some or all of the responsibility for providing and/or paying 13 for long-term-care services and supports that would otherwise be provided or paid under the Rhode 14 Island Medicaid program. The term includes, but is not limited to, a duals demonstration project, 15 and/or phase I and phase II of the integrated care initiative established by the executive office of 16 health and human services. 17 (8) “Plan of care” means a care plan established by a nursing facility in accordance with 18 state and federal regulations and that identifies specific care and services provided to a beneficiary. 19 40-8.13-2. Beneficiary choice. 20 Any managed long-term-care arrangement shall offer beneficiaries the option to decline 21 participation and remain in traditional Medicaid and, if a duals demonstration project, traditional 22 Medicare. Beneficiaries must be provided with sufficient information to make an informed choice 23 regarding enrollment, including: 24 (1) Any changes in the beneficiary’s payment or other financial obligations with respect to 25 long-term-care services and supports as a result of enrollment; 26 (2) Any changes in the nature of the long-term-care services and supports available to the 27 beneficiary as a result of enrollment, including specific descriptions of new services that will be 28 available or existing services that will be curtailed or terminated; 29 (3) A contact person who can assist the beneficiary in making decisions about enrollment; 30 (4) Individualized information regarding whether the managed care organization’s network 31 includes the healthcare providers with whom beneficiaries have established provider relationships. 32 Directing beneficiaries to a website identifying the plan’s provider network shall not be sufficient 33 to satisfy this requirement; and 34 (5) The deadline by which the beneficiary must make a choice regarding enrollment, and LC005672 - Page 44 of 79 1 the length of time a beneficiary must remain enrolled in a managed care organization before being 2 permitted to change plans or opt out of the arrangement. 3 40-8.13-3. Ombudsman process. 4 EOHHS shall designate an ombudsperson to advocate for beneficiaries enrolled in a 5 managed long-term-care arrangement. The ombudsperson shall advocate for beneficiaries through 6 complaint and appeal processes and ensure that necessary healthcare services are provided. At the 7 time of enrollment, a managed care organization must inform enrollees of the availability of the 8 ombudsperson, including contact information. 9 40-8.13-4. Provider/plan liaison. 10 EOHHS shall designate an individual, not employed by or otherwise under contract with a 11 participating managed care organization, who shall act as liaison between healthcare providers and 12 managed care organizations, for the purpose of facilitating communications and ensuring that issues 13 and concerns are promptly addressed. 14 40-8.13-5. Financial principles under managed care. 15 (a) To the extent that financial savings are a goal under any managed long-term-care 16 arrangement, it is the intent of the legislature to achieve savings through administrative efficiencies, 17 care coordination, improvements in care outcomes and in a way that encourages the highest quality 18 care for patients and maximizes value for the managed-care organization and the state. Therefore, 19 any managed long-term-care arrangement shall include a requirement that the managed care 20 organization reimburse providers for services in accordance with these principles. Notwithstanding 21 any law to the contrary, for the twelve-month (12) period beginning July 1, 2015, Medicaid 22 managed long-term-care payment rates to nursing facilities established pursuant to this section shall 23 not exceed ninety-eight percent (98.0%) of the rates in effect on April 1, 2015. 24 (1) For a duals demonstration project, the managed care organization: 25 (i) Shall not combine the rates of payment for post-acute skilled and rehabilitation care 26 provided by a nursing facility and long-term and chronic care provided by a nursing facility in order 27 to establish a single-payment rate for dual eligible beneficiaries requiring skilled nursing services; 28 (ii) Shall pay nursing facilities providing post-acute skilled and rehabilitation care or long- 29 term and chronic care rates that reflect the different level of services and intensity required to 30 provide these services; and 31 (iii) For purposes of determining the appropriate rate for the type of care identified in 32 subsection (a)(1)(ii) of this section, the managed care organization shall pay no less than the rates 33 that would be paid for that care under traditional Medicare and Rhode Island Medicaid for these 34 service types. The managed care organization shall not, however, be required to use the same LC005672 - Page 45 of 79 1 payment methodology. 2 The state shall not enter into any agreement with a managed care organization in connection 3 with a duals demonstration project unless that agreement conforms to this section, and any existing 4 such agreement shall be amended as necessary to conform to this subsection. 5 (2) For a managed long-term-care arrangement that is not a duals demonstration project, 6 the managed care organization shall reimburse providers in an amount not less than the amount that 7 would be paid for the same care by the executive office of health and human services under the 8 Medicaid program. The managed care organization shall not, however, be required to use the same 9 payment methodology as the executive office of health and human services. 10 (3) Notwithstanding any provisions of the general or public laws to the contrary, the 11 protections of subsections (a)(1) and (a)(2) of this section may be waived by a nursing facility in 12 the event it elects to accept a payment model developed jointly by the managed care organization 13 and skilled nursing facilities, that is intended to promote quality of care and cost-effectiveness, 14 including, but not limited to, bundled-payment initiatives, value-based purchasing arrangements, 15 gainsharing, and similar models. 16 (b) Notwithstanding any law to the contrary, for the twelve-month (12) period beginning 17 July 1, 2015, Medicaid managed long-term-care payment rates to nursing facilities established 18 pursuant to this section shall not exceed ninety-eight percent (98.0%) of the rates in effect on April 19 1, 2015. 20 40-8.13-6. Payment incentives. 21 In order to encourage quality improvement and promote appropriate utilization incentives 22 for providers in a managed long-term-care arrangement, a managed care organization may use 23 incentive or bonus payment programs that are in addition to the rates identified in § 40-8.13-5. 24 40-8.13-7. Willing provider. 25 A managed care organization must contract with and cover services furnished by any 26 nursing facility licensed under chapter 17 of title 23 and certified by CMS that provides Medicaid- 27 covered nursing facility services pursuant to a provider agreement with the state, provided that the 28 nursing facility is not disqualified under the managed care organization’s quality standards that are 29 applicable to all nursing facilities; and the nursing facility is willing to accept the reimbursement 30 rates described in § 40-8.13-5. 31 40-8.13-8. Level-of-care tool. 32 A managed long-term-care arrangement must require that all participating managed care 33 organizations use only the EOHHS level-of-care tool in determining coverage of long-term-care 34 supports and services for beneficiaries. EOHHS may amend the level-of-care tool provided that LC005672 - Page 46 of 79 1 any changes are established in consultation with beneficiaries and providers of Medicaid-covered 2 long-term-care supports and services, and are based upon reasonable medical evidence or 3 consensus, in consideration of the specific needs of Rhode Island beneficiaries. Notwithstanding 4 any other provisions herein, however, in the case of a duals demonstration project, a managed care 5 organization may use a different level-of-care tool for determining coverage of services that would 6 otherwise be covered by Medicare, since the criteria established by EOHHS are directed towards 7 Medicaid-covered services; provided, that the level-of-care tool is based on reasonable medical 8 evidence or consensus in consideration of the specific needs of Rhode Island beneficiaries. 9 40-8.13-9. Case management/plan of care. 10 No managed care organization acting under a managed long-term-care arrangement may 11 require a provider to change a plan of care if the provider reasonably believes that such an action 12 would conflict with the provider’s responsibility to develop an appropriate care plan under state 13 and federal regulations. 14 40-8.13-10. Care transitions. 15 In the event that a beneficiary: 16 (1) Has been determined to meet level-of-care requirements for nursing facility coverage 17 as of the date of his or her enrollment in a managed care organization; or 18 (2) Has been determined to meet level of care requirements for nursing facility coverage 19 by a managed care organization after enrollment; and there is a change in condition whereby the 20 managed care organization determines that the beneficiary no longer meets such level-of-care 21 requirements, the nursing facility shall promptly arrange for an appropriate and safe discharge (with 22 the assistance of the managed care organization if the facility requests it), and the managed care 23 organization shall continue to pay for the beneficiary’s nursing facility care at the same rate until 24 the beneficiary is discharged. 25 40-8.13-11. Reporting requirements. 26 EOHHS shall report to the general assembly and shall make available to interested persons 27 a separate accounting of state expenditures for long-term-care supports and services under any 28 managed long-term-care arrangement, specifically and separately identifying expenditures for 29 home- and community-based services, assisted-living services, hospice services within nursing 30 facilities, hospice services outside of nursing facilities, and nursing facility services. Such reports 31 shall be made twice annually, six (6) months apart, beginning six (6) months following the 32 implementation of any managed long-term-care arrangement, and shall include a detailed report of 33 utilization of each service. In order to facilitate reporting, any managed long-term-care arrangement 34 shall include a requirement that a participating managed care organization make timely reports of LC005672 - Page 47 of 79 1 the data necessary to compile the reports. 2 SECTION 14. Sections 42-7.2-10, 42-7.2-16 and 42-7.2-16.1 of the General Laws in 3 Chapter 42-7.2 entitled Office of Health and Human Services are hereby amended to read as 4 follows: 5 42-7.2-10. Appropriations and disbursements. 6 (a) The general assembly shall annually appropriate such sums as it may deem necessary 7 for the purpose of carrying out the provisions of this chapter. The state controller is hereby 8 authorized and directed to draw his or her orders upon the general treasurer for the payment of such 9 sum or sums, or so much thereof as may from time to time be required, upon receipt by him or her 10 of proper vouchers approved by the secretary of the executive office of health and human services, 11 or the secretary’s designee. 12 (b) The general assembly shall, through the utilization of federal Medicaid reimbursement 13 for administrative costs, and additional funds, appropriate such funds as may be necessary to hire 14 additional personnel for the Medicaid office as follows: one hundred (100) outreach social workers 15 to encourage, assist and expedite individuals applying for Medicaid benefits; one hundred (100) 16 new programmers in order to build digital infrastructure for the Medicaid office; thirty (30) new 17 social workers and ten (10) new programmers to help increase spend down program utilization and 18 feasibility and examine possible legal changes necessary to increase spend down program 19 eligibility; and fifty (50) additional personnel for building administrative capacity. The Medicaid 20 office shall be exempt from any limitations placed on the number of full-time equivalent personnel 21 employed by the executive office of health and human services. 22 (b) (c) For the purpose of recording federal financial participation associated with 23 qualifying healthcare workforce development activities at the state’s public institutions of higher 24 education, and pursuant to the Rhode Island designated state health programs (DSHP), as approved 25 by the Centers for Medicare & Medicaid Services (CMC) October 20, 2016, in the 11-W-00242/1 26 amendment to Rhode Island’s section 1115 Demonstration Waiver, there is hereby established a 27 restricted receipt account entitled “Health System Transformation Project” in the general fund of 28 the state and included in the budget of the office of health and human services. The office of health 29 and human services is forbidden from utilizing any funds within the health system transformation 30 project restricted receipts account for any imposition of downside risk for providers. No payment 31 models that impose downside risk or in any way deviate from fee-for-service shall be utilized for 32 the Medicaid program without explicit authorization by the general assembly. 33 (c) (d) There are hereby created within the general fund of the state and housed within the 34 budget of the office of health and human services two restricted receipt accounts, respectively LC005672 - Page 48 of 79 1 entitled “HCBS Support-ARPA” and “HCBS Admin Support-ARPA”. Amounts deposited into 2 these accounts are equivalent to the general revenue savings generated by the enhanced federal 3 match received on eligible home and community-based services between April 1, 2021, and March 4 31, 2022, allowable under Section 9817 of the American Rescue Plan Act of 2021, Pub. L. No. 5 117-2. Funds deposited into the “HCBS Support-ARPA” account will be used to finance the state 6 share of newly eligible Medicaid expenditures by the office of health and human services and its 7 sister agencies, including the department of children, youth and families, the department of health, 8 and the department of behavioral healthcare, developmental disabilities and hospitals. Funds 9 deposited into the “HCBS Admin Support-ARPA” account will be used to finance the state share 10 of allowable administrative expenditures attendant to the implementation of these newly eligible 11 Medicaid expenditures. The accounts created under this subsection shall be exempt from the 12 indirect cost recovery provisions of § 35-4-27. 13 (d) (e) There is hereby created within the general fund of the state and housed within the 14 budget of the office of health and human services a restricted receipt account entitled “Rhode Island 15 Statewide Opioid Abatement Account” for the purpose of receiving and expending monies from 16 settlement agreements with opioid manufacturers, pharmaceutical distributors, pharmacies, or their 17 affiliates, as well as monies resulting from bankruptcy proceedings of the same entities. The 18 executive office of health and human services shall deposit any revenues from such sources that 19 are designated for opioid abatement purposes into the restricted receipt account. Funds from this 20 account shall only be used for forward-looking opioid abatement efforts as defined and limited by 21 any settlement agreements, state-city and town agreements, or court orders pertaining to the use of 22 such funds. By January 1 of each calendar year, the secretary of health and human services shall 23 report to the governor, the speaker of the house of representatives, the president of the senate, and 24 the attorney general on the expenditures that were funded using monies from the Rhode Island 25 statewide opioid abatement account and the amount of funds spent. The account created under this 26 subsection shall be exempt from the indirect cost recovery provisions of § 35-4-27. No 27 governmental entity has the authority to assert a claim against the entities with which the attorney 28 general has entered into settlement agreements concerning the manufacturing, marketing, 29 distributing, or selling of opioids that are the subject of the Rhode Island Memorandum of 30 Understanding Between the State and Cities and Towns Receiving Opioid Settlement Funds 31 executed by every city and town and the attorney general and wherein every city and town agreed 32 to release all such claims against these settling entities, and any amendment thereto. Governmental 33 entity means any state or local governmental entity or sub-entity and includes, but is not limited to, 34 school districts, fire districts, and any other such districts. The claims that shall not be asserted are LC005672 - Page 49 of 79 1 the released claims, as that term is defined in the settlement agreements executed by the attorney 2 general, or, if not defined therein, the claims sought to be released in such settlement agreements. 3 (e) There is hereby created within the general fund of the state and housed within the budget 4 of the executive office of health and human services a restricted receipt account, respectively 5 entitled “Minimum Staffing Level Compliance and Enforcement”. Funds deposited into the 6 account will be used for workforce development and compliance assistance programs as included 7 in § 23-17.5-33. 8 42-7.2-16. Medicaid System Reform 2008 Medicaid System Reform. 9 (a) The executive office of health and human services, in conjunction with the department 10 of human services, the department of children, youth and families, the department of health, and 11 the department of behavioral healthcare, developmental disabilities and hospitals, is authorized to 12 design options that further the reforms in Medicaid initiated in 2008 Medicaid reform to ensure that 13 the program: utilizes competitive and value-based purchasing to maximize the available service 14 options, promotes accountability and transparency, and encourages and rewards healthy outcomes, 15 independence, and responsible choices; promotes efficiencies and the coordination of services 16 across all health and human services agencies; and ensures the state will have a fiscally sound 17 source of publicly-financed health care for Rhode Islanders in need transitions to a Medicare level 18 of care as a first step in the transition to a state-level Medicare for All system; phases out the use 19 of intermediary privatized insurance companies such as managed care entities; transitions to the 20 management of health insurers acquired due to insolvency, smoothly integrating publicly owned 21 health insurers with the Medicaid system; utilizes payment models such as fee-for-service that 22 incentivize higher quality of care and more utilization of care; provides for the financial health of 23 Rhode Island healthcare providers; encourages fair wages and benefits for Rhode Island s 24 healthcare workforce; develops and builds out the Medicaid office s human capital, technological 25 infrastructure, expertise, and general ability to manage healthcare payments to prepare for the 26 transition to a single-payer Medicare-for-All system; and guides the transition of the Rhode Island 27 healthcare funding system to a state-level Medicare-for-All system . 28 (b) Principles and goals. In developing and implementing this system of reform, the 29 executive office of health and human services and the four (4) health and human services 30 departments shall pursue the following principles and goals: 31 (1) Empower consumers to make reasoned and cost-effective choices about their health by 32 providing them with the information and array of service options they need and offering rewards 33 for healthy decisions; 34 (2) Encourage personal responsibility by assuring the information available to beneficiaries LC005672 - Page 50 of 79 1 is easy to understand and accurate, provide that a fiscal intermediary is provided when necessary, 2 and adequate access to needed services; 3 (3) When appropriate, promote community-based care solutions by transitioning 4 beneficiaries from institutional settings back into the community and by providing the needed 5 assistance and supports to beneficiaries requiring long-term care or residential services who wish 6 to remain, or are better served in the community; 7 (4) Enable consumers to receive individualized health care that is outcome-oriented, 8 focused on prevention, disease management, recovery, and maintaining independence; 9 (5) Promote competition between healthcare providers to ensure best value purchasing, to 10 leverage resources, and to create opportunities for improving service quality and performance; 11 (6) Redesign purchasing and payment methods to assure fiscal accountability and 12 encourage and to reward service quality and cost-effectiveness by tying reimbursements to 13 evidence-based performance measures and standards, including those related to patient satisfaction 14 promote payment models such as fee-for-service that incentivize higher quality of care and phase 15 out the use of payment models that shift risk to providers including, but not limited to, capitation, 16 episode-based payments, global budgets, and similar models ; and 17 (7) Continually improve technology to take advantage of recent innovations and advances 18 that help decision makers, consumers, and providers to make informed and cost-effective decisions 19 regarding health care. 20 (c) The executive office of health and human services shall annually submit a report to the 21 governor and the general assembly describing the status of the administration and implementation 22 of the Medicaid Section 1115 demonstration waiver. 23 42-7.2-16.1. Reinventing Medicaid Act of 2015. 24 (a) Findings. The Rhode Island Medicaid program is an integral component of the state’s 25 healthcare system that provides crucial services and supports to many Rhode Islanders. As the 26 program’s reach has expanded, the costs of the program have continued to rise and the delivery of 27 care has become more fragmented and uncoordinated. Given the crucial role of the Medicaid 28 program to the state, it is of compelling importance that the state conduct a fundamental 29 restructuring of its Medicaid program that achieves measurable improvement in health outcomes 30 for the people and transforms the healthcare system to one that pays for the outcomes and quality 31 they deserve at a sustainable, predictable, and affordable cost. The Reinventing Medicaid Act of 32 2015, as implemented in the budget for FY2016, involved drastic cuts to the Medicaid program, 33 along with policies that shifted risk to providers away from intermediary insurers. Since the passage 34 of that act, the finances of healthcare providers in Rhode Island have deteriorated significantly, and LC005672 - Page 51 of 79 1 it is therefore the duty of the general assembly to seek corrective action to restore critical 2 investments in the Medicaid system and redesign payment models to remove risk from providers 3 and concentrate risk in private insurance companies during their phase-out period along the 4 transition to Medicare-for-All. 5 (b) The Working Group to Reinvent Medicaid, which was established to refine the 6 principles and goals of the Medicaid reforms begun in 2008, was directed to present to the general 7 assembly and the governor initiatives to improve the value, quality, and outcomes of the health care 8 funded by the Medicaid program. 9 SECTION 15. Chapter 42-12.1 of the General Laws entitled Department of Behavioral 10 Healthcare, Developmental Disabilities and Hospitals is hereby amended by adding thereto the 11 following section: 12 42-12.1-11. The Rhode Island mental health nursing facility. 13 There is hereby established a state nursing facility for the care of Rhode Islanders in need 14 of nursing facility-level inpatient behavioral healthcare known as the Rhode Island mental health 15 nursing facility. The Rhode Island mental health nursing facility shall fall within the purview of the 16 department, and the chief executive officer, chief financial officer, and chief medical officer shall 17 be appointed by the governor with the advice and consent of the senate. 18 SECTION 16. Sections 42-12.3-3, 42-12.3-5, 42-12.3-7 and 42-12.3-9 of the General Laws 19 in Chapter 42-12.3 entitled Health Care for Children and Pregnant Women are hereby amended 20 to read as follows: 21 42-12.3-3. Medical assistance expansion for pregnancy/RIte Start. 22 (a) The secretary of the executive office of health and human services is authorized to 23 amend its Title XIX state plan pursuant to Title XIX of the Social Security Act to provide Medicaid 24 coverage and to amend its Title XXI state plan pursuant to Title XXI of the Social Security Act to 25 provide medical assistance coverage through expanded family income disregards for pregnant 26 persons whose family income levels are between one hundred eighty-five percent (185%) and two 27 hundred fifty percent (250%) of the federal poverty level. The department is further authorized to 28 promulgate any regulations necessary and in accord with Title XIX [42 U.S.C. § 1396 et seq.] and 29 Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act necessary in order to implement 30 said state plan amendment. The services provided shall be in accord with Title XIX [42 U.S.C. § 31 1396 et seq.] and Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act. 32 (b) The secretary of health and human services is authorized and directed to establish a 33 payor of last resort program to cover prenatal, delivery, and postpartum care. The program shall 34 cover the cost of maternity care for any person who lacks health insurance coverage for maternity LC005672 - Page 52 of 79 1 care and who is not eligible for medical assistance under Title XIX [42 U.S.C. § 1396 et seq.] and 2 Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security Act including, but not limited to, a 3 noncitizen pregnant person lawfully admitted for permanent residence on or after August 22, 1996 , 4 without regard to the availability of federal financial participation, provided such pregnant person 5 satisfies all other eligibility requirements. The secretary shall promulgate regulations to implement 6 this program. Such regulations shall include specific eligibility criteria; the scope of services to be 7 covered; procedures for administration and service delivery; referrals for non-covered services; 8 outreach; and public education. 9 (c) The secretary of health and human services may enter into cooperative agreements with 10 the department of health and/or other state agencies to provide services to individuals eligible for 11 services under subsections (a) and (b) above. 12 (d) The following services shall be provided through the program: 13 (1) Ante-partum and postpartum care; 14 (2) Delivery; 15 (3) Cesarean section; 16 (4) Newborn hospital care; 17 (5) Inpatient transportation from one hospital to another when authorized by a medical 18 provider; and 19 (6) Prescription medications and laboratory tests. 20 (e) The secretary of health and human services shall provide enhanced services, as 21 appropriate, to pregnant persons as defined in subsections (a) and (b), as well as to other pregnant 22 persons eligible for medical assistance. These services shall include: care coordination; nutrition 23 and social service counseling; high-risk obstetrical care; childbirth and parenting preparation 24 programs; smoking cessation programs; outpatient counseling for drug-alcohol use; interpreter 25 services; mental health services; and home visitation. The provision of enhanced services is subject 26 to available appropriations. In the event that appropriations are not adequate for the provision of 27 these services, the executive office has the authority to limit the amount, scope, and duration of 28 these enhanced services. 29 (f) The executive office of health and human services shall provide for extended family 30 planning services for up to twenty-four (24) months postpartum. These services shall be available 31 to persons who have been determined eligible for RIte Start or for medical assistance under Title 32 XIX [42 U.S.C. § 1396 et seq.] or Title XXI [42 U.S.C. § 1397aa et seq.] of the Social Security 33 Act. 34 (g) Effective October 1, 2022, individuals eligible for RIte Start pursuant to this section or LC005672 - Page 53 of 79 1 for medical assistance under Title XIX or Title XXI of the Social Security Act while pregnant 2 (including during a period of retroactive eligibility), are eligible for full Medicaid benefits through 3 the last day of the month in which their twelve-month (12) postpartum period ends. This benefit 4 will be provided to eligible Rhode Island residents without regard to the availability of federal 5 financial participation. The executive office of health and human services is directed to ensure that 6 federal financial participation is used to the maximum extent allowable to provide coverage 7 pursuant to this section, and that state-only funds will be used only if federal financial participation 8 is not available. 9 (h) Any person eligible for services under subsections (a) and (b) of this section, or 10 otherwise eligible for medical assistance under Title XIX [42 U.S.C. § 1396 et seq.] and Title XXI 11 [42 U.S.C. § 1397aa et seq.] of the Social Security Act, shall also be entitled to services for any 12 termination of pregnancy permitted under § 23-4.13-2; provided, however, that no federal funds 13 shall be used to pay for such services, except as authorized under federal law. 14 42-12.3-5. Managed care. 15 The delivery and financing of the healthcare services provided pursuant to §§ 42-12.3-3 16 and 42-12.3-4 shall may be provided through a system of managed care. The delivery and financing 17 of the healthcare services provided under this chapter may be provided through a system of 18 managed care. Beginning July 1, 2030, all payments shall be provided directly by the state without 19 an intermediate payment to a managed care entity or other form of health insurance company, 20 unless the intermediate payor is owned by the Medicaid office or another branch of state 21 government. Beginning July 1, 2026 , no new contracts may be entered into between the Medicaid 22 office and an intermediate payor such as a managed care entity or other form of health insurance 23 company for the payment of healthcare services pursuant to this chapter, unless the intermediate 24 payor is owned by the Medicaid office or another branch of state government. 25 A managed care system integrates an efficient financing mechanism with quality service 26 delivery, provides a “medical home” to assure appropriate care and deter unnecessary and 27 inappropriate care, and places emphasis on preventive and primary health care. In developing a 28 managed care system the department of human services shall consider managed care models 29 recognized by the health care financing administration. The department of human services is hereby 30 authorized and directed to seek any necessary approvals or waivers from the U.S. Department of 31 Health and Human Services, Health Care Financing Administration, needed to assure that services 32 are provided through a mandatory managed care system. Certain health services may be provided 33 on an interim basis through a fee for service arrangement upon a finding that there are temporary 34 barriers to implementation of mandatory managed care for a particular population or particular LC005672 - Page 54 of 79 1 geographic area. Nothing in this section shall prohibit the department of human services from 2 providing enhanced services to medical assistance recipients within existing appropriations. 3 42-12.3-7. Financial contributions. 4 The department of human services may not require the payment of enrollment fees, sliding 5 fees, deductibles, copayments, and/or other contributions based on ability to pay. These fees shall 6 be established by rules and regulations to be promulgated by the department of human services or 7 the department of health, as appropriate. 8 42-12.3-9. Insurance coverage — Third-party insurance. 9 (a) No payment will be made nor service provided in the RIte Start or RIte Track program 10 with respect to any health care that is covered or would be covered, by any employee welfare benefit 11 plan under which a woman or child is either covered or eligible to be covered either as an employee 12 or dependent, whether or not coverage under such plan is elected. 13 (b) A premium may be charged for participation in the RIte Track or RIte Start programs 14 for eligible individuals whose family incomes are in excess of two hundred fifty percent (250%) of 15 the federal poverty level and who have voluntarily terminated healthcare insurance within one year 16 of the date of application for benefits under this chapter. 17 (c) (b) Every family who is eligible to participate in the RIte Track program, who has an 18 additional child who because of age is not eligible for RIte Track, or whose child becomes ineligible 19 for RIte Track because of the child’s age, may be offered by the managed care provider with whom 20 the family is enrolled, the opportunity to enroll such ineligible child or children in the same 21 managed care program on a self-pay basis at the same cost, charge, or premium as is being charged 22 to the state under the provisions of this chapter for other covered children within the managed care 23 program. The family may also purchase a package of enhanced services at the same cost or charge 24 to the department. 25 SECTION 17. Section 42-12.3-14 of the General Laws in Chapter 42-12.3 entitled Health 26 Care for Children and Pregnant Women is hereby repealed. 27 42-12.3-14. Benefits and coverage — Exclusion. 28 For as long as the United States Department of Health and Human Services, Health Care 29 Financing Administration Project No. 11-W-0004/1-01 entitled “RIte Care” remains in effect, any 30 healthcare services provided pursuant to this chapter shall be exempt from all mandatory benefits 31 and coverage as may otherwise be provided for in the general laws. 32 SECTION 18. Sections 42-14.5-2 and 42-14.5-3 of the General Laws in Chapter 42-14.5 33 entitled The Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight are 34 hereby amended to read as follows: LC005672 - Page 55 of 79 1 42-14.5-2. Purpose. 2 With respect to health insurance as defined in § 42-14-5, the health insurance commissioner 3 shall discharge the powers and duties of office to: 4 (1) Guard the solvency of health insurers Claw back excessive profits, reserves charges, 5 and other monies that health insurers may have accumulated against the public interest of the people 6 of Rhode Island ; 7 (2) Protect the interests of consumers; 8 (3) Encourage fair treatment of healthcare providers; 9 (4) Encourage policies and developments that improve the quality and efficiency of 10 healthcare service delivery and outcomes; and 11 (5) View the healthcare system as a comprehensive entity and encourage and direct insurers 12 towards policies that advance the welfare of the public through overall efficiency, improved 13 healthcare quality, and appropriate access ; and 14 (6) Facilitate the transformation of the healthcare payments system to a state-level 15 Medicare-for-All system . 16 42-14.5-3. Powers and duties. 17 The health insurance commissioner shall have the following powers and duties: 18 (a) To conduct quarterly public meetings throughout the state, separate and distinct from 19 rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 20 licensed to provide health insurance in the state; the effects of such rates, services, and operations 21 on consumers, medical care providers, patients, and the market environment in which the insurers 22 operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 23 than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 24 Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 25 general, and the chambers of commerce. Public notice shall be posted on the department’s website 26 and given in the newspaper of general circulation, and to any entity in writing requesting notice. 27 (b) To make recommendations to the governor and the house of representatives and senate 28 finance committees regarding healthcare insurance and the regulations, rates, services, 29 administrative expenses, reserve requirements, and operations of insurers providing health 30 insurance in the state, and to prepare or comment on, upon the request of the governor or 31 chairpersons of the house or senate finance committees, draft legislation to improve the regulation 32 of health insurance. In making the recommendations, the commissioner shall recognize that it is 33 the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 34 of individual administrative expenditures as well as total administrative costs. The commissioner LC005672 - Page 56 of 79 1 shall make recommendations on the levels of reserves, including consideration of: targeted reserve 2 levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 3 reserves. 4 (c) To establish a consumer/business/labor/medical advisory council to obtain information 5 and present concerns of consumers, business, and medical providers affected by health insurance 6 decisions. The council shall develop proposals to allow the market for small business health 7 insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 8 the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 9 measures to inform small businesses of an insurance complaint process to ensure that small 10 businesses that experience rate increases in a given year may request and receive a formal review 11 by the department. The advisory council shall assess views of the health provider community 12 relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 13 insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 14 an annual report of findings and recommendations to the governor and the general assembly and 15 present its findings at hearings before the house and senate finance committees. The advisory 16 council is to be diverse in interests and shall include representatives of community consumer 17 organizations; small businesses, other than those involved in the sale of insurance products; and 18 hospital, medical, and other health provider organizations. Such representatives shall be nominated 19 by their respective organizations. The advisory council shall be co-chaired by the health insurance 20 commissioner and a community consumer organization or small business member to be elected by 21 the full advisory council. 22 (d) To establish and provide guidance and assistance to a subcommittee (“the professional- 23 provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 24 composed of healthcare providers and Rhode Island licensed health plans. This subcommittee The 25 health commissioner shall include provide in its annual report and presentation before the house 26 and senate finance committees the following information: 27 (1) A method whereby health plans shall disclose to contracted providers the fee schedules 28 used to provide payment to those providers for services rendered to covered patients; 29 (2) A standardized provider application and credentials verification process, for the 30 purpose of verifying professional qualifications of participating healthcare providers; 31 (3) The uniform health plan claim form utilized by participating providers; 32 (4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 33 hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make 34 facility-specific data and other medical service-specific data available in reasonably consistent LC005672 - Page 57 of 79 1 formats to patients regarding quality and costs. This information would help consumers make 2 informed choices regarding the facilities and clinicians or physician practices at which to seek care. 3 Among the items considered would be the unique health services and other public goods provided 4 by facilities and clinicians or physician practices in establishing the most appropriate cost 5 comparisons; 6 (5) All activities related to contractual disclosure to participating providers of the 7 mechanisms for resolving health plan/provider disputes; 8 (6) The uniform process being utilized for confirming, in real time, patient insurance 9 enrollment status, benefits coverage, including copays and deductibles; 10 (7) Information related to temporary credentialing of providers seeking to participate in the 11 plan’s network and the impact of the activity on health plan accreditation; 12 (8) The feasibility of regular contract renegotiations between plans and the providers in 13 their networks; and 14 (9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 15 (e) To enforce the provisions of title 27 and this title as set forth in § 42-14-5(d). 16 (f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 17 fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 18 (g) To analyze the impact of changing the rating guidelines and/or merging the individual 19 health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 20 insurance market, as defined in chapter 50 of title 27, in accordance with the following: 21 (1) The analysis shall forecast the likely rate increases required to effect the changes 22 recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 23 health insurance market over the next five (5) years, based on the current rating structure and 24 current products. 25 (2) The analysis shall include examining the impact of merging the individual and small- 26 employer markets on premiums charged to individuals and small-employer groups. 27 (3) The analysis shall include examining the impact on rates in each of the individual and 28 small-employer health insurance markets and the number of insureds in the context of possible 29 changes to the rating guidelines used for small-employer groups, including: community rating 30 principles; expanding small-employer rate bonds beyond the current range; increasing the employer 31 group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 32 (4) The analysis shall include examining the adequacy of current statutory and regulatory 33 oversight of the rating process and factors employed by the participants in the proposed, new 34 merged market. LC005672 - Page 58 of 79 1 (5) The analysis shall include assessment of possible reinsurance mechanisms and/or 2 federal high-risk pool structures and funding to support the health insurance market in Rhode Island 3 by reducing the risk of adverse selection and the incremental insurance premiums charged for this 4 risk, and/or by making health insurance affordable for a selected at-risk population. 5 (6) The health insurance commissioner shall work with an insurance market merger task 6 force to assist with the analysis. The task force shall be chaired by the health insurance 7 commissioner and shall include, but not be limited to, representatives of the general assembly, the 8 business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 9 the individual market in Rhode Island, health insurance brokers, and members of the general public. 10 (7) For the purposes of conducting this analysis, the commissioner may contract with an 11 outside organization with expertise in fiscal analysis of the private insurance market. In conducting 12 its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 13 data shall be subject to state and federal laws and regulations governing confidentiality of health 14 care and proprietary information. 15 (8) The task force shall meet as necessary and include its findings in the annual report, and 16 the commissioner shall include the information in the annual presentation before the house and 17 senate finance committees. 18 (h) To establish and convene a workgroup representing healthcare providers and health 19 insurers for the purpose of coordinating the development of processes, guidelines, and standards to 20 streamline healthcare administration that are to be adopted by payors and providers of healthcare 21 services operating in the state. This workgroup shall include representatives with expertise who 22 would contribute to the streamlining of healthcare administration and who are selected from 23 hospitals, physician practices, community behavioral health organizations , each health insurer 24 labor union representing healthcare workers , and other affected entities. The workgroup shall also 25 include at least one designee each from the Rhode Island Medical Society, Rhode Island Council 26 of Community Mental Health Organizations, the Rhode Island Health Center Association, and the 27 Hospital Association of Rhode Island. In any year that the workgroup meets and submits 28 recommendations to the office of the health insurance commissioner, the office of the health 29 insurance commissioner shall submit such recommendations to the health and human services 30 committees of the Rhode Island house of representatives and the Rhode Island senate prior to the 31 implementation of any such recommendations and subsequently shall submit a report to the general 32 assembly by June 30, 2024. The report shall include the recommendations the commissioner may 33 implement, with supporting rationale. The workgroup shall consider and make recommendations 34 for: LC005672 - Page 59 of 79 1 (1) Establishing a consistent standard for electronic eligibility and coverage verification. 2 Such standard shall: 3 (i) Include standards for eligibility inquiry and response and, wherever possible, be 4 consistent with the standards adopted by nationally recognized organizations, such as the Centers 5 for Medicare & Medicaid Services; 6 (ii) Enable providers and payors to exchange eligibility requests and responses on a system- 7 to-system basis or using a payor-supported web browser; 8 (iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 9 coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 10 requirements for specific services at the specific time of the inquiry; current deductible amounts; 11 accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 12 other information required for the provider to collect the patient’s portion of the bill; 13 (iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 14 and benefits information; 15 (v) Recommend a standard or common process to protect all providers from the costs of 16 services to patients who are ineligible for insurance coverage in circumstances where a payor 17 provides eligibility verification based on best information available to the payor at the date of the 18 request of eligibility. 19 (2) Developing implementation guidelines and promoting adoption of the guidelines for: 20 (i) The use of the National Correct Coding Initiative code-edit policy by payors and 21 providers in the state; 22 (ii) Publishing any variations from codes and mutually exclusive codes by payors in a 23 manner that makes for simple retrieval and implementation by providers; 24 (iii) Use of Health Insurance Portability and Accountability Act standard group codes, 25 reason codes, and remark codes by payors in electronic remittances sent to providers; 26 (iv) Uniformity in the processing of claims by payors; and the processing of corrections to 27 claims by providers and payors; 28 (v) A standard payor-denial review process for providers when they request a 29 reconsideration of a denial of a claim that results from differences in clinical edits where no single, 30 common-standards body or process exists and multiple conflicting sources are in use by payors and 31 providers. 32 (vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 33 payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 34 detecting and deterring fraudulent billing activities. The guidelines shall require that each payor LC005672 - Page 60 of 79 1 disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 2 the application of such edits and that the provider have access to the payor’s review and appeal 3 process to challenge the payor’s adjudication decision. 4 (vii) Nothing in this subsection shall be construed to modify the rights or obligations of 5 payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 6 prosecution under applicable law of potentially fraudulent billing activities. 7 (3) Developing and promoting widespread adoption by payors and providers of guidelines 8 to: 9 (i) Ensure payors do not automatically deny claims for services when extenuating 10 circumstances make it impossible for the provider to obtain a preauthorization before services are 11 performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 12 (ii) Require payors to use common and consistent processes and time frames when 13 responding to provider requests for medical management approvals. Whenever possible, such time 14 frames shall be consistent with those established by leading national organizations and be based 15 upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 16 management includes prior authorization of services, preauthorization of services, precertification 17 of services, post-service review, medical-necessity review, and benefits advisory; 18 (iii) Develop, maintain, and promote widespread adoption of a single, common website 19 where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 20 requirements; 21 (iv) Establish guidelines for payors to develop and maintain a website that providers can 22 use to request a preauthorization, including a prospective clinical necessity review; receive an 23 authorization number; and transmit an admission notification; 24 (v) Develop and implement the use of programs that implement selective prior 25 authorization requirements, based on stratification of healthcare providers’ performance and 26 adherence to evidence-based medicine with the input of contracted healthcare providers and/or 27 provider organizations. Such criteria shall be transparent and easily accessible to contracted 28 providers. Such selective prior authorization programs shall be available when healthcare providers 29 participate directly with the insurer in risk-based payment contracts and may be available to 30 providers who do not participate in risk-based contracts; 31 (vi) Require the review of medical services, including behavioral health services, and 32 prescription drugs, subject to prior authorization on at least an annual basis, with the input of 33 contracted healthcare providers and/or provider organizations. Any changes to the list of medical 34 services, including behavioral health services, and prescription drugs requiring prior authorization, LC005672 - Page 61 of 79 1 shall be shared via provider-accessible websites; 2 (vii) Improve communication channels between health plans, healthcare providers, and 3 patients by: 4 (A) Requiring transparency and easy accessibility of prior authorization requirements, 5 criteria, rationale, and program changes to contracted healthcare providers and patients/health plan 6 enrollees which may be satisfied by posting to provider-accessible and member-accessible 7 websites; and 8 (B) Supporting: 9 (I) Timely submission by healthcare providers of the complete information necessary to 10 make a prior authorization determination, as early in the process as possible; and 11 (II) Timely notification of prior authorization determinations by health plans to impacted 12 health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, 13 and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 14 provider-accessible websites or similar electronic portals or services; 15 (viii) Increase and strengthen continuity of patient care by: 16 (A) Defining protections for continuity of care during a transition period for patients 17 undergoing an active course of treatment, when there is a formulary or treatment coverage change 18 or change of health plan that may disrupt their current course of treatment and when the treating 19 physician determines that a transition may place the patient at risk; and for prescription medication 20 by allowing a grace period of coverage to allow consideration of referred health plan options or 21 establishment of medical necessity of the current course of treatment; 22 (B) Requiring continuity of care for medical services, including behavioral health services, 23 and prescription medications for patients on appropriate, chronic, stable therapy through 24 minimizing repetitive prior authorization requirements; and which for prescription medication shall 25 be allowed only on an annual review, with exception for labeled limitation, to establish continued 26 benefit of treatment; and 27 (C) Requiring communication between healthcare providers, health plans, and patients to 28 facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 29 by posting to provider-accessible websites or similar electronic portals or services; 30 (D) Continuity of care for formulary or drug coverage shall distinguish between FDA 31 designated interchangeable products and proprietary or marketed versions of a medication; 32 (ix) Encourage healthcare providers and/or provider organizations and health plans to 33 accelerate use of electronic prior authorization technology, including adoption of national standards 34 where applicable; and LC005672 - Page 62 of 79 1 (x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 2 workgroup meeting may be conducted in part or whole through electronic methods. 3 (4) To provide a report to the house and senate, on or before January 1, 2017, with 4 recommendations for establishing guidelines and regulations for systems that give patients 5 electronic access to their claims information, particularly to information regarding their obligations 6 to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 7 (5) No provision of this subsection (h) shall preclude the ongoing work of the office of 8 health insurance commissioner’s administrative simplification task force, which includes meetings 9 with key stakeholders in order to improve, and provide recommendations regarding, the prior 10 authorization process. 11 (i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 12 thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 13 committee on health and human services, and the house committee on corporations, with: (1) 14 Information on the availability in the commercial market of coverage for anti-cancer medication 15 options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 16 options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 17 utilization and cost-sharing expense. 18 (j) To monitor the adequacy of each health plan’s compliance with the provisions of the 19 federal Mental Health Parity Act, including a review of related claims processing and 20 reimbursement procedures. Findings, recommendations, and assessments shall be made available 21 to the public. 22 (k) To monitor the prevent by regulation transition from fee-for-service and toward global 23 and other alternative payment methodologies for the payment for healthcare services that the health 24 insurance commissioner shall deem against the interest of public health. The health insurance 25 commissioner shall have no power to impose, encourage, or in any way incentivize any rate caps, 26 global budgets, episode-based payments, or capitation structures in the payment models utilized in 27 contracts between health insurers and providers . Alternative payment methodologies should be 28 assessed for their likelihood to promote damage access to affordable health insurance care , health 29 outcomes, and performance. 30 (l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 31 payment variation, including findings and recommendations, subject to available resources. 32 (m) Notwithstanding any provision of the general or public laws or regulation to the 33 contrary, provide a report with findings and recommendations to the president of the senate and the 34 speaker of the house, on or before April 1, 2014, including, but not limited to, the following LC005672 - Page 63 of 79 1 information: 2 (1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 3 27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20, and 41 of title 27, and §§ 27- 4 18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 5 insurance for fully insured employers, subject to available resources; 6 (2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 7 the existing standards of care and/or delivery of services in the healthcare system; 8 (3) A state-by-state comparison of health insurance mandates and the extent to which 9 Rhode Island mandates exceed other states benefits; and 10 (4) Recommendations for amendments to existing mandated benefits based on the findings 11 in subsections (m)(1), (m)(2), and (m)(3) above. 12 (n) On or before July 1, 2014, the office of the health insurance commissioner, in 13 collaboration with the director of health and lieutenant governor’s office, shall submit a report to 14 the general assembly and the governor to inform the design of accountable care organizations 15 (ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value- 16 based payment arrangements, that shall include, but not be limited to: 17 (1) Utilization review; 18 (2) Contracting; and 19 (3) Licensing and regulation. 20 (o) On or before February 3, 2015, the office of the health insurance commissioner shall 21 submit a report to the general assembly and the governor that describes, analyzes, and proposes 22 recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 23 to patients with mental health and substance use disorders. 24 (p) To work to ensure the health insurance coverage of behavioral health care under the 25 same terms and conditions as other health care, and to integrate behavioral health parity 26 requirements into the office of the health insurance commissioner insurance oversight and 27 healthcare transformation efforts. 28 (q) To work with other state agencies to seek delivery system improvements that enhance 29 access to a continuum of mental health and substance use disorder treatment in the state; and 30 integrate that treatment with primary and other medical care to the fullest extent possible. 31 (r) To direct insurers toward policies and practices that address the behavioral health needs 32 of the public and greater integration of physical and behavioral healthcare delivery. 33 (s) The office of the health insurance commissioner shall conduct an analysis of the impact 34 of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and LC005672 - Page 64 of 79 1 submit a report of its findings to the general assembly on or before June 1, 2023. 2 (t) To undertake the analyses, reports, and studies contained in this section: 3 (1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 4 and competent firm or firms to undertake the following analyses, reports, and studies: 5 (i) The firm shall undertake a comprehensive review of all social and human service 6 programs having a contract with or licensed by the state or any subdivision of the department of 7 children, youth and families (DCYF), the department of behavioral healthcare, developmental 8 disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 9 health (DOH), and Medicaid for the purposes of: 10 (A) Establishing a baseline of the eligibility factors for receiving services; 11 (B) Establishing a baseline of the service offering through each agency for those 12 determined eligible; 13 (C) Establishing a baseline understanding of reimbursement rates for all social and human 14 service programs including rates currently being paid, the date of the last increase, and a proposed 15 model that the state may use to conduct future studies and analyses; 16 (D) Ensuring accurate and adequate reimbursement to social and human service providers 17 that facilitate the availability of high-quality services to individuals receiving home and 18 community-based long-term services and supports provided by social and human service providers; 19 (E) Ensuring the general assembly is provided accurate financial projections on social and 20 human service program costs, demand for services, and workforce needs to ensure access to entitled 21 beneficiaries and services; 22 (F) Establishing a baseline and determining the relationship between state government and 23 the provider network including functions, responsibilities, and duties; 24 (G) Determining a set of measures and accountability standards to be used by EOHHS and 25 the general assembly to measure the outcomes of the provision of services including budgetary 26 reporting requirements, transparency portals, and other methods; and 27 (H) Reporting the findings of human services analyses and reports to the speaker of the 28 house, senate president, chairs of the house and senate finance committees, chairs of the house and 29 senate health and human services committees, and the governor. 30 (2) The analyses, reports, and studies required pursuant to this section shall be 31 accomplished and published as follows and shall provide: 32 (i) An assessment and detailed reporting on all social and human service program rates to 33 be completed by January 1, 2023, including rates currently being paid and the date of the last 34 increase; LC005672 - Page 65 of 79 1 (ii) An assessment and detailed reporting on eligibility standards and processes of all 2 mandatory and discretionary social and human service programs to be completed by January 1, 3 2023; 4 (iii) An assessment and detailed reporting on utilization trends from the period of January 5 1, 2017, through December 31, 2021, for social and human service programs to be completed by 6 January 1, 2023; 7 (iv) An assessment and detailed reporting on the structure of the state government as it 8 relates to the provision of services by social and human service providers including eligibility and 9 functions of the provider network to be completed by January 1, 2023; 10 (v) An assessment and detailed reporting on accountability standards for services for social 11 and human service programs to be completed by January 1, 2023; 12 (vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 13 and unlicensed personnel requirements for established rates for social and human service programs 14 pursuant to a contract or established fee schedule; 15 (vii) An assessment and reporting on access to social and human service programs, to 16 include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 17 (viii) An assessment and reporting of national and regional Medicaid rates in comparison 18 to Rhode Island social and human service provider rates by April 1, 2023; 19 (ix) An assessment and reporting on usual and customary rates paid by private insurers and 20 private pay for similar social and human service providers, both nationally and regionally, by April 21 1, 2023; 22 (x) Completion of the development of an assessment and review process that includes the 23 following components: eligibility; scope of services; relationship of social and human service 24 provider and the state; national and regional rate comparisons and accountability standards that 25 result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 26 and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 27 requirements established in section 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 28 1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 29 results and findings of this process shall be transparent, and public meetings shall be conducted to 30 allow providers, recipients, and other interested parties an opportunity to ask questions and provide 31 comment beginning in September 2023 and biennially thereafter; and 32 (xi) On or before September 1, 2026, the office shall publish and submit to the general 33 assembly and the governor a one-time report making and justifying recommendations for 34 adjustments to primary care services reimbursement and financing. The report shall include LC005672 - Page 66 of 79 1 consideration of Medicaid, Medicare, commercial, and alternative contracted payments. 2 (3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 3 insurance commissioner shall consult with the Executive Office of Health and Human Services. 4 (u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 5 include the corresponding components of the assessment and review (i.e., eligibility; scope of 6 services; relationship of social and human service provider and the state; and national and regional 7 rate comparisons and accountability standards including any changes or substantive issues between 8 biennial reviews) including the recommended rates from the most recent assessment and review 9 with their annual budget submission to the office of management and budget and provide a detailed 10 explanation and impact statement if any rate variances exist between submitted recommended 11 budget and the corresponding recommended rate from the most recent assessment and review 12 process starting October 1, 2023, and biennially thereafter. 13 (v) The general assembly shall appropriate adequate funding as it deems necessary to 14 undertake the analyses, reports, and studies contained in this section relating to the powers and 15 duties of the office of the health insurance commissioner. 16 (w) The office of the health insurance commissioner shall: 17 (1) Ensure that insurers minimize administrative burdens that may delay medically 18 necessary care, by promulgating rules and regulations and taking enforcement actions to implement 19 § 27-18.9-16; and 20 (2) Convene the payor/provider workgroup described in subsection (h) of this section, or a 21 similar taskforce, comprised of members with relevant experience and expertise, to serve as a 22 standing advisory steering committee (“committee”) to review and make recommendations 23 regarding: 24 (i) The continuous improvement and simplification of the prior authorization processes for 25 medical services and prescription drugs; 26 (ii) The facilitation of communication and collaboration related to volume reduction; 27 (iii) The establishment of a tracking method to improve the collection of baseline data from 28 commercial health insurers that does not create an administrative burden; 29 (iv) The assessment of prior authorizations that have been approved, those that have been 30 approved with modifications, and the utilization of MRI services in the emergency department; and 31 (v) The assessment of improvements to the access of primary care services and other 32 quality care measures related to the elimination of prior authorizations during this program, 33 including increase in staff availability to perform other office functions; increase in patient 34 appointments; and reduction in care delay. LC005672 - Page 67 of 79 1 (x) To approve or deny any compensation of employees of health insurers subject to the 2 laws of the State of Rhode Island in excess of one million dollars ($1,000,000) per employee. 3 (y) To approve or deny dividends of stock buybacks of health insurers subject to the laws 4 of the State of Rhode Island. 5 (3) Submit such recommendations of the committee with a rationale, to the governor’s 6 office, speaker of the house of representatives, and the president of the senate, prior to the 7 implementation of any such recommendations and subsequently shall submit a full report to the 8 general assembly by July 1 of each year of the pilot program. 9 SECTION 19. Section 44-17-1 of the General Laws in Chapter 44-17 entitled Taxation of 10 Insurance Companies is hereby amended to read as follows: 11 44-17-1. Companies required to file — Payment of tax — Retaliatory rates. 12 (a) Every domestic, foreign, or alien insurance company, mutual association, organization, 13 or other insurer, including any health maintenance organization as defined in § 27-41-2, any 14 medical malpractice insurance joint underwriters association as defined in § 42-14.1-1, any 15 nonprofit dental service corporation as defined in § 27-20.1-2 and any nonprofit hospital or medical 16 service corporation as defined in chapters 19 and 20 of title 27, except companies mentioned in § 17 44-17-6 and organizations defined in § 27-25-1, transacting business in this state, shall, on or before 18 April 15 in each year, file with the tax administrator, in the form that he or she may prescribe, a 19 return under oath or affirmation signed by a duly authorized officer or agent of the company, 20 containing information that may be deemed necessary for the determination of the tax imposed by 21 this chapter, and shall at the same time pay an annual tax to the tax administrator of two percent 22 (2%) of the gross premiums on contracts of insurance, except for ocean marine insurance as referred 23 to in § 44-17-6, covering property and risks within the state, written during the calendar year ending 24 December 31st next preceding. For tax year 2028 and thereafter, this rate shall be increased to four 25 percent (4%). 26 (b) Qualifying insurers for purposes of this section means every domestic, foreign, or alien 27 insurance company, mutual association, organization, or other insurer and excludes: 28 (1) Health maintenance organizations, as defined in § 27-41-2; 29 (2) Nonprofit dental service corporations, as defined in § 27-20.1-2; and 30 (3) Nonprofit hospital or medical service corporations, as defined in §§ 27-19-1 and 27- 31 20-1. 32 (c) For tax years 2018 and thereafter, the rate of taxation may be reduced as set forth below 33 and, if so reduced, shall be fully applicable to qualifying insurers instead of the two percent (2%) 34 rate listed in subsection (a). In the case of foreign or alien companies, except as provided in § 27- LC005672 - Page 68 of 79 1 2-17(d), the tax shall not be less in amount than is imposed by the laws of the state or country under 2 which the companies are organized upon like companies incorporated in this state or upon its 3 agents, if doing business to the same extent in the state or country. The tax rate shall not be reduced 4 for gross premiums written on contracts of health insurance as defined in § 42-14-5(c) but shall 5 remain at two percent (2%) the rate in subsection (a) or the appropriate retaliatory tax rate, 6 whichever is higher. 7 (d) For qualifying insurers, the premium tax rate may be decreased based upon Rhode 8 Island jobs added by the industry as detailed below: 9 (1) A committee shall be established for the purpose of implementing tax rates using the 10 framework established herein. The committee shall be comprised of the following persons or their 11 designees: the secretary of commerce, the director of the department of business regulation, the 12 director of the department of revenue, and the director of the office of management and budget. No 13 rule may be issued pursuant to this section without the prior, unanimous approval of the committee; 14 (2) On the timetable listed below, the committee shall determine whether qualifying 15 insurers have added new qualifying jobs in this state in the preceding calendar year. A qualifying 16 job for purposes of this section is any employee with total annual wages equal to or greater than 17 forty percent (40%) of the average annual wages of the Rhode Island insurance industry, as 18 published by the annual employment and wages report of the Rhode Island department of labor and 19 training, in NAICS code 5241; 20 (3) If the committee determines that there has been a sufficient net increase in qualifying 21 jobs in the preceding calendar year(s) to offset a material reduction in the premium tax, it shall 22 calculate a reduced premium tax rate. Such rate shall be determined via a method selected by the 23 committee and designed such that the estimated personal income tax generated by the increase in 24 qualifying jobs is at least one hundred and twenty-five percent (125%) of the anticipated reduction 25 in premium tax receipts resulting from the new rate. For purposes of this calculation, the committee 26 may consider personal income tax withholdings or receipts, but in no event may the committee 27 include for the purposes of determining revenue neutrality income taxes that are subject to 28 segregation pursuant to § 44-48.3-8(f) or that are otherwise available to the general fund; 29 (4) Any reduced rate established pursuant to this section must be established in a 30 rulemaking proceeding pursuant to chapter 35 of title 42, subject to the following conditions: 31 (i) Any net increase in qualifying jobs and the resultant premium tax reduction and revenue 32 impact shall be determined in any rulemaking proceeding conducted under this section and shall 33 be set forth in a report included in the rulemaking record, which report shall also include a 34 description of the data sources and calculation methods used. The first such report shall also include LC005672 - Page 69 of 79 1 a calculation of the baseline level of employment of qualifying insurers for the calendar year 2015; 2 and 3 (ii) Notwithstanding any provision of the law to the contrary, no rule changing the tax rate 4 shall take effect until one hundred and twenty (120) days after notice of the rate change is provided 5 to the speaker of the house, the president of the senate, the house and senate fiscal advisors, and 6 the auditor general, which notice shall include the report required under the preceding provision. 7 (5) For each of the first three (3) rulemaking proceedings required under this section, the 8 tax rate may remain unchanged or be decreased consistent with the requirements of this section, 9 but may not be increased. These first three (3) rulemaking proceedings shall be conducted by the 10 division of taxation and occur in the following manner: 11 (i) The first rulemaking proceeding shall take place in calendar year 2017. This proceeding 12 shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the requirements 13 of this section, which rate shall take effect in 2018, and (B) A method for calculating the number 14 of jobs at qualifying insurers; 15 (ii) The second rulemaking proceeding shall take place in calendar year 2018. This 16 proceeding shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the 17 requirements of this section, which rate shall take effect in 2019, and (B) The changes, if any, to 18 the method for calculating the number of jobs at qualifying insurers; and 19 (iii) The third rulemaking proceeding shall take place in calendar year 2019. This 20 proceeding shall establish a rule that sets forth: (A) A new premium tax rate, if allowed under the 21 requirements of this section, which rate shall take effect in 2020, and (B) The changes, if any, to 22 the method for calculating the number of jobs at qualifying insurers. 23 (6) The tax rate established in the regulation following regulatory proceedings that take 24 place in 2019 shall remain in effect through and including 2023. In calendar year 2023, the 25 department of business regulation will conduct a rulemaking proceeding and issue a rule that sets 26 forth: (A) A new premium tax rate, if allowed under the requirements of this section, which rate 27 shall take effect in 2024, and (B) The changes, if any, to the method for calculating the number of 28 jobs at qualifying insurers. A rule issued by the department of business regulation may decrease 29 the tax rate if the requirements for a rate reduction contained in this section are met, or it may 30 increase the tax rate to the extent necessary to achieve the overall revenue level sought when the 31 then-existing tax rate was established. Any rate established shall be no lower than one percent (1%) 32 and no higher than two percent (2%). This proceeding shall be repeated every three (3) calendar 33 years thereafter, however, the base for determination of job increases or decreases shall remain the 34 number of jobs existing during calendar year 2022; LC005672 - Page 70 of 79 1 (7) No reduction in the premium tax rate pursuant to this section shall be allowed absent a 2 determination that qualifying insurers have added in this state at least three hundred fifty (350) 3 new, full-time, qualifying jobs above the baseline level of employment of qualifying insurers for 4 the calendar year 2015; 5 (8) Notwithstanding any provision of this section to the contrary, the premium tax rate shall 6 never be set lower than one percent (1%); 7 (9) The division of taxation may adopt implementation guidelines, directives, criteria, rules 8 and regulations pursuant to chapter 35 of title 42 as are necessary to implement this section; and 9 (10) The calculation of revenue impacts under this section is at the sole discretion of the 10 committee established under subsection (d)(1). Notwithstanding any provision of law to the 11 contrary, any administrative action or rule setting a tax rate pursuant to this section or failing or 12 declining to alter a tax rate pursuant to this section shall not be subject to judicial review under 13 chapter 35 of title 42. 14 SECTION 20. Relating to Capital Development Programs - Statewide Referendum. 15 Section 1. Proposition to be submitted to the people. -- At the general election to be held 16 on the Tuesday next after the first Monday in November, 2026, there shall be submitted to the 17 people of the State of Rhode Island, for their approval or rejection, the following proposition: 18 Shall the action of the general assembly, by an act passed at the January 2026 session, 19 authorizing the issuance of a bond, refunding bond, and/or temporary note of the State of Rhode 20 Island for the local capital projects and in the total amount with respect to the projects listed below 21 be approved, and the issuance of a bond, refunding bond, and/or temporary note authorized in 22 accordance with the provisions of said act? 23 Funding 24 The bond, refunding bond and/or temporary note shall be allocated to the Medicaid office 25 for oversight of the funds. 26 Project 27 (1) Group homes, assisted living facilities, and recovery beds $300,000,000 28 Approval of this question will allow the State of Rhode Island to issue general obligation 29 bonds, refunding bonds, and/or temporary notes in an amount not to exceed three hundred million 30 dollars ($300,000,000) for expansion of and investment in Rhode Island Community Living and 31 Supports. One hundred million dollars ($100,000,000) shall be allocated for investment in and 32 expansion of state group homes operated by Rhode Island Community Living and Supports. One 33 hundred million dollars ($100,000,000) shall be allocated for the construction of assisted living- 34 level care facilities for people with mental illnesses and developmental disabilities operated by LC005672 - Page 71 of 79 1 Rhode Island Community Living and Supports for persons who are eligible for Medicaid. One 2 hundred million dollars ($100,000,000) shall be allocated for the construction of inpatient recovery 3 facilities operated by Rhode Island Community Living and Supports for persons who are eligible 4 for Medicaid and suffering from substance abuse issues in need of inpatient recovery services. 5 None of these funds may be allocated to private facilities. 6 (2) Hospital facilities expansion $50,000,000 7 Approval of this question will allow the State of Rhode Island to issue general obligation 8 bonds, refunding bonds, and/or temporary notes in an amount not to exceed fifty million dollars 9 ($50,000,000) for the improvement of state operated hospital facilities. 10 (3) University of Rhode Island Medical School $500,000,000 11 Approval of this question will allow the State of Rhode Island to issue a general obligation 12 bond, refunding bond, and/or temporary note in an amount not to exceed five hundred million 13 dollars ($500,000,000) for the construction of a medical school at the University of Rhode Island. 14 The Medicaid office shall work with the University of Rhode Island Medical School to establish a 15 reasonable annual contribution to fund the debt service on this bond from tuition revenue. While 16 these contributions shall continue until the entire debt service costs are paid, the Medicaid office 17 may allow for an amortization schedule that lasts for up to fifty (50) years. 18 Section 2. Ballot labels and applicability of general election laws. -- The secretary of state 19 shall prepare and deliver to the state board of elections ballot labels for each of the projects provided 20 for in Section 1 hereof with the designations approve or reject provided next to the description 21 of each such project to enable voters to approve or reject each such proposition. The general 22 election laws, so far as consistent herewith, shall apply to this proposition. 23 Section 3. Approval of projects by people. -- If a majority of the people voting on the 24 proposition in Section 1 hereof shall vote to approve any project stated therein, said project shall 25 be deemed to be approved by the people. The authority to issue bonds, refunding bonds and/or 26 temporary notes of the state shall be limited to the aggregate amount for all such projects as set 27 forth in the proposition, which have been approved by the people. 28 Section 4. Bonds for capital development program. -- The general treasurer is hereby 29 authorized and empowered, with the approval of the governor, and in accordance with the 30 provisions of this act to issue capital development bonds in serial form, in the name of and on behalf 31 of the State of Rhode Island, in amounts as may be specified by the governor in an aggregate 32 principal amount not to exceed the total amount for all projects approved by the people and 33 designated as capital development loan of 2026 bonds. Provided, however, that the aggregate 34 principal amount of such capital development bonds and of any temporary notes outstanding at any LC005672 - Page 72 of 79 1 one time issued in anticipation thereof pursuant to Section 7 hereof shall not exceed the total amount 2 for all such projects approved by the people. All provisions in this act relating to bonds shall also 3 be deemed to apply to refunding bonds. 4 Capital development bonds issued under this act shall be in denominations of one thousand 5 dollars ($1,000) each, or multiples thereof, and shall be payable in any coin or currency of the 6 United States which at the time of payment shall be legal tender for public and private debts. 7 These capital development bonds shall bear such date or dates, mature at specified time or 8 times, but not mature beyond the end of the twentieth state fiscal year following the fiscal year in 9 which they are issued; bear interest payable semi-annually at a specified rate or different or varying 10 rates; be payable at designated time or times at specified place or places; be subject to express terms 11 of redemption or recall, with or without premium; be in a form, with or without interest coupons 12 attached; carry such registration, conversion, reconversion, transfer, debt retirement, acceleration 13 and other provisions as may be fixed by the general treasurer, with the approval of the governor, 14 upon each issue of such capital development bonds at the time of each issue. Whenever the 15 governor shall approve the issuance of such capital development bonds, the governor s approval 16 shall be certified to the secretary of state; the bonds shall be signed by the general treasurer and 17 countersigned by the secretary of state and shall bear the seal of the state. The signature approval 18 of the governor shall be endorsed on each bond. 19 Section 5. Refunding bonds for 2026 capital development program. -- The general treasurer 20 is hereby authorized and empowered, with the approval of the governor, and in accordance with 21 the provisions of this act, to issue bonds to refund the 2026 capital development program bonds, in 22 the name of and on behalf of the state, in amounts as may be specified by the governor in an 23 aggregate principal amount not to exceed the total amount approved by the people, to be designated 24 as capital development program loan of 2026 refunding bonds (hereinafter refunding bonds ). 25 The general treasurer with the approval of the governor shall fix the terms and form of any 26 refunding bonds issued under this act in the same manner as the capital development bonds issued 27 under this act, except that the refunding bonds may not mature more than twenty (20) years from 28 the date of original issue of the capital development bonds being refunded. The proceeds of the 29 refunding bonds, exclusive of any premium and accrual interest and net the underwriters cost, and 30 cost of bond insurance, shall, upon their receipt, be paid by the general treasurer immediately to 31 the paying agent for the capital development bonds which are to be called and prepaid. The paying 32 agent shall hold the refunding bond proceeds in trust until they are applied to prepay the capital 33 development bonds. While the proceeds are held in trust, the proceeds may be invested for the 34 benefit of the state in obligations of the United States of America or the State of Rhode Island. LC005672 - Page 73 of 79 1 If the general treasurer shall deposit with the paying agent for the capital development 2 bonds the proceeds of the refunding bonds, or proceeds from other sources, amounts that, when 3 invested in obligations of the United States or the State of Rhode Island, are sufficient to pay all 4 principal, interest, and premium, if any, on the capital development bonds until these bonds are 5 called for prepayment, then such capital development bonds shall not be considered debts of the 6 State of Rhode Island for any purpose starting from the date of deposit of such monies with the 7 paying agent. The refunding bonds shall continue to be a debt of the state until paid. 8 The term bond shall include note, and the term refunding bonds shall include 9 refunding notes when used in this act. 10 Section 6. Proceeds of capital development program. -- The general treasurer is directed to 11 deposit the proceeds from the sale of capital development bonds issued under this act, exclusive of 12 premiums and accrued interest and net the underwriters cost, and cost of bond insurance, in one or 13 more of the depositories in which the funds of the state may be lawfully kept in special accounts 14 (hereinafter cumulatively referred to as such capital development bond fund ) appropriately 15 designated for each of the projects set forth in Section 1 hereof which shall have been approved by 16 the people to be used for the purpose of paying the cost of all such projects so approved. 17 All monies in the capital development bond fund shall be expended for the purposes 18 specified in the proposition provided for in Section 1 hereof under the direction and supervision of 19 the director of administration (hereinafter referred to as director ). The director, or designee, shall 20 be vested with all power and authority necessary or incidental to the purposes of this act, including, 21 but not limited to, the following authority: 22 (1) To acquire land or other real property or any interest, estate, or right therein as may be 23 necessary or advantageous to accomplish the purposes of this act; 24 (2) To direct payment for the preparation of any reports, plans and specifications, and 25 relocation expenses and other costs such as for furnishings, equipment designing, inspecting, and 26 engineering, required in connection with the implementation of any projects set forth in Section 1 27 hereof; 28 (3) To direct payment for the costs of construction, rehabilitation, enlargement, provision 29 of service utilities, and razing of facilities, and other improvements to land in connection with the 30 implementation of any projects set forth in Section 1 hereof; and 31 (4) To direct payment for the cost of equipment, supplies, devices, materials, and labor for 32 repair, renovation, or conversion of systems and structures as necessary for the 2026 capital 33 development program bonds or notes hereunder from the proceeds thereof. No funds shall be 34 expended in excess of the amount of the capital development bond fund designated for each project LC005672 - Page 74 of 79 1 authorized in Section 1 hereof. 2 Section 7. Sale of bonds and notes. --Any bonds or notes issued under the authority of this 3 act shall be sold at not less than the principal amount thereof, in such mode and on such terms and 4 conditions as the general treasurer, with the approval of the governor, shall deem to be in the best 5 interests of the state. 6 Any bonds or notes issued under the provisions of this act and coupons on any capital 7 development bonds, if properly executed by the manual or electronic signatures of officers of the 8 state in office on the date of execution, shall be valid and binding according. to their tenor, 9 notwithstanding that before the delivery thereof and payment therefor, any or all such officers shall 10 for any reason have ceased to hold office. 11 Section 8. Bonds and notes to be tax exempt and general obligations of the state. -- All 12 bonds and notes issued under the authority of this act shall be exempt from taxation in the state and 13 shall be general obligations of the state, and the full faith and credit of the state is hereby pledged 14 for the due payment of the principal and interest on each of such bonds and notes as the same shall 15 become due. 16 Section 9. Investment of monies in fund. -- All monies in the capital development fund not 17 immediately required for payment pursuant to the provisions of this act may be invested by the 18 investment commission, as established by chapter 10 of title 35, entitled state investment 19 commission, pursuant to the provisions of such chapter; provided, however, that the securities in 20 which the capital development fund is invested shall remain a part of the capital development fund 21 until exchanged for other securities; and provided further, that the income from investments of the 22 capital development fund shall become a part of the general fund of the state and shall be applied 23 to the payment of debt service charges of the state, unless directed by federal law or regulation to 24 be used for some other purpose, or to the extent necessary, to rebate to the United States treasury 25 any income from investments (including gains from the disposition of investments) of proceeds of 26 bonds or notes to the extent deemed necessary to exempt (in whole or in part) the interest paid on 27 such bonds or notes from federal income taxation. 28 Section 10. Appropriation. -- To the extent the debt service on these bonds is not otherwise 29 provided, a sum sufficient to pay the interest and principal due each year on bonds and notes 30 hereunder is hereby annually appropriated out of any money in the treasury not otherwise 31 appropriated. 32 Section 11. Advances from general fund. -- The general treasurer is authorized, with the 33 approval of the director and the governor, in anticipation of the issuance of bonds or notes under 34 the authority of this act, to advance to the capital development bond fund for the purposes specified LC005672 - Page 75 of 79 1 in Section 1 hereof, any funds of the state not specifically held for any particular purpose; provided, 2 however, that all advances made to the capital development bond fund shall be returned to the 3 general fund from the capital development bond fund forthwith upon the receipt by the capital 4 development fund of proceeds resulting from the issue of bonds or notes to the extent of such 5 advances. 6 Section 12. Federal assistance and private funds. -- In carrying out this act, the director, or 7 designee, is authorized on behalf of the state, with the approval of the governor, to apply for and 8 accept any federal assistance which may become available for the purpose of this act, whether in 9 the form of a loan or grant or otherwise, to accept the provision of any federal legislation therefor, 10 to enter into, act and carry out contracts in connection therewith, to act as agent for the federal 11 government in connection therewith, or to designate a subordinate so to act. Where federal 12 assistance is made available, the project shall be carried out in accordance with applicable federal 13 law, the rules and regulations thereunder and the contract or contracts providing for federal 14 assistance, notwithstanding any contrary provisions of state law. Subject to the foregoing, any 15 federal funds received for the purposes of this act shall be deposited in the capital development 16 bond fund and expended as a part thereof. The director or designee may also utilize any private 17 funds that may be made available for the purposes of this act. 18 Section 13. Effective Date. -- Sections 1, 2, 3, 10, 11 and 12 of this act shall take effect 19 upon passage. The remaining sections of this act shall take effect when and if the state board of 20 elections shall certify to the secretary of state that a majority of the qualified electors voting on the 21 proposition contained in Section 1 hereof have indicated their approval of all or any projects 22 thereunder. 23 SECTION 21. Rhode Island Medicaid Reform Act of 2008 Joint Resolution. 24 WHEREAS, The General Assembly enacted chapter 12.4 of title 42 entitled The Rhode 25 Island Medicaid Reform Act of 2008 ; and 26 WHEREAS, A legislative enactment is required pursuant to Rhode Island General Laws 27 chapter 12.4 of title 42; and 28 WHEREAS, Rhode Island General Laws § 42-7.2-5(3)(i) provides that the Secretary of the 29 Executive Office of Health and Human Services ( Executive Office ) is responsible for the 30 implementation of Medicaid policies; and 31 WHEREAS, In pursuit of a higher quality system of care, the General Assembly grants 32 legislative approval of the following proposals and directs the Secretary to implement them; and 33 WHEREAS, If implementation requires changes to rules, regulations, procedures, the 34 Medicaid state plan, and/or the section 1115 waiver, the General Assembly directs and empowers LC005672 - Page 76 of 79 1 the Secretary to make said changes; further, adoption of new or amended rules, regulations and 2 procedures may also be required: 3 (a) Raising Nursing Facility Personal Needs Allowance. The Executive Office will raise 4 the personal needs allowance for nursing facility residents to two hundred dollars ($200). 5 (b) Medicare Equivalent Rate. The Executive Office will raise all Medicaid rates, except 6 for hospital rates, dental rates, and outpatient behavioral health rates to equal the Medicare 7 equivalent rate. Specific to early intervention services, a payment of fifty dollars ($50.00) per 8 member per month payment shall be established in addition to these rates, and a floor of fifty 9 percent (50%) rate increase shall be established within the calculation of the Medicare equivalent 10 rate. 11 (c) Setting Outpatient Behavioral Healthcare Rates at one hundred fifty percent (150%) of 12 Medicare Equivalent Rates. The Executive Office will set outpatient behavioral health rates at one 13 hundred fifty percent (150%) of the Medicare equivalent rate. The Executive Office will maximize 14 federal financial participation if and when available, though state-only funds will be used if federal 15 financial participation is not available. 16 (d) FQHC APM Modernization. The Executive Office will make certain modifications to 17 modernize and standardize the alternative payment methodology option for federally qualified 18 health centers. 19 (e) RIteShare Freedom of Choice. The Executive Office will make employee participation 20 in the RIteShare program voluntary. 21 (f) Elderly and Disabled Eligibility Expansion. The Executive Office will expand Medicaid 22 eligibility for elderly and disabled residents to one hundred thirty-three percent (133%) of the 23 federal poverty level. 24 (g) Payments Streamlining. The Executive Office will conduct a multifaceted initiative to 25 begin the phase-out of intermediary payers such as managed care entities, streamlining payments 26 and reducing wasteful expenditures on intermediary payers. 27 (h) End to Health System Transformation Project. The Executive Office will end the Health 28 System Transformation Project to reduce risk exposure to providers and increase the efficiency of 29 the payments system. 30 (i) Rhode Island Mental Health Nursing Facility. The Executive Office will open a state 31 nursing facility to serve patients with significant mental health needs. 32 (j) Dental Optimization. The Executive Office will make an array of changes to dental 33 benefits offered under Medicaid. Rates will be the rates utilized in § 27-18-54; § 27-19-30.1 § 27- 34 20-25.2; and § 27-41-27.2; billing will be extended to teledentistry services, Silver Diamine LC005672 - Page 77 of 79 1 Fluoride (code D1354), and denture billing (codes D5130, D5140, D5221, D5222, D5213, and 2 D5214); the mobile dentistry encounter rate will be raised to the FQHC rate; and a fifty percent 3 (50%) payment shall be established for undeliverable dentures. 4 (k) Transition to State-Level Medicare for All. The Executive Office is empowered to 5 begin the process of negotiating the necessary waivers for a transition to a state-level Medicare for 6 All health care payments system for Rhode Island. These waivers shall include the combining of 7 all federal health care funding streams into the system financing including, but not limited to, 8 Medicaid, Medicare, federal health care tax exemptions, and exchange subsides established 9 pursuant to the U.S. Patient Protection and Affordable Care Act of 2010. The Executive Office 10 plans to begin the transition process after the completion of the raising of the Medicaid system to 11 a Medicare standard of care and the associated stabilization of the Rhode Island health care 12 workforce and provider network; provided, however, that the Executive Office, understanding the 13 complexity of the proposed waiver application, reserves the right to begin the waiver negotiation 14 process before the transition of Medicaid to a Medicare standard is complete. The Executive Office 15 shall only proceed with the waiver and transition should waiver conditions be favorable to the state 16 as a whole, in the judgment of the Executive Office. In the event that a full waiver cannot be 17 complete, and health insurers have been acquired by the Medicaid Office due to insolvency and the 18 Medicaid Office s goal of payer system stabilization, the Executive Office is empowered to seek 19 limited waivers for the streamlining and integration of acquired health insurers with the Medicaid 20 system. The Executive Office shall submit the final approved waiver and transition plan to the 21 general assembly for final approval; now, therefore be it 22 RESOLVED, That the General Assembly hereby approves the proposals stated above in 23 the recitals; and be it further 24 RESOLVED, That the Secretary of the Executive Office of Health and Human Services is 25 authorized to pursue and implement any waiver amendments, state plan amendments, and/or 26 changes to the applicable department s rules, regulations and procedures approved herein and as 27 authorized by chapter 12.4 of title 42; and be it further 28 RESOLVED, That this Joint Resolution shall take effect upon passage. 29 SECTION 22. This act shall take effect upon passage; provided, however, the RICHIP 30 program shall not come into operation until the necessary waivers are obtained, and the final 31 financing proposal is approved by the general assembly. ======== LC005672 ======== LC005672 - Page 78 of 79 EXPLANATION BY THE LEGISLATIVE COUNCIL OF A N A C T RELATING TO HEALTH AND SAFETY -- THE RHODE ISLAND COMPREHENSIVE HEALTH INSURANCE PROGRAM *** 1 This act would establish a universal, comprehensive, affordable single-payer health care 2 insurance program and help control health care costs, which would be referred to as, the Rhode 3 Island Comprehensive Health Insurance Program (RICHIP). The program would be paid for by 4 consolidating government and private payments to multiple insurance carriers into a more 5 economical and efficient improved Medicare-for-all style single-payer program and substituting 6 lower progressive taxes for higher health insurance premiums, co-pays, deductibles and costs due 7 to caps. This program would save Rhode Islanders from the current overly expensive, inefficient 8 and unsustainable multi-payer health insurance system that unnecessarily prevents access to 9 medically necessary health care. 10 This act would take effect upon passage; provided, however, the RICHIP program would 11 not come into operation until the necessary waivers are obtained, and the final financing proposal 12 is approved by the general assembly. ======== LC005672 ======== LC005672 - Page 79 of 79