S2573 AN ACT RELATING TO HEALTH AND SAFETY -- THE RHODE ISLAND…

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S2573

2026 -- S 2573
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LC004685
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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:
Senators Bell, Ujifusa, Valverde, Kallman, Murray, and Mack

Date Introduced:
February 13, 2026

Referred To:
Senate Health & Human Services
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;

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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

LC004685 - Page 3 of 79
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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

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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

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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

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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;

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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;

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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

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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;

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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.

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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.

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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;

LC004685 - 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

LC004685 - 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.

LC004685 - 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

LC004685 - 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;

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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.

LC004685 - 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.

LC004685 - 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.

LC004685 - 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.

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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.

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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.

LC004685 - 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,

LC004685 - 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.

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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:

LC004685 - 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

LC004685 - 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

LC004685 - 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.

LC004685 - 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:

LC004685 - 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

LC004685 - 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,

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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;

LC004685 - 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

LC004685 - 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.

LC004685 - 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-

LC004685 - 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

LC004685 - 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;

LC004685 - 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

LC004685 - 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

LC004685 - 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.

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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

LC004685 - 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.
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LC004685 - 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.
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LC004685 - Page 79 of 79
Plain English Breakdown

Bill History

Official Summary Text

Current Bill Text
