§ 40-8.9-9 - Long-term care re-balancing system reform goal.
SECTION 40-8.9-9
§ 40-8.9-9 Long-term care re-balancingsystem reform goal. – (a) Notwithstanding any other provision of state law, the department of humanservices is authorized and directed to apply for and obtain any necessarywaiver(s), waiver amendment(s) and/or state plan amendments from the secretaryof the United States department of health and human services, and to promulgaterules necessary to adopt an affirmative plan of program design andimplementation that addresses the goal of allocating a minimum of fifty percent(50%) of Medicaid long-term care funding for persons aged sixty-five (65) andover and adults with disabilities excluding services for persons withdevelopmental disabilities to home and community-based care on or beforeDecember 31, 2013; provided, further, the executive office of health and humanservices shall report annually as part of its budget submission, thepercentage distribution between institutional care and home andcommunity-based care by population and shall report current and projectedwaiting lists for long-term care and home and community-based care services.The department is further authorized and directed to prioritize investments inhome and community-based care and to maintain the integrity and financialviability of all current long-term care services while pursuing this goal.
(b) The reformed long-term care system re-balancing goal isperson-centered and encourages individual self-determination, familyinvolvement, interagency collaboration, and individual choice through theprovision of highly specialized and individually tailored home-based services.Additionally, individuals with severe behavioral, physical, or developmentaldisabilities must have the opportunity to live safe and healthful lives throughaccess to a wide range of supportive services in an array of community-basedsettings, regardless of the complexity of their medical condition, the severityof their disability, or the challenges of their behavior. Delivery of servicesand supports in less costly and less restrictive community settings, willenable children, adolescents and adults to be able to curtail, delay or avoidlengthy stays in long-term care institutions, such as behavioral healthresidential treatment facilities, long-term care hospitals, intermediate carefacilities and/or skilled nursing facilities.
(c) Pursuant to federal authority procured under §42-7.2-16 of the general laws, the department of human services is directed andauthorized to adopt a tiered set of criteria to be used to determineeligibility for services. Such criteria shall be developed in collaborationwith the state's health and human services departments and, to the extentfeasible, any consumer group, advisory board, or other entity designated forsuch purposes, and shall encompass eligibility determinations for long-termcare services in nursing facilities, hospitals, and intermediate carefacilities for the mentally retarded as well as home and community-basedalternatives, and shall provide a common standard of income eligibility forboth institutional and home and community-based care. The department is,subject to prior approval of the general assembly, authorized to adoptcriteria for admission to a nursing facility, hospital, or intermediate carefacility for the mentally retarded that are more stringent than those employedfor access to home and community-based services. The department is alsoauthorized to promulgate rules that define the frequency of re-assessments forservices provided for under this section. Legislatively approved levels of caremay be applied in accordance with the following:
(1) The department shall apply pre-waiver level of carecriteria for any Medicaid recipient eligible for a nursing facility, hospital,or intermediate care facility for the mentally retarded as of June 30, 2009,unless the recipient transitions to home and community based services becausehe or she: (a) Improves to a level where he/she would no longer meet the pre-waiver level of care criteria; or (b) The individual chooses home and communitybased services over the nursing facility, hospital, or intermediate carefacility for the mentally retarded. For the purposes of this section, a failedcommunity placement, as defined in regulations promulgated by the department,shall be considered a condition of clinical eligibility for the highest levelof care. The department shall confer with the long-term care ombudsperson withrespect to the determination of a failed placement under the ombudsperson'sjurisdiction. Should any Medicaid recipient eligible for a nursing facility,hospital, or intermediate care facility for the mentally retarded as of June30, 2009 receive a determination of a failed community placement, therecipient shall have access to the highest level of care; furthermore, arecipient who has experienced a failed community placement shall betransitioned back into his or her former nursing home, hospital, orintermediate care facility for the mentally retarded whenever possible.Additionally, residents shall only be moved from a nursing home, hospital, orintermediate care facility for the mentally retarded in a manner consistentwith applicable state and federal laws.
(2) Any Medicaid recipient eligible for the highest level ofcare who voluntarily leaves a nursing home, hospital, or intermediate carefacility for the mentally retarded shall not be subject to any wait list forhome and community based services.
(3) No nursing home, hospital, or intermediate care facilityfor the mentally retarded shall be denied payment for services rendered to aMedicaid recipient on the grounds that the recipient does not meet level ofcare criteria unless and until the department of human services has: (i)performed an individual assessment of the recipient at issue and providedwritten notice to the nursing home, hospital, or intermediate care facilityfor the mentally retarded that the recipient does not meet level of carecriteria; and (ii) the recipient has either appealed that level of caredetermination and been unsuccessful, or any appeal period available to therecipient regarding that level of care determination has expired.
(d) The department of human services is further authorizedand directed to consolidate all home and community-based services currentlyprovided pursuant to § 1915(c) of title XIX of the United States Code intoa single system of home and community-based services that include options forconsumer direction and shared living. The resulting single home andcommunity-based services system shall replace and supersede all § 1915(c)programs when fully implemented. Notwithstanding the foregoing, the resultingsingle program home and community-based services system shall include thecontinued funding of assisted living services at any assisted living facilityfinanced by the Rhode Island housing and mortgage finance corporation prior toJanuary 1, 2006, and shall be in accordance with chapter 66.8 of title 42 ofthe general laws as long as assisted living services are a covered Medicaidbenefit.
(e) The department of human services is authorized topromulgate rules that permit certain optional services including, but notlimited to, homemaker services, home modifications, respite, and physicaltherapy evaluations to be offered subject to availability of state-appropriatedfunding for these purposes.
(f) To promote the expansion of home and community-basedservice capacity, the department of human services is authorized and directedto pursue rate reform for homemaker, personal care (home health aide) and adultday care services, as follows:
(1) A prospective base adjustment effective, not later thanJuly 1, 2008, across all departments and programs, of ten percent (10%) of theexisting standard or average rate, contingent upon a demonstrated increase inthe state-funded or Medicaid caseload by June 30, 2009;
(2) Development, not later than September 30, 2008, ofcertification standards supporting and defining targeted rate increments toencourage service specialization and scheduling accommodations including, butnot limited to, medication and pain management, wound management, certifiedAlzheimer's Syndrome treatment and support programs, and shift differentialsfor night and week-end services; and
(3) Development and submission to the governor and thegeneral assembly, not later than December 31, 2008, of a proposed rate-settingmethodology for home and community-based services to assure coverage of thebase cost of service delivery as well as reasonable coverage of changes in costcaused by wage inflation.
(g) The department, in collaboration with the executiveoffice of human services, shall implement a long-term care options counselingprogram to provide individuals or their representatives, or both, withlong-term care consultations that shall include, at a minimum, informationabout: long-term care options, sources and methods of both public and privatepayment for long-term care services and an assessment of an individual'sfunctional capabilities and opportunities for maximizing independence. Eachindividual admitted to or seeking admission to a long-term care facilityregardless of the payment source shall be informed by the facility of theavailability of the long-term care options counseling program and shall beprovided with long-term care options consultation if they so request. Eachindividual who applies for Medicaid long-term care services shall be providedwith a long-term care consultation.
(h) The department of human services is also authorized,subject to availability of appropriation of funding, to pay for certainexpenses necessary to transition residents back to the community; provided,however, payments shall not exceed an annual or per person amount.
(i) To assure the continued financial viability of nursingfacilities, the department of human services is authorized and directed todevelop a proposal for revisions to § 40-8-19 that reflect the changes incost and resident acuity that result from implementation of this re-balancinggoal. Said proposal shall be submitted to the governor and the general assemblyon or before January 1, 2010.
(j) To ensure persons with long-term care needs who remainliving at home have adequate resources to deal with housing maintenance andunanticipated housing related costs, the department of human services isauthorized to develop higher resource eligibility limits for persons on homeand community waiver services who are living in their own homes or rentalunits.