§ 40-8.13-1. Definitions. For purposes of this section the following terms shall have the meanings indicated: (1) “Beneficiary” means an individual who is eligible for medical assistance under the Rhode Island Medicaid state plan established in accordance with 42 U.S.C. § 1396, and includes individuals who are additionally eligible for benefits under the Medicare program […]
§ 40-8.13-10. Care transitions. In the event that a beneficiary: (1) Has been determined to meet level-of-care requirements for nursing facility coverage as of the date of his or her enrollment in a managed care organization; or (2) Has been determined to meet level of care requirements for nursing facility coverage by a managed care […]
§ 40-8.13-11. Reporting requirements. EOHHS shall report to the general assembly and shall make available to interested persons a separate accounting of state expenditures for long-term-care supports and services under any managed long-term-care arrangement, specifically and separately identifying expenditures for home- and community-based services, assisted-living services, hospice services within nursing facilities, hospice services outside of […]
§ 40-8.13-12. [Repealed.] History of Section.P.L. 2015, ch. 141, art. 5, § 19; P.L. 2019, ch. 88, art. 13, § 9; repealed by P.L. 2021, ch. 162, art. 12, § 7, effective July 1, 2021.
§ 40-8.13-2. Beneficiary choice. Any managed long-term-care arrangement shall offer beneficiaries the option to decline participation and remain in traditional Medicaid and, if a duals demonstration project, traditional Medicare. Beneficiaries must be provided with sufficient information to make an informed choice regarding enrollment, including: (1) Any changes in the beneficiary’s payment or other financial obligations […]
§ 40-8.13-3. Ombudsman process. EOHHS shall designate an ombudsperson to advocate for beneficiaries enrolled in a managed long-term-care arrangement. The ombudsperson shall advocate for beneficiaries through complaint and appeal processes and ensure that necessary healthcare services are provided. At the time of enrollment, a managed care organization must inform enrollees of the availability of the […]
§ 40-8.13-4. Provider/plan liaison. EOHHS shall designate an individual, not employed by or otherwise under contract with a participating managed care organization, who shall act as liaison between healthcare providers and managed care organizations, for the purpose of facilitating communications and ensuring that issues and concerns are promptly addressed. History of Section.P.L. 2014, ch. 145, […]
§ 40-8.13-5. Financial principles under managed care. (a) To the extent that financial savings are a goal under any managed long-term-care arrangement, it is the intent of the legislature to achieve savings through administrative efficiencies, care coordination, improvements in care outcomes and in a way that encourages the highest quality care for patients and maximizes […]
§ 40-8.13-6. Payment incentives. In order to encourage quality improvement and promote appropriate utilization incentives for providers in a managed long-term-care arrangement, a managed care organization may use incentive or bonus payment programs that are in addition to the rates identified in § 40-8.13-5. History of Section.P.L. 2014, ch. 145, art. 18, § 6.
§ 40-8.13-7. Willing provider. A managed care organization must contract with and cover services furnished by any nursing facility licensed under chapter 17 of title 23 and certified by CMS that provides Medicaid-covered nursing facility services pursuant to a provider agreement with the state, provided that the nursing facility is not disqualified under the managed […]
§ 40-8.13-8. Level-of-care tool. A managed long-term-care arrangement must require that all participating managed care organizations use only the EOHHS level-of-care tool in determining coverage of long-term-care supports and services for beneficiaries. EOHHS may amend the level-of-care tool provided that any changes are established in consultation with beneficiaries and providers of Medicaid-covered long-term-care supports and […]
§ 40-8.13-9. Case management/plan of care. No managed care organization acting under a managed long-term-care arrangement may require a provider to change a plan of care if the provider reasonably believes that such an action would conflict with the provider’s responsibility to develop an appropriate care plan under state and federal regulations. History of Section.P.L. […]
