§ 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 value for the managed-care organization
and the state. Therefore, any managed long-term-care arrangement shall include a requirement
that the managed care organization reimburse providers for services in accordance
with these principles. Notwithstanding any law to the contrary, for the twelve-month
(12) period beginning July 1, 2015, Medicaid managed long-term-care payment rates
to nursing facilities established pursuant to this section shall not exceed ninety-eight
percent (98.0%) of the rates in effect on April 1, 2015.
(1) For a duals demonstration project, the managed care organization:
(i) Shall not combine the rates of payment for post-acute skilled and rehabilitation care
provided by a nursing facility and long-term and chronic care provided by a nursing
facility in order to establish a single-payment rate for dual eligible beneficiaries
requiring skilled nursing services;
(ii) Shall pay nursing facilities providing post-acute skilled and rehabilitation care
or long-term and chronic care rates that reflect the different level of services and
intensity required to provide these services; and
(iii) For purposes of determining the appropriate rate for the type of care identified in
subsection (a)(1)(ii) of this section, the managed care organization shall pay no
less than the rates that would be paid for that care under traditional Medicare and
Rhode Island Medicaid for these service types. The managed care organization shall
not, however, be required to use the same payment methodology.
The state shall not enter into any agreement with a managed care organization in connection
with a duals demonstration project unless that agreement conforms to this section,
and any existing such agreement shall be amended as necessary to conform to this subsection.
(2) For a managed long-term-care arrangement that is not a duals demonstration project,
the managed care organization shall reimburse providers in an amount not less than
the amount that would be paid for the same care by the executive office of health
and human services under the Medicaid program. The managed care organization shall
not, however, be required to use the same payment methodology as the executive office
of health and human services.
(3) Notwithstanding any provisions of the general or public laws to the contrary, the
protections of subsections (a)(1) and (a)(2) of this section may be waived by a nursing
facility in the event it elects to accept a payment model developed jointly by the
managed care organization and skilled nursing facilities, that is intended to promote
quality of care and cost-effectiveness, including, but not limited to, bundled-payment
initiatives, value-based purchasing arrangements, gainsharing, and similar models.
(b) Notwithstanding any law to the contrary, for the twelve-month (12) period beginning
July 1, 2015, Medicaid managed long-term-care payment rates to nursing facilities
established pursuant to this section shall not exceed ninety-eight percent (98.0%)
of the rates in effect on April 1, 2015.