§ 40-8.5-1.1. Managed healthcare delivery systems.
(a) To ensure that all medical assistance beneficiaries, including the elderly and all
individuals with disabilities, have access to quality and affordable health care,
the executive office of health and human services ("executive office�) is authorized
to implement mandatory managed-care health systems.
(b) "Managed care� is defined as systems that: integrate an efficient financing mechanism
with quality service delivery; provide a "medical home� to ensure appropriate care
and deter unnecessary services; and place emphasis on preventive and primary c
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§ 40-8.5-1.1. Managed healthcare delivery systems.
(a) To ensure that all medical assistance beneficiaries, including the elderly and all
individuals with disabilities, have access to quality and affordable health care,
the executive office of health and human services ("executive office�) is authorized
to implement mandatory managed-care health systems.
(b) "Managed care� is defined as systems that: integrate an efficient financing mechanism
with quality service delivery; provide a "medical home� to ensure appropriate care
and deter unnecessary services; and place emphasis on preventive and primary care.
For purposes of this section, managed care systems may also be defined to include
a primary care case-management model, community health teams, and/or other such arrangements
that meet standards established by the executive office and serve the purposes of
this section. Managed care systems may also include services and supports that optimize
the health and independence of beneficiaries who are determined to need Medicaid-funded
long-term care under chapter 8.10 of this title or to be at risk for the care under
applicable federal state plan or waiver authorities and the rules and regulations
promulgated by the executive office. Any Medicaid beneficiaries who have third-party
medical coverage or insurance may be provided such services through an entity certified
by, or in a contractual arrangement with, the executive office or, as deemed appropriate,
exempt from mandatory managed care in accordance with rules and regulations promulgated
by the executive office.
(c) In accordance with § 42-12.4-7, the executive office is authorized to obtain any approval through waiver(s), category
II or III changes, and/or state-plan amendments, from the Secretary of the United
States Department of Health and Human Services, that are necessary to implement mandatory,
managed healthcare delivery systems for all Medicaid beneficiaries. The waiver(s),
category II or III changes, and/or state-plan amendments shall include the authorization
to extend managed care to cover long-term-care services and supports. Authorization
shall also include, as deemed appropriate, exempting certain beneficiaries with third-party
medical coverage or insurance from mandatory managed care in accordance with rules
and regulations promulgated by the executive office.
(d) To ensure the delivery of timely and appropriate services to persons who become eligible
for Medicaid by virtue of their eligibility for a United States Social Security Administration
program, the executive office is authorized to seek any and all data-sharing agreements
or other agreements with the Social Security Administration as may be necessary to
receive timely and accurate diagnostic data and clinical assessments. This information
shall be used exclusively for the purpose of service planning, and shall be held and
exchanged in accordance with all applicable state and federal medical record confidentiality
laws and regulations.