§ 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 such 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 subdivisions (1) and (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.

History of Section. (P.L. 2014, ch. 145, art. 18, § 6; P.L. 2015, ch. 141, art. 5, § 18; P.L. 2016, ch. 142, art. 7, § 6.)