§ 40-8.5-1.1. Managed health care 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; provides a "medical home" to assure 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 40-8.10 or to be at risk for such 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-health-care-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. Such 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 U.S. 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. Such 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.

History of Section. (P.L. 2008, ch. 100, art. 17, § 6; P.L. 2009, ch. 68, art. 22, § 3; P.L. 2009, ch. 69, § 3; P.L. 2010, ch. 23, art. 20, § 3; P.L. 2016, ch. 142, art. 7, § 4.)