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art.010/4/010/3/010/2

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ARTICLE 10 SUBSTITUTE A

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RELATING TO MEDICAL ASSISTANCE -- MANAGED CARE

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     SECTION 1. Sections 40-8.4-4 and 40-8.4-12 of the General Laws in Chapter 40-8.4

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entitled "Health Care For Families" are hereby amended to read as follows:

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     40-8.4-4. Eligibility. -- (a) Medical assistance for families. - There is hereby established

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a category of medical assistance eligibility pursuant to section 1931 of Title XIX of the Social

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Security Act, 42 U.S.C. section 1396u-1, for families whose income and resources are no greater

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than the standards in effect in the aid to families with dependent children program on July 16,

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1996 or such increased standards as the department may determine. The department of human

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services is directed to amend the medical assistance Title XIX state plan and to submit to the U.S.

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Department of Health and Human Services an amendment to the RIte Care waiver project to

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provide for medical assistance coverage to families under this chapter in the same amount, scope

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and duration as coverage provided to comparable groups under the waiver. The department is

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further authorized and directed to submit such amendments and/or requests for waivers to the

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Title XXI state plan as may be necessary to maximize federal contribution for provision of

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medical assistance coverage under this chapter. However, implementation of expanded coverage

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under this chapter shall not be delayed pending federal review of any Title XXI amendment or

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waiver.

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      (b) Income. - The director of the department of human services is authorized and

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directed to amend the medical assistance Title XIX state plan or RIte Care waiver to provide

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medical assistance coverage through expanded income disregards or other methodology for

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parents or relative caretakers whose income levels are below one hundred eighty-five percent

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(185%) one hundred seventy-five percent (175%) of the federal poverty level.

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      (c) Resources. - Except as provided herein, no family or child shall be eligible for

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medical assistance coverage provided under this section if the combined value of the child's or the

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family's liquid resources exceed ten thousand dollars ($10,000); provided, however, that this

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subsection shall not apply to:

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      (1) children with disabilities who are otherwise eligible for medical assistance coverage

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as categorically needy under Section 134(a) of the Tax Equity and Fiscal Responsibility Act of

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1982 [federal P.L. 97-248] commonly known as Katie Beckett eligible, upon meeting the

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requirements established in Section 1902(e)(3) of the federal Social Security Act; and

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      (2) pregnant women.

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      Liquid Resources are defined as any interest(s) in property in the form of cash or other

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financial instruments or accounts which are readily convertible to cash or cash equivalents. These

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include, but are not limited to: cash, bank, credit union or other financial institution savings,

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checking and money market accounts, certificates of deposit or other time deposits, stocks, bonds,

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mutual funds, and other similar financial instruments or accounts. These do not include

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educational savings accounts, plans, or programs; retirement accounts, plans, or programs; or

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accounts held jointly with another adult, not including a spouse, living outside the same

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household but only to the extent the applicant/recipient family documents the funds are from

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sources owned by the other adult living outside the household, plus the proportionate share of any

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interest, dividend or capital gains thereon. The department is authorized to promulgate rules and

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regulations to determine the ownership and source of the funds in the joint account.

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      (d) (c) Waiver. - The department of human services is authorized and directed to apply

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for and obtain appropriate waivers from the Secretary of the U.S. Department of Health and

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Human Services, including, but not limited to, a waiver of the appropriate provisions of Title

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XIX, to require that individuals with incomes equal to or greater than one hundred fifty percent

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(150%) one hundred seventy-five percent (175%) of the federal poverty level pay a share of the

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costs of their medical assistance coverage provided through enrollment in either the RIte Care

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Program or under the premium assistance program under section 40-8.4-12, in a manner and at an

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amount consistent with comparable cost-sharing provisions under section 40-8.4-12, provided

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that such cost sharing shall not exceed five percent (5%) of annual income for those with annual

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income in excess of one hundred thirty-three percent (133%); and provided, further, that cost-

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sharing shall not be required for pregnant women or children under age one.

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     40-8.4-12. RIte Share Health Insurance Premium Assistance Program. – (1)(a) Basic

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RIte Share Health Insurance Premium Assistance Program.

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      (1) The department of human services is authorized and directed to amend the medical

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assistance Title XIX state plan to implement the provisions of section 1906 of Title XIX of the

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Social Security Act, 42 U.S.C. section 1396e, and establish the Rhode Island health insurance

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premium assistance program for RIte Care eligible parents with incomes up to one hundred

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eighty-five percent (185%) one hundred seventy-five percent (175%) of the federal poverty level

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who have access to employer-based health insurance. The state plan amendment shall require

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eligible individuals with access to employer-based health insurance to enroll themselves and/or

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their family in the employer-based health insurance plan as a condition of participation in the RIte

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Share program under this chapter and as a condition of retaining eligibility for medical assistance

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under chapters 5.1 and 8.4 of this title and/or chapter 12.3 of title 42 and/or premium assistance

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under this chapter, provided that doing so meets the criteria established in section 1906 of Title

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XIX for obtaining federal matching funds and the department has determined that the individual's

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and/or the family's enrollment in the employer-based health insurance plan is cost-effective and

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the department has determined that the employer-based health insurance plan meets the criteria

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set forth in subsection (d). The department shall provide premium assistance by paying all or a

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portion of the employee's cost for covering the eligible individual or his or her family under the

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employer-based health insurance plan, subject to the cost sharing provisions in subsection (b),

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and provided that the premium assistance is cost-effective in accordance with Title XIX, 42

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U.S.C. section 1396 et seq.

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      (2) Resources. - Except as provided herein, no family, individual, or child shall be

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eligible for medical assistance coverage provided under this section if the combined value of the

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child's or family's liquid resources exceeds ten thousand dollars ($10,000); provided, however,

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that this subsection shall not apply to:

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      (i) children with disabilities who are otherwise eligible for medical assistance coverage

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as categorically needy under Section 134(a) of the Tax Equity and Fiscal Responsibility Act of

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1982 [federal P.L. 97-248] commonly known as Katie Beckett eligible, upon meeting the

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requirements established in section 1902(e)(3) of the federal Social Security Act, and

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      (ii) pregnant women.

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      (b) Individuals who can afford it shall share in the cost. - The department of human

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services is authorized and directed to apply for and obtain any necessary waivers from the

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secretary of the United States Department of Health and Human Services, including, but not

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limited to, a waiver of the appropriate sections of Title XIX, 42 U.S.C. section 1396 et seq., to

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require that individuals eligible for RIte Care under this chapter or chapter 12.3 of title 42 with

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incomes equal to or greater than one hundred fifty percent (150%) one hundred thirty-three

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percent (133%) of the federal poverty level pay a share of the costs of health insurance based on

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the individual's ability to pay, provided that the cost sharing shall not exceed five percent (5%) of

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the individual's annual income. The department of human services shall implement the cost-

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sharing by regulation, and shall consider co-payments, premium shares or other reasonable means

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to do so.

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      (c) Current RIte Care enrollees with access to employer-based health insurance. - The

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department of human services shall require any individual who receives RIte Care or whose

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family receives RIte Care on the effective date of the applicable regulations adopted in

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accordance with subsection (f) to enroll in an employer-based health insurance plan at the

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individual's eligibility redetermination date or at an earlier date determined by the department,

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provided that doing so meets the criteria established in the applicable sections of Title XIX, 42

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U.S.C. section 1396 et seq., for obtaining federal matching funds and the department has

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determined that the individual's and/or the family's enrollment in the employer-based health

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insurance plan is cost-effective and has determined that the health insurance plan meets the

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criteria in subsection (d). The insurer shall accept the enrollment of the individual and/or the

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family in the employer-based health insurance plan without regard to any enrollment season

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restrictions.

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      (d) Approval of health insurance plans for premium assistance. - The department of

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human services shall adopt regulations providing for the approval of employer-based health

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insurance plans for premium assistance and shall approve employer-based health insurance plans

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based on these regulations. In order for an employer-based health insurance plan to gain approval,

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the department must determine that the benefits offered by the employer-based health insurance

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plan are substantially similar in amount, scope, and duration to the benefits provided to RIte Care

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eligible persons by the RIte Care program, when the plan is evaluated in conjunction with

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available supplemental benefits provided by the department. The department shall obtain and

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make available to persons otherwise eligible for RIte Care as supplemental benefits those benefits

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not reasonably available under employer-based health insurance plans which are required for RIte

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Care eligible persons by state law or federal law or regulation.

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      (e) Maximization of federal contribution. - The department of human services is

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authorized and directed to apply for and obtain federal approvals and waivers necessary to

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maximize the federal contribution for provision of medical assistance coverage under this section.

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      (f) Implementation by regulation. - The department of human services is authorized and

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directed to adopt regulations to ensure the establishment and implementation of the premium

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assistance program in accordance with the intent and purpose of this section, the requirements of

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Title XIX and any approved federal waivers.

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     SECTION 2. Section 40-21-1 of the General Laws in Chapter 40-21 entitled "Medical

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Assistance - Prescription Drugs" is hereby amended to read as follows:

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     40-21-1. Prescription drug program. -- The department of human services is hereby

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authorized and directed to amend its practices, procedures, regulations and the Rhode Island state

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plan for medical assistance (Medicaid) pursuant to title XIX of the Federal Social Security Act

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[42 U.S.C. section 1396 et seq.]to modify the prescription drug program:

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      (1) To establish a preferred drug list (PDL);

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      (2) To enter into supplemental rebate, discount or other agreements with pharmaceutical

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companies; and

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      (3) To negotiate either state-specific supplemental rebates or to participate in a multi-

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state pooling supplemental rebate program.

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      Determinations of drugs included on the PDL will be made by the State Department of

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Human Services, and a listing of such drugs shall be maintained on a public website. In making

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these determinations, the department shall consider the recommendations of the Medicaid

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Pharmaceutical and Therapeutics Committee, whose membership shall include practicing

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pharmacists and physicians, faculty members of the University of Rhode Island's College of

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Pharmacy, and consumers or consumer representatives. Drugs exempt from the PDL shall

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include: (1) antipsychotics; (2) anti-retrovirals; and (3) organ transplant medications. Physicians

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will be informed about prior authorization procedures for medications not on the PDL, and

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seventy-two (72) hour emergency supplies may be dispensed if authorizations cannot be obtained.

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     (4) To mandate the dispensing of generic drugs to individuals eligible for medical

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assistance (Medicaid) under sections 40-8.4-4, 42-12.3-4 and 42-12.3-15.

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     SECTION 3. This article shall take effect as of July 1, 2008.