"Transformative" Medicaid Funding Clears RI House Finance Committee

CPNRI Advocacy Day at the RI STate House 2024 - Photo Courtesy CPNRI

By Gina Macris

The House Finance Committee has recommended Rhode Island fully fund nearly $160 million in Medicaid rate hikes for a broad range of community social and human services – nearly tripling spending proposed by Governor Dan McKee.

The measure, believed to be the largest single-year Medicaid hike in Rhode Island, still needs formal approval by the full House and Senate as part of the next state budget.

But the fact that it cleared the powerful House Finance Committee May 31 signals that General Assembly leadership is prepared to turn aside McKee’s proposal to phase in the rate hikes over three years and slow down the pace of future rate reviews. McKee’s plan was not well received by the Senate Finance Committee in a hearing May 2.

The recommended reimbursement hikes, some totaling more than 50 percent, would apply to privately-run organizations that provide a wide swath of services, from early intervention for babies with disabilities, to treatment for substance use disorder for adults, to supports for the aging. Other services include treatment for autism and behavioral problems, juvenile justice, vocational, and rehabilitation services.

The rate hikes were recommended by the state’s Office of the Health Insurance Commissioner (OHIC), following legislation passed in 2022 that required the office to conduct a review of federal-state Medicaid reimbursement rates every other year.

The goal is to enable service providers in Rhode Island to pay their workers wages competitive to those in neighboring Massachusetts and other New England states.

McKee had put a total of $56 million in federal-state Medicaid funding into his budget proposal. But the House Finance Committee added $103.2 million, for a total of $159.2 million. The committee raised the state’s share from $22.1 million to $62.4 million.

The proposed Medicaid spending could serve as a sign of good faith in talks expected between the state and the Justice Department to resolve alleged civil rights violations of more than 500 children and adolescents, which the federal government said were “warehoused” at the state’s only pediatric psychiatric hospital between 2017 and 2022 for lack of community options.

The state Department of Children, Youth and Families has indicated a willingness to cooperate with the U.S. Attorney’s Office, which announced May 13 the results of a joint two-year investigation with Office of Civil Rights in the U.S. Department of Health and Human Services.

U.S. Attorney Zachary Cunha said the state had violated the Integration Mandate of the federal Americans With Disabilities Act by failing to provide services to children with behavioral health needs in the most integrated setting appropriate.

The House Finance Committee’s move to fully fund the OIHC recommended Medicaid payments won quick praise from a major organization representing service agencies.

The Community Provider Network of Rhode Island, which represents three dozen service providers for people with intellectual and developmental disabilities, said through a spokesperson that the committee’s proposal represents the largest single-year investment in Medicaid services in Rhode Island.

“This investment will have a transformative impact on people with disabilities, seniors, children, families and more,” the spokesman said, in urging the House and Senate to pass the measure as proposed.

Added Grace Duffy, CPNRI Policy Coordinator, “Fully funding rate reform is a significant step in making sure people with disabilities receive the support they need.”

She continued,”This investment is a pledge to build a state where everyone, regardless of ability, has the opportunity to thrive.”

The name of the Department of Children, Youth and Families was misstated in the original version of this article and has been corrected.

Bill Promoting Olmstead Plan Passes RI Senate

By Gina Macris

The Rhode Island Senate on May 21 passed a bill that would lead to an Olmstead plan for funding an array of community-based health and human services to prevent the unnecessary segregation of children and adults with disabilities.

The bill is moving through the General Assembly at a critical time, just a week after U.S. Attorney Zachary A. Cunha alleged the state has failed “miserably and repeatedly” to meet its legal obligations to provide appropriate services to children with mental health and developmental disabilities in their communities.

Instead, children and adolescents have been “warehoused” at the state’s only children’s psychiatric hospital, Bradley Hospital in East Providence, Cunha said, calling the state’s reliance on a single option an “appalling failure.”

The state must respond by tomorrow, May 23, to alleged violations of the Integration Mandate of the Americans with Disabilities Act (ADA), according to a spokesman for Cunha.

The Senate’s proposed Olmstead plan takes its name from a 1999 U.S. Supreme Court decision which reinforced the Integration Mandate of the ADA. The decision said the ADA requires public services for people with disabilities to be offered in the least restrictive environment that is therapeutically appropriate, and that environment is presumed to be the community.

Rhode Island is the only state in New England and one of seven in the nation that does not have an Olmstead plan, said Sen. Louis DiPalma, D-Middletown, in describing the bill on the floor of the Senate.

Last week’s allegations of civil rights violations serve as a prime example of the reason the state needs such a plan, said DiPalma, the chief sponsor of the legislation.

The bill, which has been sent to the House, would establish a 25-member commission to make annual recommendations for “integration for all” to the governor and the General Assembly, beginning on Jan. 15, 2025. The bill also requires the commission to do a comprehensive assessment of needs and accomplishments every five years.

More immediately, a spokeswoman for Governor Dan McKee has said the state will cooperate with the DOJ to resolve the brand new Olmstead civil rights allegations.

The findings, the result of a joint investigation of the U.S. Attorney’s Office and the Department of Health and Human Services, make two broad recommendations:

· The state must ensure that existing community-based services are available in sufficient quantity to prevent long and repeated hospitalizations at Bradley. These services include intensive in-home and community services, crisis services, and therapeutic foster care.

· The state Department of Children, Youth, and Families must make improvements in discharge planning to smooth the way for a prompt transition to the most integrated setting that is appropriate.

Rhode Island has a new law that could go a long way toward adequately funding community-based children’s services and satisfying the demands of the Olmstead complaint.

In 2022, the General Assembly enacted a requirement that all federal-state Medicaid reimbursement rates for struggling community-based social and human services undergo a review every two years by the Office of the Health Insurance Commissioner (OHIC).

The first OHIC rate review recommended hefty hikes which would have cost an estimated $90 million in state revenue in a single year, according to a spokeswoman for Governor McKee.

That does not include more than $50 million for health care providers outside the OHIC review and $29.1 million for Certified Community Behavioral Health Clinics, she said.

The governor has recommended implementing the recommended OHIC rates over three years, including $22.1 million that would represent the state’s share of the federal-state Medicaid match in the next fiscal year. He would also slow the pace of future rate reviews in each of four categories of services to once every four years.

But companion bills sponsored by DiPalma and Rep. Tina Spears, (D-Charlestown, South Kingstown, New Shoreham, and Westerly,) in the House would require the governor to use figures from OHIC rate recommendations in his budget. It would also require the twice-yearly caseload estimating conference to adopt the latest OHIC rate recommendations in advising the governor and the General Assembly on Medicaid costs for the next budget year.

In an email to supporters, Spears says those two bills “gained traction” after 100 advocates went to the State House May 14.

Grass roots advocacy for those relying on a broad array of community-based health and human services has been a hard slog for nearly 15 years.

In 2014, the state entered into an Olmstead consent decree with the DOJ to end the segregation of adults with developmental disabilities. It was not until 2021, when it faced the threat of heavy fines for alleged non-compliance, that the state began overhauling Medicaid rates to community service providers and changing its approach to services for adults with developmental disabilities.

Those changes are still underway, and federal oversight continues in the developmental disabilities case.

Consent Decree Drives Proposed Hike In RI DD Spending

By Gina Macris

Rhode Island Governor Dan McKee would add more than $30 million to developmental disabilities spending to raise starting pay for direct care workers to $20 an hour, hike dozens of reimbursement rates to private service providers, and add ten new staff to help implement a 2014 consent decree.

The pay increase, costing $29.9 million in federal-state Medicaid funding, would be the third annual hike intended to help private agencies and the so-called “self-directed” population managing their own service programs. The wage increase would comply with a federal court order that dates back two years.

In 2021, when the starting wage for direct care workers was $13.18 an hour, Chief Judge John J. McConnell, Jr. ordered the state to raise wages to $20 an hour by 2024, calling a lack of staff the single biggest barrier to implementing the day-to-day requirements of the consent decree, albeit not the only one.

In 2022, with pay raised to $15.75 an hour, the Rhode Island system added 106 new direct care workers from January through June.

On July 1, 2022, the starting pay increased again to $18 an hour, and the state, prodded by the court, launched a workforce initiative to recruit candidates for direct care jobs. In September alone, the system filled 146 vacancies, according to data collected by an independent court monitor.

Yet there were still 693 vacancies in some three dozen private agencies and as many as 1,000 job openings among self-directed consumers and families, the monitor reported in early November.

overview of proposed DD spending - RI Department of Administration

In all, McKee seeks a total of nearly $417.4 million for all developmental disability services in the fiscal year beginning July 1, including slightly more than $385 million for the privately-run system, the backbone of consent decree compliance. That figure for private agency and self-directed services represents a bump of about $32.2 million over the current allocation of about $352.9 million.

A parallel network of state-run group homes would get $32.4 million in the next budget, or almost $1.8 million more than the current funding level of $30.8 million.

The budget for the next fiscal year, July 1,2023-June 30, 2024, will finance the state’s final push to comply with the consent decree before the deadline on June 30, 2024.

The state agreed in 2014 that by mid-2024, it would eliminate sheltered workshops paying sub-minimum wages and move away from isolated day care centers. Instead, there would be a de-centralized network of individualized services enabling adults with developmental disabilities to become integrated in their communities.

The Department of Justice (DOJ) has said that Rhode Island will likely miss the 2024 deadline if it moves at the current pace. The DOJ cited numerous factors contributing to a lack of services, particularly the individualized services in the community that are the cornerstone of the consent decree. A far-reaching federal court order issued Dec. 6 lists some 50 requirements that must be completed by the deadline on June 30, 2024.

McKee wants the new consent decree implementation staff on board as early as possible.

A spokesman for the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) said the department hopes to complete the hiring process by the fourth quarter, which runs from April through June. The cost for these added workers would be $203,275 for the first full year, taking into account federal Medicaid reimbursements and savings from staff turnover in other positions, according to McKee’s executive summary of the spending plan.

Eight of the ten positions will be permanently added to the Division of Developmental Disabilities (DDD), the BHDDH spokesman said.

The DDD jobs include:

• an “interdepartmental project manager”

• a “chief of staff for development training and continuous quality improvement”

• ·an “associate administrator for community services”

• five positions promoting community development as it relates to adults with developmental disabilities

The salaries will range from $66,162 to $95,552 a year, the BHDDH spokesman said.

Two other employees not attached to BHDDH will help implement an outside consultant’s recommendations for reimbursement rates for private providers.

Undertaking a rate review itself was part of a court order issued in October, 2021. Consultants disclosed preliminary recommendations last September that called for increases ranging from about 25 percent to 97 percent in dozens of reimbursement categories to private providers.

But McKee said in an executive summary of the budget that the consultant’s report is “currently under review and may further increase the recommended amount of financing” allocated to the private developmental disabilities system.

Among other actions, the Dec. 6 court order requires the state to identify successful pilot programs promoting integration that have been developed by private service providers during the past year and make those programs available to all those who want them, regardless of the way consultants have structured reimbursements to the private sector.

The consent decree has brought more transparency to budgeting by generating pressure on the General Assembly to include adults with developmental disabilities in the biannual caseload estimating conference, a public process used to project the state’s obligations for public assistance, like food stamps. Developmental disability costs were added in 2021.

The most recent caseload estimating conference, in November, projected there will be $8.5 million less in reimbursements to private service providers than budgeted for the current fiscal year because the population is expected to use fewer support services than initially budgeted.

McKee’s proposal takes the caseload estimating conference projections into account, as well as other related costs, in reducing developmental disabilities services by about $4.4 million, from about $352.9 million to about $348.5 million, in the current fiscal year.

The caseload estimating conference also highlighted the fact that consumers and families often must appeal individual budget allocations to get needed services – a feature of the current reimbursement system which the federal court has cited as a weakness.

Projections for the current fiscal year include $22.8 million in successful appeals, or $5.8 million more than budgeted. An independent court monitor has said consumers should not have to make lengthy appeals to get the individualized services to which they are entitled.

The consent decree draws its authority from the Supreme Court’s Olmstead decision, re-affirmed the Integration Mandate of the Americans With Disabilities Act, requiring public services for all persons with disabilities to help them lead regular lives in the their communities.

Developmental disabilities funding makes up about two thirds of the overall BHDDH budget, which is currently funded at about $597.1 million. McKee would raise the BHDDH total to about $619.6 million in the next fiscal year, with more than half the revenue coming from federal Medicaid reimbursements.