H 7825

2026 -- H 7825
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LC005093
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  STATE  OF        RHODE  ISLAND
  IN GENERAL ASSEMBLY
  JANUARY SESSION, A.D. 2026
  ____________
  AN ACT
   RELATING TO STATE AFFAIRS AND GOVERNMENT -- OFFICE OF HEALTH AND
  HUMAN SERVICES
  Introduced By: Representatives Stewart, Giraldo, Kislak, Potter, Tanzi, Handy, and
  Boylan
  Date Introduced: February 26, 2026
  Referred To: House Finance
It is enacted by the General Assembly as follows:
1SECTION 1. The intent of this legislation is to protect Rhode Islanders and the state
2 Medicaid program from high prescription drug costs by requiring greater pharmacy benefit
3 manager (PBM) transparency and accountability.
4SECTION 2. Section 42-7.2-5 of the General Laws in Chapter 42-7.2 entitled "Office of
5 Health and Human Services" is hereby amended to read as follows:
642-7.2-5. Duties of the secretary.
7The secretary shall be subject to the direction and supervision of the governor for the
8 oversight, coordination, and cohesive direction of state-administered health and human services
9 and in ensuring the laws are faithfully executed, notwithstanding any law to the contrary. In this
10 capacity, the secretary of the executive office of health and human services (EOHHS) shall be
11 authorized to:
12(1) Coordinate the administration and financing of healthcare benefits, human services, and
13 programs including those authorized by the state’s Medicaid section 1115 demonstration waiver
14 and, as applicable, the Medicaid state plan under Title XIX of the U.S. Social Security Act.
15 However, nothing in this section shall be construed as transferring to the secretary the powers,
16 duties, or functions conferred upon the departments by Rhode Island public and general laws for
17 the administration of federal/state programs financed in whole or in part with Medicaid funds or
18 the administrative responsibility for the preparation and submission of any state plans, state plan
1 amendments, or authorized federal waiver applications, once approved by the secretary.
2(2) Serve as the governor’s chief advisor and liaison to federal policymakers on Medicaid
3 reform issues as well as the principal point of contact in the state on any such related matters.
4(3)(i) Review and ensure the coordination of the state’s Medicaid section 1115
5 demonstration waiver requests and renewals as well as any initiatives and proposals requiring
6 amendments to the Medicaid state plan or formal amendment changes, as described in the special
7 terms and conditions of the state’s Medicaid section 1115 demonstration waiver with the potential
8 to affect the scope, amount, or duration of publicly funded healthcare services, provider payments
9 or reimbursements, or access to or the availability of benefits and services as provided by Rhode
10 Island general and public laws. The secretary shall consider whether any such changes are legally
11 and fiscally sound and consistent with the state’s policy and budget priorities. The secretary shall
12 also assess whether a proposed change is capable of obtaining the necessary approvals from federal
13 officials and achieving the expected positive consumer outcomes. Department directors shall,
14 within the timelines specified, provide any information and resources the secretary deems necessary
15 in order to perform the reviews authorized in this section.
16(ii) Direct the development and implementation of any Medicaid policies, procedures, or
17 systems that may be required to assure successful operation of the state’s health and human services
18 integrated eligibility system and coordination with HealthSource RI, the state’s health insurance
19 marketplace.
20(iii) Beginning in 2015, conduct on a biennial basis a comprehensive review of the
21 Medicaid eligibility criteria for one or more of the populations covered under the state plan or a
22 waiver to ensure consistency with federal and state laws and policies, coordinate and align systems,
23 and identify areas for improving quality assurance, fair and equitable access to services, and
24 opportunities for additional financial participation.
25(iv) Implement service organization and delivery reforms that facilitate service integration,
26 increase value, and improve quality and health outcomes.
27(4) Beginning in 2020, prepare and submit to the governor, the chairpersons of the house
28 and senate finance committees, the caseload estimating conference, and to the joint legislative
29 committee for health-care oversight, by no later than September 15 of each year, a comprehensive
30 overview of all Medicaid expenditures outcomes, administrative costs, and utilization rates. The
31 overview shall include, but not be limited to, the following information:
32(i) Expenditures under Titles XIX and XXI of the Social Security Act, as amended;
33(ii) Expenditures, outcomes, and utilization rates by population and sub-population served
34 (e.g., families with children, persons with disabilities, children in foster care, children receiving
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1 adoption assistance, adults ages nineteen (19) to sixty-four (64), and elders);
2(iii) Expenditures, outcomes, and utilization rates by each state department or other
3 municipal or public entity receiving federal reimbursement under Titles XIX and XXI of the Social
4 Security Act, as amended;
5(iv) Expenditures, outcomes, and utilization rates by type of service and/or service
6 provider;
7(v) Expenditures by mandatory population receiving mandatory services and, reported
8 separately, optional services, as well as optional populations receiving mandatory services and,
9 reported separately, optional services for each state agency receiving Title XIX and XXI funds; and
10(vi) Information submitted to the Centers for Medicare & Medicaid Services for the
11 mandatory annual state reporting of the Core Set of Children’s Health Care Quality Measures for
12 Medicaid and Children’s Health Insurance Program, behavioral health measures on the Core Set of
13 Adult Health Care Quality Measures for Medicaid and the Core Sets of Health Home Quality
14 Measures for Medicaid to ensure compliance with the Bipartisan Budget Act of 2018, Pub. L. No.
15 115-123.
16The directors of the departments, as well as local governments and school departments,
17 shall assist and cooperate with the secretary in fulfilling this responsibility by providing whatever
18 resources, information, and support shall be necessary.
19(5) Resolve administrative, jurisdictional, operational, program, or policy conflicts among
20 departments and their executive staffs and make necessary recommendations to the governor.
21(6) Ensure continued progress toward improving the quality, the economy, the
22 accountability, and the efficiency of state-administered health and human services. In this capacity,
23 the secretary shall:
24(i) Direct implementation of reforms in the human resources practices of the executive
25 office and the departments that streamline and upgrade services, achieve greater economies of scale
26 and establish the coordinated system of the staff education, cross-training, and career development
27 services necessary to recruit and retain a highly-skilled, responsive, and engaged health and human
28 services workforce;
29(ii) Encourage EOHHS-wide consumer-centered approaches to service design and delivery
30 that expand their capacity to respond efficiently and responsibly to the diverse and changing needs
31 of the people and communities they serve;
32(iii) Develop all opportunities to maximize resources by leveraging the state’s purchasing
33 power, centralizing fiscal service functions related to budget, finance, and procurement,
34 centralizing communication, policy analysis and planning, and information systems and data
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1 management, pursuing alternative funding sources through grants, awards, and partnerships and
2 securing all available federal financial participation for programs and services provided EOHHS-
3 wide;
4(iv) Improve the coordination and efficiency of health and human services legal functions
5 by centralizing adjudicative and legal services and overseeing their timely and judicious
6 administration;
7(v) Facilitate the rebalancing of the long-term system by creating an assessment and
8 coordination organization or unit for the expressed purpose of developing and implementing
9 procedures EOHHS-wide that ensure that the appropriate publicly funded health services are
10 provided at the right time and in the most appropriate and least restrictive setting;
11(vi) Strengthen health and human services program integrity, quality control and
12 collections, and recovery activities by consolidating functions within the office in a single unit that
13 ensures all affected parties pay their fair share of the cost of services and are aware of alternative
14 financing;
15(vii) Assure protective services are available to vulnerable elders and adults with
16 developmental and other disabilities by reorganizing existing services, establishing new services
17 where gaps exist, and centralizing administrative responsibility for oversight of all related
18 initiatives and programs.
19(7) Prepare and integrate comprehensive budgets for the health and human services
20 departments and any other functions and duties assigned to the office. The budgets shall be
21 submitted to the state budget office by the secretary, for consideration by the governor, on behalf
22 of the state’s health and human services agencies in accordance with the provisions set forth in §
23 35-3-4.
24(8) Utilize objective data to evaluate health and human services policy goals, resource use
25 and outcome evaluation and to perform short and long-term policy planning and development.
26(9) Establish an integrated approach to interdepartmental information and data
27 management that complements and furthers the goals of the unified health infrastructure project
28 initiative and that will facilitate the transition to a consumer-centered integrated system of state-
29 administered health and human services.
30(10) At the direction of the governor or the general assembly, conduct independent reviews
31 of state-administered health and human services programs, policies, and related agency actions and
32 activities and assist the department directors in identifying strategies to address any issues or areas
33 of concern that may emerge thereof. The department directors shall provide any information and
34 assistance deemed necessary by the secretary when undertaking such independent reviews.
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1(11) Provide regular and timely reports to the governor and make recommendations with
2 respect to the state’s health and human services agenda.
3(12) Employ such personnel and contract for such consulting services as may be required
4 to perform the powers and duties lawfully conferred upon the secretary.
5(13) Assume responsibility for complying with the provisions of any general or public law
6 or regulation related to the disclosure, confidentiality, and privacy of any information or records,
7 in the possession or under the control of the executive office or the departments assigned to the
8 executive office, that may be developed or acquired or transferred at the direction of the governor
9 or the secretary for purposes directly connected with the secretary’s duties set forth herein.
10(14) Hold the director of each health and human services department accountable for their
11 administrative, fiscal, and program actions in the conduct of the respective powers and duties of
12 their agencies.
13(15) Identify opportunities for inclusion with the EOHHS’ October 1, 2023, budget
14 submission, to remove fixed eligibility thresholds for programs under its purview by establishing
15 sliding scale decreases in benefits commensurate with income increases up to four hundred fifty
16 percent (450%) of the federal poverty level. These shall include but not be limited to, medical
17 assistance, childcare assistance, and food assistance.
18(16) Ensure that insurers minimize administrative burdens on providers that may delay
19 medically necessary care, including requiring that insurers do not impose a prior authorization
20 requirement for any admission, item, service, treatment, or procedure ordered by an in-network
21 primary care provider. Provided, the prohibition shall not be construed to prohibit prior
22 authorization requirements for prescription drugs. Provided further, that as used in this subsection
23 (16) of this section, the terms “insurer,” “primary care provider,” and “prior authorization” means
24 the same as those terms are defined in § 27-18.9-2.
25(17) The secretary shall convene, in consultation with the governor, an advisory working
26 group to assist in the review and analysis of potential impacts of any adopted federal actions related
27 to Medicaid programs. The working group shall develop options for administrative action or
28 general assembly consideration that may be needed to address any federal funding changes that
29 impact Rhode Island’s Medicaid programs.
30(i) The advisory working group may include, but not be limited to, the secretary of health
31 and human services, director of management and budget, and designees from the following: state
32 agencies, businesses, healthcare, public sector unions, and advocates.
33(ii) As soon as practicable after the enactment federal budget for fiscal year 2026, but no
34 later than October 31, 2025, the advisory working group shall forward a report to the governor,
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1 speaker of the house, and president of the senate containing the findings, recommendations and
2 options for consideration to become compliant with federal changes prior to the governor’s budget
3 submission pursuant to § 35-3-7.
4(18) Ensure managed care organizations (“MCOs”) and pharmacy benefit managers
5 (“PBMs”) working for the Rhode Island Medicaid program are transparent, do not increase
6 unnecessary costs for the Rhode Island Medicaid program and patients, and demonstrate
7 improvement in patient health outcomes by requiring contracts with MCOs ensure PBMs to cease
8 and prohibit activities that result in spread pricing, a payment model in which PBMs charge a health
9 plan more than it reimburses the pharmacy for a prescription drug and retains the difference.
10SECTION 3. This act shall take effect upon passage.
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  EXPLANATION
  BY THE LEGISLATIVE COUNCIL
  OF
  AN ACT
 RELATING TO STATE AFFAIRS AND GOVERNMENT -- OFFICE OF HEALTH AND
  HUMAN SERVICES
  ***
1This act would require the secretary of the executive office of health and human services
2 (EOHHS) to monitor and mandate changes to the price-setting practices of pharmacy benefit
3 managers to prohibit the spread pricing payment model.
4This act would take effect upon passage.
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