FY25 Medicaid Reimbursement Rate Updates

Increased reimbursement rates will go into effect for RI Medicaid across all covered providers and services on October 1, 2024, in response to recommendations from the RI Office of the Health Insurance Commissioner (OHIC).  

Click here to view the latest OHIC rate review minimum fee schedule for managed care--updated as of August 22, 2024.

The scheduled rate increase is set to be the largest in the program’s history and requires a great deal of coordination between the State, federal partners, managed care organizations, and providers to successfully implement. The following workstreams must make a series of updates prior to these new rates going live. 

• Policy Updates: Medicaid policy staff must identity every service’s authorization as either in the State Plan or the Section 1115 Waiver.  The location of each service dictates the steps necessary to seek federal approval.  
  • State Plan Amendments: State plan amendments (SPAs) first must go through a 30-day public comment period before they can be submitted to CMS for review and approval. EOHHS must complete a submission package for CMS which includes public and tribal notices, revised state plan pages, a fiscal impact summary, and funding questions. Once submitted, CMS has 90 days to review the amendments or request additional information. At this time the 90-day clock is stopped, and the state works with CMS to answer any questions. The approval from CMS is retroactive to the effective date submitted with the SPA.  
  • CMS Waivers: All waiver changes must be sent to the Centers for Medicare and Medicaid Services (CMS) via email and include a full description of the proposed change by service, procedure code, and a comparison of current vs. proposed rates. 
• Finance Updates: Medicaid Finance staff must prepare an updated fee schedule for every code and modifier combination affected by the Enacted Budget. This includes error-checking, identifying codes necessary for a managed care minimum fee schedule, cross-referencing fee-for-service billing codes with MCO billing codes, and preparing the rate sheet so that it contains all the information necessary to update the Medicaid Management Information System (MMIS), which is the system that processes payments for any Medicaid claims submitted according to the update fee schedule.   
• MCO Management and Oversight Updates: The managed care oversight team must amend contracts to reflect updated rates and direct MCOs to update their provider amendments with the changes. MCOs have 45 days to review proposed contract changes and submit questions and concerns to EOHHS. Once the amended contract is fully executed, the MCOs have 90 days to implement all changes. Implementation may include renegotiating changes to provider contracts, updating computer and billing systems and ensuring that providers are paid correctly under their new agreements. MCO subcontractors must also be compliant with the changes.  

The FY25 Enacted Budget includes a 14.5% increase to the fee-for-service direct, other direct, and indirect components of the nursing facility per diem. Facilities will be contacted via email in mid to late-September with the new 10/1/2024 rates. The rates are available on our website here. 

EOHHS already has the requisite State Plan Authority to implement the SFY 25 Enacted rate increases; therefore, no State Plan Amendment is needed. Medicaid Finance staff must manually update all components of the nursing facility per diem. Then, the rates are shared with the Medicaid Management Information System (MMIS) vendor to update our billing system to pay at the new rates. 

The Rhode Island Certified Community Behavioral Health Clinic (CCBHC) demonstration is launching on October 1, 2024, with eight providers currently in the last stages of preparation to offer services in this capacity. 

• Rates for Year 1 are communicated to Managed Care Organizations (MCOs) by week of August 26 (initial rates were provided in early July). They will be posted to the website by September 13. 
• MCO and provider system testing began on August 13. MCO attestation of successful completion of testing with providers and confirmation of readiness for billing is due to the state by August 27. MCO internal and mock provider testing has been successful so far, with no issues reported. 
• Contracts between MCOs and CCBHC providers are under final review with providers, with fully executed contracts due to the state by August 28. Fully executed contracts between CCBHCs and Designated Collaborating Organizations (DCOs) are also due to the state on 8/28. 
• EOHHS is providing final approval for providers to go-live on October 1 by August 30. 
• Click here to learn more about the CCBHC initiative in Rhode Island.