In June 2016, the Rhode Island General Assembly passed the Lead and Copper Drinking Water Protection Act, requiring schools, day care facilities, public playgrounds, shelters and foster homes with children under six, and other state facilities to certify that drinking water conduits are lead-safe. It also directs state inspectors to conduct an annual lead and copper test at these facilities. In conjunction with the law, which will be implemented once regulations are promulgated, the state created a commission to study lead in the water system.
Documentation of Lead-Safe Remodeler/Renovator License Required to Receive a Building Permit to Complete Housing Renovations
In 2011, the City of Providence began requiring applicants for building permits at pre-1978 homes to provide proof of training and licensing in lead-safe work practices. The state of Rhode Island requires all construction contractors working in homes and child care facilities built before 1978 to hold a Lead-Safe Remodeler/Renovator License or a higher level of lead hazard control certification. The lead-safe remodeler/renovator program has been overseen by the state since 2001. It is authorized by the U.S. Environmental Protection Agency to administer the federal Renovation, Repair, and Painting rule in Rhode Island. To increase compliance with the state remodeler/renovator law, the City of Providence will issue permits for construction work at properties covered by the law only if proof of licensure is provided. In January 2015, the City of Pawtucket put in place a similar requirement: contractors must document their training and licensure to receive a building permit for renovations.
Use of Local Housing Officials to Enforce Lead Hazard Mitigation Law
The state of Rhode Island passed the Lead Hazard Mitigation Act in 2002 and implemented regulations in 2004. Under the law, rental property owners are required to attend a training on unsafe lead conditions, inspect/repair any lead hazards at their properties, make residents aware of their findings and actions, address residents’ lead-hazard concerns, use lead-safe work practices during maintenance, and verify each unit’s compliance through a lead inspector. Typically, the owner must have the property inspected every two years and prove its safety for children by showing a Certificate of Conformance (COC) or a Lead-Safe or Lead-Free Certificate. Owners of two- and three-dwelling properties who live onsite are exempt from the law.
Since the law’s enactment the state has been challenged by compliance. In 2014, when the Providence Plan completed an evaluation of the Lead Hazard Mitigation Law, it found that only 20 percent of the covered properties had complied with the regulations within the first five years of implementation. Several cities have taken steps to improve enforcement. Providence, for example, created a separate division of Housing Court to address lead violations.
The Inspection and Standards division reported that of 537 lead violation cases filed over the first four years, 484 resulted in corrective action. An analysis conducted by the Rhode Island Department of Health discovered that between 2012 and 2013, there was a significant decline in children with elevated blood lead levels in Providence. Notably, the declines coincided with the implementation of the building permitting requirements and the lead docket.
Medicaid Reimbursement for Lead Follow-Up Services and Lead Centers and Reimbursement
Rhode Island Medicaid, which covers nearly 40 percent of children in the state and roughly half of children below six with elevated blood lead levels, provides reimbursement for lead follow-up services under its 1115 demonstration waiver (known as the Rhode Island Comprehensive Demonstration). The waiver gives Rhode Island the flexibility to “redesign the state’s Medicaid program to provide cost-effective services that will ensure beneficiaries receive the appropriate services in the least restrictive and most appropriate setting.”
Lead follow-up services eligible for reimbursement in Rhode Island are provided through four “lead centers” certified through the state health department. Because the services are offered under specifications of the contract with Rhode Island Medicaid, the centers have the flexibility to hire a range of personnel to deliver in-home lead services. These include community health workers, nurses, and certified lead inspectors.
Medicaid reimbursement is currently available to the lead centers for follow-up services provided to Medicaid-enrolled children up to age six who are identified to have elevated blood lead levels. The lead centers bill by the “Current Procedural Terminology” billing code for each service provided to Medicaid recipients. Medicaid reimburses them for an initial visit, a follow-up visit, or to close the case. The lead centers are reimbursed by the state for services provided to non-Medicaid-enrolled children.
Follow-Up Services: Education, Case Management, Assessment, and Inspection
Written Rhode Island Medicaid standards require the lead centers to contact associated healthcare providers when providing lead follow-up services. For each child or family, the lead center identifies a specific case manager who handles all communication and coordination with the child’s primary care provider or treating physician, all treatment providers and community support agencies, and the child’s health plan, when appropriate. When necessary, the lead center case manager also works with the Rhode Island Department of Human Services and Department of Health, serving as the point of contact for the child, family, and all providers and agencies.
Along with case management, other Medicaid-reimbursable follow-up services provided to children under age six with elevated blood lead levels by Rhode Island lead center staff include:
- Visual assessment of the primary residence
- Nutrition counseling
- Lead education
- Interim controls to limit exposure to lead hazards
- Information on safe cleaning techniques
- In-home education
For children with blood lead levels elevated above the designated threshold (as set by the U.S. Centers for Disease Control and Prevention), Medicaid also reimburses for a Comprehensive Environmental Lead Inspection of the home by a Rhode Island Department of Health lead inspector. After the inspection, lead center staff review the results with the family to help them understand sources of lead in their home.
The lead centers provide some education and other services to children with blood lead levels that are high but do not exceed the designated threshold. However, these services are funded by a Rhode Island Department of Health contract, not by Medicaid. The services include an educational home visit to discuss lead poisoning, nutrition, and cleaning practices that can protect children from additional lead risks; a Visual Environmental Lead Assessment by a trained community health worker, which provides education and preventative next steps; and the provision of soil and dust wipes for the home. The Rhode Island Department of Health is also piloting a limited environmental investigation (soil testing only) in partnership with the lead centers for children with lower blood lead elevations that do not meet the designated threshold.
Additional Services: Structural Remediation
While Rhode Island Medicaid can provide some reimbursement for window replacement and spot repair of conditions found to pose a lead-related threat to children with elevated blood lead levels, this structural remediation benefit has been used rarely. The primary reasons include: (1) the current reimbursement rate for window replacements is less than the typical replacement cost and (2) the mechanisms by which lead centers receive this reimbursement are cumbersome. In an effort to increase use, the Rhode Island Department of Health is exploring ways to improve the window replacement program. One possibility may be a revolving loan fund since lead centers must pay for replacement first and seek Medicaid reimbursement later.
In addition, when a lead violation is found and a notice of violation issued, property owners and families are automatically referred to local Housing and Urban Development-funded lead hazard control grant programs that may pay for structural remediation. Access to these grant programs depend on income, the property’s age (pre-1978), and the presence of a child under age six living in or frequently visiting the home or unit. The Rhode Island Department of Health is currently assessing how often cited owners use these grant programs and whether or not there are enrollment barriers.
Use of Medicaid Reimbursement for Lead Follow-Up Services
This table from the Rhode Island Executive Office of Health and Human Services shows the total number of Medicaid-enrolled children who received lead follow-up services from the Rhode Island lead centers and the corresponding amount of total Medicaid reimbursement for selected years between 2006 and 2014.
Rhode Island’s current Medicaid 1115 demonstration waiver is in place through 2018, and there has been consistent support for the continuation of the lead follow-up service reimbursement program in the state. Stakeholders attribute this enthusiasm to the relatively low total cost of the lead program within Rhode Island’s overall Medicaid budget, along with the well-known dangers of lead poisoning.
In August, 2017, the Health Impact Project, a collaboration between the Robert Wood Johnson Foundation (RWJF) and Pew Charitable Trusts released: Ten Policies to Prevent and Respond to Childhood Lead Exposure. The Trust for America’s Health (TFAH), National Center for Healthy Housing (NCHH), Urban Institute, Altarum Institute, Child Trends and many researchers and partners contributed to the report. TFAH and NCHH worked with Pew, RWJF and local advocates and officials to put together the above case study about lead poisoning and prevention initiatives.
The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.