PROVIDENCE –– Half a year has passed since Governor Carcieri announced he could save state taxpayers $67 million by transforming Rhode Island’s health-care system for the elderly, poor and disabled.

The dramatic changes would require an unprecedented “global Medicaid waiver” from the federal government, but the plan would ultimately improve services for needy residents, the governor said, while allowing him to close a massive budget deficit without raising taxes.

But six months later –– and a month after the General Assembly approved a state budget that depends on the Medicaid savings –– lawmakers and Rhode Island’s 186,000 Medicaid recipients have yet to see a written plan.

Administration officials have already missed at least two self-imposed deadlines to submit the global waiver application to federal authorities.

“Originally it was supposed to be [July] 12th, then the 15th, now it’s the end of the month,” said House Finance Committee Chairman Steven M. Costantino, who is closely monitoring the administration’s progress. “Every day there’s a delay I’m worried.”

The stakes are extremely high, Costantino said, because delays could throw the state budget out of balance. That may mean new rounds of painful cuts, or more pressure to raise taxes, in the coming legislative session.

Another Finance Committee member, Rep. Thomas C. Slater, D-Providence, also notes that the fate of thousands of seniors and dozens of health-care providers depends on the changes.

“They’re in limbo,” Slater said. “We said last February, March, ‘Where’s the plan? Where’s the plan?’ And we never got it. It’s the same thing now.”

Carcieri spokeswoman Amy Kempe denied Journal requests last week to release a draft of the global waiver.

“We won’t provide anything until it is in its final form,” she said. “I think it’s important to maintain the integrity of the global waiver and to make sure the information that is out there is 100-percent accurate in its final form. An earlier draft with even slight revisions may cause some confusion.”

In seeking a global Medicaid waiver, the Carcieri administration is trying to do what no state has done before.

Rhode Island is essentially seeking a lump-sum payment from the federal government to cover all Medicaid spending for the next five years. (Medicaid programs consume roughly one third of the state’s $6.9-billion budget.)

In exchange for capping spending, the administration would receive an unprecedented flexibility to change Medicaid programs usually closely regulated by the federal government.

Lawmakers and top administration officials acknowledge the waiver plan carries significant risk. If the state spends its entire grant sooner than five years, it would have lost access to matching federal Medicaid dollars, and would be forced to slash programs or pay for them completely with state funds.

Carcieri, whose final term expires in 2010, said he’s not concerned about running out of money.

“If [federal Medicaid officials] agree to it, and they agree to the funding, I’m not worried about that,” he said last week. “The whole key to this is the flexibility that the waiver will give us, instead of getting caught up in the maze of regulations.”

Carcieri added that he wasn’t particularly concerned with application delays. The waiver must be in place by Oct. 1 to meet budgeted projections, according to the Department of Human Services.

“We’re driving there. We’re still hopeful,” he said. “We’re doing everything we can to get it completed. We want to do it properly.”

DHS Director Gary Alexander said the proposal would likely be submitted to the federal Centers for Medicare & Medicaid Services by “the end of the month to the beginning of early August.”

DHS Associate Director Murray Blitzer noted that the state was moving to implement some changes before the waiver is approved. For example, he listed efforts to create new co-pays for low-income health-care recipients, new reimbursement rates for community health-care providers, and plans to divert seniors away from nursing homes.

While the waiver would affect all Medicaid programs –– subsidized health insurance for the low-income, prescription drug plans, transportation programs –– the plan largely focuses on transforming Rhode Island’s long-term care system for seniors and the disabled.

Long-term care for the elderly and adults with disabilities accounted for 66 percent, or $1.1 billion, of Rhode Island’s Medicaid spending in fiscal year 2006, according to the state’s most recent annual Medicaid spending report.

The administration is contemplating stricter nursing home admission standards, which could divert hundreds of seniors into less expensive community-based programs. Senior advocates generally support the concept, but fear there aren’t enough community services in place to work with seniors.

The Senior Agenda Coalition, for example, has warned of waiting lists for some services.

Costantino noted that the legislature will play a significant oversight role throughout the waiver process.

Administration officials must submit the proposed waiver to the Assembly 10 days before it goes to CMS. The Assembly then has 30 days to block the administration from entering into a waiver agreement with the federal government.

“We’re very nervous about the financing of the global waiver,” Costantino said. “We’re very nervous about the five years –– you may be left with two years with no money.”

speoples@projo.com