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210-RICR-10-00-1 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 – EOHHS GENERAL PROVISIONS SUBCHAPTER 00 - GENERAL PROVISIONS PART 1 - OVERVIEW OF THE RHODE ISLAND MEDICAID AND CHILDREN’S HEALTH INSURANCE PROGRAMS 1.1 Statutory Authority of the State Agency A. R.I. Gen. Laws § 42-7.2-2 created the Rhode Island Executive Office of Health and Human Services (EOHHS) in 2006. EOHHS serves “as the principal agency of the executive branch of state government for managing the departments of children, youth and families, health, human services, and behavioral healthcare, developmental disabilities and hospitals.” B. EOHHS is responsible for administering the State’s Medicaid program, which provides health care services and supports to a significant number of Rhode Islanders on an annual basis. C. The statutory foundations of the Rhode Island Medicaid program are Title XIX of the Social Security Act (42 U.S.C. § 1396a et seq.), and R.I. Gen. Laws Chapters 40-8 and 42-7.2. Statutory authority for health care coverage funded in whole or in part by the federal Children’s Health Insurance Program (CHIP) is derived from 42 U.S.C. § 1397aa et seq., of the U.S. Social Security Act, which establishes that program and provides the legal basis for providing health coverage, services and supports to certain targeted low-income children and pregnant women through Medicaid. D. EOHHS is designated as the “single state agency”, authorized under Title XIX and, as such, is legally responsible for the fiscal management and administration of the Medicaid program. As health care coverage funded by CHIP is administered through the State’s Medicaid program, EOHHS also serves as the CHIP State Agency under federal and State laws and regulations. E. The Medicaid and CHIP State Plans and the Rhode Island’s Medicaid Section 1115 demonstration waiver provide the necessary authorities for the health care administered through the Medicaid program and establish the respective roles and responsibilities of beneficiaries, providers, and the State. 1.2 Definitions A. As used herein, these definitions have the following meaning:
1. “CHIP State Plan” means the State of Rhode Island’s State Plan identifying the eligibility categories and services authorized for federal financial participation under Title XIX of the federal Social Security Act establishing the Children’s Health Insurance Program (CHIP). 2. “Executive Office of Health and Human Services" or "EOHHS” means the state agency established in 2006 under the provisions of R.I. Gen. Laws Chapter 42-7.2 within the executive branch of state government and serves as the principal agency for the purposes of managing the Departments of Children, Youth, and Families (DCYF); Health (RIDOH); Human Services (DHS); and Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH). EOHHS is designated as the “single state agency,” authorized under Title XIX of the U.S. Social Security Act (42 U.S.C. § 1396a et seq.) and, as such, is legally responsible for the program / fiscal management and administration of the Medicaid Program. 3. “Medicaid State Plan” means State of Rhode Island’s State Plan identifying the eligibility categories and services authorized for federal financial participation under Title XIX of the federal Social Security Act establishing the Medicaid program. 4. “State agency” means EOHHS. 1.3 Purposes and Scope of the Medicaid Program A. The Rhode Island Medicaid program is the joint federal/state health care program that provides publicly funded health coverage to low-income individuals and families, adults without dependent children age nineteen (19) to sixty-four (64), elders, and persons with disabilities who otherwise cannot afford or obtain the services and supports they need to live safe and healthy lives. B. Eligibility -- Coverage Groups. A coverage group is a classification of individuals eligible to receive Medicaid benefits based on a shared characteristic such as age, income, health status, and level of need criteria. Pursuant to the authority provided under the Medicaid and CHIP State Plans and the State’s Section 1115 demonstration waiver, health coverage, services, and supports are available to individuals and families who meet the eligibility requirements for the following coverage groups: 1. Medicaid Affordable Care Coverage (MACC) Groups –A single income standard – Modified Adjusted Gross Income or “MAGI” – must be used to determine the eligibility of all applicants under the Medicaid affordable care coverage groups, which are as follows: a. Families with children and young adults, pregnant women, infants and parents/caretakers with income up to the levels sets forth in Part 30-00-3 of this Title;
b. Adults between the ages of nineteen (19) and sixty-four (64) without dependent children who meet the income limits set forth in the Part 30-00-3 of this Title, including any persons in this age group who are awaiting a determination of eligibility for Medicaid on the basis of age, blindness, or disability pursuant to Part 40-05-1 of this Title or receipt of Supplemental Security Income (SSI) pursuant to Part 40-00-3 of this Title; 2. Integrated Health Care Coverage (IHCC) Groups – All applicants for Medicaid who must meet both clinical and financial eligibility requirements or who are eligible based on their participation in another needs-based, federally funded health and human services program are not subject to the MAGI. The State has reclassified these categorically and medically needy populations into coverage groups based on shared eligibility characteristics, level of need, and/or access to integrated care options as follows: a. Adults between the ages the ages of nineteen (19) and sixty-four (64) who are blind or disabled and elders age sixty-five (65) and older who meet the financial and clinical eligibility for Medicaid- funded coverage established pursuant Part 40-05-1 of this Title; b. Persons of any age who require long-term services and supports in an institutional or home and community-based setting who meet the financial and clinical criteria established pursuant to the Parts 50- 00-6 and 50-00-5 of this Title, respectively, or in the case of children eligible under the Katie Beckett provision, who meet the criteria in the Part 50-10-3 of this Title; c. Individuals eligible for Medicaid-funded health coverage on the basis of their participation in another publicly funded program including children and young adults receiving services authorized by the Department of Children, Youth and Families and persons of any age who are eligible on the basis of receipt of SSI benefits. d. Medically needy individuals who meet all the eligibility criteria for coverage except for excess income. Individuals in this coverage group achieve eligibility by applying a flexible test of income which applies excess income to certain allowable medical expenses thereby enabling the individual to “spend down” to within a medically needy income limit (MNIL) established by the Medicaid agency. e. Low-income elders and persons with disabilities who qualify for the Medicare Premium Payment Program (MPP) authorized by the Title XIX. Medicaid pays the Medicare Part A and/or Part B premiums for MPP beneficiaries.
C. Benefits. Medicaid beneficiaries are eligible for the full scope of services and supports authorized by the Medicaid State Plan and the Section 1115 demonstration waiver. 1. General scope of coverage. Although there is variation in benefits by coverage group, in general Medicaid health coverage includes the following: Doctor’s office visits Immunizations Prescription and over-the- counter medications Lab tests Residential treatment Behavioral health services Drug or alcohol treatment Early and Periodic, Screening, Detection and Treatment (EPSDT) Referral to specialists Hospital care Emergency care Urgent Care Long-term Services and Supports (LTSS) in home and community-based and health care institutional settings such as nursing homes Home health care Skilled nursing care Nutrition services Interpreter services Childbirth education programs Prenatal and post-partum care Parenting classes Smoking cessation programs Transportation services Dental care Expedited LTSS Organ transplants Durable Medical Equipment 2. EPSDT. Title XIX authorizes Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for all Medicaid beneficiaries who are under age twenty-one (21) for the purposes of identifying and treating behavioral health illnesses and conditions. Medically necessary EPSDT services must be provided irrespective of whether they are within the scope of Medicaid State Plan covered services.
3. Limits. Certain benefits covered by the Medicaid State Plan or the State’s Section 1115 waiver are subject to limits under federal and/or State law. Program-wide benefit limits are set forth in § 1.5 of this Part. Limits and restrictions applicable to specific coverage groups are located in the rules describing the coverage group and service delivery. 1.4 Program Administration A. Applications and Eligibility. EOHHS implements a “no wrong door” policy to ensure persons seeking eligibility for Medicaid health care coverage have the option to apply at multiple locations throughout the State and in a manner that is best suited to their needs including, but not limited to, in-person, on-line, by telephone, or by U.S. mail. Application and eligibility information for the MACC groups is located in the Part 30-00-3 of this Title. An overview of the application process for the IHCC groups is located in Part 40-00-1 of this Title. 1. Determinations. EOHHS must make timely and efficient eligibility, enrollment, and renewal decisions. Accordingly, EOHHS or an entity designated by the Secretary for such purposes must review and make eligibility and renewal determinations for Medicaid health care coverage in accordance with applicable State and federal laws, rules, and regulations. 2. Timeliness. In general, determinations must be made in no more than thirty (30) days from the date a completed application is received by EOHHS or its designee unless clinical eligibility factors must be considered. In instances in which both clinical and financial eligibility factors are material to the application process, as for eligibility for Medicaid-funded LTSS or coverage for persons with disabilities, determinations must be made in ninety (90) days. Applicable time-limits and other eligibility requirements are set forth in the Rhode Island Code of Regulations, Title 210, in the chapters related to each population Medicaid serves by eligibility coverage groups. 3. Cooperation. As a condition of eligibility, the Medicaid applicant/ beneficiary must meet certain cooperation requirements, such as providing the information needed for an eligibility determination, taking reasonable action to make income or resources available for support, assigning of rights to medical support or other third-party payments for medical care, or pursuing eligibility for other benefits. Failure to cooperate may result in a denial or termination of eligibility. B. Eligibility Agent -- DHS. The Medicaid State Agency is authorized under Title XIX and federal implementing regulations to enter into agreements with other State agencies for the purposes of determining Medicaid eligibility. EOHHS has entered into a cooperative agreement with the Rhode Island Department of Human Services (DHS) that authorizes the DHS to conduct certain eligibility functions. In accordance with 42 C.F.R. § 431.10(e)(3), the DHS has agreed to
carry out these functions in accordance with the Medicaid State Plan, the State’s Section 1115 demonstration waiver, and the rules promulgated by EOHHS. C. Written Notice. EOHHS is responsible for notifying an applicant, in writing, of an eligibility determination. If eligibility has been denied, the notice to the applicant sets forth the reasons for the denial along with the applicable legal citations and the right to appeal and request a fair hearing. The Appeals Process and Procedures for EOHHS Agencies and Programs (Subchapter 05 Part 2 of this Chapter) regulations describe in greater detail the appeal and hearing process. D. Mandatory Managed Care Service Delivery. To ensure that all Medicaid beneficiaries have access to quality and affordable health care, EOHHS is authorized to implement mandatory managed care delivery systems. Managed care is a health care delivery system that integrates an efficient financing mechanism with quality service delivery, provides a medical home to assure appropriate care and deter unnecessary services, and places emphasis on preventive and primary care. Managed care systems also include a primary care case management model in which ancillary services are provided under the direction of a physician in a practice that meets standards established by the Medicaid agency. Managed care systems include the Medicaid program’s integrated care options such as long-term services and supports and primary care health coverage for eligible beneficiaries. The managed care options for Medicaid beneficiaries vary on the basis of eligibility as follows: 1. Families with children eligible under the Part 30-00-1 of this Title are enrolled in a RIte Care managed care plan in accordance with the Part 30- 05-2 of this Title or, as applicable, an employer health plan approved by EOHHS for the RIte Share Premium Assistance Program in accordance with the Part 30-05-3 of this Title unless specifically exempted; 2. Adults ages nineteen (19) to sixty-four (64) eligible in accordance with the Part 30-00-1 of this Title are enrolled in a Rhody Health Partners managed care plan in accordance with the Part 30-05-2 of this Title or, as applicable, an employer health plan approved by EOHHS for the RIte Share premium assistance program in accordance with the Part 30-05-3 of this Title unless specifically exempted; 3. Elders and adults who are blind or living with a disability and between the ages of nineteen (19) and sixty-four (64) eligible pursuant to Part 40-05-1 of this Title are enrolled in a Rhody Health Partners plan or Connect Care Choice primary care case management practices in accordance with Part 40-10-1 of this Title. 4. Persons eligible for Medicaid-funded long-term services and supports in accordance with the Part 50-00-1 of this Title have the choice of self- directed care, fee-for-service, or enrolling for services in PACE, Rhody
Health Options, or Connect Care Choice Community Partners in accordance with Part 40-10-1 of this Title. 5. Persons eligible as medically needy or as a result of participation in another publicly funded health and human services program may be enrolled in fee-for-service or a managed care plan depending on the basis of eligibility. See exemptions in the Part 30-05-2 of this Title "RIte Care Program" Parts 30-05-2 and 40-10-1 of this Title related to coverage group. E. Waiver eligibility and services. Until 2009, the Medicaid program utilized authorities provided through its RIte Care Section 1115 and multiple Title 1915(c) waivers to expand eligibility and access to benefits beyond the scope provided for in the Medicaid State Plan. At that time, the State received approval from the Secretary of the U.S. Department of Health and Human Services (DHHS) to operate the Rhode Island Medicaid program under a single Section 1115 demonstration waiver. All Medicaid existing Section 1115 and Section 1915(c) waiver authorities have been incorporated into the Medicaid program-wide Section 1115 demonstration waiver, as it has been renewed and extended, since it was initially approved in 2009. 1.5 Program-wide Limits and Restrictions A. Both federal and State law impose certain limits and restrictions on the scope, amount, and duration of the health care coverage, services, and supports financed and administered through the Medicaid program. B. Benefits authorized under the Medicaid State Plan and the State’s Sections 1115 demonstration waiver are limited as follows: 1. Organ Transplant Operations. Medicaid provides coverage for organ transplant operations deemed to be medically necessary upon prior approval by EOHHS. a. Medical necessity for an organ transplant operation is determined on a case-by-case basis upon consideration of the medical indications and contraindications, progressive nature of the disease, existence of alternative therapies, life threatening nature of the disease, general state of health of the patient apart from the particular organ disease, any other relevant facts and circumstances related to the applicant and the particular transplant procedure. b. Prior Written Approval of the Secretary or his/her designee is required for all covered organ transplant operations. Procedures for submitting a request for prior approval authorizations are available
through the provider portal on the EOHHS website at: www.eohhs.ri.gov/providers. c. Authorized Transplant Operations provided as Medicaid services, upon prior approval, when certified by a medical specialist as medically necessary and proper evaluation is completed, as indicated, by the transplant facility as follows: (1) Certification by medical specialist required -- kidney transplants, liver transplants, corneal transplants, and bone marrow transplants. (2) Certification by an appropriate medical specialist and evaluation at the transplant facility - pancreas transplants, lung transplants, heart transplants, heart/lung transplants. d. Other Organ Transplant Operations as may be designated by the Secretary of EOHHS after consultation with medical advisory staff or medical consultants. 2. Pharmacy Services for Dual Eligible Beneficiaries. Under federal law, states providing a Medicaid-funded pharmacy benefit must extend or restrict coverage and co-pays to beneficiaries eligible for both Medicaid and Medicare as follows: a. Medicare Part D Wrap. Medicaid beneficiaries who receive Medicare Part A and/or Part B, qualify for Part D and must receive their pharmacy services through a Medicare-approved prescription drug plan. Therefore, these dually eligible Medicaid-Medicare beneficiaries are not eligible for the Medicaid pharmacy benefits. There are, however, certain classes of drugs that are not covered by Medicare Part D plans. Medicaid coverage is available to those receiving Medicare for these classes of drugs. The classes of drugs covered by Medicaid are: vitamins and minerals (with the exception of prenatal vitamins and fluoride treatment), Medicaid-approved over-the-counter medications, cough and cold medications, smoking cessation medications, and covered weight loss medications (with prior authorization). When purchasing these classes of drugs, Medicaid beneficiaries are required to pay a co- payment of one dollar ($1.00) for generic drug and three dollars ($3.00) for a brand name drug prescription. b. Medicare Part D Cost-sharing Exemption. There is no Medicare Part D cost-sharing for full benefit Medicaid-Medicare dual eligible beneficiaries who would require the level of services provided in a long-term health facility if they were not receiving Medicaid-funded home and community-based services under Title XIX waiver
authority, the Medicaid State Plan, or through enrollment in a Medicaid managed care organization. To obtain the cost-sharing exemption, the Medicare Part D plan sponsor must receive proof of participation in one of the following Medicaid-funded home and community-based services programs: Preventive/Core Services, Personal Choice, Habilitation, Shared Living, and Assisted Living as well as the co-pay program administered by the Division of Elderly Affairs (DEA). C. Federal law and regulations authorize the Medicaid agency or its authorized contractual agent (managed care plan/organization) to place appropriate restrictions on a Medicaid-funded benefit or service based on such criteria as medical necessity or on utilization control (42 C.F.R. § 440.230(d)). The Medicaid "Pharmacy Home" lock-in Program was established under this authority to restrict access to full pharmacy services in instances in which there is documented excessive use by a beneficiary. Beneficiaries are "locked-in" to specific providers in order to monitor services received and reduce unnecessary or inappropriate utilization. This program is intended to prevent Medicaid beneficiaries from obtaining excessive quantities of prescribed drugs through multiple visits to physicians and pharmacies. Additional information on the Pharmacy Home Lock-in Program is contained in Part 30-05-2 of this Title ("Managed Care Delivery Options"). 1.6 Cooperation Requirements A. As a condition of eligibility, the Medicaid applicant/ beneficiary must meet certain cooperation requirements, such as providing the information needed for an eligibility determination, taking reasonable action to make income or resources available for support, assigning of rights to medical support or other third-party payments for medical care, or pursuing eligibility for other benefits. Failure to cooperate may result in a denial of eligibility or case closure. 1.7 Direct Reimbursement to Beneficiaries A. Some individuals, while appealing a determination of Medicaid ineligibility, incur and pay for covered services. Direct reimbursement may be available to beneficiaries in certain circumstances. Direct reimbursement is available to such individuals if, and only if, all of the following requirements are met: 1. A written request to appeal a denial or discontinuance of Medicaid coverage is received by the State within the time frame specified in the) "Appeals Process and Procedures for EOHHS Agencies and Programs" (Subchapter 05 Part 2 of this Chapter) regulations. 2. The original decision to deny or discontinue Medicaid coverage is reversed on appeal by the Appeals Officer or by the Regional Manager or Chief Supervisor/Supervisor).
3. Reimbursement is only available if the original decision was reversed. Reimbursement is not made, for example, if the original decision is reversed because information or documentation, not provided during the application period, is provided at the time of the appeal. 4. The beneficiary submits the following: a. A completed Application for Reimbursement form; b. A copy of the medical provider's bill or a written statement from the provider which includes the date and type of service; c. Proof of the date and amount of payment made to the provider by the beneficiary or a person legally responsible for the beneficiary. A cash receipt, a copy of a canceled check or bank debit statement, a copy of a paid medical bill, or a written statement from the medical provider may be used as proof of payment, provided the document includes the date and amount of the payment and indicates that payment was made to the medical provider by the beneficiary or a person legally responsible for the beneficiary. 5. Payment for the medical service was made during the period between a denial of Medicaid eligibility and a successful appeal of that denial. That is, payment was made on or after the date of the written notice of denial (or the effective date of Medicaid termination, if later) and before the date of the written decision issued by the EOHHS Appeals Office, or decision by the Regional Manager/Chief Casework Supervisor after, reversing such denial is implemented (or the date Medicaid eligibility is approved, if earlier). 1.8 Procedure and Notification A. Notices of Medicaid ineligibility provide applicants and beneficiaries with information about their rights to appeal the agency's decision. These notices also contain specific information about the availability of direct reimbursement if a written appeal is filed and the State’s initial decision is overturned as incorrect. The rules governing appeals and hearings are located in "Appeals Process and Procedures for EOHHS Agencies and Programs" (Subchapter 05 Part 2 of this Chapter) regulations. B. The EOHHS Appeals Office must provide individuals who may qualify with an Application for Reimbursement form to request repayment for medical expenses which they incurred and paid while their appeal was pending. C. The individual must complete and sign the Application for Reimbursement form and include: 1. A copy of the provider's bill showing date and type of service; and
2. Proof that payment was made by the beneficiary or a person legally responsible for the beneficiary between the date of the erroneous denial and the date of the successful appeal decision. The completed form and required documentation is returned to the appropriate department representative. D. If either the bill or proof of payment is not included with the Application form, the Medicaid agency representative offers to assist the beneficiary in obtaining the required documentation and sends a reminder notice requesting return of the required information within thirty (30) days from the date of receipt of the Application for Reimbursement form. If all documents are not received within thirty (30) days, or if the documentation provided indicates that medical service or payment was not made between the date of Medicaid denial (or termination) and the date of Medicaid acceptance (or reinstatement), the agency representative denies the request for reimbursement. E. Otherwise, the agency representative forwards a referral form, attaching the beneficiary's written request for reimbursement and all supporting documentation to the Medicaid agency for a decision on payment. The Medicaid agency is responsible for providing the individual with written notification of the agency's decision and rights to appeal.
210-RICR-10-00-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 - EOHHS GENERAL PROVISIONS SUBCHAPTER 00 - GENERAL PROVISIONS PART 1 - “OVERVIEW OF THE RHODE ISLAND MEDICAID AND CHILDREN’S HEALTH INSURANCE PROGRAMS” Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 03/17/2024 February 24, 2024 E-SIGNED by Richard Charest on 2024-02-24 12:37:03 EST February 26, 2024 E-SIGNED by Department of State on 2024-02-26 08:51:46 EST
210-RICR-10-00-3 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 – EOHHS GENERAL PROVISIONS SUBCHAPTER 00 – N/A PART 3 – Medicaid and Children’s Health Insurance Program (CHIP) Non-Financial General Eligibility Requirements 3.1 Overview A. In accordance with Title XIX and XXI (42 U.S.C. §§ 1396a and 1396k), all Medicaid applicants and beneficiaries shall meet certain non-financial general eligibility requirements related to: identity, date of birth/age, Social Security Numbers (SSNs), residency, U.S. citizenship, and immigrations status. Rhode Island resident children under the age of nineteen (19) are not subject to any of the eligibility requirements related to citizenship and immigration status. In addition, certain applicants must agree to meet cooperation requirements. The scope of the cooperation requirements varies depending on eligibility category and the age of the applicant or beneficiary and may pertain to medical and child support, liens and estate recovery, providing application information, and reporting changes among others. B. The provisions set forth herein are included in the State’s plan for ensuring compliance with these and related federal requirements and are designed to promote ease of access to Medicaid while preserving program integrity. Toward this end, the State uses electronic data matches to the full extent possible to verify required information and limits the requests for supporting documentation to instances in which discrepancies between information sources are detected or electronic verification fails unless explicitly directed otherwise by federal or State law. 3.2 Scope and Purpose A. This rule identifies the non-financial eligibility requirements for Medicaid and CHIP- funded health coverage administered through the RI Medicaid program. The rule also cites the location in this Title of any other more specific or additional, related provisions. Lastly, the rule sets forth the respective roles and responsibilities of both the State and applicants and beneficiaries in ensuring information about these requirements is obtained in the most efficient and least burdensome way that Rhode Island’s integrated eligibility system (IES) allows within the parameters established in federal law. B. Provisions related to the verification of financial eligibility are set forth as follows: Part 30-00-5 of this Title, for children, families, and ACA expansion adults who are evaluated using the Modified Adjusted Gross Income (MAGI) standard and children
deemed eligible on the basis of participation in other federal programs; and Part 40-05- 1 of this Title for elders and adults with disabilities who are subject to the Supplemental Security Income (SSI) method for determining financial eligibility for Community Medicaid and Medicaid long-term services and supports (LTSS). 3.3 Legal Authority A. This Part is promulgated pursuant to federal authorities as follows: 1. Federal Law: Title XIX of the U.S. Social Security Act, 42 U.S.C. § 1396a, §§ 1115, 1902(dd), and 1903(v)(4); Title XXI of the Social Security Act, 42 U.S.C. § 1396k; § 2107(e)(1)(j) and 2111 and § 1111 of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009 (Pub. Law 111-3); §§ 401, 402(b), 403, and 421 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (Pub. Law 104-193); § 6036 of the Deficit Reduction Act of 2005 (Pub. Law 109-171); 2. Federal Regulations: 42 C.F.R. §§ 435.406, 435.945-949 and 440.250-255; 3. The Medicaid State Plan and the Title XIX, § 1115(a) Demonstration Waiver (11- W-00242/1), effective through December 31, 2018. B. Applicable State authority is derived from R.I. Gen. Laws Chapters 40-8; 40-8.4 to 40- 8.12; and 42-12.3. C. The Rules in this Part supersede Medicaid Code of Administrative Rules (MCAR), Section #0304, “Technical Eligibility Requirements”, unless otherwise indicated, pertaining to all Medicaid eligibility coverage groups and pathways. 3.4 Definitions A. As used herein, the following terms shall be construed as follows: 1. “CHIP state plan” means the State of Rhode Island’s State Plan identifying the eligibility categories and services authorized for federal financial participation under Title XIX of the Federal Social Security Act establishing the Children’s Health Insurance Program (CHIP). 2. “Immigrant” means a non-citizen who has been granted the right by the United States Citizenship and Immigration Service (USCIS) to reside permanently in the United States and to work without restrictions in the United States. Such a person is also known as a Lawful Permanent Resident (LPR). All immigrants are eventually issued a "green card" (USCIS Form I-551), which is the evidence of the non-citizen’s LPR status. 3. “Lawfully present” means the status of a non-citizen who has been granted permission to remain in the United States by the USCIS. This status includes
immigrant qualified non-citizens who would otherwise be eligible for Medicaid or CHIP coverage if were not for the Federal five (5) year bar and certain non- immigrants with visas who have been granted permission to live and/or work in the U.S. for a specific purpose and/or on a time-limited basis. 4. “Lawfully residing” means the eligibility category established under the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009 that gives States the option to provide coverage to a non-citizen children and pregnant women who are lawfully present and would otherwise be subject to the Federal five (5) year bar. 5. “Medicaid state plan” means State of Rhode Island’s State Plan identifying the eligibility categories and services authorized for Federal financial participation under Title XIX of the Federal Social Security Act establishing the Medicaid program. 6. “National” means a person who owes his or her sole allegiance to the United States, including all U.S. citizens, and persons who were born in American Samoa or were born in the Commonwealth of the Northern Mariana Islands who have chosen to be U.S. nationals instead of U.S. citizens. 7. “Non-citizen” means a person who is not a U.S. citizen or national. 8. “Nonimmigrant” means a person who has been granted the right to reside temporarily in the United States for a specific purpose. Each nonimmigrant is admitted into the U.S. in the nonimmigrant status which corresponds to the type of visa issued. The type of visa issued determines whether the nonimmigrant is treated as qualified or non-qualified for Federal means-tested benefit eligibility purposes. 9. “Non-qualified non-citizen” means a nonimmigrant who is not eligible for Federal means tested benefits, an immigrant who is out-of-status, or a non-citizen who has entered the United States illegally or without proper documentation. 10. "Qualified” or “Non-qualified non-citizens" means the terms used in Federal immigration law to categorize immigrant and nonimmigrant non-citizens. The terms do not by themselves indicate whether an immigrant is eligible for benefits. "Qualified," "non-qualified" and undocumented non-citizens may be eligible for some forms of federally-funded benefits. 11. “United States (U.S.) citizens” means a person who is born in the United States, Puerto Rico, Guam or the U.S. Virgin Islands; or whose parent is a U.S. citizen; or who is a former non-citizen who has been naturalized as a U.S. citizen.
3.5 Attestations, Consent and Identity Proofing A. Attestations and consent. In accordance with Federal Regulations at 42 C.F.R. § 435.945, when reviewing non-financial eligibility requirements, the State generally accepts: self-attestation when the person completing the application is requesting eligibility; and attestation by an adult who is in the applicant's household or family, or who is acting as an authorized representative, when the person requesting eligibility is a minor or incapacitated. 1. Application signature – To attest to the truthfulness of the information provided, an application must be signed either electronically or manually when submitted to be considered valid. The State notifies an applicant when a signature is missing and held in pending status until the State receives the required signature from the applicant/head of household. If the application or appropriate sections or proxies thereof are not returned with a signature by the date due, the application is closed and no further action is taken by the State. 2. Consent for electronic data matches – Applicants are asked to provide consent for the State to conduct electronic data matches related to income and other non-financial eligibility factors at the time of application. Refusal to provide such consent does not constitute non-cooperation and, as such, cannot alone result in the denial of eligibility. The State will proceed with an eligibility determination without the applicant’s consent. However, without this consent, the application processing time may increase and the State may require applicants to provide supplemental forms of paper documentation to support attestations and self- attestations for persons seeking Medicaid eligibility in the household. B. Identity proofing. Identity proofing is a mechanism for assuring that an applicant is who he or she claims to be. This assurance is required to query the Federal and State electronic databases necessary to verify attestations. In addition, these sources contain confidential, or private information that is protected by law and can only be obtained by and disclosed to the applicant subsequent to identity proofing. Therefore, identity proofing is required for anyone seeking affordable health coverage financed by Medicaid, Federal tax credits, and/or State subsidies through a State eligibility system or health insurance exchange based on the Modified Adjusted Gross Income (MAGI) methodology. 1. Applicant’s responsibilities – Applicants for Medicaid Affordable Care Coverage (MACC) eligibility under Chapter 30, who are subject to MAGI eligibility determinations, must comply with the provisions for establishing an on-line account set forth in § 30-00-3.14 of this Title unless choosing to apply using a paper application. The identity proofing process occurs in conjunction with the creation of an account. a. Beginning the process. The identify proofing process must be completed prior to the start of an on-line application by an adult acting as the head of
the household or as authorized representative in the case of minors. The process involves answering a series of questions about a variety of personal matters including current and past residences, place of birth and so forth. b. Alternative forms of proof. If the electronic process does not provide the required level of proof, an applicant may upload into his or her account or submit by fax, mail, or in-person, any of the forms of documents listed in § 3.9 of this Part: 2. State responsibilities – Identity proofing is conducted as an electronic process and occurs in conjunction with the creation of account. a. Remote Identity Proofing (RIDP). This process is conducted by a Federal contractor in accordance with nationwide standards. The applicant’s responses to questions related to identity are evaluated using a multifaceted authentication process. Once the proofing process is completed, the on-line application process may begin and access personal information held by trusted sources like the Social Security Administration, the Internal Revenue Service, and the Department of Homeland Security. This information becomes available to both the applicant and the State in real-time rather than after the application is submitted. b. Agency assistance and alternative forms of proof. The State must provide assistance upon request to aid in both creating an account and in facilitating identity proofing for applicants who are unable to obtain the required level of verification through the RIDP process. In addition, the State must make applicants aware of and accept the alternative forms of identity proof identified in § 3.9 of this Part. c. Limits. The identity proofing process is permitted only at the time of initial account creation. The State is prohibited from requiring a beneficiary to repeat the process during post-eligibility reviews or at the time of renewal. The State must also provide applicants with assurances that the identity proofing process, which is conducted by a credit rating agency, does not affect an applicant’s credit standing or is not treated as a credit, rather than an identity check, for the purposes of establishing an application account. 3.6 Non-financial Eligibility Factors A. Self-attestations and attestations at the time of initial application are accepted for certain non-financial eligibility requirements. Verification of this information is required in some by Federal or State law or Regulation, as indicated in § 3.6(B) of this Part below. Rhode Island has opted to utilize approved Federal and State electronic
interfaces with the IES for verification purposes when available, as authorized in 42 C.F.R. §§ 435.948 through 435.956. Paper documentation is therefore utilized only in instances when there is no information available through an electronic data source or there is a discrepancy between a self-attestation or an attestation and the electronic data source. B. All persons seeking Medicaid eligibility must provide a date of birth (age) and an SSN. Rhode Island resident children under the age of nineteen (19) are not subject to the eligibility requirements related to citizenship and immigration status and are not required to provide proof of legal immigration status or to have an SSN. Attestations and self-attestations about Rhode Island residency are accepted and require no verification, However, attestations and self-attestations about age and SSN are verified through electronic data sources. All applicants must provide an SSN, show proof that one has been requested, or seek the assistance of an agency representative to apply for an SSN before a determination of eligibility can be made. 1. Information and verification by coverage category – The respective responsibilities of applicants and the State associated with non-financial eligibility factors such as SSN and residency may vary by category of coverage. Accordingly, the applicable provisions are set forth in the Chapters of this Title related to each category of coverage, as indicated below: a. Medicaid Affordable Care Coverage (MACC) Groups and Non-MAGI eligible children and youth. Required information and verification for families, children, ACA expansion adults and pregnant women whose eligibility is determined using the MAGI standard is located at Part 30-00- 1 of this Title; For members of these populations deemed eligible due to a characteristic (newborns) or by current or past participation in a Federal or State program (SSI or Rhode Island Department of Children, Youth and Families (DCYF)) are set forth in Part 30-00-1 of this Title. b. Integrate Health Care Coverage (IHCC) Groups and Non-MAGI eligible adults and elders – Information related to non-financial eligibility requirements for all coverage groups subject to determinations using the SSI methodology, including the SSI and Community Medicaid eligibility pathway and Medicare Premium Payment Program (MPPP) are set forth in the application provisions in Part 40-00-1 of this Title and general eligibility section of Part 40-05-1 of this Title. c. LTSS – All new applicants for LTSS must meet the general eligibility requirements related to age, SSN and residency. Existing Medicaid beneficiaries who are seeking LTSS do not have to provide additional information about these non-financial factors if already known to the State and, therefore, are not subject to verification. For applicants pursing the ACA adult MAGI pathway, the non-financial eligibility requirements are set forth in Part 30-00-1 of this Title. For all other LTSS applicants, the
provisions related to the SSI methodology for Community Medicaid located in Part 40-05-1 of this Title apply. 2. State responsibilities – The State must provide assistance upon request to help applicants obtain and verify information about non-financial eligibility factors. Such information must be accessible to persons with limited English proficiency as well as persons with disabilities. The State’s responsibilities related to application information and verification include, but are not limited to: a. Information for applicants/beneficiaries. The State must inform applicants in both on-line and paper application forms whether attestations related to non-financial eligibility factors are verified, by what means, and how the information will be used in accordance with the applicable provisions of this Title. In addition, when a discrepancy is noted between a data source and an attestation, the State must provide any assistance requested by the applicant to validate and/or correct the information from the data source. b. Information from applicants. An applicant is only required to provide the information necessary to determine eligibility. In addition, the following limits apply: (1) Any information requested by the State about non-applicants in the household must be related to the applicant’s eligibility. Therefore, information pertaining to a non-applicant’s tax filing status, relationship, or income is requested when constructing a MAGI household. Information about the income and resources of a non- applicant spouse is generally required to determine Medicaid eligibility for most of the Integrated Health Care Coverage Group members (request, income, and resources may be required for some types of eligibility). (2) Request for the SSN of a non-applicant is permitted only if the State indicates clearly that it is being provided voluntarily and for purposes directly connected to initial or continuing eligibility for Medicaid. A non-applicant requesting eligibility for someone else in the household is not required to provide an SSN. (3) The State does not request information about the citizenship and immigration status of non-applicants in the household. 3.7 Citizenship and Immigration Status A. The requirements related to citizenship and immigration eligibility factors for Medicaid and CHIP-funded coverage categories are established in Federal law as follows:
1. Citizenship – The Federal Deficit Reduction Act (DRA) of 2005 (42 U.S.C. §§ 1305 and 1396r) requires states to provide Medicaid coverage to otherwise eligible applicants who are citizens and nationals of the United States when appropriate verification of self-attestations is provided. 2. Non-citizens – In accordance with the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA, 42 U.S.C. § 1305) and the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009 (42 U.S.C. § 1396), the following non-citizens are provided with Medicaid or CHIP- funded coverage when all other eligibility requirements are met: a. Adults. Qualified non-citizens over age nineteen (19) as defined in PRWORA eligible under the Medicaid State Plan – (1) Prior Entry – Qualified non-citizens who entered the United States before August 1, 1996; (2) Exempt from five (5) year bar – Qualified non-citizens who are exempt from the five (5) year bar on Medicaid coverage under Federal law at § 402(b) of PRWORA (8 U.S.C. § 1612(b)), including non-citizens with the following statuses: (AA) Refugees. Admitted under § 207 of Immigration and Naturalization Act (INA) including Afghan and Iraqi Special Immigrants (SIV’s) as permitted under Pub. Law 111-118; (BB) Asylees. Granted Asylum under § 208 of INA; (CC) Deportation withheld under § 243(h) of INA; (DD) Amerasian entrants. Pursuant to § 584 of the Foreign Operations, Export Financing and Related Programs Appropriations Act of 1988 (as contained in § 101(e) of Pub. Law 100-202 and amended by the 9th provision under Migration and Refugee Assistance in Title II of the Foreign Operations, Export Financing and Related Programs Appropriations Act, 1988, Pub. Law 100-461 as amended); (EE) Cuban or Haitian entrants. As defined in § 501(e) of the Refugee Education Assistance Act of 1980; (FF) U.S. Military. Lawfully residing and honorably discharged veterans (except one discharged for reasons of immigration status), or on active duty in the U.S. Armed forces, and their lawfully residing spouses and unmarried dependent children, and the un-remarried widow or widower of the veteran;
(GG) Battered non-citizens. Certain battered spouses, battered children or parents, or children of a battered person with a petition approved or pending under §§ 204(a)(1)(A) or (B) or 244(a)(3) of INA; (HH) American Indians. Born outside the U.S. in Canada and is at least fifty percent (50%) American Indian blood and to whom the provisions of § 289 of the INA apply; or is a member of a federally-recognized tribe as defined in § 4(e) of the Indian Self- Determination and Education Act; (II) Victims of trafficking. Certified by the U.S. Department of Human Services (HHS) Office of Refugee Resettlement pursuant to § 107(b) of the Victims of Trafficking and Violence Protection Act of 2000, as a victim of a severe form of trafficking; (JJ) Receiving disability assistance. Legally entered the U.S. on or after August 22, 1996 and received disability related benefits for a condition that is a disability or is pending a disability determination in accordance with 42 U.S.C. § 1381. (KK) SSI recipients. Receiving benefits for the U.S. Supplemental Security Income (SSI) program. Treated as a qualified exempt non-citizen under provisions of Pub. Law 105-306, if SSI benefits, and associated Title XIX Medicaid were continued and was lawfully residing in the U.S. and receiving SSI on Augusy 22, 1996. (3) After the five (5) year bar – Qualified non-citizens who were subject to the five (5) year bar (waiting period) on Medicaid eligibility AFTER the five (5) year period is complete, including: (AA) Lawful permanent residents (LPRs) Green card holders; (BB) Parolees. Granted parole for at least one (1) year under § 212(d)(5) of the Immigration and Nationality Act (INA), except when paroled for prosecution, deferred inspection, or pending removal proceedings; (CC) Conditional entrants. Granted conditional entry under § 203(a)(7) of immigration law in effect before April 1, 1980. b. Children and youth. Rhode Island resident children under the age of nineteen (19) are not subject to the five (5) year waiting period/bar. As authorized under the Children’s Health Insurance Program
Reauthorization Act of 2009 (CHIPRA, 42 U.S.C. § 1396) and as described in 8 C.F.R. § 103.12(a)(4) the following non-citizen children and youth are NOT subject to the five (5) year waiting period/bar regardless of their date of entry into the U.S. (1) Qualified Non-citizens – The full range of qualified non-citizens set forth in subpart (a) above and legal non-immigrants whose admission to the United States is not conditioned on having a permanent residence in a foreign country (such immigrants include citizens of the Compact of Free Association States who are considered permanent nonimmigrants but does not include visitors for business or pleasure or students). (2) Legally Residing Non-Citizens – (AA) Temporary resident status. Pursuant to §§ 210 or 245A of the Immigration and Nationality Act (INA) 8 U.S.C. §§ 1101- 1178; (BB) Temporary protected status. Pursuant to § 244 of the INA (8 C.F.R. § 244); (CC) Cuban-Haitian entrants. As defined in § 202(b) of Pub. Law 99-603 (8 U.S.C. § 1152), as amended; (DD) Family unity. Pursuant to § 301 of Pub. Law 101-649 (8 U.S.C. § 1151), as amended, as well as pursuant to § 1504 of Pub. Law 106-554 (8 C.F.R. § 245a); (EE) Deferred enforced departure (DED). In accordance with a decision made by the President; (FF) Deferred action status. As set forth in INA Service Operations Instructions at OI § 242.1(a)(22); (GG) Adjusted status. The spouse or child of a United States citizen whose visa petition has been approved and who have a pending application for adjustment of status. (3) INA Non-citizens – The following categories of non-immigrant children under § 101(a)(15) of the Immigration and Nationality Act (INA) (8 U.S.C. § 1101) are also eligible for coverage under Title XXI: (AA) Immediate family. Parents or children of individuals with special immigration status under § 101(a)(27) of the INA as
permitted under §101(a)(15)(N) of the INA (8 U.S.C. § 1101); (BB) Fiance(e) of a citizen as permitted under § 101(a)(15)(K) of the INA (8 U.S.C. § 1101); (CC) Religious workers under § 101(a)(15)(R) (8 U.S.C. § 1101); (DD) U.S. Attorney General’s discretion. The Attorney General of the United States has determined the non-citizen is in possession of critical reliable information concerning a criminal or terrorist organization, enterprise or operation as permitted under § 101(a)(15)(S) of the INA (8 U.S.C. § 1101); (EE) Victims of trafficking. As permitted under § 101(a)(15)(T) of the INA (8 U.S.C. § 1101); (FF) U.S. Department of Justice. When assisting in a criminal investigation as permitted under § 101(a)(15)(U) of the INA (8 U.S.C. § 1101); (GG) Battered non-citizens; (HH) Petition pending. A petition pending for three (3) years or more as permitted under § 101(a)(15)(V) of the INA (8 U.S.C. § 1101). c. Pregnant women. All pregnant women who otherwise meet the requirements for Medicaid are eligible without regard to immigration status. 3. Non-qualified non-citizens – In accordance with the provisions of PRWORA, non-citizens who are not pregnant and do not have current documentation of a qualified non-citizen status are not eligible for Medicaid or CHIP coverage except in instances of a medical emergency. Rhode Island resident children under the age of nineteen (19) are not subject to eligibility requirements related to citizenship and immigration status. The provisions governing Medicaid coverage for non-citizens who are RI residents in emergency circumstances are set forth in Part 40-05-1 of this Title. 4. Alternative forms of coverage – Lawfully present qualified non-citizens who are ineligible for Medicaid/CHIP funded coverage, may qualify for commercial health insurance coverage through the State’s health insurance marketplace known as HealthSource RI (HSRI). To facilitate access to affordable health coverage, any non-citizen who applies for Medicaid and is denied on the basis of immigration
status is automatically evaluated for an HSRI plan and is informed if such coverage options are available in the eligibility determination notice. B. The State verifies self-attestations and attestations of citizenship and satisfactory immigration status through designated electronic Federal and State data sources through the IES to the full extent feasible. Rhode Island resident children under the age of nineteen (19) are not subject to eligibility requirements related to citizenship and immigration status 1. Exemptions – The provisions set forth in this Part related to citizenship and immigration status do not apply to the following exempt persons/coverage groups: a. Persons eligible on the basis of the current or past receipt of Supplemental Security Income (SSI) as specified under Part 40-05-1 of this Title. b. Anyone entitled to or enrolled in any part of Medicare, including applicants for the Medicaid Premium Payment Program (MPPP) pursuant to Part 40- 05-1 of this Title. c. Recipients of Social Security Disability Insurance (SSDI) and/or federally authorized and funded rehabilitative services, administered through the Rhode Island Department of Human Services (DHS) or the Rhode Island Office of Rehabilitative Services (ORS) seeking any type of Medicaid coverage; d. Children and youth, up to age twenty-one (21), who are in the care and custody of the Rhode Island Department of Children, Youth and Families (DCYF) and/or participating in foster care and adoption subsidy assistance and maintenance programs and former foster care youth eligible under the Federal Chafee Independent Act pursuant to Part 30- 00-1 of this Title; e. Newborns deemed eligible for Medicaid or CHIP in accordance with Part 30-00-1 of this Title. 2. Citizenship – An applicant has met the Medicaid citizenship eligibility requirement when the applicant is an adult and has made a self-attestation of United States citizenship, or the applicant is a minor or incapacitated person and an adult living in the same household or an authorized representative has made a declaration of citizenship on the behalf of the minor or incapacitated person; and the declaration has been verified by an authorized electronic data source. 3. Immigration status – An applicant has met the Medicaid/CHIP immigration status requirement when the applicant has made a self-attestation of satisfactory immigration status; or an attestation of such status has been made on the
applicant’s behalf by an adult living in the same household or an authorized representative in instances in which the applicant is a minor or incapacitated. An attestation of immigration status may also be accepted when provided by a responsible person with first-hand knowledge of the immigration status of the applicant, but only if the attestation is verified by an authorized electronic data source or approved form of documentation. Special provisions apply in certain circumstance as follows: a. Veterans. For purposes of determining whether the exemption from the five (5) year bar for qualified non-citizen veterans and their families applies, the State must verify that the veteran is in honorably discharged or active military duty status, or is the spouse or unmarried dependent child of such person. If the State is unable to verify this information through electronic means, self-attestation with paper documentation providing proof of the veteran’s status and/or relationship to the veteran is accepted. b. Participants in other Federal means-tested programs – The State does not re-verify the citizenship or immigration status of an applicant for Medicaid/CHIP funded coverage who is currently participating in a State administered means-tested Federal program, providing verification of citizenship and immigration status is a condition of eligibility, has been successfully completed, and record of such is maintained and can be accessed through the IES. 4. Verification sources – The primary electronic data sources for verifying citizenship and immigration status used by the State is the Federal State Verification and Exchange System (SVES) which operates through the Verify Lawful Presence (VLP) interface with the Federal data hub (MACC group members subject to MAGI determinations); and, an electronic data exchange with the U.S. Citizenship and Immigration Services (USCIS). As indicated in § 3.7(C) of this Part below, if verification through these sources does not succeed, the State may use alternative electronic or paper forms of verification. 5. Record of verification – The State maintains a record of having verified citizenship and immigration status for each applicant in the IES in accordance with the requirements in 42 C.F.R. § 431.17(c). 6. Agency assistance – A State agency eligibility specialist is available to provide assistance to an applicant who is unable to provide a declaration or attestation, correct errors or inconsistences, or obtain any required documents as a result of a disability, homelessness, and/or the absence of someone who can act as authorized representative on his/her behalf.
7. Authorized representative – An authorized representative may submit proof of citizenship, identity and/or satisfactory immigration status on the behalf of an application or beneficiary. 8. Limits – Verification of citizenship and satisfactory immigration status occurs at the point of initial application. Unless an applicant/beneficiary reports a change in citizenship or immigration status, or the State receives information indicating such a change has or may occur, the State may not initiate or require re- verification of either eligibility factor at the point of annual renewal, on a quarterly basis as part of the post-eligibility verification (PEV) process set forth in Part 30- 00-5 of this Title, or subsequent to a break in coverage. 3.7.1 Prompt Resolution and Reasonable Opportunity A. Verification of citizenship and/or immigration status through primary electronic data sources and interfaces may not succeed. In such instances, the verification process proceeds as follows: 1. Prompt resolution – It is the State’s responsibility to promptly attempt to resolve any inconsistencies issues, including typographical or other clerical errors, between information provided by the applicant and information from a primary electronic data source, and resubmit corrected information through such electronic services or an alternative electronic mechanism. 2. Reasonable Opportunity – If prompt resolution fails to provide verification within five (5) working days, the State provides a reasonable opportunity period. During the reasonable opportunity period, the State continues efforts to complete verification of the citizenship and/or satisfactory immigration status, or request documentation if necessary. a. Notice. The State must provide notice to an applicant indicating that a reasonable opportunity period is being initiated. The period begins on the date the notice is received by the applicant which is presumed to be five (5) days after the date on the notice. The notice provides the applicant with the following: (1) Temporary, provisional eligibility – A statement indicating that a reasonable opportunity period has been initiated. During this period, temporary, provisional Medicaid eligibility is provided to applicants in the household for whom verification is pending for up to ninety (90) days. Temporary, provisional eligibility begins on the first (1st) day of the month in which the application was filed and ends when verification is completed, the applicant fails to cooperate or cannot provide any requested verification, or the reasonable opportunity period expires, whichever comes first.
(2) Alternative forms of proof – An additional documentation request (ADR) is included in the notice. The ADR identifies the outstanding verification issues (discrepancy, error, missing data); indicates the corrective action required and how to obtain assistance from the state agency, if appropriate; and provides a list of alternative accepted forms of verification, including paper documentation. b. Additional State responsibilities – During the reasonable opportunity period: (1) No limits on coverage – The State may not delay, deny, reduce or terminate coverage for a person who has been determined otherwise eligible for Medicaid during the reasonable opportunity period, in accordance with 42 C.F.R. § 435.911(c). (2) Extensions – The State may extend the reasonable opportunity period in instances in which the applicant is making a good faith effort to obtain any necessary documentation or the State needs more time to verify status through other available electronic data sources or to assist an applicant in obtaining documents needed to verify his or her status. (3) End of eligibility – At least thirty (30) days prior to the termination of the period of temporary, provisional eligibility, the State provides an adverse action notice containing the reason for the terminating eligibility and denying the application for Medicaid. The notice must contain the right to appeal the eligibility determination decision. c. Applicant’s responsibilities. An applicant must respond to the notice ADR in no more than thirty (30) days plus an additional five (5) days to cover mailing time – a total of thirty-five (35) days. An applicant may show good cause for failing to respond, by providing proof of mail delays or an emergency situation and request an extension of the reasonable opportunity period. An applicant also has the right to appeal and request a hearing. Reapplication is required. 3.8 Sponsor Deeming A. Under the deeming provisions for non-citizens, the income and resources of the sponsor(s) are counted as available and received, even if not in fact received, by the applicant. Income and resources of the sponsor(s) and of the sponsor's spouse (when living together) are counted when determining the income and resources of the non- citizen applicant. 1. Scope and application – Deeming applies ONLY to lawful permanent residents (LPR) who:
a. Entered the U.S. or were granted LPR status on or after December 19, 1997; and b. Were sponsored by a person or entity with U.S. citizenship status such a family member, employer, or representative of an academic institution or business owner; and c. Received legally binding affidavit(s) of support from the sponsor (USCIS form 1-864). 2. Eligibility duration – Deeming continues until the non-citizen: a. Attains U.S. citizenship; or b. Can be credited with forty (40) quarters of work as defined under Title II of the Social Security Act, provided that no credit is given for any quarter after December 31, 1996 in which any Federal means tested benefit was received. Federal means tested benefits include, but are not limited to: Supplemental Nutrition Assistance Program (SNAP), RI Works, Child Care Assistance Program (CCAP), Supplemental Security Income (SSI) and Low-income Heating Assistance Program (LIHEAP). (1) Non-citizens may be credited with quarters from their own employment, their spouse's employment, and their parent's employment. (2) Verification of qualifying quarters must be obtained from Social Security Administration records. A written statement, signed by the applicant under penalty of perjury, may be used as temporary verification of quarters worked while awaiting information requested from Social Security. B. Deeming provisions may be waived for a period of one (1) year in certain circumstances for sponsored immigrants. 1. Battery or cruelty – Deeming requirements may be waived when a non-citizen demonstrates that he or she or a child or dependent have been battered or subjected to extreme cruelty while in the U.S. by certain persons who were living in the same household. a. The battery must have a substantial connection to the need for Medicaid benefits such as to enable the non-citizen and any children/dependents to: (1) Become self-sufficient following separation from the abuser;
(2) Escape the abuser or the community where the abuser lives, or to gain protection from the abuser; (3) Obtain health coverage due to a loss of income or a period of health insurance ineligibility suffered as a result of separation from the abuser; (4) Address health care issues or disabilities resulting from the abuse; b. In the absence of such a connection to Medicaid, the non-citizen may show that he or she does not have sufficient income or resources for food or shelter without the abuser’s financial support and, therefore, may be considered indigent. (1) To be considered indigent, the sum of all income including any cash or in-kind assistance must be at or below one hundred thirty percent (130%) of the FPL. (2) When determining whether a person is indigent, only the total amount of income and resources actually deemed to the non- citizen during a twelve (12) month period is counted. This is also the amount used when determining Medicaid eligibility for the non- citizen and any children and dependents. c. The State is required under Federal law to notify the USCIS with the name of the sponsor and the sponsored non-citizens receiving Medicaid under this Part. The sponsor must reimburse the State for any Medicaid payments paid for covered services during a waiver period, with the exception of payments for emergency services. d. A waiver related to abuse may be renewed if the non-citizen demonstrates the battery or cruelty has been recognized in the order of a judge or administrative law judge or a prior determination of the USCIS and the need for benefits remains the same; or the non-citizen requests a continuation of the waiver based on the indigent standard set forth in § 3.8(B)(1)(b) of this Part above. e. Accepted forms of proof of battery or cruelty at the time of the initial application for a waiver and, as appropriate, continuation of the waiver include, but are not limited to: (1) An approved USCIS petition; (2) Restraining order; (3) Third party affidavit,
(4) Signed affidavit from the applicant, or (5) Health care, or public or private agency records. 2. Emergency services – Deeming provisions do not apply to eligibility determinations for emergency services. 3.9 Evidence Accepted for Verification Purposes A. Accepted forms of documented evidence for each non-financial eligibility factor is set forth below: 1. Identity – The State accepts the following as proof of identity, provided such document has a photograph or other identifying information sufficient to establish identity, including, but not limited to, name, age, sex, race, height, weight, eye color, or address: a. Driver's license issued by a State or Territory; b. School identification card; c. U.S. military card or draft record; d. Identification card issued by the Federal, State, or local government; e. Military dependent's identification card; f. U.S. Coast Guard Merchant Mariner card; g. For children under the age of nineteen (19), a clinic, doctor, hospital, or school record, including preschool or day care records; h. Two (2) other documents containing consistent information that corroborates an applicant's identity. Such documents include, but are not limited to, employer identification cards; high school, high school equivalency and college diplomas; marriage certificates; divorce decrees; and property deeds or titles. i. Finding of identity from a Federal or State governmental agency. The State may accept as proof of identity a finding of identity from a another government agency, federal or state, including but not limited to a public assistance, law enforcement, internal revenue or tax bureau, or corrections agency, if the identity of the applicant has been verified and certified. j. If the applicant does not have any of the documentation cited herein, the State accepts an affidavit signed, under penalty of perjury, by a person
other than the applicant who can reasonably attest to the applicant's identity. Such affidavit must contain the applicant's name and other identifying information establishing identity. The affidavit does not have to be notarized. 2. Social Security Number – The following are accepted forms of proof of Social Security Number: a. Social Security Card b. Social Security Records c. Tax return or other document showing SSN and identity. 3. Date of Birth/Age – In addition to a birth certificate, the State accepts the following evidence of date of birth: U.S. Passport Naturalization Certificate Hospital Birth Records Social Security Administration Award Letter if DOB is included Adoption Records Affidavit of a Third Party School Records Military Service Records Physician Records USCIS Immigration Documents Driver’s License or State-issued Photo ID Church Records (Baptismal Certificate, Confirmation Papers, Marriage Certificate) Social Security Card or Records Voter Registration Card Life Insurance Policy Family Bible Marriage License State/Federal Census Record 4. Citizenship – The evidence accepted as proof of citizenship varies in accordance with the following: a. Stand-alone evidence of citizenship. The State accepts the following as sufficient evidence of citizenship:
(1) A U.S. passport, including a U.S. Passport Card issued by the Department of State, without regard to any expiration date as long as such passport or Card was issued without limitation; (2) A Certificate of Naturalization; (3) A Certificate of U.S. Citizenship; (4) A valid State-issued driver's license if the State issuing the license requires proof of U.S. citizenship, or obtains and verifies a SSN from the applicant who is a citizen before issuing such license; (5) Documentary evidence issued by a federally-recognized Indian Tribe identified in the Federal Register by the Bureau of Indian Affairs within the U.S. Department of the Interior, and including Tribes located in a State that has an international border, which identifies tribe that issued the document; the applicant by name; and; confirms the applicant’s membership, enrollment, or affiliation with the Tribe; (6) A data match with the Social Security Administration. b. Secondary evidence – If primary evidence of citizenship is unavailable, the following must be accepted as satisfactory evidence to establish citizenship if also accompanied by an identity document listed in § 3.10(A)(3) of this Part: (1) A U.S. public birth certificate showing birth in one of the fifty (50) States, the District of Columbia, Guam, American Samoa, Swain's Island, Puerto Rico (if born on or after January 13, 1941), the Virgin Islands of the U.S. or the CNMI (if born after November 4, 1986, (CNMI local time)). The birth record document may be issued by a State, Commonwealth, Territory, or local jurisdiction. If the document shows the application was born in Puerto Rico or the Northern Mariana Islands before the applicable date referenced in this paragraph, the applicant may be a collectively naturalized citizen. In such instances, the State accepts the evidence identified in 42 C.F.R. § 435.945; (2) At State option, a cross match with a State vital statistics agency documenting a record of birth; (3) A Certification of Report of Birth, issued to U.S. citizens who were born outside the U.S; (4) A Report of Birth Abroad of a U.S. Citizen;
(5) A Certification of birth in the United States; (6) A U.S. Citizen I.D. card; (7) A Northern Marianas Identification Card issued by the U.S. Department of Homeland Security (or predecessor agency); (8) A final adoption decree showing the child's name and U.S. place of birth, or if an adoption is not final, a Statement from a State- approved adoption agency that shows the child's name and U.S. place of birth; (9) Evidence of U.S. Civil Service employment before June 1, 1976; (10) U.S. Military Record showing a U.S. place of birth; (11) A data match with the SAVE Program or any other process established by USCIS to verify that an applicant is a citizen; (12) Documentation that a child meets the requirements of § 101 of the Child Citizenship Act of 2000 as amended (8 U.S.C. § 1431); (13) Medical records, including, but not limited to, hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility, or other institution that indicate a U.S. place of birth; (14) Life, health, or other insurance record that indicates a U.S. place of birth; (15) Official religious record recorded in the U.S. showing that the birth occurred in the U.S.; (16) School records, including pre-school, Head Start and daycare, showing the child's name and U.S. place of birth; (17) Federal or State census record showing U.S. citizenship or a U.S. place of birth; (18) If the applicant does not have one of the documents listed in §§ 3.9(A)(4)(b)(1) through (17) of this Part herein, he or she may submit an affidavit signed by another person under penalty of perjury who can reasonably attest to the applicant's citizenship, and that contains the applicant's name, date of birth, and place of U.S. birth. The affidavit does not have to be notarized. c. Verification of citizenship by a Federal agency or another State. The State may rely, without further documentation of citizenship or identity, on a
verification of citizenship made by a Federal agency or another State, if such verification was done on or after July 1, 2006. 5. Satisfactory Immigration Status – In the event that electronic data sources fail, the State may require an applicant to provide the appropriate form of evidence to prove status, as listed below: Immigration Status Birth Certificate (if born in the U.S.) – otherwise this does not show immigration status in the U.S. U.S. Passport Naturalization Certificate Military Service Records Alien Resident Card (I-155) (also known as a “Green Card”) Employment Authorization Card (I-688B) For recent arrivals, a temporary I-551 stamp in a foreign passport or on USCIS Form I-94 Unexpired Re-entry Permit (Form I-327) Forms AR-3 and AR-3a, Alien Registration Receipt Card USCIS Form I-94 with stamp showing admission under 203(a)(7) of the INA, refugee- conditional entry USCIS Form I-688B (or USCIS employment authorization card) annotated 274a.12(a)(3); USCIS Form I-766 annotated A3. For lawful permanent residents who are victims of domestic violence – IRS form I551 or I551B coded IB1 through IB3, IB6 through IB8, B11, B12, B16, B17, B20 through B29, B31 through B33, B36 through B38, BX1 through BX3, BX6, BX7 or BX 8 For victims of domestic violence petitioning for legal status who are considered as "qualified aliens" under PROWORA – IRS Form 797 showing an approved 1-360 or 1-13 self- petitioning as a spouse or child of a U.S. citizen or lawful permanent resident; OR USCIS Form 797 showing a Notice of Prima Facie Determination USCIS Form I-94 with date of admission and annotated with unexpired status as listed in § 0304.05.45.05
Immigration Status Dated USCIS letter or court order indicating a lawfully residing status listed in § 0304.05.45.05 An unexpired USCIS employment authorization document (I-688-B) annotated with status code Applicants for asylum: I-94, I-589 on file, I-688B coded 274a.12(c)(8) Applicants for suspension of deportation: I-94, I-256A on file, I-688B coded 274a.12(c)(10) Non-citizens granted stays of deportation by court order statute or Regulation or by individual determination of USCIS whose departure the USCIS does not contemplate enforcing: letter or Granted a stay of deportation, I-688B coded 274.12(c)(12) Non-citizens granted suspension of deportation pursuant to § 244 of INA (8 U.S.C. § 1254) whose departure the USCIS does not contemplate enforcing: letter/order from the immigration judge and a Form I-94 showing suspension of deportation granted Non-citizens residing in the United States pursuant to an Order of Supervision: USCIS Form I-220B, I-688B coded 274a.12(c)(18) Temporary Protected Status: I-94 "Temporary Protected Status" and/or I-688B employment authorization coded 274a.12(a)(12) Deferred Enforced Departure: Letter from USCIS; I-688B coded 274a.12(a)(11) Family Unity: USCIS approval notice, I-797, and/or I-688B coded 274a.13 Non-citizens granted deferred action status: Letter indicating that the non-citizen's departure has been deferred and/or I-688B coded 274a.12(c)(14) Non-citizens who have filed applications for adjustment of status whose departure the USCIS does not contemplate enforcing: Form I-94 or I-181 or passport stamped with either of the following: "adjustment application" or "employment authorized during status as adjustment applicant"; and/or I-688B coded 274a.12(c)(9) USCIS Form I-94 annotated with stamp showing entry as a refugee under § 207 of the INA and date of entry USCIS Form I-688B (or USCIS Employment Authorization Card) annotated 274a.12(a)(3) USCIS Form I-766 annotated A3 USCIS Form I-571
Immigration Status USCIS Form 551 (Resident Alien Card) coded RE-6, RE-7, RE-8, or RE-9 USCIS Form I-94 annotated with stamp showing a grant of asylum Grant letter from the Asylum Office of the USCIS USCIS Form I-688B annotated with 274a.12(a)(S) USCIS Form I-766 annotated Order from Immigration Judge granting asylum Order from an Immigration Judge showing the date of a grant of deportation withheld under § 243(h) of the INA USCIS Form I-688B (or USCIS employment authorization card) annotated 274a.12(a)(10) USCIS Form I-766 annotated A10 USCIS Form 551 with codes CU6, CU7, or CH6 Unexpired temporary I-551 stamp in a foreign passport or USCIS Form I-94 with codes CU6 or CU7 USCIS Form I-94 with stamp showing the individual paroled as a Cuban/Haitian Entrant under § 212(d)(5) of the INA An USCIS Form I-94 annotated with a stamp showing grant of parole under § 212(d)(5) of the INA and a date showing granting of parole for at least one (1) year is acceptable verification of this status ORS issues a certification letter to adults and a letter of benefit eligibility pursuant to § 107(b) of the Trafficking Victims Protection Act of 2000 to children under eighteen (18) years of age: For adult, the ORS certification letter is proof of qualified non-citizen status; For children under age eighteen (18), the ORS letter of benefit eligibility is proof of qualified non-citizen status. B. The State accepts a photocopy, facsimile, scanned or other copy of a document that must be accepted to the same extent as an original document identified as accepted evidence under this Part, unless information on the copy submitted is inconsistent with other information available to the State or the State otherwise has reason to question the validity of, or the information in, the document.
3.10 Cooperation Requirements A. As a condition of eligibility, all Medicaid applicants and beneficiaries must meet certain cooperation requirements which enable to State to meet Federal laws, Rules and Regulations related to obtaining and retaining Federal matching funds for the program. 1. General cooperation requirements – Applicants and beneficiaries must: a. Application information. Provide any information requested by the State that is necessary to determine eligibility for Medicaid; b. Assignment of rights. Medical support or other third-party payments for health care services must be assigned to the State. An applicant must also assign to the EOHHS any third-party payments for any other household members eligible under the Medicaid and CHIP State Plan and/or Section 1115 demonstration waiver for whom he or she has the legal authority under State law to make such an assignment. This assignment obligation takes effect under State law upon an applicant's filing for Medicaid; c. Child support. Cooperate in establishing paternity and obtaining support, except when an exemption exists, with the State’s Office of Child Care Enforcement. Exemptions exist for pregnant women with no other children until the birth of the child, parent/caretakers in child-only application cases, and children in general. The State does not deny initial eligibility to an adult applying for Medicaid pending cooperation with the child support requirement. However, termination of eligibility is initiated if an adult applicant or beneficiary does not cooperate by the time of the first periodic electronic verification; d. Enrollment in RIte Share. An applicant with access to cost-effective employer-sponsored insurance (ESI) must enroll in the plan as a condition of eligibility. Medicaid-eligible children are not denied eligibility or subject to the loss of coverage, if their parent/caretakers with access to coverage do not cooperate and enroll in the approved plan. Specific provisions governing the RIte Share program are located in Part 30-05-3 of this Title; e. Alternative sources of support and assistance. Take all reasonable actions to make income/resources available to meet needs. A reasonable action is one that will likely result in more financial benefit accruing to a household than the cost of Medicaid coverage. In addition, for eligibility to continue to exist, a beneficiary who claimed that income or resources owned by or owed to him or her are unavailable must show a good faith effort to continue to take reasonable actions unless the State approves a
good cause exemption made in writing. Reasonable actions include, but are not limited to: (1) Filing applications for other benefits to which an applicant/beneficiary may be entitled including, but not limited to, State and federally-funded health care and cash assistance programs and income tax credits and private or public retirement benefits, food assistance, or supplemental insurance; (2) Making formal requests to other joint owners to sell or otherwise liquidate jointly held property; (3) Requesting guardians, trustees, and other legally authorized representatives to make resources or income available from estates, trusts, settlements, and other financial instruments; (4) Retain counsel to petition a court to adjudicate any monetary or property claim which the client may have against any person; and (5) Report to the State at the time of renewal or more frequently upon request progress being made toward making the resource or income available for use. f. Quality Assurance. Assist the State by providing full cooperation in any quality assurance and/or program integrity activities. 2. Third-party liability – All applicants and beneficiaries must identify and provide information about third-party payers liable for Medicaid covered services and supports and, as required in § 3.10(A)(1) of this Part above, assign rights to payments. Beyond cooperating in this manner, the State generally pursues third- party liability without further assistance from the beneficiary. However, the State may require a beneficiary to: a. Appear at a designated State or local office to provide information or evidence relevant to the case; b. Serve as a witness at a court or other proceeding; c. Provide information, or attest to lack of information, under penalty of perjury; d. Pay to the State any support or medical care funds received that are covered by the assignment of rights; and e. Take any other reasonable steps to assist in establishing paternity and securing medical support and payments and in identifying and providing information to assist the State in pursuing any liable third party.
B. Non-cooperation with any requirement that is a condition of eligibility may result in the denial or termination of Medicaid eligibility for applicants and beneficiaries nineteen (19) years of age or older unless specifically exempt in Federal or State laws or the Rules and/or Regulations established under this Title. Such exemptions are identified, as appropriate, in the Chapters of this Title pertaining to each coverage category as indicated in § 3.6(B)(1) of this Part above.
210-RICR-10-00-3 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 - EOHHS GENERAL PROVISIONS SUBCHAPTER 00 - GENERAL PROVISIONS PART 3 - MEDICAID AND CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) NON-FINANCIAL GENERAL ELIGIBILITY REQUIREMENTS (210-RICR-10-00-3) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 12/29/2022 February 27, 2023 E-SIGNED by Ana Novais on 2023-02-27 17:20:19 EST February 28, 2023 E-SIGNED by Department of State on 2023-02-28 07:57:04 EST
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210-RICR-10-00-4 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 - EOHHS GENERAL PROVISIONS SUBCHAPTER 00 - GENERAL PROVISIONS Part 4 - Collections and Payments: Liens and Recovery of Medicaid Payments 4.1 LEGAL authority
In accordance with federal mandates and R.I. Gen. Laws § 40-8-15, this lien and recovery regulation applies to the estates of recipients, whether categorically or medically needy, fifty-five (55) years of age or older at the time of receipt of Medicaid. 4.2 OVERVIEW A. A lien shall attach against property, which is included or includable in the decedent’s probate estate, regardless of whether or not a probate proceeding has been commenced in a probate court. Such a lien shall only be effective upon proper prior notice and if the lien is recorded in the land evidence records in accordance with R.I. Gen. Laws § 40-8-15. B. This Part, as it applies to all probate proceeding of a decedent aged fifty-five years (55) or older, shall include voluntary informal probate proceedings and any references to an executor or administrator shall include, without limitation, a voluntary executor or voluntary administrator. 4.3 Definitions A. As used in this section, the following terms shall be construed as follows: 1. "Estate", with respect to a deceased individual, means all real and personal property and other assets included or includable within the individual's probate estate. 2. “Executive Office of Health and Human Services" or "EOHHS” means the state agency established in 2006 under the provisions of R.I. Gen. Laws Chapter 42-7.2 et seq. within the executive branch of state government and serves as the principal agency for the purposes of managing the Departments of Children, Youth, and Families (DCYF); Health (DOH); Human Services (DHS); and Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH). The EOHHS is designated as the “single state agency,” authorized under Title XIX of the U.S. Social
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Security Act (42 U.S.C. § 1396a et seq.) and, as such, is legally responsible for the program / fiscal management and administration of the Medicaid Program. 4.4 APPLICATION OF THE LIEN A. The lien shall apply to the individual's estate which includes all real and personal property and other assets that are included or includable within the individual's probate estate. Consequently, an individual's probate estate may be comprised of liquid assets as well as real property, including any resources remaining at the time of death which were allowable in the individual's Medicaid eligibility determination. B. Other than as provided in § 4.15 of this Part, a lien cannot attach to assets which are not the subject of a probate estate initiated within the State of Rhode Island, or in any other state in which the individual was a domiciliary. Real or personal property which passes by operation of law, or passes to beneficiaries under a contract, deed, annuity, or other instruments such as trust agreements or insurance policies, or any other property which does not require the initiation of a probate process to convey title or beneficial interests or ownership to others, is excluded from the lien process. C. The lien shall attach against property of a beneficiary, which is included or includable in the decedent’s probate estate, regardless of whether or not a probate proceeding has been commenced in the probate court by EOHHS or by any other party. Provided, however that such lien shall only attach and shall only be effective against the beneficiary’s real property included or includable in the beneficiary’s probate estate upon proper prior notice and if such lien is recorded in the land evidence records and is in accordance with R.I. Gen. Laws § 40-8-15. Decedents who have received Medicaid are subject to the assignment and subrogation provisions of R.I. Gen. Laws §§ 40-6-9 and 40-6-10. D. The lien for the recovery of Medicaid expenditures: 1. Does not attach during the beneficiary’s lifetime; 2. Does not attach to any real or personal property that is not included or includable in the deceased Medicaid beneficiary’s probate estate. E. The lien for the recovery of Medicaid expenditures: 1. Does cover all periods of receipt of Medicaid from and after age fifty-five (55). 2. The recipient does not have to be receiving Medicaid at the time of death. 3. Does attach at death to all assets included or includable within the individual's probate estate. That is, any and all assets that are subject to
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Probate or to assets where there is no probate due to the use of the Rhode Island "small estates" statute (R.I. Gen. Laws § 33-24-1 et seq.). 4. Does attach to and remain a lien upon the estate property, whether or not the property is transferred, and upon all property acquired by the executor or administrator in substitution therefore while that property remains in his or her hands until the Medicaid is paid, but the lien shall not affect any tangible personal property or intangible personal property after it has passed to a bona fide purchaser for value. If there are questions concerning the passage to a bona fide purchaser, the case will be referred to the EOHHS Legal Office as referenced in § 4.5 of this Part. 5. Notice of said lien shall be sent to the duly appointed executor or administrator, the decedent’s legal representative, if known, or to the decedent’s next of kin or heirs at law as stated in the decedent’s last application for Medicaid, thirty (30) days prior to filing in the land evidence records. Said notice shall include appeal rights as noted in § 4.11 of this Part. 4.5 REQUIREMENTS FOR TRANSFER/SALE OF PROPERTY A. Whenever an individual who is receiving Medicaid, transfers an interest in real or personal property on or after July 1, 2012, such individual shall notify the EOHHS within ten (10) days of the transfer: 1. EOHHS Legal Office, Virks Building, 3 West Road, Cranston, RI 02920 B. Such notice shall also be sent to the individual’s local office. The notice shall include, at a minimum, the individual’s name, social security number or, if different, the EOHHS identification number, the date of transfer and the dollar value, if any, paid or received by the individual who received benefits, and the name of the person and relationship of the person to whom the transfer was made. C. In the event a Medicaid beneficiary fails to provide the required notice of the transfer to EOHHS and in the event the beneficiary, his/her guardian, conservator or agent under a power of attorney, if applicable, his/her spouse and/or immediate family members knew or should have known that such individual failed to provide such notice and that person(s) receives any distribution of less than fair market value as a result of the transfer, he or she shall be liable to the EOHHS to the extent of the uncompensated value of the transfer, up to the amount of Medicaid benefits paid on behalf of the beneficiary. D. Moreover, any such individual shall be subject to the provisions of R.I. Gen. Laws § 40-6-15 and any remedy provided by applicable state and federal laws and rules and regulations. Failure to comply with the notice requirements set forth in the section shall not affect the marketability of title to real estate transferred.
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4.6 EXCEPTIONS TO THE LIEN A. A lien shall not apply: 1. For periods of receipt of Medicaid before the beneficiary reached the age of fifty-five (55). 2. If the beneficiary is survived by: a. A spouse; or b. A child who is under the age of twenty-one (21); or c. A child who is blind or permanently and totally disabled as defined in Title XVI (SSI) of the Social Security Act. B. An individual who is a survivor of the deceased beneficiary, as described above, need not be residing in property of the estate or be a beneficiary of the estate. C. Receipt of SSI, RSDI or Railroad Retirement (RR) benefits is acceptable evidence of disability. However, if the child is not in receipt of such benefits, the characteristic of disability must be determined by EOHHS. 4.7 REDUCTIONS OF THE LIEN UNDER QLTCIP PROGRAM A. RI has established a Qualified Long-Term Care Insurance Partnership (QLTCIP) program. This Qualified LTC Insurance Partnership provides: 1. For the disregard of a Medicaid applicant's resources in an amount equal to the benefits paid by their QLTCIP policy as of the time of their application for Medicaid; and 2. For the total amount paid by the individual's QLTCIP policy at the time of death to be disregarded in the determination of the amount to be recovered from a beneficiary's estate. 3. The amount that will be protected during estate recovery is the same amount that was disregarded in the eligibility determination. (There may be continuing QLTCIP policy payments after Medicaid eligibility is established, so if the person later gains assets, he/she may have more protected than he/she had at the time of eligibility). 4. Thus, the total amount paid by the individual's QLTCIP at the time of death is to be disregarded in the determination of the amount to be recovered from a beneficiary's estate.
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4.8 CLIENT NOTIFICATION
During application for Medicaid for the individual who is fifty-five (55) or older at the time of application or who will turn fifty-five (55) before renewal, the individual, or his/her representative, must be advised that, under Rhode Island law, receipt of Medicaid may constitute a lien upon his/her estate. Similarly, at renewal for Medicaid for an individual who is fifty-five (55) years of age or older or who will become fifty-five (55) before the next renewal, it must be explained to such individual that the lien is an attachment against the individual's estate, taking effect at death, which allows EOHHS to recover from the individual's estate any Medicaid paid on behalf of the individual from the time s/he became fifty-five (55) years of age (and after the effective date of the law). The exceptions in § 4.6 of this Part relative to certain survivors must be explained to the applicant. 4.9 RECOVERY A. Based on the information regarding the deceased's resources and the assistance which would by law be recovered, a decision regarding recovery is made by EOHHS. B. EOHHS Recovery Practices: 1. Upon the filing of a petition for admission to probate of a decedent’s will or for administration of a decedent’s estate, when the decedent was fifty-five (55) years or older at the time of death, a copy of said petition and a copy of the death certificate shall be sent to the EOHHS: a. EOHHS Legal Office, Virks Building, 3 West Road, Cranston, RI 02920. 2. The notice requirements of this section are in addition to any notice that may be required pursuant to R.I. Gen. Laws § 33-11-5.1 entitled “Duty to notify known or reasonably ascertainable creditors.” 3. If the EOHHS requests additional information, an executor or administrator shall complete and send to EOHHS a form prescribed by that office and shall provide such additional information within thirty (30) days of the request. Petitioners shall maintain documentation evidencing notice to the EOHHS Legal Office and file a copy of this notice with the probate court prior to hearing. In the case of a voluntary probate proceeding, since there is no hearing, a copy of the notice to EOHHS shall be filed with the probate court with the voluntary petition. 4. For estates open on or after July 1, 2012, should a petitioner fail to send a copy of the petition and a copy of the death certificate to the EOHHS Legal Office and a decedent has received Medicaid for which the EOHHS
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is authorized to recover, no distribution and/or payments, including Administration fees, shall be disbursed. Any person and/or entity that receives a distribution of assets from the decedent’s estate shall be liable to the EOHHS to the extent of such distribution. 5. Compliance with the provisions of this section shall be consistent with the requirements set forth in R.I. Gen. Laws § 33-11-5 and the requirements of the affidavit of notice set forth in R.I. Gen. Laws § 33-11-5.2. Nothing in these sections shall limit the EOHHS from recovery, to the extent of the distribution, in accordance with all state and federal laws. 6. EOHHS initiates estate recoveries upon receipt of information (from internal or external sources) relative to the death of a Medicaid beneficiary who was at least fifty-five (55) years of age, and responds to requests from estate representatives to release and/or discharge liens upon payment of reimbursable amounts. C. EOHHS does not automatically file an encumbrance in the land evidence records. D. Usually, the recovery process begins with a letter to the next of kin or legal representatives requesting estate asset information. In most cases, there are no assets left after payment of funeral expenses and other preferred debts (R.I. Gen. Laws § 33-12-11) and no recovery is pursued by the EOHHS. If requested, EOHHS will issue a discharge of lien. If there are any assets remaining to pay the EOHHS claim, in whole or in part, EOHHS will request reimbursement by letter which provides an accounting of the Medicaid expenditures. Upon receipt of payment, EOHHS will issue a discharge of lien. E. If the EOHHS is notified of the pendency of a probate estate either in response to a written notice from the executor/administrator, (see R.I. Gen. Laws § 33-11-5.1 for notice to creditor requirements), the EOHHS Legal Office will file a formal claim in the estate. Land evidence lien notices are not normally filed at this time. 4.10 DISCHARGE OF LIEN A. EOHHS will issue a discharge of its lien in each of the following situations: 1. Upon payment in full of its claim; 2. Upon payment of its claim in part by payment to EOHHS of all remaining estate assets after allowance for the preferences outlined in R.I. Gen. Laws § 33-12-11 and any court-approved expenses relating to any pre- existing guardianship or conservatorship of the decedent. a. EOHHS does not "compromise" or reduce its claim except as provided above;
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b. EOHHS will require the sale or liquidation of non-liquid assets; 3. Upon determination that §§ 4.10(A)(1) and (2) if this Part above are satisfied and the lien is recorded in the land evidence records. 4.11 DISCHARGE OF INAPPLICABLE RECORDED LIEN A. EOHHS will issue a discharge of a recorded lien upon a determination by EOHHS that the lien is inapplicable. Inapplicability occurs in the following situations: 1. If there is a statutory exception as found in § 4.6 of this Part; or 2. The decedent was never a beneficiary of Medicaid, was not age fifty-five (55), or was receiving Medicaid but was not "Medically Needy" or "Categorically Needy" during the relevant time periods; or 3. The EOHHS received reimbursement from another third-party source or insurer; or 4. No assets are included or includable in the decedent's probate estate; or 5. There is no required form to request a discharge of an inapplicable lien. A written request for discharge should be sent to: a. EOHHS, Virks Building, 3 West Road Cranston, RI 02920 and should contain, at a minimum: (1) A copy of the Death Certificate; (2) The decedent's Social Security Number; (3) A detailed explanation of the basis for a finding of inapplicability, with appropriate documentation for the finding. Acceptable documentation may include affidavits; (4) A description of the real estate (tax assessor's plat/lot numbers and street address). B. EOHHS will review and verify the information and will compare with information previously disclosed on Medicaid applications on file with the EOHHS. If approved, EOHHS will issue and record a discharge of lien within forty-five (45) days of receipt of the request for discharge due to inapplicability or refer the request to the EOHHS Legal Office, if necessary. Any interested party who disputes the applicability of the land records lien, within thirty (30) days of the proper prior notice as provided in § 4.4 of this Part shall be afforded an opportunity to request an administration hearing (R.I. Gen. Laws § 42-35-9).
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4.12 UNDUE HARDSHIP CONSIDERATION A. EOHHS may make adjustments to and settle estate liens to obtain the fullest amount practicable. B. A lien may be postponed in whole or in part when EOHHS determines execution of the lien would work an undue hardship. C. An undue hardship may be found to exist and execution of the lien may be postponed if a sale of real property, in the case of an individual's home, would be required to satisfy a claim, if all of the following conditions are met. D. An heir or beneficiary may request that the EOHHS delay the execution of its lien if: 1. An individual was using the property as a principal place of residence on the date of the recipient's death; and 2. That individual resided in the decedent's home on a continual basis for at least twenty-four (24) months immediately prior to the date of the deceased recipient's death; and 3. That individual has, from the time EOHHS first presented its claim for recovery against the deceased recipient's estate and after, annual gross income in an amount not to exceed 250 percent (250%) of the then applicable federal poverty level (FPL) income standard based on the same family size, and assets not to exceed the then applicable Medically Needy resource standards. E. If an individual meets the above criteria, the heir(s) or beneficiary(ies) may submit a request to the EOHHS Legal Office for consideration of undue hardship and the delay of the execution of EOHHS’s lien against the property if it appears that the individual is able to continue to reside in the property. F. Requests for consideration of undue hardship will be reviewed by a team of three members therein designated by the Medicaid Director. The review team will render decisions by giving due consideration to the equities involved as well as the obligations of the parties involved. G. Additionally, undue hardship will be determined by EOHHS on a case-by-case basis and will include, but will not be limited to, the following: 1. Be rendered homeless without the resources to find suitable housing; or 2. Lose his/her means of livelihood; or 3. Be deprived of food, clothing, shelter, or medical care such that life would be endangered should a finding of undue hardship be denied.
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4.13 APPLICATION FOR UNDUE HARDSHIP CONSIDERATION A. A requestor shall mail his or her application for an undue hardship consideration in writing to EOHHS within forty-five (45) days after the date EOHHS has filed its claim with probate court. The application shall include the following information: 1. The relationship of the undue hardship applicant to the decedent and copies of documents establishing that relationship; and 2. The basis for the application and documentation supporting the undue hardship applicant's position; and 3. Supporting documentation that the requestor has the legal standing and will be allowed to continue to reside in the property indefinitely should the undue hardship request be approved. B. EOHHS may require additional documentation, such as a current title examination or a list of existing creditors, as adequate proof that its decision to defer its lien will not otherwise adversely affect its claim. C. EOHHS shall review each application and issue a written decision within ninety (90) days after the application was received by EOHHS. EOHHS shall consider and base its decision on all information received with the application and any independent investigation it may undertake. D. The decision shall be the final decision of EOHHS. 4.14 UNDUE HARDSHIP GRANTED A. If EOHHS finds that an undue hardship exists, the execution of the lien is delayed for as long as: 1. The undue hardship grantee is alive and residing in the property; and has income and assets not to exceed the amounts specified in this Part. 2. The undue hardship circumstances upon which the decision is based continue to exist; and 3. As long as the property is adequately maintained and continues to exist in its then current state. B. The circumstances of the hardship will be subject to review by EOHHS at least every two years; provided however, that the grantee must notify EOHHS of any material change in circumstances, income and/or assets.
1
4.15 TRANSFER/SALE OF PROPERTY UNDER HARDSHIP
If the owner of the property sells or transfers ownership of the home, EOHHS will execute the lien.
210-RICR-10-00-4 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 - EOHHS GENERAL PROVISIONS SUBCHAPTER 00 - GENERAL PROVISIONS PART 4 - “COLLECTIONS AND PAYMENTS: LIENS AND RECOVERY OF MEDICAID PAYMENTS” (FORMERLY MEDICAID CODE OF ADMINISTRATIVE RULES, SECTION # 0312) (210-RICR-10-00-4) Type of Filing: Refile Capabilities Department of State _________________________________________________________________ Regulation Effective Date Original Signing Date _________________________________________________________________ Department of State Initials Department of State Date 01/04/2022 N/A December 14, 2021 E-SIGNED by Department of State on 2021-12-14 16:10:28 EST
210-RICR-10-00-5 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 – EOHHS General Provisions SUBCHAPTER 00 – N/A PART 5 - Collections and Payments: Interception of Insurance Payments 5.1 Legal Authority A. Federal law requires the Executive Office of Health and Human Services (EOHHS) to seek recovery of Medicaid expenses from Medicaid beneficiaries’ third-party payments. The purpose of this regulation is to set forth the process for the recovery of such payments by the State using the Medical Assistance Intercept System (MAIS) as mandated by R.I. Gen. Laws Chapter 27-57.1. B. In accordance with R.I. Gen. Laws § 40-6-9 and applicable administrative rules, when applying for Medicaid, an applicant automatically assigns, as a condition of eligibility, his/her rights of subrogation to the EOHHS for any third-party payments from insurers. Nothing in this Part shall limit EOHHS from recovery of any other monies allowed, to the extent of the distribution, in accordance with all state and federal laws. 5.2 Definitions A. For the purposes of this regulation, the following terms shall be construed as follows: 1. “Executive Office of Health and Human Services” or “EOHHS” means the state agency that is designated under the Medicaid State Plan as the single state agency responsible for the administration of the Title XIX Medicaid Program. 2. “Worker’s Compensation” means an insurance program that provides wage replacement and medical benefits to employees injured during the course of their employment in exchange for the mandatory relinquishment of the employee’s right to sue the employer. 5.3 Process for Recovery A. Every domestic insurer or insurance company authorized to issue policies of liability insurance and any worker's compensation insurer or self-insured employer, shall review information provided by the EOHHS, pursuant to R.I. Gen. Laws Chapter 27-57.1, indicating whether or not the claimant has received Medicaid funded services as a result of an accident or loss which is the basis of
the claim. Said review shall occur within thirty (30) days prior to making any payment equal to or in excess of five hundred dollars ($500.00) to any claimant who is a resident of this state, for personal injury or Workers’ Compensation benefits under a contract of insurance. For Workers’ Compensation insurers, or self-insured employers, said review shall occur within thirty (30) days prior to making any lump sum settlement (R.I. Gen. Laws § 28-33-25), denial and dismissal settlement (R.I. Gen. Laws § 28-33-25.1) or specific compensation (R.I. Gen. Laws § 28-33-19) payment equal to or in excess of five-hundred dollars ($500) to any claimant who is a resident of this state. B. The EOHHS shall electronically furnish these insurers and insurance companies with a database data match option report of names of individuals with last known addresses, as of the date of the report, who have received Medicaid in excess of five hundred dollars ($500). C. To facilitate the efficient and prompt reporting of those Medicaid beneficiaries in one centralized location, the duty and responsibility of the insurance companies doing business is as follows: 1. Utilize one centralized database, to which the EOHHS shall report and administer. 2. Any insurer receiving information identifying a Medicaid beneficiary shall maintain the confidentiality of that information to the full extent required under federal and state law. Minimal data elements, including, but not limited to, the date of injury and other necessary identifying information, shall be shared with an agency contracted by the EOHHS which maintains a centralized database of insurance claims. 3. The contracted centralized database is required to keep confidential: any personal and personnel information; records sufficient to identify a person applying for or receiving Medicaid; preliminary drafts, notes, impressions, memoranda, working papers, and work products; as well as any other records, reports, opinions, information, and statements deemed confidential pursuant to state or federal law or regulation, or rule of court. Any such confidential data shall not be disclosed to the insurer except that in the case of Workers’ Compensation where the agency shall share that information necessary for the Workers’ Compensation insurer or self- insured employer to comply with its obligations pursuant to R.I. Gen. Laws §§ 28-33-5 to 28-33-8. 4. Matched results indicating that a beneficiary is a claimant of an insurer are returned to the EOHHS through its contracted agency. Proper quality assurance shall be performed by the contracted agency to insure the claim is open. The contracted agency may also collect additional information from the insurer, including but not limited to contact information.
D. If the insurer determines from the information provided by the EOHHS, pursuant to R.I. Gen.Laws § 27-57.1-4, that the claimant or payee has received Medicaid funded services, as a result of an accident or loss which is the basis of the claim, the insurer shall, except to the extent that payments are subject to liens or interests (such as, health care providers, attorney fees, holders of security interests, or the assignment of rights under R.I. Gen. Laws §§ 40-6-9 and 40-6- 10), withhold from payment the amount to the extent of the distribution for Medicaid as a result of an accident or loss, dating back to the date of the incident. Insurers shall not pay any amount of the settlement to the claimant or claimant’s legal representative prior to payment to Medicaid in satisfaction of its lien and shall not accept promises to pay Medicaid and/or hold harmless from any person, firm, or corporation. The insurer shall pay such lien amount to the EOHHS and shall pay the balance to the claimant or other entitled person. Workers’ Compensation claimants who receive Medicaid, provided in accordance with R.I. Gen. Laws Chapter 40-8, shall be subject to the provisions of R.I. Gen. Laws Chapter 27-57.1. The Workers’ Compensation reimbursement payments made to the EOHHS shall be limited to that set forth in R.I. Gen. Laws Chapter 28-33 and R.I. Gen. Laws § 40-6-10. 5.4 Notice A. The EOHHS shall provide written notice to the insurer, claimant and his/her attorney, if any, which shall include the date, name, social security number, case number, total amount of the payment proposed to be withheld to reimburse the state for Medicaid funded services and a list of the items and services, including dates of service for which reimbursement is sought. The notice shall explain the right to request a hearing pursuant to § 5.5 of this Part. B. Claimant’s counsel shall have access to the centralized database to update all liens prior to settlement as provided for herein; and to ensure compliance with R.I. Gen. Laws Chapter 27-57.1 and R.I. Gen. Laws §§ 40-6-9 and 40-6-10. Claimants should be aware that the liens under the intercept rules currently apply to “fee-for-service” Medicaid. If a claimant is also covered by a Medicaid Managed Care Organization (MCO), that entity may also have a Medicaid lien. 5.5 Request for Hearing
Any payments made by an insurer pursuant to these rules, shall be made to the EOHHS, unless there is a request for an administrative hearing by the claimant. Any claimant aggrieved by any action taken under these procedures may, within thirty (30) days of the date of the notice to the claimant, request an administrative hearing from the EOHHS. If there is an administrative hearing, the insurer must remit payment within ten (10) business days of and in accordance with the hearing decision.
5.6 Timeline for Payment by Insurer
The insurer shall make any payments required, pursuant to these rules, to the EOHHS, thirty (30) days after the date of notification to the claimant or his/her attorney. Provided, however, that if the claimant has requested a hearing, payment shall not be made until ten (10) days after the hearing decision and in accordance with the hearing decision. 5.7 Severability
If any provisions of these regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these regulations which can be given effect, and to this end the provisions of these regulations are declared to be severable.
210-RICR-10-00-5 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 - EOHHS GENERAL PROVISIONS SUBCHAPTER 00 - GENERAL PROVISIONS PART 5 - INTERCEPTION OF INSURANCE PAYMENTS (210-RICR-10-00-5) Type of Filing: Refile Capabilities Department of State _________________________________________________________________ Regulation Effective Date Original Signing Date _________________________________________________________________ Department of State Initials Department of State Date 01/04/2022 N/A December 14, 2021 E-SIGNED by Department of State on 2021-12-14 16:11:05 EST
210-RICR-10-00-6 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 - EOHHS GENERAL PROVISIONS SUBCHAPTER 00 - GENERAL PROVISIONS Part 6 - Collection of Overpayments Via State Tax Refund Offset 6.1 Legal authority
In accordance with R.I. Gen. Laws §§ 44-30.1-1, 44-30.1-3, 44-30.1-4 and 44- 30.1-8 entitled, “Setoff of Refund of Personal Income Tax”, the Executive Office of Health and Human Services (EOHHS) is authorized to recover Medicaid benefit overpayments and cost share arrearages through the offset of the individual’s state income tax refund. 6.2 Definitions A. For the purposes of this section, the following definitions apply: 1. “Medicaid benefit overpayment” means any amount paid to or on behalf of a Medicaid beneficiary for a Medicaid benefit to which the beneficiary was not entitled, including but not limited to, an overpayment of a RIte Share premium.
2. “Medicaid cost share arrearage” means any amount due and owed to EOHHS as a result of a Medicaid beneficiary’s failure to pay their cost share obligation, including any amount due for a cost sharing obligation or Medicaid premium obligation, imposed in accordance with R.I. Gen. Laws Chapter 40-8.4. 6.3 Criteria for Claims Referred for Setoff A. The Medicaid claim referred for setoff must comply with the State Personal Income Tax Refund Offset procedure (as below). B. The Medicaid claim must be: 1. Established by court order, by administrative hearing conducted by EOHHS, or by written agreement between the EOHHS and the individual: a. Greater than or equal to the minimum amount required for submission for setoff by the R.I. Division of Taxation. The Division of Taxation shall, from time to time, determine the minimum amount of claim to which the setoff procedure may be applied.
b. Submitted in the name of one individual or must be reduced by any amount submitted as a separate claim for other individuals who are jointly or severally liable for the claim; and c. Not involved in a bankruptcy stay or discharged in bankruptcy. C. In addition, EOHHS must notify the individual of the intended action prior to offset and of her or his appeal rights. 6.4 Setoff Procedures and Notification of Debtor A. EOHHS will notify the individual of its intent to refer a claim to the R.I. Division of Taxation for offset and provide the individual with thirty (30) days to appeal the intended referral by presenting evidence that all or part of the claim is not legally enforceable. The thirty (30) day notice (“pre-offset notice”) shall contain the following information: 1. The amount of the claim(s); 2. That the claim is legally enforceable; 3. The individual's Medicaid Case Identifier; 4. That the claim(s) is to be referred to the R.I. Division of Taxation for offset unless the claim is paid in full within thirty (30) days of the date of the letter; 5. Instructions about how to pay the claim(s), and the address and telephone number to call to discuss the claim and the intended intercept. 6. That the individual has the right to appeal the offset. The notice will advise: a. That the individual is entitled to an administrative hearing to contest the setoff. The appeal request must be in writing and must be received by EOHHS not later than thirty (30) days after the date of the notice. b. The general nature of the potential defenses available to the debtor; c. The rights of non-obligated spouses with respect to income tax refunds in the event a joint return is filed; d. The individual's right to judicial review of the administrative hearing decision.
B. The notice must also state that a claim may not be referred for offset where a bankruptcy stay is in effect or if the claim has been discharged in bankruptcy. 6.5 Transfer of Funds by the R.I. Division of Taxation A. At the time of the transfer of funds to EOHHS, the R.I. Division of Taxation shall notify the debtor that the transfer has been made. B. The notice shall state the name of the debtor, the amount of Medicaid benefit overpayment or cost share arrearage being claimed, the amount of the refund in excess of the amount claimed, if any, and that the transfer of funds to EOHHS was made. C. In the case of a joint refund, the R.I. Division of Taxation notice shall also state the name of a taxpayer-spouse named in the return, if any, against whom no Medicaid benefit overpayment or cost share arrearage is claimed, the opportunity to request that the refund be divided between the spouses by filing an amended income tax return showing each spouse's share of the tax and the contribution to the overpayment of tax resulting in the refund. D. Upon receipt of funds transferred from the R.I. Division of Taxation, EOHHS deposits and holds the funds in an escrow account until final determination of setoff. Upon final determination of the amount of the claim to be set-off by: 1. default for failure to apply for an administrative hearing, or by 2. decision of the administrative hearing officer, EOHHS shall remove from the account of the claim payment from the escrow account and credit the amount to the debtor's obligation. The pendency of judicial proceedings to review the administrative decision shall not stay nor delay the setoff, transfer, and disbursement of the tax refund in question. E. With respect to setoff for Medicaid benefit overpayments and cost share arrearages, the R.I. Division of Taxation shall provide the debtor's address and social security number to EOHHS. The information obtained by EOHHS through the R.I. Division of Taxation retains its confidentiality and is only used by EOHHS in pursuit of its Medicaid benefit overpayments and cost share arrearages collection duties and practices, and any employee or prior employee of EOHHS who unlawfully discloses that information for any other purpose, except as specifically authorized by law, is subject to the penalties specified by R.I. Gen. Laws § 44-30-95(c). 6.6 ADMINISTRATIVE HEARINGS A. As appropriate, an administrative hearing may be held pursuant to the "Medicaid Code of Administrative Rules, Section #0110, 'Complaints and Appeals'".
B. The hearing officer must issue her or his decision in writing in accordance with the "Medicaid Code of Administrative Rules, Section #0110, 'Complaints and Appeals'". If the decision is made that the claim does not meet the requirements for offset, EOHHS must take appropriate corrective action. 6.7 Severability
If any provisions of these regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these regulations which can be given effect, and to this end the provisions of these regulations are declared to be severable.
210-RICR-10-00-6 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 - EOHHS GENERAL PROVISIONS SUBCHAPTER 00 - GENERAL PROVISIONS PART 6 - COLLECTION OF OVERPAYMENTS VIA STATE TAX REFUND OFFSET (FORMERLY MEDICAID CODE OF ADMINISTRATIVE RULES, SECTION #0313) (210-RICR-10-00-6) Type of Filing: Refile Capabilities Department of State _________________________________________________________________ Regulation Effective Date Original Signing Date _________________________________________________________________ Department of State Initials Department of State Date 01/04/2022 N/A December 14, 2021 E-SIGNED by Department of State on 2021-12-14 16:11:38 EST
210-RICR-10-00-7 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 – EOHHS GENERAL PROVISIONS SUBCHAPTER 00 – GENERAL PROVISIONS PART 7 – MEDICAID PROGRAM INSTITUTIONS FOR MENTAL DISEASES 7.1 Legal Authority
The State of Rhode Island Executive Office of Health and Human Services (EOHHS), as the single state agency responsible for the State of Rhode Island Medicaid Program, reviews compliance with federal requirements to determine whether a Medicaid provider remains eligible for Medicaid reimbursement. R.I. Gen. Laws § 42-7.2-2 (a)(6); Title XIX of the U.S. Social Security Act, 42 U.S.C. § 1396a et seq. This includes ensuring compliance with federal regulations regarding whether a facility is excluded from the Medicaid program as an Institution for Mental Disease (IMD). 42 C.F.R. § 435.1010; CMS State Medicaid Manual, § 4390. This IMD compliance review is critical to the proper administration of the Medicaid Program in compliance with all applicable federal laws and regulations. 7.2 Purpose and Scope
This regulation applies to any hospital, nursing facility, or other institution of more than sixteen (16) beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services shall be considered an IMD and be excluded from Medicaid reimbursement. Whether a facility is an IMD is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of mental disease whether or not the facility is licensed as such. 7.3 Definitions A. For purposes of this section, the following definitions apply: 1. “At-risk facility” means a facility that is considered at risk of becoming an IMD if one (1) of the following applies: a. The facility was identified as an At-Risk Facility during a prior IMD review by EOHHS; b. Forty-five percent (45%) or more of the facility’s residents or patients carry a primary diagnosis of a mental disorder or disease
and/or have been determined to need specialized services for serious mental illness. 2. “Institution for Mental Disease” or “IMD” means a hospital, nursing facility, or other institution of more than sixteen (16) beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services. A facility is considered an IMD if its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. Provided however, an intermediate care facility for individuals with intellectual disabilities shall not be considered an IMD. 3. “Mental diseases” means diseases listed as mental disorders in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), incorporated herein by reference (not including any later editions thereof), with the exception of intellectual disabilities, senility, and organic brain syndrome. This publication is available at: http://www.cdc.gov/nchs/icd/icd10cm.htm. 7.4 IMD Determination Review Process A. EOHHS shall make the final determination as to whether any hospital, nursing facility, or other institution of more than sixteen (16) beds is an IMD and excluded from the Medicaid program. EOHHS shall identify: 1. Facilities that are at risk of becoming IMDs; 2. The course of action to be taken when such facilities have been identified as at risk of becoming an IMD; and 3. The course of action to be taken if a facility is identified as an IMD. B. Medicaid payment is not available for services provided to individuals in an IMD who are age twenty-one (21) and over, and under age sixty-five (65), except as permitted in 42 C.F.R. § 438.6(e) and in the Section 1115 Waiver Demonstration. C. All Medicaid certified providers with more than sixteen (16) beds shall bi-annually complete and submit to EOHHS an IMD compliance self-assessment reporting tool and attestation of compliance to Medicaid. Specifically: 1. All hospitals on or before May 1, 2020, and bi-annually on December 1st and May 1st thereafter, shall submit an IMD compliance self-assessment reporting tool and attestation of compliance to EOHHS. 2. All other Medicaid certified providers with more than sixteen (16) beds shall submit an IMD compliance self-assessment reporting tool and
attestation of compliance to EOHHS on December 1, 2020, and bi- annually on May 1st and December 1st thereafter. 3. Providers must allow EOHHS to sample attestations for lookbacks and validation by paid claims reviews and/or conduct on-site reviews and record reviews. The self-assessment and reporting tools shall be available on the EOHHS website. D. At the conclusion of each bi-annual IMD review, EOHHS shall make one (1) of the following determinations: 1. The facility is not at risk of becoming an IMD; 2. The facility is an At-Risk Facility, as defined herein; 3. The facility is determined to be an IMD. E. In determining whether a facility with over sixteen (16) beds is considered an IMD, EOHHS reviews and considers the overall character of the facility. EOHHS consideration shall include, but is not limited to, the following criteria: 1. Whether the facility is designated and/or licensed as a psychiatric or behavioral health facility by the State of Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals pursuant to R.I. Gen. Laws Chapters 40.1-5, 40.1-24 and 40.1-24.5; 2. Whether the facility is accredited as a psychiatric or behavioral health facility by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or another similarly nationally-recognized accreditation entity, which accredits and certifies health care organizations and programs in the United States; 3. Whether the facility specializes in providing psychiatric and/or psychological care and treatment, as evidenced by consideration of the following indicators: a. Fifty percent (50%) or more of individuals residing in the facility have medical records indicating that they are at the facility because of a mental disease; b. Fifty percent (50%) or more of the facility’s staff have specialized psychiatric/psychological training; c. Fifty percent (50%) or more of individuals residing in the facility are receiving psychopharmacological drugs; and d. Whether the current need for institutionalization for more than fifty percent (50%) of all the individuals at the facility results from mental
diseases. In determining whether this criterion is met, EOHHS shall consider whether more than fifty percent (50%) of individuals residing in the facility have serious mental illness or are receiving care and treatment for substance abuse disorder and have been determined to need specialized services for serious mental illness. If it is not possible to make the determination of the status of a patient solely based on their current diagnosis, the patient should be classified according to their diagnosis at the time of admission, if the patient was admitted within the past year. A patient should not be included in the mentally ill category when no clear distinction is possible. F. Upon completion of the IMD review, EOHHS shall proceed with the follow-up activities corresponding to the determination that was made for the facility. 1. Facilities determined not to be at risk of becoming an IMD shall be notified and, if necessary, shall be removed from the list of facilities that are at risk of becoming an IMD. 2. At-Risk Facilities shall be notified of the determination and shall be monitored by EOHHS following the At-Risk Facility determination. Such monitoring may include the performance of additional, unannounced, on- site IMD reviews by EOHHS. 3. Facilities determined to be an IMD: a. The facility shall be notified of the IMD determination, that eligibility to receive Medicaid vendor payment shall be suspended and that the facility has thirty (30) days from the date the notice was mailed to exercise its right to request an appeal of the IMD finding by EOHHS. b. If the facility appeals EOHHS’ IMD determination, eligibility to receive vendor payment shall continue to be suspended throughout the appeal process. G. EOHHS shall identify and maintain a list of At-Risk Facilities. IMD reviews shall be conducted for any At-Risk Facility on the list. EOHHS IMD reviews of At-Risk Facilities shall be scheduled as follows: 1. At-Risk-Facilities shall be subject to an initial on-site IMD review of any facility that is newly identified by EOHHS as meeting the above criteria as an At-Risk Facility. 2. At-Risk-Facilities shall have an annual IMD review, that may include on- site visits, in each At-Risk Facility for a minimum of two (2) consecutive years after EOHHS identifies the facility as at risk of being determined an IMD.
H. A facility that has been determined to be an IMD may, following a period of not less than six (6) months, submit a written request to EOHHS requesting a redetermination survey when changes have been made in its overall character and patient mix such that the administrator of the facility believes it would no longer qualify as an IMD. EOHHS shall respond to such requests by conducting a redetermination survey. 1. If the IMD redetermination survey finds that the facility no longer meets the definition of an IMD as set forth herein, EOHHS shall provide the facility with the effective date that the facility is not an IMD, to allow the facility to initiate vendor payment for all eligible individuals. 2. If the redetermination survey finds that the facility continues to be an IMD, the facility shall be notified of the determination, the basis for the determination, that it has thirty (30) days from the date the notice was mailed to exercise its appeal rights, and that if the facility does not exercise its appeal rights within that time frame it may not request another redetermination survey for at least six (6) months from the date of the determination. 7.5 Administrative Hearings A. As appropriate, an administrative hearing may be held pursuant to Subchapter 05 Part 2 of this Chapter. B. The hearing officer must issue her or his decision in writing in accordance with Subchapter 05 Part 2 of this Chapter. If the decision is made that the claim does not meet the requirements for offset, EOHHS must take appropriate corrective action.
210-RICR-10-00-7 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 10 - EOHHS GENERAL PROVISIONS SUBCHAPTER 00 - GENERAL PROVISIONS PART 7 - MEDICAID PROGRAM INSTITUTIONS FOR MENTAL DISEASES Type of Filing: Refile Capabilities Department of State _________________________________________________________________ Regulation Effective Date Original Signing Date _________________________________________________________________ Department of State Initials Department of State Date 01/04/2022 08/05/2020 December 14, 2021 E-SIGNED by Department of State on 2021-12-14 16:12:20 EST
210-RICR-30-00-1 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 – MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 – AFFORDABLE COVERAGE GROUPS PART 1 – Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways 1.1 Overview A. The principal purpose of the Federal Patient Protection and Affordable Care Act (ACA), Pub. Law No. 111-148, was to increase access to health care by leveraging resources, expanding choice, and removing the administrative, financial, and legal barriers that have prevented people from obtaining the coverage they need. Toward this end, the ACA: 1. Consolidated many of the existing Medicaid coverage groups associated with the now defunct Federal Aid to Families with Dependent Children Program (AFDC) into three (3) broad categories: children, pregnant people and newborns, and parents/caretaker relatives; 2. Created an optional Medicaid coverage group for adults between the ages of nineteen (19) and sixty-four (64) who otherwise do not qualify for Medicaid and are not eligible for or enrolled in Medicare; 3. Established a new income counting methodology – Modified Adjusted Gross Income (MAGI) - for evaluating income eligibility for Medicaid and other publicly supported forms of affordable commercial coverage across these populations; 4. Eliminated distinctions in the financial criteria and standardized the income eligibility requirements for the Medicaid populations subject to the MAGI. This, in turn, made it possible for the States to reorganize the MAGI-eligible populations with similar characteristics into distinct, easily identifiable, Medicaid affordable care coverage (MACC) groups; 5. Mandated that the States automate the application and renewal process for populations subject to the MAGI methodology by building the capacity to determine eligibility on-line and conduct electronic verifications through a variety of government approved data sources; and 6. Applied these changes not only to Medicaid, but also to the Children’s Health Insurance Program (CHIP), which is administered through the Medicaid program in Rhode Island, and HealthSource RI (HSRI), the State’s health insurance marketplace.
1.2 Scope and Purpose A. The purpose of this Rule is to establish the Medicaid Affordable Care Coverage (MACC) groups and the eligibility pathways for individuals who share one (1) or more of their characteristics and are exempt from the MAGI methodology and/or the provisions for the Integrated Health Care Coverage (IHCC) groups under Chapter 40 of this Title. B. In Rhode Island, CHIP eligibility is administered as an expansion through the Medicaid program rather than through a separate State program as the principal distinction for most eligibility pathways relates to claiming of Title XIX versus Title XXI Federal financial participation rates. The exceptions, as indicated in this Rule, are the CHIP-only eligibility pathways for lawfully present qualified non-citizen children up to the age of nineteen (19) and qualified and non-qualified pregnant women who meet the income limits set forth herein. 1.3 Legal Authority A. This Part is promulgated pursuant to Federal authorities as follows: 1. Federal Law: § 1115 of the Social Security Act, 42 U.S.C. § 1315; Title XIX of the Social Security Act, 42 U.S.C. §§ 1396a-1396w-8; Title XXI of the Social Security Act, 42 U.S.C. §§ 1397aa-1397mm; 42 U.S.C. § 1396k; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. Law No. 111-148. 2. Federal Regulations: 42 C.F.R. Parts 431, 435, 440, and 441. 3. The Medicaid State Plan and the Section 1115 Demonstration Waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. B. Applicable State authority is derived from R.I. Gen. Laws Chapters 40-8, 40-8.4, 40-8.12, and 42- 12.3. 1.4 Incorporated Materials A. These regulations hereby adopt and incorporate 42 C.F.R. § 435.1110 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. 1.5 Definitions A. For the purposes of Medicaid MACC and non-MAGI eligibility groups covered under this Part, the following definitions apply: 1. “ACA expansion adults” means the eligibility pathway established by the Federal Patient Protection and Affordable Care Act (ACA), Pub. Law No. 111-148, and by R.I. Gen. Laws Chapter 40-8.12, for persons between the ages of nineteen (19) and sixty-four (64) who
are not eligible for or enrolled in Medicare and do not qualify for Medicaid in any other eligibility group. 2. "CHIPRA 214" means the Children's Health Insurance Program Reauthorization Act of 2009, Pub. Law No. 111-3. 3. “Dependent child” means a child under the age of eighteen (18) or under the age of nineteen (19), if enrolled full-time in school. 4. "Extended Medicaid" or "Transitional Medicaid" means Medicaid eligibility granted to certain individuals who previously qualified for benefits pursuant to § 1931 of the Social Security Act, 42 U.S.C. § 1396u-1, but no longer qualify due to excess income. 5. “Hospital presumptive eligibility” means the temporary and time-limited Medicaid eligibility pathway for persons who meet certain requirements and are receiving care in a hospital pending submission of a complete application. 6. “Managed care organization” or “MCO” means a health plan system that integrates an efficient financing mechanism with quality service delivery and a "medical home" to assure appropriate preventive care and deter unnecessary services. 7. “Medicaid Affordable Care Coverage Group” or “MACC” means a classification of persons eligible to receive Medicaid based on similar characteristics who are subject to the MAGI income counting methodology for determining income eligibility. 8. “Rhode Island Code of Regulations” or “RICR” means the compilation of Rules governing the Rhode Island Medicaid program promulgated in accordance with the State’s Administrative Procedures Act (R.I. Gen. Laws Chapter 42-35). 9. “Medicaid member” means a Medicaid beneficiary enrolled in a managed care plan. 10. “Modified adjusted gross income” or “MAGI” means income, adjusted by any amount excluded from gross income under 26 U.S.C. § 911, and any interest accrued. 11. “Navigator” means a person working for a State-contracted organization that provides certified assisters who have expertise in Medicaid eligibility and enrollment. 12. “Non-citizen” means anyone who is not a U.S. citizen at the time of application including lawfully present immigrants and persons born in other countries who are present in the U.S. without documentation. 13. “Non-MAGI coverage group” means a Medicaid coverage group that is not subject to the modified adjusted gross income counting methodology for eligibility determination purposes. For the purposes of this Part, it includes Medicaid for persons who qualify for Medicaid based on their eligibility for another publicly funded program, including children in the substitute care under the auspices of the DCYF such as current, and some
instances, former foster care recipients and anyone receiving Supplemental Security Income (SSI). 14. “Qualified non-citizen” means a person legally present in the United States based on immigration status who, if otherwise eligible for Medicaid, is prohibited or “barred” under Federal law from receiving Medicaid coverage for a period of five (5) years from the date the immigration status was secured from the United States Citizenship and Immigration services (USCIS). Certain qualified non-citizens are exempt from the five (5) year Medicaid ban. 15. “Rhody Health Partners” means the Medicaid managed care delivery system for ACA expansion adults (see Subchapter 05 Part 2 of this Chapter) and adults with disabilities (See Chapter 40 of this Title). 16. “RIte Share” means the Medicaid premium assistance program for eligible individuals and families who have access to cost-effective commercial health insurance plans coverage. 17. "Section 1115 Waiver" means the waiver authorized pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. 18. "Section 1931" or "§ 1931" means § 1931 of Title XIX of the Social Security Act, 42 U.S.C. § 1396u-1. 19. “Self-attestation” means the act of a person affirming through an electronic or written signature that the statements the person made when applying for Medicaid eligibility are truthful and correct. 20. "Title IV-E" means Title IV-E of the Social Security Act, 42 U.S.C. §§ 670-679c. 21. “Title XIX” means Title XIX of the U.S. Social Security Act, 42 U.S.C. §§ 1396-1396w-8, that established the Medicaid program and provides the legal basis for providing services and benefits to certain populations in each MACC group. 22. “Title XXI” means Title XXI of the U.S. Social Security Act, 42 U.S.C. §§ 1397aa-1397mm, that established the Children’s Health Insurance Program (CHIP) and provides the legal basis for providing services and benefits to certain targeted low-income children and pregnant women through Medicaid. 1.6 Eligibility Pathways for MACC and Non-MAGI Groups A. Rhode Island’s Medicaid MACC groups are comprised of individuals who share an eligibility characteristic, such as age or relationship as follows, unless otherwise indicated below. MACC group members do not have access to retroactive coverage under the terms and conditions of the State’s Section 1115 Waiver.
1. Parents/Caretaker Relatives. The defining characteristic of this coverage group is a relationship with a child up to the age of eighteen (18), or the age of nineteen (19) if enrolled in school full-time, who is eligible for Medicaid. Parent/caretaker eligibility is a function of how the eligible child is claimed for tax purposes as a dependent when constructing a MAGI household. This coverage group includes: a. Parents/caretaker relatives who are eligible under the Medicaid State Plan through the authority provided by § 1931 with income up to the threshold described in the table at § 1.6(B) of this Part. b. Other parents/caretaker relatives with income up to the threshold described in the table at § 1.6(B) of this Part. c. Parents/caretakers with income from one hundred thirty-three percent (133%) to one hundred seventy-five percent (175%) of the FPL, not including the five percent (5%) disregard, who would have been eligible for Medicaid on December 31, 2013, may qualify for the Rhode Island Affordable Health Care Coverage Assistance Program. Parents/caretakers eligible for this program may obtain a State subsidized “silver” commercial plan through the Rhode Island’s health insurance marketplace as specified in Subchapter 10 Part 1 of this Chapter. The State’s integrated eligibility system automatically evaluates the parents/caretakers of Medicaid-eligible children for this Program if they do not qualify for coverage under this Part. 2. Pregnant people. Members of this coverage group can be of any age. The pregnant person and each expected child are counted separately when constructing the household and determining family size. Eligibility extends for the duration of the pregnancy and, as of October 1, 2022, twelve (12) months post-partum. The coverage group includes all pregnant people with income up to the threshold described in the table at § 1.6(B) of this Part. Retroactive medical coverage is available for up to ninety (90) days prior to the eligibility date for otherwise eligible pregnant people. a. Pregnant people are eligible for coverage through Medicaid if they meet Medicaid requirements for citizenship and immigration (described in further detail below at § 1.7 of this Part) and either: 1. Have income under 190% FPL; or 2. Have income under 253% FPL and also have third-party liability insurance. b. Pregnant people are eligible for coverage through CHIP if they: 1. Meet Medicaid citizenship and immigration requirements (see § 1.7 of this Part) have income between 190 and 253% FPL, and do not have third party liability insurance; or
2. Meet requirements under CHIPRA 214 for lawful presence but do not meet Medicaid's citizenship and immigration requirements (see § 1.7 of this Part) have income under 253% FPL, and do not have third party liability insurance. c. CHIP medical coverage for those pregnant people who do not meet Medicaid or CHIP requirements for citizenship/immigration status (see § 1.7 of this Part) is based on the eligibility status of the unborn child. d. As of October 1, 2022, twelve (12) month post-partum coverage shall be extended to people who: 1. Are not eligible for Medicaid under another Medicaid eligibility category; or 2. Do not have qualified non-citizen status for Medicaid, whose births are financed by Medicaid through coverage of the child and who, before October 1, 2022, were only eligible to receive State-only extended family planning benefits postpartum, as outlined in Subchapter 05 Part 2 of this Chapter. 3. Children. Age is the defining characteristic of members of this MACC group. This coverage group includes: a. Infants under age one (1) unless a deemed newborn (see § 1.7(A) of this Part) up to age nineteen (19) who have family income up to the threshold described in the table at § 1.6(B) of this Part; and b. All children, including all non-citizen children not legally present, up to the age of nineteen (19), who have income up to the threshold described in the table at § 1.6(B) of this Part. 4. ACA Expansion Adults – The group consists of citizens and qualified non-citizens with income up to the threshold described in the table at § 1.6(B) of this Part who meet the age characteristic and are not otherwise eligible for, or enrolled in, Medicare or Medicaid under any other State plan or Section 1115 waiver coverage group. Adults found eligible awaiting a determination for Supplemental Security Income (SSI) or the receipt of Social Security benefits are also eligible under this coverage group during the two (2) year application pending and benefit waiting periods. B. MACC Group Income Eligibility – The income thresholds and ceilings for the MACC groups eligible through these pathways are summarized as follows:
MACC Group Income Threshold – As percent of the FPL Income Ceiling with the five percent (5%) disregard – As a percent of the FPL a. § 1931 Parents/Caretakers 116% 121% b. Other Parents/Caretakers 133% 138% c. Pregnant People 253% 258% d. Children up to age nineteen (19) (through age eighteen (18)) 261% 266% e. ACA Expansion Adults 133% 138% C. There are currently multiple Medicaid coverage groups that are not subject to the MAGI methodology. Eligibility for adults who are nineteen (19) years of age and older who are not subject to the MAGI methodology is set forth as follows: 1. Persons twenty-one (21) years of age and older eligible for Medicaid based on receipt of Supplemental Security Income (SSI), Optional State Supplemental Payments (SSP), and/or SSI-protected status – Part 40-00-1 of this Title; 2. Low income elders sixty-five (65) and older, and adults with disabilities (EAD) between the ages of nineteen (19) and sixty-four (64) with income up to one hundred percent (100%) of the FPL to who do not qualify for SSI and are eligible for or enrolled in in Medicare – Part 40-00-1 of this Title; 3. Full or partial Medicare-Medicaid dual eligible beneficiaries participating in the Medicare Premium Payment Program – Part 40-00-1 of this Title; 4. People eligible for Medicaid through the Breast and Cervical Cancer Treatment Program (BCCTP) – Part 40-00-1 of this Title; 5. Adults seeking initial or continuing eligibility for Medicaid long-term services and supports (LTSS) who are eligible for or enrolled in Medicare or are age sixty-five (65) and older with service needs requiring the level of care typically provided in health institutions –Part 50-00-1 of this Title;
6. Otherwise ineligible children with serious disabilities up to age nineteen (19) who qualify under Katie Beckett process because they are receiving the level of care at home that is typically provided in a health institution - Part 50-10-3 of this Title; 7. Medically needy eligible persons who become eligible for Medicaid by spending down excess income on allowable health expenses – Part 40-00-1 of this Title. D. People exempt from the MAGI income counting methodology with eligibility covered under this Part are as set forth below: 1. No income determination required – Individuals and families up to age twenty-one (21) whose eligibility does not require an income determination for Medicaid, including those eligible on the basis of: a. Supplemental Security Income (SSI). Children and young adults with disabilities determined by the Federal Social Security Administration (SSA) to be eligible for SSI benefits who are up to age nineteen (19) or in the custody of the State, up to age twenty-one (21), including those residing in health institutions; and b. DCYF programs. Children and youth eligible on the basis of their participation in a DCYF foster care, kinship or guardian program whether in a home-based, residential or institutional setting, including young adults aging out of foster care in Rhode Island, up to age twenty-six (26) who are eligible under the Federal Foster Care Independence Act of 1999 (Chafee Act) as amended by the Patient Protection and Affordable Care Act, Pub. Law No. 111-148 and the SUPPORT for Patients and Communities Act, Pub. Law No. 115-271. c. Former Foster Youth Status. Children and youth eligible on the basis of their participation in foster care in a state or Tribe within a state other than Rhode Island, up to age twenty-six (26) who are eligible under the SUPPORT for Patients and Communities Act, Pub. Law No. 115-271. 2. Deemed eligibility - Infants born to Medicaid-eligible pregnant people are deemed eligible from date of birth to age one (1) without regard to changes in income or other factors as long as they remain residents of the State. 3. Transitional/extended Medicaid –§ 1931 Parent/Caretakers who no longer qualify for Medicaid coverage under § 1931 due to earnings from work, including recipients of the RI Works Program administered by the Rhode Island Department of Human Services, as well as any children in their household and their spouse, may qualify for continued coverage through this pathway. Eligibility for extended Medicaid is for twelve (12) months.
1.7 MACC Group General Eligibility Requirements A. All applicants for MACC Group eligibility must meet State residency requirements. Applicants for MACC Group eligibility who are over the age of nineteen (19) must meet citizenship/immigration status requirements. There are also certain cooperation requirements. Adults must typically meet the cooperation requirements, whether applying for themselves or on behalf of a dependent child. Verification of these requirements is an automated process conducted through electronic data matches. Failure to meet Medicaid general eligibility requirements or provide supporting documentation upon request is considered non- cooperation and generally results in the denial or discontinuation of eligibility. Children are exempt from sanctions due to non-cooperation. The scope and application of each of these eligibility requirements are as follows: 1. Age – “Age” is one of the principal factors affecting eligibility for Medicaid and assignment to the appropriate Medicaid service delivery system MACC group. 2. MACC Group Age Limits – The age requirements associated with each of the MACC groups are as follows: MACC Coverage Groups Age Requirements Parents/Caretakers Parents/Caretakers (of any age) with a dependent child up to age eighteen (18) or nineteen (19) if enrolled in school full-time Pregnant People Any age Children Up to age nineteen (19) ACA Expansion Adults Ages nineteen (19) to sixty-five (65) a. Verification – An applicant’s self-attestation of age and identity is accepted at the time of application. Post-eligibility electronic verification of date of birth is conducted through the U.S. Social Security Administration (SSA) and/or the Rhode Island Department of Health, Division of Vital Statistics. This information is used to determine capitation rates for enrollees in Medicaid managed care plans; these rates vary by age. If electronic verification is unsuccessful, submission of paper documentation may be required for these purposes. See Part 5 of this Subchapter for satisfactory forms of documentation. 3. Social Security Number – To support verification of age, income, and citizenship/immigration status, individual applying for Medicaid who have been
assigned a Social Security Number (including children) shall provide their Social Security Number (SSN) as a condition of eligibility for the program. a. Only members of a household who are applying for Medicaid coverage are required to provide an SSN. An SSN of a non-applicant may be requested to electronically verify income. However, unwillingness on the part of a non- applicant to provide an SSN upon request shall not be used as the basis for denying eligibility to an applicant who has provided an SSN. If an SSN is unavailable, other proof of income shall be accepted. b. Limits on Use – Applicants shall also be informed that an SSN can be utilized only in the administration of the Medicaid program, including for use in verifying age and income eligibility. c. Verification – An SSN is verified through an electronic data-match with the SSA. Applicants (not including children) must provide documentation of SSN if the data match fails. Acceptable forms of documentation are identified in Part 5 of this Subchapter. 4. State Residency – Anyone who is applying for eligibility must be a resident of the State. Any person living in the State voluntarily, who intends to reside in Rhode Island for any reason is considered a resident of the State. Under Federal Regulations a person does not need a fixed address in the State to be considered a Rhode Island resident. Therefore, homelessness is not a bar to eligibility. a. For individuals who are twenty-one (21) years of age or older, or under the age of twenty-one (21) and capable of expressing intent as an emancipated or married individual – If the applicant is not living in an institution, the State of residence is the State where the applicant is living voluntarily with the intention to reside; or entered voluntarily with a job commitment or seeking employment, whether or not currently employed. b. For individuals under the age of twenty-one (21) who are not emancipated or married – If the applicant is not living in an institution, the State of residence is the State where the child/young adult resides or the State of the parent/care- taker with whom the child lives. Under the requirements of this provision, the residence of a pregnant person's unborn child is, the State in which the pregnant person resides. A non-citizen pregnant person who lives in Rhode Island is considered to be a resident, irrespective of whether the person's immigration status indicates they are in the country permanently or for a limited time (i.e., in the United States on a temporary visa of any kind). c. For individuals living in institutions – Most Medicaid applicants living in institutional settings are not included in the MACC groups.
d. Disputes – If there is a dispute over residency for determining Medicaid eligibility, the applicant is a resident of the State in which the applicant is physically located. The MAGI standard of the State where the applicant is physically located applies when determining eligibility. e. Verification – Self-attestation of the intent to remain in the State is accepted. Evidence that an applicant is receiving public benefits in another State may result in a denial of eligibility if paper documentation of residency is not provided. 5. Citizenship and Immigration Status – The citizenship requirements for Medicaid eligibility for individuals and families in MACC groups vary depending on the basis of eligibility. Some non-citizens are not eligible for Medicaid; some are eligible for Medicaid only after a five (5) year waiting period; and some are eligible without a waiting period. Children up to the age of nineteen (19) are not subject to citizenship requirements to be eligible for Medicaid, and pregnant people are not subject to citizenship requirements under CHIP. a. Non-Citizens ineligible Except in Emergency Situations (1) Non-qualified non-citizens. The non-qualified category of non-citizens includes citizens of other nations who are not considered to be immigrants under current Federal law, including those in the United States on temporary or time-limited visa (such as visitors and students) and those who are present in the country without proper documentation (includes people with no or expired status). (2) Non-qualified non-citizens who are adults are not eligible for Medicaid, except in emergency situations (Part 10-00-3 of this Title). Non- emergency services may be obtained through Federally Qualified Community Health Centers. See Rhode Island Community Health Association at www.richa.org. b. Non-Citizens barred from Medicaid During Five (5) Year Waiting Period (1) Qualified non-citizens. The qualified non-citizens category includes persons who are citizens of other nations who are lawfully present in the United States. Qualified non-citizens are barred from Medicaid for a waiting period of five (5) years under Federal law. Certain exemptions from the bar apply: c. Non-Citizens Exempt from the Five (5) Year Waiting Period (1) Qualified non-citizen children up to the age of nineteen (19) who are lawfully present in the United States but who were born in another nation are eligible for Medicaid as members of the MACC group for
children and young adults. Children in this subcategory of qualified non- citizens are eligible during the five (5) year bar under an option contained in Title XXI, the Children’s Health Insurance Program (CHIP). Qualified non-citizen pregnant people are also eligible for Medicaid in the MACC group, under an option in CHIP. (2) There are several other subcategories of non-citizens who are exempt from the five (5) year bar as specified in Part 10-00-3 of this Title. All non-exempt qualified non-citizens are eligible to obtain coverage through State and Federal health insurance marketplaces, such as HealthSource RI.com in Rhode Island, and may be qualified for certain tax credits. d. Non-qualified non-citizen pregnant people in the applicable MACC group are eligible for Medicaid coverage. The pregnant person's eligibility is tied to the eligibility of the baby they are carrying. For the purposes of MACC group eligibility, the baby in utero is deemed to be a United States citizen and Rhode Island resident and remains so as a newborn as long as the birth occurs in Rhode Island. e. Verification of citizenship/immigration status — All members of a household applying for Medicaid coverage shall provide their immigration and citizenship status. However, no adverse eligibility determination shall be made regarding children up to the age of nineteen (19) for whom citizenship/immigration status is not provided. Non-applicants are exempt from this requirement. Any information provided by an applicant or obtained through electronic verification under § 1.7(A)(5)(e) of this Part shall only be used to verify status. Under the ACA, citizenship and immigration status are verified: (1) Electronically. The Medicaid agency shall use electronic verification through the Federal hub (see Part 5 of this Subchapter) to the full extent feasible through: (AA) Social Security Administration (SSA) or Rhode Island Department of Health, Division of Vital Statistics for citizens. (BB) U.S. Citizenship and Immigration Services (USCIS) for non–U.S. adult citizens via the Systematic Alien Verification for Entitlements (SAVE) database. (2) Non-electronic. If unable to verify immigration status electronically, enrollees have an opportunity to provide other documents or to fix the records. (3) Self-Attestation. An applicant’s attestation is accepted without electronic verification providing appropriate paper documentation is
provided to the Medicaid agency within ninety (90) days of the eligibility determination. Failure to provide the required documentation within that period results in a termination of Medicaid and the initiation of the Medicaid recoupment process. 6. Relationship – The State evaluates the relationship of household members applying for the MACC group for parent/caretakers using the following: a. Caretaker Relative – For the purposes of MACC group eligibility, parent/caretaker is any adult living with a Medicaid-eligible dependent child who has assumed primary responsibility for that child. This definition includes, but is not limited to: (1) Father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew or niece; (2) The spouse of such parent or relative, even after the marriage is terminated by death or divorce; or (3) Another relative of the child based on blood, adoption or marriage; domestic partner of parent or other caretaker relative. If the parents are in the household, it is presumed that other members in the household are not assuming primary responsibility for the child’s care. (4) Dependent child – For the purposes of determining eligibility the members of the MACC group for parents/caretakers, a dependent child is a child under the age of eighteen (18) or under the age of nineteen (19) if enrolled full-time in school. b. Verification – Self-attestation on the application is accepted as verification of relationship, except for deeming of newborns. 1.8 MACC and Non-MAGI Special Eligibility Categories A. Deemed Newborn Eligibility – Babies born to Medicaid-eligible pregnant people who are residents of Rhode Island are deemed eligible from the date of birth. Once deemed eligible as a newborn, the infant remains eligible for one (1) year and, as such, has eligibility through a non- MAGI eligibility pathway. Accordingly, retroactive coverage is available for periods prior to the application date if the newborn was otherwise deemed eligible. The Medicaid-eligible parent of the newborn must comply with the following: 1. Enumeration – The parent/caretaker of a newborn must obtain an SSN for a newborn. Failure to enumerate the child results in a sanction against the parent/caretaker, not the child. The child will remain eligible even if lacking an SSN because of parent/caretaker's failure to cooperate. The sanction against the mother is loss of her eligibility for failure
to cooperate. This sanction will be removed once the mother meets the enumeration requirements; or 2. Record of birth – If the newborn’s SSN is not provided at birth, Medicaid eligibility is provided under the mother’s SSN if the hospital record of birth is submitted by the parents. The hospital record of birth is a written document indicating that the newborn was discharged in the mother's care and information related to date of birth and verifying citizenship. The hospital record of birth must be signed by the appropriate authorized representative of the hospital. If the infant was not born in a hospital, proof of application for an SSN, self-attestation and signed attestation of an attending health provider or birthing assistant may be accepted as a record of birth. 3. Verification – The birth may be reported by the parent/caretaker, or another family member or friend, the parent/caretaker's Medicaid managed care plan, or the hospital in which the child was born. See § 1.8(A)(2) of this Part above for information pertaining to the hospital record of birth. B. Federal law and Regulations prohibit the use of Federal matching funds for health care provided on the premises of correctional facilities to otherwise MACC-eligible persons while incarcerated. Accordingly, full Medicaid health coverage of such persons is suspended during periods of incarceration. While the suspension remains in effect, the State is responsible for reimbursing costs related to acute care hospital stays of twenty-four (24) or more hours, but only when the otherwise Medicaid-eligible incarcerated person receives that care off the premises of the correctional facility. 1. Reinstatement upon Release. Medicaid health coverage that has been suspended due to incarceration must be reinstated promptly by the Medicaid agency upon the person’s release from a correctional facility. 2. Residency. Suspension of Medicaid health coverage is limited to Rhode Island residents while incarcerated in correctional facilities. Medicaid health coverage for Rhode Islanders incarcerated in the correctional facilities of other States or in a Federal penitentiary is terminated in accordance with the residency requirements set forth herein. C. Infants. An infant born to an incarcerated pregnant person with suspended eligibility is treated as a deemed newborn in accordance with § 1.8(A) of this Part above and is qualified to receive Medicaid health coverage until the end of the month of the infant’s first (1st) birthday. D. Hospital Presumptive Eligibility – Under 42 C.F.R. § 435.1110 (2023), States must allow qualified hospitals to provide presumptive Medicaid eligibility to individuals who are not already Medicaid members for a limited period. This form of “presumptive eligibility” is only available in certain circumstances when a qualified hospital determines, on the basis of preliminary information, that an individual has the characteristics for Medicaid eligibility. Such individuals are “presumed eligible” for Medicaid until the end of the following month or the date full
eligibility is determined, whichever comes first. The State will make presumptive eligibility available to persons who have been determined by a qualified hospital to meet the characteristics of one (1) of the MACC groups eligible for Title XIX coverage. Persons eligible under CHIP are excluded. See Part 4 of this Subchapter, Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals, promulgated by EOHHS for additional detail on the provisions governing hospital presumptive eligibility determinations in Rhode Island. E. Section 1931 Extended/Transitional Medicaid –Parents/caretakers eligible for Medicaid under § 1931 may be eligible for extended Medicaid for twelve (12) months when their income exceeds the § 1931 family eligibility limit . Requirements for extended Medicaid are as follows: 1. Eligibility Criteria – A parent/caretaker who becomes ineligible for § 1931 Medicaid benefits may be eligible for extended Medicaid if: a. The parent/caretaker has a child living in the home who is under the age of eighteen (18) or between the age of eighteen (18) and nineteen (19) if the child is a full-time student in a secondary school, or at the equivalent level of vocational or technical training, and is reasonably expected to complete the program before or in the month of their nineteenth (19th) birthday. A student attending summer school full time, as defined by school authorities, is considered a full-time student for these purposes; and b. Eligibility for § 1931 Medicaid coverage was discontinued because of earned income of a parent/caretaker or other member of the family due to: employment; increased hours of employment; or an increase in wages. While there must be a relationship between earned income and the loss of eligibility for § 1931 Medicaid to qualify for extended Medicaid, the increase in earned income need not be the only factor causing the loss. Often employment linked with other changes such as changes in the household composition combine to cause the loss of eligibility. c. The parent/caretaker and the child in the home continue to be Rhode Island Residents 2. EOHHS evaluates all household members for Medicaid and CHIP eligibility on all bases before evaluating eligibility for extended Medicaid. Extended Medicaid is provided to those beneficiaries who are ineligible on all other bases and: a. Are living in the household and whose needs and income were included in determining § 1931 eligibility of the assistance unit at the time such benefits were discontinued; b. Have needs and income that would be taken into account in determining § 1931 Medicaid eligibility using the MAGI income counting methodology if the family were applying for either of these programs in the current month. A child born after § 1931 benefits are discontinued, or a child, parent, or step-parent who
returns home after § 1931 benefits are discontinued, is included as a member of the family for purposes of providing extended Medicaid. 3. Extended Medicaid is not provided to any beneficiary who has been legally determined to be ineligible for cash assistance because of fraud at any time during the last prior six (6) months in which the family received benefits. 4. Notice Requirements and Beneficiary Responsibilities – A notice is sent informing the family of the right to extended Medicaid for twelve (12) months. The notice also sets forth the following beneficiary responsibilities. The family must: c. Report circumstances which could result in the discontinuance of extended benefits (e.g., no age appropriate child in the family or a move out-of-State). 5. Start of Extended Medicaid– The first (1st) month of extended Medicaid is the first (1st) full or partial month in which the parent/caretaker loses § 1931 eligibility. 6. Limits – An Extended Medicaid period is limited to twelve (12) months. The Medicaid agency must provide a notice of closing if eligibility is discontinued prior to the end of the twelve (12) month limit. Eligibility is always discontinued on the last day of a month. 7. Prior to termination of extended Medicaid, each member of the family is evaluated for Medicaid coverage in every other possible MACC and IHCC group category as well as for commercial coverage subsidized by the Federal and/or State government offered through HealthSource RI, the State’s health insurance market. Notice to the beneficiary indicates the alternative forms of coverage available and how to enroll or if additional information is required to determine whether eligibility for these other cover options exists. F. Children with Special Circumstances 1. This category includes children and youth who are or were in the care and custody of the Rhode Island Department of Children, Youth and Family and, by virtue of that status, are automatically eligible for Medicaid without a MAGI-based income determination. They are included in this Rule as they share the characteristics of the MACC group coverage group for children and youth though eligible through a non-MAGI pathway. However, members of these groups may be eligible for up to ninety (90) days of retroactive coverage prior to the eligibility date. 2. The DCYF is responsible for certifying the eligibility of children and youth in the coverage group and in making the referral for Medicaid to the appropriate unit of the designated State agency and for notifying the agency when there is a change in circumstances that may affect a child’s Medicaid eligibility, coverage, or service delivery options. The change in circumstance could be related to placement, the child’s financial status, or a return to the family and/or termination of participation in the applicable programs. Prior to any change that may result in the end of Medicaid eligibility, the DCYF must
ensure that the beneficiary and/or their family or guardians are aware that alternative forms of Medicaid are available and provide assistance as appropriate. 3. Adoption Subsidy/IV-E Foster Children – This non-MAGI coverage group is the eligibility pathway for children in DCYF substitute care under the authority of Title IV-E of the U.S. Social Security Act. The coverage group includes foster children, children in kinship guardianship care and adopted children whose Medicaid eligibility is based on participation in the following DCYF administered, Title IV-E programs: a. The Foster Care Maintenance Program – This Program provides federally-funded foster care payments on behalf of the following children: Children previously eligible under the Federal Foster Care Maintenance Program under Title IV-A of the Social Security Act, 42 U.S.C. §§ 601-619; Certain children voluntarily placed or involuntarily removed from their homes; and Children in public non- detention type facilities housing no more than twenty-five (25) children. Children for whom a cash payment is made under the foster care program are deemed eligible for Medicaid. Medicaid eligibility for children in the Foster Care Maintenance program exists as long as the Title IV-E payment continues to be made for them or up to the age of twenty-one (21) if still in foster care. b. The Adoption Assistance Program – The Title IV-E authorized and funded adoption assistance program provides Federal funding for continuing payments for hard-to-place children with special needs. Children in this Program must be SSI beneficiaries at the time of adoption. An adoption subsidy cash payment is not a necessary condition of Medicaid eligibility for these adoption assistance children. They continue to be eligible for Medicaid as long as a Title IV-E adoption assistance agreement is in effect. An interlocutory order or final decree also need not exist. c. Residency requirements – Title IV-E adoption assistance children, kinship guardianship assistance children, and Title IV-E foster care children are eligible for Medicaid in their States of residence. Accordingly, Rhode Island is required to provide Medicaid coverage to children eligible under this pathway as long as they remain residents of the State and under the care and custody of DCYF, even if services are being provided in a jurisdiction of another State. 4. Non IV-E Foster Child Under 18 – This coverage group includes children under the age of eighteen (18), or if a child is eighteen (18) years old, the child will complete high school before their nineteenth (19th) birthday, who are in foster family care or in a kinship guardianship care and are not eligible for Title IV-E. 5. Non IV-E, State Adoption Assistance – This coverage group is hard-to-place children for whom the State provides adoption/guardianship assistance and who are not eligible for Title IV-E. The basis of eligibility for Medicaid is deprivation of parental support occasioned by the child's separation from their family.
6. The determination of financial need. When a child is not living in a home maintained by the child's parents, the State considers only the child's own income and resources. 7. Age Limit. Medicaid under this coverage group may be provided until the child reaches the age of twenty-one (21). 8. Post Foster Care Medicaid Eligibility for individuals born before January 1, 2005 – The Foster Care Independence Act of 1999 established the John H. Chafee Foster Care Independence Program, 42 U.S.C. § 1396a(a)(10). This Medicaid eligibility pathway is open to youth who were in foster care in Rhode Island on their eighteenth (18th) birthday. Medicaid eligibility for youth qualifying for this coverage continues until the age of twenty-six (26) as long as the individuals remain residents of the State. a. Living arrangement. A post foster care adolescent may be residing independently or with others (including family members). b. Renewal. A renewal of Medicaid eligibility is completed once in a twelve (12) month period to ensure that the beneficiary eligible in this group is a resident of Rhode Island. c. Limits. Under the terms of the Chafee Act, young adults may only qualify for Medicaid under this group if not otherwise eligible through SSI or as aged, blind or disabled and/or in need of long term services and supports. In addition, although eligible for the full scope of Medicaid State Plan and Section 1115 waiver services available to all adults, the EPSDT benefit for children continues up to the age of twenty-one (21) only. 9. Post Foster Care Medicaid Eligibility for individuals born on or after January 1, 2005 – The Foster Care Independence Act of 1999 established the John H. Chafee Foster Care Independence Program, 42 U.S.C. § 1396a(a)(10), and was later amended by the Patient Protection and Affordable Care Act, Pub. Law No. 111-148, and the SUPPORT for Patients and Communities Act, Pub. Law No. 115-271. This Medicaid eligibility pathway is open to individuals between the ages of 18 and 26 who were in foster care under the responsibility of a state or a Tribe within a state, including children who were cared for under the unaccompanied refugee minor program, and were enrolled in Medicaid upon the time their foster care assistance ended. An individual may qualify for this eligibility pathway even if the individual was in foster care in a state or Tribe within a state other than Rhode Island. Medicaid eligibility for youth qualifying for this coverage continues until the age of twenty-six (26) as long as the individual remains a resident of the State. a. Living arrangement. A post foster care youth may be residing independently or with others (including family members). b. Renewal. A renewal of Medicaid eligibility is completed once in a twelve (12) month period to ensure that the beneficiary eligible in this group is a resident of Rhode Island.
c. Limits: Individuals may only qualify for this group if they are not enrolled through a different Medicaid eligibility pathway, even if they meet the eligibility requirements of another eligibility pathway. Although eligible for the full scope of Medicaid State Plan and Section 1115 waiver services available to all adults, the EPSDT benefit for children continues up to the age of twenty-one (21) only. 1.9 Cooperation Requirements A. All applicants and beneficiaries subject to this Part must cooperate with an array of requirements as a condition of obtaining or retaining (post-eligibility) eligibility. Specific requirements related to application and renewal are located in Part 3 of this Subchapter and for the purposes of evaluating and verifying income are set forth in Part 5 of this Subchapter. B. Cooperation requirements applicable across populations are as follows: 1. Third Party Liability (TPL) – Third Party Liability refers to any individual, entity (e.g., insurance company) or program (e.g., Medicare) that may be liable for all or part of a Medicaid applicant’s coverage. Under § 1902(a)(25) of the Social Security Act, 42 U.S.C. § 1396a(a)(25), the State is required to take all reasonable measures to identify legally liable third (3rd) parties and treat verified TPL as a resource of the Medicaid beneficiary once determined eligible. Applicants/beneficiaries must furnish information about all sources of TPL. The State and Medicaid managed care organizations, under contractual agreements with the State, are responsible for identifying and pursuing TPL for beneficiaries covered by employer-sponsored health insurance plans through the RIte Share program. Failure to cooperate with the TPL requirement or to enroll in a RIte Share plan as required in Subchapter 05 Part 3 of this Chapter results in the ineligibility of the parent. 2. Referral to Office of Child Support Services (OCSS) – All applicants reporting an absent parent are referred to the Office of Child Support Services within the Department of Human Services, once they have been determined eligible for Medicaid and received appropriate notice. Compliance with the OCSS requirement is a condition of retaining eligibility. As a condition of eligibility, an applicant who can legally assign rights for a dependent child born out of wedlock is required to do so and cooperate in establishing the parentage of that child for the purposes of obtaining medical care support and medical care payments for both the applicant and the child. Failure to cooperate in assigning rights results in a determination of ineligibility for the parent, unless a good cause exemption has been granted by the State. In instances when domestic violence may be the basis for an exemption to the cooperation requirement, referral to the Family Violence Option Project may be made to assist the parent seeking an exemption. 3. RIte Share Premium Assistance Program – Individuals and families determined to have access to cost-effective employer-sponsored health insurance (ESI) are required to enroll in the ESI plan if so directed by the State. Members of the MACC groups with access to ESI who are eligible for Medicaid will be permitted to enroll in a Medicaid
managed care plan, as appropriate. The Medicaid agency will conduct a post-enrollment review of those members with access to ESI to determine whether participation in RIte Share is required. The provisions governing the RIte Share program are located in Subchapter 05 Part 3 of this Chapter. C. Duty to Report – All Medicaid applicants and beneficiaries have a duty to report changes in income, family size, address, and access to ESI within ten (10) days of the date the change takes effect. Failure to make timely reports may result in the denial or discontinuation of Medicaid eligibility. D. A Medicaid applicant or member must have the opportunity to claim good cause for refusing to cooperate. Good cause may be claimed by contacting a DHS or EOHHS agency representative. To claim good cause, a person must state the basis of the claim in writing and present corroborative evidence within twenty (20) days of the claim; provide sufficient information to enable the investigation of the existence of the circumstance that is alleged as the cause for non-cooperation; or, provide sworn statements from other individuals supporting the claim. E. Basis for Claim. A determination of good cause is based on the evidence establishing or supporting the claim and/or an investigation by Medicaid agency staff of the circumstances used as justification for the claim of good cause for non-cooperation. F. State Requirements. The determination as to whether good cause exists must be made within thirty (30) days of the date the claim was made unless the agency needs additional time because the information required to verify the claim cannot be obtained within the time standard. The person making the claim must be notified accordingly, provided with the reason for the decision, and the right to appeal through the EOHHS Administrative Fair Hearing Process specified in Part 10-05-2 of this Title. G. A Medicaid beneficiary may terminate Medicaid eligibility at any time. Such requests must be made in writing and submitted to a State agency or HSRI representative in-person, via U.S. Mail, fax, on-line via the beneficiary’s secure account, or made by telephone to HSRI when telephonic recording capabilities exist. The Medicaid agency is responsible for providing the Medicaid beneficiary with a formal notice of the voluntary termination of Medicaid eligibility that indicates the effective date, the impact of terminating eligibility for each member of the household, and the right of the beneficiary to reapply for Medicaid health coverage at any time. 1.10 Information A. For Further Information or to Obtain Assistance 1. Applications for affordable coverage are available online on the following websites: a. www.eohhs.ri.gov b. www.dhs.ri.gov
c. www.HealthSourceRI.com 2. Applicants may also apply in person at one of the Department of Human Services offices or by U.S. Mail. Request an application by calling 1-855-697-4347 and TTY 1-888-657- 3173.3. For assistance finding a place to apply or for assistance completing the application, please call: 1- 855-840-HSRI (4774). 1.11 Severability A. If any provisions of these Regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable.
210-RICR-30-00-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 - AFFORDABLE COVERAGE GROUPS PART 1 - MEDICAID AFFORDABLE CARE COVERAGE GROUPS OVERVIEW AND ELIGIBILITY PATHWAYS (210-RICR-30-00-1) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 08/17/2025 July 28, 2025 E-SIGNED by Richard Charest on 2025-07-28 10:40:49 EDT July 28, 2025 E-SIGNED by Department of State on 2025-07-28 10:42:26 EDT
210-RICR-30-00-3 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 – MEDICAID FOR CHILDREN, FAMILIES AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 – AFFORDABLE COVERAGE GROUPS PART 3 – MEDICAID APPLICATION AND RENEWAL PROCESS 3.1 Application Process for Medicaid Affordable Coverage: No Wrong Door 3.1.1 Scope, Purpose, and Legal Authority A. One of the central goals of the federal Affordable Coverage Act (hereinafter the ACA) of 2010 (Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq.) was to improve access to and the availability of affordable health coverage. Toward this end, the ACA mandated that the States reform the Medicaid application and renewal system to make it easier for consumers to navigate and gain access to and retain affordable health care coverage. B. The purpose of this Rule is to set forth the application and renewal processes for members of the Medicaid Affordable Care Coverage (MACC) groups subject to MAGI-based income eligibility determinations. The Rule also sets forth the respective roles and responsibilities of the EOHHS, its eligibility agents, and applicants/beneficiaries. In addition, the Rule establishes the application and renewal processes for children in the Integrated Health Care Coverage (IHCC) groups who are exempt from MAGI determinations under Federal law and Regulations and, therefore, the Medicaid State Plan because their eligibility is tied to participation in other publicly funded programs including Federal Supplemental Security Income (SSI), and the programs for children and youth at- risk or in the custody of the Rhode Island Department of Children, Youth and Families (DCYF). C. This Part is promulgated pursuant to: 1. Federal authorities as follows: a. Federal Laws – § 1115 of the Social Security Act, 42 U.S.C. § 1315; Title IV-E of the Social Security Act, 42 U.S.C §§ 670-679(c), Title XIX of the Social Security Act, 42 U.S.C. §§ 1396a-1396w-8; and Title XXI of the U.S. Social Security Act, §§ 42 U.S.C. 1397aa 1397mm; § 1413(b)(1)(A) of the Patient Protection and Affordable
Care Act; and § 5112 of the Consolidated Appropriations Act, Pub. Law 117-328. b. Federal Regulations – 42 C.F.R. §§ 435.603; 435.902 through 910; 435.916; and 435.1025 c. The Medicaid State Plan and the Section 1115 Demonstration Waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. 2. State authorities – R.I. Gen. Laws Chapters 40-6, 40-8, and 42-7.2. 3.1.2 Incorporated Materials A. These regulations hereby adopt and incorporate 42 C.F.R. § 435.916 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. B. These regulations hereby adopt and incorporate 42 C.F.R. § 435.603 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. C. These regulations hereby adopt and incorporate 42 C.F.R. § 435.902-910 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. D. These regulations hereby adopt and incorporate 42 C.F.R. § 435.1005 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations 3.1.3 Definitions A. As used herein, the terms below have the meanings described: 1. “Application access points” means the various contact points where consumers or their representatives can access the application process either directly through the State’s integrated eligibility system’s consumer portal (online) or with the assistance of EOHHS, the Department of Human Services (DHS), or HealthSource RI (HSRI) representatives, or an application entity designated by the State for such purposes (in-person, by telephone or a mail-in application). 2. “Application entity” means an organization or firm acting on a State agency’s behalf that provides applicants for affordable coverage with an application access point including the EOHHS, the DHS, the HealthSource RI (HSRI) and any organizations designated for such purposes that maintain a staff of certified navigators or in-person assistors.
3. “Continuous eligibility” or “CE” means a period of eligibility during which a member cannot be disenrolled due to changes in circumstances with certain exceptions. Exceptions include a request for disenrollment by the beneficiary, the beneficiary is no longer a resident of the state, the agency determines that eligiblity was erroneously granted at the most recent determination, redetermination, or renewal due to agency error or fraud, abuse, or perjury attributed to the beneficiary, or the beneficiary is deceased. 4. “Enrollee” means a Medicaid member or beneficiary who is enrolled in a Medicaid managed care plan. 5. “Integrated Health and Human Services Eligibility System" or "IES” means the State's eligibility system that enables applicants, through a single application, to be considered for several human service programs simultaneously, including affordable health coverage and human services. 6. “Medicaid Affordable Care Coverage Group” or “MACC” means a classification of persons eligible to receive Medicaid based on similar characteristics who are subject to the MAGI standard for determining income eligibility as set forth in Part 1 of this Subchapter. 7. “MAGI standard” means the method for evaluating Medicaid income eligibility using the modified adjusted gross income (MAGI) standard established under the ACA. The MAGI is the standard for determining income eligibility for all MACC groups. 8. “Modified passive renewal” means a method for determining continuing eligibility using electronic data sources and information provided by beneficiaries. This method is only used when the eligibility factors subject to change cannot be evaluated fully by the available electronic data sources or information in the beneficiary’s account. This process may also be used when there is insufficient information to determine whether a beneficiary who is losing coverage due to a change in an eligibility factor is eligible in another coverage group, such as when a MACC adult is about to turn sixty-five (65) and must be evaluated using the SSI methodology specified in Chapter 40 of this Title. 9. “Navigator” means a person working for a State-contracted organization with certified assisters who have expertise in Medicaid eligibility and enrollment. 10. “Non-MAGI coverage group” means a Medicaid coverage group that is not subject to the modified adjusted gross income eligibility determination. For the purposes of this Part, the term refers to the children and youth who are eligible for Medicaid based on their participation in another publicly funded program and/or by Federal law, including infants born to Medicaid eligible
mothers, recipients of Supplemental Security Income (SSI) cash assistance under age twenty-one (21), and children and youth who are, or in some instances were, in the care and/or custody of the Rhode Island Department of Children, Youth and Families (DCYF). 11. “Passive or ex parte renewal” means a method for determining continuing eligibility that uses electronic data sources to confirm ongoing eligibility without information or action on the part of a beneficiary, unless certain types of discrepancies are detected. The State may require members to resolve discrepancies in pre-populated forms or in online accounts. 3.1.4 Application Access Points A. Under the State’s “No Wrong Door Policy”, consumers must have easy access to a choice of application access points. New applicants for affordable coverage may access the eligibility system and complete the application process through application entities that have been designated for this purpose and on their own or with assistance, if necessary, through any of the following access points: 1. Online Consumer Portal – Applicants have the option of accessing the eligibility system and applying online using a self-service portal through links on the EOHHS (eohhs.ri.gov) and DHS (dhs.ri.gov) websites or directly through HSRI (HealthSourceRI.com). The information applicants provide is entered directly into the IES and is processed electronically in real-time. 2. In-person or by telephone – Applicants may apply in-person at DHS field offices with the assistance of an agency representative or on their own using kiosks established for this purpose. The Contact Center also provides access to walk-in applicants and consumers who make contact by telephone. If an applicant is unwilling or unable to apply online, an agency or Contact Center representative must enter the information into the IES on the applicant’s behalf. 3. On-paper – Applicants may submit paper applications in-person or by U.S. Mail, e-mail transmissions, and facsimile transmissions to the address specified on the application. Paper applications are available online, through the U.S. Mail upon written request or telephone request (1-855- 840-4774 or 1-888-657-3173 (TTY)), or in-person at any DHS field office or the Contact Center. Upon receipt, an agency or Contact Center representative must enter the information provided on the paper application directly into the eligibility system portal and submit the application for a determination on the applicant’s behalf. 4. Application Entities – Applicants may access the eligibility system with the assistance of application entities that provide navigators or other in-person assisters (IPAs). Members of these entities assist applicants in completing
paper applications or applying through the online portal. A list of these application entities is available from the Contact Center or online by visiting the EOHHS website (www.eohhs.ri.gov ). 3.1.5 Completing and Submitting the Application A. In general, the process of completing and submitting an application proceeds in accordance with the following: 1. Account Creation – To initiate the application process, the applicant, agency or Contact Center representative, or application entity assisting the applicant, must create a login and establish an account in the eligibility system. a. The applicant must provide personally identifiable information for the purpose of creating an online account and establishing identity during this process. Verification of this information is automated through the Federal data hub (see Part 30-00-5 of this Title). Documentation verifying identity may be required if the automated verification process is unsuccessful. Acceptable forms of identity proof include, but are not limited to, a driver’s license, school registration, voter registration card. Documents may be submitted via mail, fax, on-line upload, to a DHS Office, or the HSRI. (See Part 30-00-5 of this Title for additional information). b. Once identity is verified, the Medicaid agency must conduct account matches to determine whether the applicant or members of the applicant’s household have other accounts or are currently receiving benefits. It is the State’s responsibility to resolve account matching issues and notify the applicant of any necessary actions. 2. Account Duration – An application account is open for a period of ninety (90) days. Applicants must restart the process if they have not completed and submitted an application within that period. a. Applications may be started at any time. Once started, progress can be saved at any point and the application returned to at a later time. Incomplete applications not submitted within ninety (90) days are automatically deleted in the eligibility system. b. Eligibility determinations for Medicaid. Determinations must be made within thirty (30) days from the date the completed application is received. The application remains open after that period if the State or its eligibility designee (DHS) or agents (application entities) are responsible for delays in the eligibility determination.
c. Temporary eligibility period. If there are discrepancies between an applicant’s attestations and electronic data matches on immigration eligibility factors, eligibility is granted for a period of no more than ninety (90) days. The application remains open during this period to allow the applicant sufficient time to obtain necessary documentation. 3. Application Materials – Applicants must answer all the required questions for each member of their household. Application questions focus on the need for all types of affordable coverage and specific Medicaid eligibility criteria related to the applicable MACC group. In general, applicants will be able to provide answers to the application questions with information used when filing Federal tax forms and/or documents commonly used for identification and income verification purposes. When applying through the web portal online, electronic verification through data matches will limit the applicant’s need to refer to these materials. However, when using a paper application, access to these materials may be necessary. Materials that may be of assistance in such instances include, but are not limited to: a. Federal tax filing status b. Household/family size c. Social Security Numbers d. Birth dates e. Passport or other immigration numbers f. Federal tax returns g. Information about any health coverage available to you or your family, including any information you have about the health insurance your current employer offers even if you are not covered by your employer’s insurance plan h. W-2 forms with salary and wage information if you work for an employer i. 1099 forms, if you are self-employed. 4. Application Completeness – Before a determination of eligibility is made, all questions on the application must be completed. Applicants must be informed and offered the opportunity to provide any additional documentation or explanations necessary to proceed to the determination of eligibility. Such information will be provided to applicants immediately through a notification from the eligibility system when using the self- service portal. The agency or HSRI, or application entity entering the
information into the eligibility system on the applicant’s behalf, must provide this information to the applicant immediately once it becomes available, by letter or phone if the applicant is not present. However, the application filing date is not established until the completed form is submitted. 5. Voluntary Withdrawal. An applicant may request that an application for Medicaid health coverage be withdrawn at any time either through their secure online account or by submitting the request in writing via the U.S. Mail or fax to the EOHHS or DHS agency or a HSRI representative. Withdrawal of the application may also be made by telephone to the HSRI. The State sends a notice to the applicant verifying the time and date of the voluntary withdrawal and indicating that the applicant may reapply at any time. 3.1.6 Attestation of Application Information A. All questions on the application must be answered in a truthful and accurate manner. Every applicant must self-attest to the truthfulness and accuracy of the question responses and documentation submitted by providing an electronic signature under penalty of perjury. 1. Electronic Matches – Federal, State, and commercially available data sources.The eligibility factors subject to verification and the verification process is located in Part 30-00-5 of this Title. 2. Attestation – Before an application can be submitted, the applicant, or the person/entity acting on the applicant’s behalf, must authenticate by signature that the information provided is genuine, correct, and true. When applying online, the attestation is conducted electronically. An agency or HSRI representative or an authorized application entity must verify that the application was signed (mail application), a voice signature was obtained (telephone application), or that the applicant signed a declaration in- person. The signature provided by the applicant in these instances is an attestation to both the applicant’s identity and the truthfulness and accuracy of the information on the application. There are circumstances when an applicant’s attestations and verification data matches show discrepancies. (See Part 30-00-5 of this Title for the provisions governing reconciliation of such differences). 3.1.7 Privacy of Application Information A. Application information must only be used to determine eligibility and what types of coverage a person is qualified to receive. Accordingly, the State, HSRI, or application entity must maintain the privacy and confidentiality of all application information and in the manner required by applicable Federal and State laws and Regulations and as provided in Part 10-05-1 of this Title.
3.1.8 Notice of Determination of Eligibility A. Once an application is completed and the required verifications are performed, eligibility for Medicaid and other forms of affordable coverage is made for each member of the household. (For information on other forms of affordable coverage, see www.HealthSourceRI.com or call HSRI at 1-855-840-4774). B. Household members determined Medicaid-eligible may enroll immediately in the health plan of choice. A formal notice will be generated after the determination indicating which household members are eligible for Medicaid or other forms of affordable coverage, the legal basis for the determination of eligibility, and the plan in which each household member is enrolled, if applicable. The notice will be sent via the applicant’s secure online account if opting to receive agency communications in such a manner or by mail in a reasonable time period. A “reasonable time” period usually will not exceed ten (10) business days, but in no instance will it extend beyond the thirty (30) day application period. C. The notice must also advise the applicant of the right to appeal and request a hearing, in accordance with Part 10-05-2 of this Title. 3.1.9 Agency and Applicant Roles and Responsibilities A. The State and applicants have shared and distinct responsibilities in the application process. 1. Medicaid agency – Under current State and Federal laws, the Medicaid State Agency is required to: a. Assist applicants in completing all necessary forms. b. Provide applicants with an interpreter or translator services upon request. c. Assure all information applicants provide is kept confidential unless otherwise authorized to share with other State and Federal agencies for the purposes of verification and enrollment. d. Make timely determinations of eligibility in accordance with applicable laws and Regulations. e. Accept appeals and hold hearings on agency actions related to eligibility decisions in accordance with Part 10-05-2 of this Title. f. Provide a mechanism for beneficiaries to voluntarily withdraw eligibility for Medicaid health coverage at any time by submitting a written request via the U.S. Mail or fax to the EOHHS or DHS agency or an HSRI representative.
2. Applicant Rights and Responsibilities – All applicants have the following: a. Applicant Rights – The right to obtain help in completing forms; to an interpreter or translator, upon request; to be treated free from discrimination on the basis of race, color, national origin, sex, gender identity or sexual orientation, age or disability; to have personal information remain confidential; and to file an appeal and request a hearing on eligibility actions. b. Applicant Responsibilities – The responsibility to: (1) Disclose certain information including Social Security Numbers and proof necessary to determine eligibility; (2) Report changes in income, family size and other application information as soon as possible; and (3) Sign the application and thereby agree to comply with any applicable laws related to the type of eligibility requested and the coverage received. 3.2 Renewal of Eligibility for Medicaid Affordable Care Coverage Groups 3.2.1 Scope and Purpose A. All MACC group members are subject to MAGI-based renewals, focusing on the eligibility factors subject to change. Such factors include changes in income, household composition or family size (due to death, marital status, birth or adoption of child), and/or State residency. Children who are determined eligible for Medicaid will receive one (1) year of continuous eligibility (CE). Disenrollments for any reason that are followed by requests for eligibility reinstatements are also subject to this process for members of the MACC groups. 3.2.2 Responsibilities of the State A. The State is responsible to ensure that the Medicaid renewal process occurs once every twelve (12) months for all MACC group members. Towards this end, the State must meet the following requirements: 1. Basis of Renewal – The eligibility renewal must be based on information already available to the State to the full extent feasible. Accordingly, the State must use information about the Medicaid member from reliable sources including, but not limited to, the member’s automated eligibility account, current paper records, or data bases that may be accessed through the Federal data hub or the State’s own affordable care coverage eligibility system.
2. Restrictions – The State must not request or use information when conducting renewals pertaining to: eligibility factors that are not subject to change or concern matters that are not relevant to continuation of Medicaid eligibility. Eligibility factors subject to change include income, household or family size, State residency and certain immigration statuses. Factors that are not subject to change include, but are not limited to, native born or naturalized U.S. citizenship, date of birth, and Social Security Number. 3. Renewal Strategy – The State utilizes a passive “ex parte” renewal process for all MACC group members when determining continuing eligibility and whether a beneficiary who is losing coverage due to a change in an eligibility factor qualifies for Medicaid in another coverage group to the full extent feasible. This renewal method confirms eligibility factors subject to change through electronic data sources and only requires action on the part of the beneficiary if certain discrepancies are detected by the State or self-reported. The State will use both active and passive renewal methods until all MACC group members have been subject to a MAGI-based income eligibility determination at least once. Accordingly, the State will conduct renewals as follows: a. Initial review. The State redetermines eligibility at least sixty (60) days before the renewal date using information known to the IES and from various data sources and provides notice to the beneficiary indicating the results of this review. The notice contains the information that served as the basis for this eligibility review and indicates one (1) of the following: (1) Passive Ex Parte Renewal – Medicaid eligibility has been renewed “ex parte” and no further action on the part of the beneficiary is required unless, upon reviewing the information in the notice, the beneficiary identifies an error or a change in an eligibility factor subject to change that must be reported to the State; or (2) Modified Passive Renewal – Medicaid eligibility has not been renewed due to missing information or a discrepancy between sources of information related to an eligibility factor subject to change. In such instances, the notice contains an additional documentation request (ADR) specifying the type of information that must be submitted for the renewal of eligibility to proceed. b. Renewal decision. If the beneficiary is not required to take any action and does not find cause to self-report a change, Medicaid eligibility is continued automatically for another year, effective on the renewal date. However, in order to be considered in this final
renewal decision, change self-reports and ADR responses must submitted at least thirty (30) days from the date of the renewal notice. The State redetermines eligibility based on this information. If the beneficiary receives an ADR and does not take the action required, this redetermination is based solely on the information known to the IES through self-attestations and applicable data sources. A formal notice is issued with the State’s final renewal decision if eligibility is discontinued on this basis at least fifteen (15) days prior to the eligibility continuation or termination date. Information received by the State at any time prior to the eligibility termination date is considered. However, if the information is submitted after the tenth day of the renewal month, a change from managed care to fee-for-service service delivery may result. c. Reinstatement. A reinstatement of Medicaid eligibility is permitted without a full reapplication, in instances in which a beneficiary takes the actions required to resolve a discrepancy or information gap in the ninety (90) day period after eligibility is terminated. 4. Consent – The State must obtain the consent of the Medicaid member to retrieve and verify electronically information related to eligibility factors subject to change including any federal tax information required to review income eligibility. Such consent is obtained during the initial application for Medicaid eligibility when the Medicaid member signs the application, under penalty of perjury. 5. Enrollment – A Medicaid member whose eligibility has been continued through the annual renewal process must remain in the same Medicaid health plan unless the renewal occurs during an open enrollment period. If an open enrollment process is not underway at the time of renewal, the provisions set forth in Part 30-05-2 of this Title prevail. 6. Access – The State must ensure that any application or supplemental forms required for renewal are accessible to persons who have limited proficiency in English or who have a disability. 3.2.3 Responsibilities of Medicaid Members A. Medicaid members must ensure that the State has access to accurate and complete information about any eligibility factors subject to change at the time of the annual renewal. Accordingly: 1. Consent – At the time of the initial application or first MAGI-based renewal, Medicaid members must provide the State with consent to retrieve and review any information not currently on record pertaining to the eligibility factors subject to change through electronic data matches conducted through the State’s affordable coverage eligibility system. Once
such consent is provided, the State may retrieve and review such information when conducting all subsequent annual renewals. 2. Duty to Report -- Medicaid members are required to report changes in eligibility factors to the Medicaid agency within ten (10) days from the date the change takes effect. Self-reports are permitted through the eligibility system on-line portal. Medicaid members also may report such changes in person, via fax, by mail, or telephone with the assistance of HSRI, DHS agency representative, or Navigator. Failure to report in a timely manner, as noted above, may result in the discontinuation of Medicaid eligibility. 3. Cooperation – Medicaid members must provide any documentation that otherwise cannot be obtained related to any eligibility factors subject to change when requested by the State. The information must be provided within the timeframe specified by the State in the notice to the Medicaid member stating the basis for making the agency’s request. 4. Voluntary Termination – A Medicaid member may request to be disenrolled from a Medicaid health plan or to terminate Medicaid eligibility at any time. Disenrollment results in the termination of Medicaid eligibility. 5. Reliable Information – Medicaid members must sign under the penalty of perjury that all information provided to the Medicaid agency at the time of application and any annual renewals thereafter is accurate and truthful. 3.3 Information 3.3.1 For Further Information or to Obtain Assistance A. Applications for affordable coverage are available online on the following websites: 1. www.eohhs.ri.gov 2. www.dhs.ri.gov 3. www.HealthSourceRI.com B. Applicants may also apply in person at one of the DHS offices or by U.S. Mail. Request an application by calling 1-855-840-4774 or TTY 1-888-657-3173. C. For assistance finding a place to apply or for assistance completing the application, please call: 1-855-840-HSRI (4774). 3.4 Severability A. If any provisions of these Regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions
or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable.
210-RICR-30-00-3 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 - AFFORDABLE COVERAGE GROUPS PART 3 - MEDICAID APPLICATION AND RENEWAL PROCESSES 210-RICR-30-00-3 Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 08/28/2025 August 08, 2025 E-SIGNED by Richard Charest on 2025-08-08 14:50:33 EDT August 08, 2025 E-SIGNED by Department of State on 2025-08-08 15:00:11 EDT
210-RICR-30-00-4 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 – AFFORDABLE COVERAGE GROUPS Part 4 – Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals 4.1 Overview and Statutory Authority A. The goal of the federal Affordable Care Act (ACA) of 2010 is to improve access to high quality health insurance coverage for people of all ages and income levels. In keeping with this purpose, the ACA established a presumptive eligibility program for certain individuals and families in the newly reconfigured Medicaid Affordable Care Coverage (MACC) groups. The MACC groups in Rhode Island are described in Part 30-00-1 of this Title. B. Federal regulations governing the program at 42 C.F.R. § 435.1110 require the states to provide Medicaid for a limited period of time to individuals who are determined by a “qualified hospital”, on the basis of preliminary information, to be presumptively eligible for Medicaid. This initial determination is made by the hospital on the basis of the characteristics for MACC group eligibility. The states have the discretion under these provisions to tailor presumptive eligibility requirements program within certain parameters to meet their own unique needs. C. Legal Authority 1. This Part is promulgated pursuant to Federal authorities as follows: a. Federal Law: § 1115 of the Social Security Act, 42 U.S.C. § 1315; Title XIX of the Social Security Act, 42 U.S.C. §§ 1396a-1396w-7; Title XXI of the Social Security Act, 42 U.S.C. §§ 1397aa-1397mm; 42 U.S.C. § 1396k; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. Law No. 111-148. b. Federal Regulations: 42 C.F.R. Parts 431.1110. c. The Medicaid State Plan and the Section 1115 Demonstration Waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315.
4.2 Incorporated Materials A. These regulations hereby adopt and incorporate 42 C.F.R. § 435.1110 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. 4.3 Scope and Purpose of Hospital Presumptive Eligibility Program for Medicaid A. For individuals with MACC-like characteristics, presumptive eligibility may be determined by a qualified hospital, licensed in Rhode Island, and is only available in certain circumstances contingent upon preliminary information supplied by the individual. Further, presumptive eligibility is only available on a temporary basis – until the last day of the month following the initial determination of presumptive eligibility or the date full eligibility is determined, whichever comes first. 1. Implementation – Effective January 27, 2014, the State will accept applications from qualified hospitals that wish to make presumptive eligibility determinations pursuant to 42 C.F.R. § 435.1110. If a qualified hospital determines that an individual meets the characteristics of one of the MACC groups identified in Part 30-00-1 of this Title (and as below) they will be granted eligibility 2. Governing Provisions – The purpose of these rules is to set forth the provisions governing hospital presumptive eligibility determinations including, but are not limited to the: a. Populations for which qualified, participating hospitals may conduct presumptive eligibility assessments and scope of coverage; b. Requirements for a hospital to participate in the Hospital Presumptive Eligibility Program; c. Application timelines and procedures for individuals who qualify for Medicaid coverage during the presumptive eligibility period. 4.4 Definitions A. “Children’s Health Insurance Program” or “CHIP” means the program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children. The program was designed to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid. B. “Executive Office of Health and Human Services” or “EOHHS” means the designated “single state agency”, authorized under Title XIX of the U.S. Social Security Act (42 U.S.C. § 1396a et seq.), to be legally responsible for the
programmatic oversight, fiscal management, and administration of the Medicaid program. C. “Hospital Presumptive Eligibility” or “HPE” means Medicaid eligibility granted on a temporary basis to a person who meets certain criteria during a defined period. D. “Medicaid Affordable Care Coverage Groups” or “MACC Groups” means a classification of persons eligible to receive Medicaid based on similar characteristics who are subject to the MAGI standard for determining income eligibility beginning January 1, 2014. E. “Qualified Hospital” means any licensed Rhode Island hospital participating in the Medicaid program that elects to participate in the HPE Program by executing a Notice of Intent to Participate in the HPE Program and a Memorandum of Understanding with EOHHS to conduct presumptive eligibility determinations, participates in training and certification sponsored by EOHHS, and remains in good standing with EOHHS protocols. F. “Self-Attestation” means the act of a person affirming through an electronic or written signature that the statements the person made when applying for Medicaid eligibility are truthful and correct. 4.5 Populations for Which Qualified Participating Hospitals May Conduct Presumptive Eligibility Assessments A. Qualified hospitals that elect to participate in the HPE Program may complete presumptive eligibility assessments for individuals who have the characteristics of members of the MACC groups funded through Title XIX. HPE excludes individuals eligible for coverage funded through CHIP and any individuals eligible for Medicaid on the basis of age, blindness or disability and/or in need of Medicaid-funded long-term services and supports.
4.6 Scope of Coverage A. Eligibility Period. The hospital presumptive eligibility period will begin on, and include, the date the hospital makes the HPE determination. The hospital presumptive eligibility period ends on the date that the Medicaid agency renders a determination for full Medicaid eligibility; or the last day of the month following the month in which the hospital made the HPE determination, whichever comes first. B. Covered Services. Individuals determined eligible for HPE, will receive the same scope of State Plan and Section 1115 waiver services as members of a MACC group, except as follows: 1. All HPE beneficiaries -- No transportation services.
2. Pregnant individuals -- Maternity services are limited to prenatal ambulatory care only. (Birthing expenses are not covered.) C. Service Delivery. Individuals determined to be presumptively eligible for Medicaid will be enrolled in a fee-for-service plan. When full Medicaid eligibility is determined, participants will be enrolled at EOHHS’ discretion in a managed care organization (MCO), as indicated in Subchapter 05 Part 2 of this Chapter. 4.7 Requirements for Hospitals to Participate in the HPE Program A. A hospital must meet certain requirements to be deemed qualified to participate in the HPE. 1. Participation. A qualified hospital must be licensed in RI and a participating Medicaid provider under the Rhode Island Medicaid State Plan or Section 1115 waiver. The hospital must notify EOHHS of its election to make presumptive eligibility determinations, and agree to HPE determinations in compliance with State policies/procedures and these rules. 2. Application Process: The qualified hospital must: a. Assist individuals in completing and submitting the full application for health insurance affordability programs in Rhode Island. This assistance includes assuring that the individual understands any documentation requirements. b. NOT require individuals assessed for HPE to verify information related to any HPE eligibility criteria/characteristic, including pregnancy. c. Accept self-attestation of income, citizenship, and residency, as applicable, when determining eligibility. d. Provide individuals with written notice after the HPE determination is made that includes, but is not limited to: (1) HPE determination (i.e., approved or denied); (2) If approved, the beginning and ending dates; (3) If denied, the reason(s) for the denial, options for submitting a regular Medicaid application and information on how to make application. e. The qualified hospital must utilize EOHHS-approved materials and methods in determining HPE and completing full Medicaid
applications, including the EOHHS and HSRI websites and the State’s single streamlined application. 3. Confidentiality. The qualified hospital must comply with all applicable State and federal laws and regulations regarding patient privacy and the confidentiality of health care communications and information. 4. Records Retention. In accordance with the provisions of the state agency’s record retention policy, the qualified hospital shall maintain organized records of all HPE applications for ten (10) years from the date the last Medicaid billing was submitted to EOHHS. 5. Medicaid Agency Notification. The qualified hospital shall notify the state agency of HPE approvals, and the applicable date ranges, within five (5) business days. 6. Hospital Staff. The qualified hospital must only use employees of the hospital to assist with HPE applications. The hospital is prohibited from subcontracting HPE work to a non-hospital based company or independent contractor. In addition: a. Each qualified hospital shall have a minimum of one (1) staff member trained and certified to perform HPE duties on each shift. b. The hospital must affirm that all HPE personnel meet the minimum qualifications specified herein and comply with EOHHS policies and procedures for participation in the Medicaid hospital presumptive eligibility program and participate in all trainings, knowledge-based tests, and keep up-to-date on notifications with regard to HPE. The hospital must assign one accountable individual to be the liaison with the State Medicaid Agency and its designees. c. The qualified hospital HPE staff must assist Medicaid applicants with the completion and submission of a Medicaid application. Additionally, qualified hospital staff must provide the information specified in this subsection pertaining to the HPE decision, eligibility period, and requirement to complete a full application. d. HPE staff must complete the requisite EOHHS training and maintain knowledge of any program changes. HPE staff training must include: in-person training; computer-based training; and proficiency testing and certification. Training and testing shall be completed at specific intervals as directed by EOHHS, but no less than annually. (1) Assignment of Qualified Hospital Staff Online Application Credentials. Prior to assignment of online HPE administrator credentials, qualified hospital staff must complete EOHHS-
approved training and provide documentation of completion of training in the format required. Proof of training also must be made available upon request by applicants. (2) Proficiency standards. Hospital HPE staff must achieve the minimum certification testing score set forth in contractual standards established with EOHHS. 4.8 Reporting A. All qualified hospitals must submit monthly reports in a standardized format as defined by EOHHS. These reports must be submitted electronically by the fifth business day of the month following HPE determinations. The reports must reflect accurate measurement of the performance requirements described in § 4.9 of this Part below. In addition, the qualified hospital must prepare and submit any ad-hoc reports to EOHHS upon request. 4.9 Performance Requirements A. The EOHHS requires that a qualified hospital meet certain performance standard to continue participation in the HPE. First, the qualified hospital must submit full Medicaid applications for ninety-five percent (95%) of the individuals granted HPE within five (5) calendar days from the date of the initial determination of presumptive eligibility. Second the percentage of these Medicaid applications that must be deemed fully complete by the EOHHS -- that is, contain no errors or otherwise require the State’s intervention in processing -- is set forth in contractual standards between the hospital and the EOHHS. Last, the number of individuals qualifying for HPE who must be determined to be eligible for full Medicaid, as determined by the EOHHS, is also set forth in the Notice of Intent to Participate in the HPE Program and a Memorandum of Understanding with EOHHS for the qualified hospital established by EOHHS. In the event a qualified hospital does not meet acceptable performance standards, participation in the HPE may be suspended or terminated at the discretion of the EOHHS. 4.10 Office of Program Integrity Agency Authority A. The EOHHS may undertake an array of actions to assess whether qualified hospitals are meeting the performance standards for the program. The EOHHS Office of Program Integrity (OPI) has been assigned responsibility for performing routine audits and intensive reviews of the HPE program, as appropriate. The OPI is also responsible for overseeing the development and submission of any hospital Corrective Action Plans deemed warranted. 4.11 Corrective Action A. In the event a qualified hospital does not achieve proficiency on the performance requirements outlined in § 4.9 of this Part, the EOHHS may require the
development of Corrective Action Plan (CAP) indicating interventions the hospital proposed to take to achieve compliance with these and/or other contractual standards. The OPI is responsible for reviewing and monitoring compliance with the CAP. HPE determinations may be suspended while the CAP is being prepared or implemented, as appropriate. B. EOHHS reserves the right to request modifications to the CAP if the CAP is deemed ineffective to achieve compliance; C. The qualified hospital must submit weekly CAP reports to EOHHS measuring the outcome of the corrective actions the hospital has instituted; D. HPE suspensions remain in full force and effect until such time as the hospital demonstrates to EOHHS that it has instituted corrective measures to bring the hospital into full compliance with State and federal requirements. 4.12 For Further Information or to Obtain Assistance A. For further information or to obtain assistance, please contact: 1-855-697-4347. 4.13 Severability A. If any provisions of these Regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable.
210-RICR-30-00-4 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 - AFFORDABLE COVERAGE GROUPS PART 4 - PRESUMPTIVE ELIGIBILITY FOR MEDICAID AS DETERMINED BY RHODE ISLAND HOSPITALS (210-RICR-30-00-4) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 12/25/2024 December 05, 2024 E-SIGNED by Richard Charest on 2024-12-05 12:00:08 EST December 05, 2024 E-SIGNED by Department of State on 2024-12-05 12:25:46 EST
210-RICR-30-00-5 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 – MEDICAID FOR CHILDREN, FAMILIES AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 – AFFORDABLE COVERAGE GROUPS PART 5 – MEDICAID MAGI FINANCIAL ELIGIBILITY DETERMINATIONS AND VERIFICATION 5.1 Scope and Legal Authority A. The purpose of this rule is to describe the Modified Adjust Gross Income (MAGI) standard and explain how it is applied; and establish the role and responsibilities of the State and consumers when determining MAGI-related eligibility for the Medicaid Affordable Care Coverage (MACC) groups identified in Part 1 of this Subchapter. B. This Part is promulgated pursuant to: 1. Federal authorities as follows: a. Federal Laws: § 1115 of the Social Security Act, 42 U.S.C. § 1315; Title IV of the Social Security Act, 42 U.S.C. §§ 601-687; Title XIX of the Social Security Act, 42 U.S.C. §§ 1396a-1396w-8; Title XXI of the Social Security Act, §§ 42 U.S.C. 1397aa 1397mm; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148; § 1004 of the Health Care and Education Reconciliation Act of 2010, Pub. Law 111-115; Title I § 11051(c) of the Tax Cuts and Jobs Act of 2017, Pub. Law 115-197, § 5112 of the Consolidated Appropriations Act, Pub. Law 117-328. b. Federal Regulations – 42 C.F.R. §§ 435.603; 435.902-910; 435.916; and 435.1005 c. The Medicaid State Plan and the Section 1115 Demonstration Waiver. granted pursuant to § 1115 of the Social Security Act, 42 U.S.C § 1315 2. State authorities – R.I. Gen. Laws Chapters 40-6, 40-8, and 42-7.2.
5.2 Incorporated Materials A. These regulations hereby adopt and incorporate 42 C.F.R. § 435.603 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. B. These regulations hereby adopt and incorporate 42 C.F.R. § 435.902-910 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. C. These regulations hereby adopt and incorporate 42 C.F.R. § 435.916 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. D. These regulations hereby adopt and incorporate 42 C.F.R. § 435.1005 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. E. These regulations hereby adopt and incorporate 42 C.F.R. § 435.948-949 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. 5.3 Definitions A. As used herein, the following terms shall be defined as follows: 1. “Affordable Care Act” or “ACA” means the federal Patient Protection and Affordable Care Act of 2010. 2. “Attestation” means the act of a person affirming through an electronic or written signature that the statements the person made when applying for Medicaid eligibility are truthful and correct. 3. “Caretaker” or “Caretaker relative” means any adult living with a Medicaid- eligible dependent child that has assumed primary responsibility for that child as defined in Part 1 of this Subchapter. 4. “Continuous eligibility” or “CE” means a period of eligibility during which a member cannot be disenrolled due to changes in circumstances with certain exceptions. Exceptions include a request for disenrollment by the beneficiary, the beneficiary is no longer a resident of the state, the agency determines that eligibility was erroneously granted at the most recent determination, redetermination, or renewal due to agency error or fraud, abuse, or perjury attributed to the beneficiary, or the beneficiary is deceased.
5. “Custodial parent” means a relationship that is defined by a court order or binding separation, divorce or custody agreement establishing physical custody of a minor child. If no order or agreement exists, or in the event of a shared custody agreement, the custodial parent is the parent with whom the child spends most nights. 6. “Federal poverty level” or “FPL”, as used herein, means the most recently published federal poverty level by the U.S. Department of Health and Human Services. 7. “Federal data hub” or “Data hub” means the database of the United States population built by the U.S. Internal Revenue Service (IRS) and Health and Human Services (HHS) used to facilitate determinations for coverage, including Medicaid, under the ACA. 8. “HealthSource RI” means the entity that allows persons, families, and small businesses to access insurance, as well as federal subsidies to assist in the payment of that coverage. 9. “Household composition” means, for the purposes of determining MAGI eligibility, the person(s) filing taxes, whether jointly or separately, and anyone included as a tax dependent of the person(s) filing taxes. Special relationship rules for household composition may apply when the person filing taxes is not the custodial parent of the tax dependent. 10. “MAGI” means modified adjusted gross income, adjusted by any amount excluded from gross income under 26 U.S.C. § 36B of the IRS Code, and any interest accrued. 11. “Medicaid Affordable Care Coverage Group” or “MACC” means a classification of persons eligible to receive Medicaid based on similar characteristics who are subject to the MAGI standard for determining income eligibility. 12. “Non-MAGI coverage group” means a Medicaid coverage group that is not subject to the modified adjusted gross income standard for eligibility determination. 13. “Reasonable compatibility” means an allowable difference or discrepancy between the information provided in the application and the information reported by an electronic data source. 14. “Reconciliation” means the point in the verification process when discrepancies between an applicant’s attestation and information from data sources are resolved.
5.4 MAGI Household Construction A. The principal factor for determining MAGI-based eligibility is tax filing status and household composition and size, based on the rules for household construction. 1. General rules of household construction – For the purposes of calculating MAGI, a household consists of an applicant and the people the applicant claims as a deduction for a personal exemption when filing federal income taxes. Under IRS rules, the taxpayer may claim a personal exemption deduction for him/herself, a spouse, and tax dependents. Non-family members may be included as tax dependents under certain circumstances and are treated as part of the tax household accordingly. 2. Special Medicaid rules of household construction – The following rules for constructing a household are applied when making MAGI-based Medicaid eligibility determinations: a. “Relationship-based” rules are used when an applicant is neither filing taxes nor being claimed as a tax dependent, and under the exceptions outlined in § 5.5 of this Part. b. Medicaid household rules are “person specific” within a family. Therefore, a Medicaid household must be constructed for each person within a family. c. For married couples living together, each spouse must be included in the household of the other spouse, regardless of whether they expect to file a joint federal tax return or whether one (1) spouse expects to be claimed as a tax dependent by the other spouse. d. If a pregnant person is applying for coverage or is part of another applicant’s household, the household size must be adjusted to reflect the number of children that they are expecting. Specifically, the pregnant person is counted as one (1) plus the number of children they expect to deliver. This pregnancy-adjusted household size is used to determine the applicable FPL for the pregnant person as well as for other members of their household. 5.5 Exceptions Requiring Application of Relationship Household Rules A. Relationship-based household composition rules must be applied when an applicant meets the criteria for an exception from the tax-based household rules. These alternative relationship-based rules must be used to determine both household size and the income of the household members included as part of total household income.
1. Relationship-based rules – The household is determined based upon the family members who live with the applicant. The rules vary slightly for children versus adults. a. Adults. The relationship-based rules for adults require that the household consist of the following persons: (1) The adult applying for coverage; (2) The applicant’s spouse, if living with the applicant; (3) The applicant’s biological, adopted, and step-children under age nineteen (19) years, if living with the applicant. b. Children under age nineteen (19). The relationship-based rules for minor children require that the household consist of the following persons: (1) The child applying for coverage; and the child’s parents (including step-parents), if living with the child; (2) Any of the child’s siblings (including step-siblings), if living with the child. 2. Triggers – The exceptions that trigger the use of relationship-based rules are as follows: a. Applicant does not plan to file taxes and does not expect to be claimed as a tax dependent by another tax filer. Full information on who is required to file taxes under federal law is located in IRS Publication 501 (IRS Publication 501 is available at: http://www.irs.gov/publications/p501/ar02.html#en_US_2012_publi nk1000220851). b. Tax dependents meet specified criteria. In situations in which an applicant will be claimed as a tax dependent on another person’s federal tax form, the relationship-based rules apply if the applicant meets any of the following criteria: (1) Applicant is claimed or expects to be claimed by a tax filer who is not the applicant’s parent or step-parent. (2) Applicant lives with both parents, but only one (1) parent will claim the child as a tax dependent. In this case, child refers to the parent-child relationship and not the age of the applicant.
(3) Applicant is a child under nineteen (19) who lives with a custodial parent but will be claimed as a tax dependent by a non-custodial parent. 3.
Summary of Application of Relationship-Based Rules Applicant is not planning to file taxes and is not claimed as a tax dependent by another tax filer Applicant is claimed as a dependent by a tax filer who is not the applicant’s parent Applicant is a child under nineteen (19) who lives with both parents, but only one (1) parent will claim the child as a tax dependent Applicant is a child under nineteen (19) who lives with a custodial parent, but will be claimed as a tax dependent by the non-custodial parent 5.6 Determination of Household Income A. To be eligible for Medicaid using the MAGI standards, an applicant’s current monthly household income must meet the standard applicable to the applicant’s MACC group which can be found in Part 30-00-1 of this Title. B. When calculating whether an applicant is income-eligible for Medicaid under one of these coverage groups, the following factors must be considered: the members of the applicant’s household that must be included; types of countable income; current income and reasonably predicted changes; and conversion of monthly income to the FPL standards. 1. Countable household income – The Subsection below identifies all forms of countable income included when determining MAGI-based Medicaid eligibility, including those that are specific to Medicaid eligibility only. a. Adjusted Gross Income (AGI). Adjusted gross income is gross income adjusted by “above-the-line” deductions. AGI includes wages and salaries and income from a broad array of other sources, such as unemployment benefits, alimony, taxable interest, and capital gains. “Above-the-line” deductions are the adjustments people can make to their gross income. These include alimony payments, interest on student loans, and other items that appear on page one (1) of Form 1040. However, they do not include charitable
contributions, mortgage interest and other “below-the-line” deductions. b. Social Security benefits. All Social Security income benefits are considered countable income when using the MAGI standard to determine eligibility for affordable coverage. This includes Social Security benefits that are considered both taxable and non-taxable income for federal tax purposes. c. Interest Income. Income received from bank accounts, money market accounts, certificates of deposit, and deposited insurance dividends are considered countable taxable income. Additionally, interest on some bonds issued by and used to finance state and local government operations is also counted for the MAGI even though treated as tax-exempt for federal tax purposes. d. Foreign earned income. Foreign earned income is countable for the MAGI. This includes all income received from sources within a foreign country or countries earned for services when either performed by: a U.S. citizen and a bona fide resident of a foreign country for an uninterrupted period of time that includes an entire tax year; or a U.S. citizen or resident who, during any period of twelve (12) consecutive months, is present in a foreign country for at least three hundred thirty (330) full days during that period. e. Medicaid specific adjustments to income. Special Medicaid adjustments are as follows: (1) Taxable lump sum payments (such as gifts, prizes, income and property tax refunds) are counted only in the month received. (2) Educational scholarships, awards or fellowships used for education purposes are excluded from consideration as income. (3) Certain types of income for American Indian/Alaska Native persons are excluded. f. Treatment of other sources of income for Medicaid eligibility are summarized in the table that follows:
MAGI-Based Medicaid Eligibility Rules Income Source Treatment of Income Self-employment income Counted with deductions for most expenses, depreciation, and business losses Salary deferrals (flexible spending, cafeteria and 401(k) plans) Not counted Child support received Not counted Alimony paid Alimony payments under separation or divorce agreements finalized after December 31, 2018 are not deductible by the payer. Alimony payments under separation or divorce agreement finalized on or before December 31, 2018 continue to be deductible by the payer except when such agreement is modified and when such modification expressly states that alimony is not deductible to the payer or includible in the income of the recipient Veterans’ benefits Not counted Workers’ compensation Not counted Gifts and inheritances Not counted TANF and SSI Not counted Qualified Lump Sum Income Winnings less than eighty thousand dollars ($80,000) are
MAGI-Based Medicaid Eligibility Rules Income Source Treatment of Income counted as income in the month received. Winnings of at least eighty thousand dollars ($80,000) but less than ninety thousand dollars ($90,000) are counted as income in equal installments over two months. For every additional ten thousand dollars ($10,000) in winnings over ninety thousand dollars ($90,000), one (1) month is added to the period over which total winnings are divided, in equal installments, and counted as income. Discharged Student Loan Debt Not counted Moving Expenses Not counted Alimony Received Alimony payments under separation or divorce agreements finalized after December 31, 2018 are not included in the income of the recipient. Alimony payments under separation or divorce agreements finalized on or before December 31, 2018 continue to be included in the income of the recipient for the duration of the agreement except when such agreement is modified, when such modification expressly states that alimony is not deductible to the payer or includible in the income of the recipient
2. Household members included in MAGI calculation – An individual’s household income is the sum of the MAGI-based income of every individual included in the individual’s household who is expected to be required to file a tax return. These rules are based on whether or not a person is “expected” to be required to file a tax return; it does not matter whether they eventually do so or not. 3. Use of current income and accounting for reasonably predicted changes – For new Medicaid applicants, the State must use a household’s current monthly income and household size when evaluating eligibility. A prorated portion of reasonably predictable changes in income, if there is a basis for anticipating the changes, such as a signed contract for employment, a clear history of predictable fluctuations in income, or other indications of future changes in income may be considered in determining eligibility. Future changes in income and household size must be verified in accordance with the verification and reasonable compatibility requirements as delineated in this Part. 4. Comparing household income to the FPL – To determine income eligibility for Medicaid based on the MAGI calculation, the State must compare a household’s current monthly income to the FPL guidelines for the appropriate household size. The State must use the most recently published FPL level in effect in the month during which an applicant applies for coverage. If an applicant’s FPL level is within five (5) percentage points over the FPL for the coverage group for which they would be eligible, a disregard of five (5) percentage points of the FPL shall be added to the highest income eligibility standard listed above for that coverage group. 5.7 Verification of Income Using the MAGI Methodology A. To achieve the ACA’s goal of improving and streamlining access to all forms of affordable coverage, including Medicaid, the federal government established a data hub containing information related to various eligibility factors. The federal data hub facilitates the electronic information exchange necessary to verify eligibility both at the time of initial application and during annual renewals thereafter. States have the flexibility to augment the electronic verification process the federal data hub uses with any additional data bases deemed appropriate. Rhode Island has elected to combine the use of electronic data sources for income verification including those that are commercially available, available through federal partners, and those that are available at the state-level to ensure accuracy, timeliness and completeness. B. The purpose of § 5.8 of this Part is to identify the principal facets of the verification process, including the electronic matches made through the federal data hub, and State-automated data bases and alternatives. In addition, the provisions of this rule also set forth the respective roles and responsibilities of the
EOHHS, in its capacity as the Single State Medicaid Agency and applicants in assuring this process functions in the most secure, effective, and efficient manner possible. 5.8 Verification Process A. As indicated in Part 10-00-3 of this Title, attestations are accepted without verification for residency, household composition, pregnancy and caretaker relative status. In general, this verification process proceeds as follows: 1. Data matching – The State must assure that an applicant’s information is entered into the integrated eligibility system (IES) and matched electronically to the full extent feasible through the federal data hub, State data sources, and commercial data sources. a. Federal Data Hub. The federal data hub contains electronic information from various agencies of the United States government, including the IRS, Social Security Administration (SSA), HHS (Centers for Medicare and Medicaid Services (CMS) and other agencies), Department of Homeland Security (USDHS), Department of Veterans Affairs (VA), Department of Defense (DoD), Peace Corps, and Office of Personnel Management (OPM). Various categories of data from these sources are used to match on income, employment, health, entitlements, citizenship, and criminal history. A full list of the data included in the federal hub and the rules governing its use are located in 42 C.F.R. §§ 435.948 and 435.949. b. State data sources. The State draws from databases from an array of public agencies to verify income including the RI Department of Labor and Training (DLT), Divisions of Revenue and Motor Vehicles, and EOHHS agencies including Department of Human Services (DHS). Specific databases include State Wage Information Collection Agency (SWICA) and State unemployment compensation information (UI). c. Commercial wage verification. The State may contract with one of several commercially available products/resources for a comprehensive detailing of wage data from some of the nation's largest employers. 2. Reasonable compatibility – The State must use a reasonable compatibility standard, or an allowable difference, to match data sources with self- reported application information. If the data sources match the applicant’s attestation, or are found “reasonably compatible,” the State must ensure that the IES bases the determination on the information in the application.
The State uses this standard for income verification and may apply it to other eligibility factors in the future. 3. Reasonable explanation – The State must provide the applicant with the opportunity to provide an explanation and documentation if the data sources do not match the attestation or are not reasonably compatible. Accordingly, the IES issues a request to the applicant for this information and provides a list of reasonable explanation options. 4. Reconciliation process – The explanation provided by an applicant must be used to determine whether it is feasible to reconcile a discrepancy between an attestation and data matches to determine whether reconciliation is feasible. If the applicant provides a reasonable explanation, the final determination of eligibility will be based on the information the applicant provided. If the applicant is unable to provide a reasonable explanation, documentation will then be required to verify or correct the attestation and reconcile the discrepancy. 5. Privacy – The verification process utilizes personally identifiable information (PII) from both the federal data hub and State data sources. An account is maintained for each person who completes and submits an application through the State’s IES. This account includes PII and other eligibility-related information used in the determination and annual renewal process. The State must assure the privacy of the information in these accounts in accordance with the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information and R.I. Gen. Laws §§ 40-6-12 and 40-6- 12.1. Also, the State must limit any use of account information to matters related to the administration of the Medicaid program including eligibility determinations, Medicaid health plan enrollment, appeals, and customer services. See also Part 10-05-1 of this Title, Confidentiality Rule. 6. Account Duration – Once an account in the IES is established, a person seeking Medicaid has ninety (90) days to complete and submit the application for a determination. The IES eliminates the account and all eligibility information from all sources, federal and State, if an application has not been completed by the end of that period. The State must determine eligibility within thirty (30) days from the date the competed application is submitted. 7. Post-eligibility verification – See § 5.15 of this Part. B. The following lists key eligibility factors, the types of verification required for attestations, if any, and the verification sources for MACC Group applicants/ beneficiaries:
1. Identity – An applicant must provide proof of identity when applying through the IES or filing a paper application. The requirements related to identify proofing are set forth in Part 30-00-3 of this Title. Certain applicants may not be able to obtain identity proofing through the federal hub due to data limitations. Pre-eligibility verification is required through an alternative electronic paper documentation source in these instances to establish an account. 2. Income – Electronic verification of attested income is required by the State. Multiple electronic data sources may be used for this purpose.. The reasonable compatibility standard applies when there are discrepancies between the applicant’s income self-attestation and information from electronic data sources. 3. General Eligibility – Non-Financial Factors – (Social Security Numbers, Age, Citizenship, Death, Date of Birth, Residency, and Incarceration). Information on these eligibility factors is verified against various State and federal data sources. Information specific to verification requirements for MAGI populations is located in Part 30-00-3 of this Title; for Medicaid and CHIP-funded eligibility more generally, the applicable provisions are set forth in Part 30-00-3 of this Title. 5.9 Medicaid Reasonable Compatibility Standards A. When information obtained through the federal data hub, State data sources and commercial data sources is found reasonably compatible with the applicant’s attestation, no further verification is required, and the eligibility determination will proceed. The reasonable compatibility standards set forth below by the State are applicable to income verification. The term “data” refers to information obtained through electronic data matches across federal and State sources. B. Overview of Standards Medicaid Reasonable Compatibility Standards for Income Attestation and Data Scenario Reasonable Compatibility Standard Attestation and income data from external sources are below applicant’s Medicaid eligibility levels. Reasonably Compatible: Person eligible for Medicaid
Medicaid Reasonable Compatibility Standards for Income Attestation and Data Scenario Reasonable Compatibility Standard Attestation and income data from external sources are above applicant’s Medicaid eligibility levels. Reasonably Compatible: Person ineligible for Medicaid; eligibility for a qualified health plan (QHP) is determined The attestation is below the applicant’s Medicaid eligibility level and the income data from external sources are above the applicant’s Medicaid eligibility level, and the difference between the attestation and data is ten percent (10%) or less. Reasonably Compatible: Person eligible for Medicaid The attestation is below the applicant’s Medicaid eligibility level and the income data from external sources are above the applicant’s Medicaid eligibility level, and the difference between the attestation and data is greater than ten percent (10%). Not Reasonably Compatible: pursue discrepancy reconciliation. Person may provide a reasonable explanation and/or provide the State with documentation of current income. 1. Income attestation and data are both below Medicaid eligibility levels – Attestation and data sources are reasonably compatible if the difference or discrepancy between the two (2) does not affect the eligibility of the applicant. In other words, even if there is a difference between what an applicant says he or she earned and what the data shows was actually earned, the attestation and data are considered reasonably compatible if both are below Medicaid eligibility levels. 2. Attestation and data are both above Medicaid eligibility levels – Attestation and data sources are reasonably compatible if they are both above the Medicaid eligibility levels. Under such a scenario, the person would be found ineligible for Medicaid. For example, this would occur if an applicant attests to income above the eligibility ceiling for the applicable MACC
group and electronic data-based verification indicates that the applicant’s income is higher than that amount. The applicant is not eligible for Medicaid in either case. Eligibility for affordable care with federal advance premium tax credits and cost-sharing reductions is then reviewed. 3. Income attestation – The difference between the income attestation and the data is less than ten percent (10%) – An income attestation and data from electronic sources are considered reasonably compatible if the difference between the applicant’s attestation and the data sources is less than ten percent (10%). The applicant is eligible, provided all other eligibility criteria are met. 4. Income attestation – The difference between the income attestation and data sources is greater than ten percent (10%). An income attestation and data on income sources are considered to be not reasonably compatible if the difference between the applicant’s attestation and data sources is greater than ten percent (10%); a reasonable explanation is pursued. 5.10 Reasonable Explanations A. When attestation and data sources are not reasonably compatible, the IES provides the applicant with prompts for resolving any identified discrepancies. The applicant is asked first to provide an explanation. Before an eligibility determination is made, the applicant will be afforded an opportunity to explain any discrepancies between their income attestation and the income source data. B. The following chart is a list of acceptable explanations when there is a discrepancy between an income attestation and data sources. If the applicant provides any one (1) of these explanations, eligibility will be based on their attestation and no further verification is required. The State has only implemented reasonable explanation options for income discrepancies. Reasonable Explanations for Discrepancy in Income Lost job Decrease in hours Multiple employers Self-employed Do not file taxes Have not filed taxes yet Homeless Fluctuating income Work on commissions Income from capital gains Income from dividends Income from royalties Seasonal worker Divorce or marriage
Reasonable Explanations for Discrepancy in Income Victim of domestic violence Victim of natural disaster Death in family Victim of identity theft 5.11 Reconciliation Period A. If the applicant’s data verification is not reasonably compatible with the attested information and the applicant has been unable to provide a reasonable explanation for discrepancies, applicants will be given a thirty (30) day application period to submit satisfactory documentation. Medicaid eligibility is only available during the reconciliation period as specified § 5.12 of this Part below. 5.12 Satisfactory Documentation and Alternative Forms of Verification A. During the reconciliation process, applicants will be asked to submit satisfactory documentation to verify income eligibility as indicated below: Income Verification Sources Pay stubs representative of the last four (4) weeks of income Earnings Statement Employment Letter Book Keeping Records Property Unit Proof Owner Occupied Proof Monthly Rental Income Proof Reports from Social Security, Veteran’s Administration, and other agencies When the applicant is unable to obtain the information requested, Departmental forms (Wage Report, AP-50; Bank Clearance, AP-91; Clearance with VA, AP-150 and AP-151) are used.
Income Verification Sources Mortgage Breakdown Proof Income Tax Returns B. The State may provide an alternate verification process. This alternative process is available when one (1) or more of the following conditions apply: 1. The IRS’s only tax data for the applicant is over two (2) years old; 2. The applicant attests that the family size or family members have changed since the tax information being used for the determination was filed; 3. The applicant attests that a change in circumstances has occurred or is reasonably expected to occur that may affect eligibility; 4. The applicant attests to a change in tax filing status that has or is reasonably expected to change the tax filer’s annual income; or 5. An applicant in the tax filer’s family has applied for unemployment benefits. 5.13 Post-Eligibility Verification (PEV) by the Integrated Eligibility System (IES) A. The IES will conduct post-eligibility verification of the beneficiary’s information. The IES runs post-eligibility verifications on the following beneficiary information: 1. Factors reviewed: a. Incarceration status (Rhode Island Department of Corrections data) b. Death data (Department of Health Vital Records data) c. Current Income – Wages (electronic data sources) d. Current Income – Unemployment Income (UI) (Department of Labor and Training) 2. Timelines: a. Post-eligibility verification for incarceration, death data, and current unemployment insurance information will be checked monthly.
b. Post-eligibility verification for current income/wages runs approximately every ninety (90) days (such as February, May, August, and November). 3. PEV Results – The State may take the following action or actions based upon the PEV process: a. All information is current and accurate and the difference between the total attested income supplied by the beneficiary and the information supplied by an external data source(s) is within the state’s established reasonable compatibility standard, no action on the part of the State or the beneficiary is required. The beneficiary continues to receive benefits without interruption. b. During the post-eligibility verification process, if the income from electronic data sources is above the applicable Medicaid eligibility threshold, and the difference between the electronic data source and the total attested income is more than ten percent (10%), the IES will check each line of income and send out a notice to the beneficiary(ies) indicating the source of income that cannot be verified and requesting that it be reviewed and verification documentation related to current income be provided. (1) The beneficiary will have ten (10) days to respond to such a notice. The ten (10) day period begins on the fifth day after the notice was mailed by the State. The beneficiary may either log onto the automated account (www.healthyrhode.ri.gov) and change information, send via U.S. mail, or bring the documentation to a local DHS office. Upon receipt of the verification documentation, the State will redetermine eligibility. (2) After the time period to provide documentation has elapsed, if the person has not provided documentation or reported a change, the State will redetermine eligibility using the data from external sources. (3) If any member of the beneficiary’s household has died or if there is a change in the household composition, the State will seek further information from the beneficiary before terminating coverage. If terminated, the beneficiary will then have to re-apply (i.e., log onto the automated account (www.healthyrhode.ri.gov); send via U.S. mail; or bring the documentation to a local DHS office).
(4) A notice of the beneficiary’s new eligibility status will be sent, along with a Medicaid termination notice with appeal rights (Part 10-05-2 of this Title, as applicable). B. A beneficiary will not be terminated by the State based on a change in income without first considering other possible categories of eligibility based on factors including age, disability status, and level-of-care needs. C. All children found eligible for CHIP or Medicaid will be granted one (1) year of continuous eligibility (CE) from the date they are found eligible. During their CE period, children will not be disenrolled due to changes in circumstances. The following are the only exceptions to the CE provision: 1. The child attains age 19; 2. The child or child’s representative requests a voluntary termination of eligibility; 3. The child ceases to be a resident of the state; 4. The agency determines that eligibility was erroneously granted at the most recent determination, redetermination, or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child’s representative; or 5. The child is deceased. 6. The child is found eligible for Medicaid (applies only to those initially eligible via CHIP).
210-RICR-30-00-5 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 - AFFORDABLE COVERAGE GROUPS PART 5 - “MEDICAID MAGI FINANCIAL ELIGIBILITY DETERMINATIONS AND VERIFICATION” (210-RICR-30-00-5) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 08/28/2025 August 08, 2025 E-SIGNED by Richard Charest on 2025-08-08 14:49:46 EDT August 08, 2025 E-SIGNED by Department of State on 2025-08-08 14:58:19 EDT
210-RICR-30-05-2 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 – MEDICAID FOR CHILDREN, FAMILIES AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 05 – SERVICE DELIVERY OPTIONS PART 2 – MEDICAID MANAGED CARE DELIVERY OPTIONS 2.1 RIte Care Overview A. RIte Care was initially established as a statewide managed care demonstration project in 1994 under a waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. The project's goal was to use a managed care delivery system to increase access to primary and preventative care for certain individuals and families who otherwise might not be able to afford or obtain affordable coverage. Medicaid members participating in RIte Care are enrolled in a managed care organization (MCO). EOHHS contracts with MCOs to provide these health services to members at a capitated rate (fixed cost per enrollee per month). RIte Care managed care plans serve the following MACC coverage groups: children, parent caretakers, foster children (DCYF custody), and pregnant women. B. Individuals who have access to employer-sponsored health insurance plans are evaluated for participation in the RIte Share Premium Assistance Program in accordance with provisions contained in "RIte Share Premium Assistance Program" (Part 3 of this Subchapter). Adults in these families are required to enroll any Medicaid-eligible family members in a RIte Share approved plan as a condition of retaining Medicaid eligibility. Medicaid is provided on a fee-for- service basis for certain beneficiaries in the populations RIte Care plans serve. 2.2 Scope and Purpose A. The purpose of this Rule is to describe the RIte Care delivery system and the respective roles and responsibilities of EOHHS and the individuals and families that are receiving affordable coverage through a RIte Care MCO. 2.3 Legal Authority A. This Part is promulgated pursuant to Federal authorities as follows: 1. Federal Law: § 1115 of the Social Security Act, 42 U.S.C. § 1315; Title XIX of the Social Security Act, 42 U.S.C §§ 1396a-1396w-8; Title XXI of the Social Security Act, 42 U.S.C. §§ 1397aa-1397mm; 42 U.S.C. §
1396k; the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (Pub. Law 110–343), 2. Federal Regulations: 42 C.F.R. Parts 431, 433, 438, 440, 456, 457 . 3. The Medicaid State Plan and the Section 1115 Demonstration Wavier granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315 B. Applicable State authority is derived from R.I. Gen. Laws Chapters 40-8, 40-8.4, 40-8.12, and 42-12.3. 2.4 Definitions A. For the purposes of this Rule, the following definitions apply: 1. “Advance practice provider” or “APP” means and includes physician assistants, certified nurse practitioners, psychiatric clinical nurse specialists, and certified nurse midwives. These individuals must maintain compliance with all applicable statutes and regulations and not exceed their scopes of practice. 2. “Appeal” means a formal request by a covered person or provider for reconsideration of a decision, such as a utilization review recommendation, a benefit payment, or administrative action. 3. “Applicant” means a person seeking Medicaid coverage under this Part, in accordance with the provisions established in Rhode Island General Laws and Public Laws. 4. “Care manager” means a nurse or social worker with specialized training in providing care management services. 5. “Complementary alternative medicine” or “CAM” means treatment from a chiropractor, acupuncturist, and/or massage therapist. 6. “Days” means calendar days. 7. “Employer sponsored insurance” or “ESI” means health insurance or a group health plan offered to employees by an employer. This includes plans purchased by small employers through HealthSourceRI. 8. “Enrollee” means a Medicaid member or “beneficiary” who is enrolled in a Medicaid managed care plan. 9. “Executive Office of Health and Human Services" or "EOHHS” means the State agency established in 2006 under the provisions of R.I. Gen. Laws Chapter 42-7.2 within the executive branch of State government and serves as the principal agency for the purposes of managing the
Departments of Children, Youth, and Families (DCYF); Health (DOH); Human Services (DHS); and Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH). The EOHHS is designated as the “single state agency,” authorized under Title XIX of the U.S. Social Security Act, 42 U.S.C. §§ 1396-1396w-8, and, as such, is legally responsible for the program/fiscal management and administration of the Medicaid Program. 10. “Grievance” means an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to: a. Quality of care or services provided; b. Aspects of interpersonal relationships such as rudeness of a provider or employee; c. Failure to respect the member’s rights regardless of whether remedial action is requested; d. Right to dispute an extension of time proposed by the MCO to make an authorization decision. 11. “In lieu of services” means cost effective alternative services/equipment, even where those services/equipment are not identified as an in-plan benefit, when the use of such alternative services/equipment are medically appropriate and cost effective, such as the purchase of an air conditioner, where clinically appropriate, which helps a beneficiary avoid hospitalization. 12. “Limited English proficiency” or “LEP” means that enrollees do not speak English as their primary language and may have a limited ability to read, write, speak, or understand English and may be eligible to receive language assistance for a particular type of service, benefit, or encounter. 13. “Managed care organization" or "MCO” means a health plan system that integrates an efficient financing mechanism with quality service delivery, provides a "medical home" to assure appropriate care and deter unnecessary services, and emphasizes preventive and primary care. 14. “Medicaid affordable care coverage group” or "MACC" means a classification of persons eligible to receive Medicaid based on similar characteristics who are subject to the MAGI methodology for determining income eligibility. Income thresholds for each group can found in Part 30- 00-1 of this Title.
15. “Medically needy” means a classification of persons eligible to receive Medicaid based upon similar characteristics who are subject to the MAGI standard for determining income eligibility. 16. “Navigator” means a person working for a State-contracted organization with certified assisters who have expertise in Medicaid eligibility and enrollment. 17. “Non-MAGI coverage group” means a Medicaid coverage group that is not subject to the modified adjusted gross income eligibility determination. Includes Medicaid for persons who are aged, blind or living with disabilities and persons in need of long-term services and supports as well as individuals who qualify for Medicaid based on their eligibility for another publicly-funded program, including children in foster care, anyone receiving Supplemental Security Income (SSI) or eligible for or enrolled in the Medicare Premium Assistance Program. 18. “Peer navigator” means paraprofessionals with specialized training who are community resource specialists employed and supervised by peer advocacy organizations. 19. “Prospective Medicaid enrollee” means a Medicaid beneficiary who has not enrolled in an MCO. 20. “Prudent layperson standard” means the standard used to determine the need for an emergency room visit. An “emergency” is defined as a condition that a prudent layperson “who possesses an average knowledge of health and medicine” expects may result in: a. Placing a patient in serious jeopardy; b. Serious impairment of bodily function; or c. Serious dysfunction of any bodily organs. 21. “Rhody health partners” means the Medicaid managed care program that delivers affordable health coverage to eligible adults without dependent children, ages nineteen (19) to sixty-four (64), under § 2.18 of this Part and adults with disabilities eligible under Part 40-10-1 of this Title. 22. “RIte care” means the Medicaid managed care delivery system for eligible parents/caretakers, pregnant women, children up to age nineteen (19), young adults older than age nineteen (19), and foster children (DCYF custody) (see § 2.1 of this Part). 23. “RIte share” means the Medicaid premium assistance program for eligible individuals and families who have access to cost-effective commercial coverage.
24. "Section 1115 Waiver" means the waiver authorized pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. 25. "Section 1931" or "§ 1931" means § 1931 of the Social Security Act, 42 U.S.C. § 1396u-1. 26. "Title IV-E" means Title IV-E of the Social Security Act, 42 U.S.C. §§ 670- 679c. 27. "Title XIX" means Title XIX of the Social Security Act, 42 U.S.C. §§ 1396- 1396w-7 28. "Urgent medical problem” means a medical, physical, or mental condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of medical attention within twenty-four (24) hours could reasonably be expected to result in: a. Placing the patient's health in serious jeopardy; b. Serious impairment to bodily function; or c. Serious dysfunction of any bodily organ or part. 2.5 Coverage Groups in RIte Care A. The RIte Care population consists of members of: certain Medicaid affordable care coverage (MACC) groups; coverage groups whose eligibility is NOT based on the MAGI methodology (non-MAGI) and several non-Medicaid coverage groups. 1. Medicaid Affordable Care Coverage (MACC) Groups – RIte Care plans provides coverage for individuals in the following MACC groups with incomes up to the thresholds described in Part 30-00-1 of this Title: a. Parents and caretaker relatives who have dependent children up to age eighteen (18) or, if attending school full-time, up to age nineteen (19). b. Pregnant women including non-citizen pregnant women. c. Children up to age nineteen (19) including qualified non-citizen children. 2. Non-MAGI MACC Beneficiaries – Rite Care MCOs also provide health services to: a. Children up to age eighteen (18) or nineteen (19) if completing school who are in foster care and/or receiving adoption subsidy
under the applicable provisions of Title IV-E of the Social Security Act (see Part 30-00-1 of this Title). b. Children up to age twenty-one (21) who are Medicaid eligible as a result of receiving Supplementary Security Income (SSI). Individuals in the SSI eligible group under age twenty-one (21) who are enrolled in RIte Care managed care may continue enrollment in a RIte Care MCO when they turn twenty-one (21) years of age until such time as SSI eligibility is discontinued. c. Young adults aging out of foster care between the ages of eighteen (18) and twenty-six (26) who were born prior to January 1, 2005. Young adults who were in participating in foster care, kinship, and guardianship programs authorized by the Rhode Island Department of Children, Youth and Families (DCYF) on the date they turned eighteen (18) are eligible, without regard to income, for continued Medicaid coverage until the age of twenty-six (26) under the Foster Care Independence Act of 1999, as amended by the Affordable Care Act of 2010. Members of this population are only eligible in Rhode Island if they were residing in the State at the time they aged out of DCYF foster care. EPSDT services continue only up to age twenty-one (21) for members of this non-MAGI coverage group. d. Young adults aging out of foster care between the ages of eighteen (18) and twenty-six (26) who were born on or after January 1, 2005. Young adults who were participating in foster care, kinship, and guardianship programs in any state on the date they aged out of the foster care system of their state or Tribe within a state, including children who were cared for under the unaccompanied refugee minor program, without regard to income, for continued Medicaid coverage until the age of twenty-six (26) under the SUPPORT for Patients and Communities Act, Pub. L. No. 115-271. Members of this population are only eligible in Rhode Island if they were enrolled in Medicaid and under the care of the foster care system of their state or Tribe within a state on the date that they aged out of such foster care system. Medicaid eligibility for youth qualifying for this coverage continues until the age of twenty-six (26) as long as the individual remains a resident of the State. EPSDT services continue only up to age twenty-one (21) for members of this non- MAGI coverage group. 2.6 Excluded Medicaid Coverage Groups A. There are MACC group beneficiaries who receive coverage on a fee-for-service basis rather than through a RIte Care plan, as follows:
1. Members of these coverage groups who are covered by employer- sponsored or other third (3rd) party health insurance, may receive Medicaid on a fee-for-service basis, rather than through enrollment in a RIte Care MCO: a. IV-E foster children and children receiving adoption subsidy (see Part 30-00-1 of this Title). b. SSI recipients under age twenty-one (21) (Part 30-00-1 of this Title). c. Children with disability – Katie Beckett Eligible under Part 50-10-3 of this Title. Children under age nineteen (19) who: are living at home; require a hospital, nursing home or ICF-ID level of care; and would qualify for Medicaid if in a licensed health care institution. d. SSI recipients over age twenty-one (21). 2. Medically needy populations. Flex-test cases are included in the RIte Care program but receive services in the fee-for-service system. With the exception of Katie Beckett children, long-term care coverage groups (Part 50-00-1 of this Title) do not receive services through a RIte Care MCO. 3. Extended family planning group. Beneficiaries eligible through this pathway in this RIte Care waiver group are entitled to a limited scope of services rather than comprehensive benefits. The group consists of women who meet the following conditions: income must be above the Medically Needy income limit; if pregnant, income must not exceed the threshold for that eligiblity group described in Part 30-00-1 of this Title; the women must be twelve (12) months postpartum or twelve (12) months post-loss of pregnancy and, as a result, subject to discontinuation of Medicaid eligibility. Coverage is available for up to twenty-four (24) months. 2.7 Retroactive Coverage A. Requests for retroactive eligibility are evaluated at the time of application, but must not delay a decision on prospective eligibility. Retroactive eligibility is not available to MACC groups enrolled in RIte Care. Foster and adoption subsidy children in Non-MAGI coverage groups are eligible for retroactive coverage if eligible for SSI. Retroactive coverage is also available to SSI-related eligible individuals and SSI-related medically needy flex-test cases. If eligibility exists, retroactive payment for services is on a fee-for-service basis and does not exceed a three-month time period.
2.8 Overview of RIte Care Services A. Individuals enrolled in RIte Care receive the full scope of services covered under the Medicaid State Plan and the State’s Section 1115 waiver, unless otherwise indicated. Covered services may be provided through the MCO or through the fee-for-service delivery system if the service is “out-of-plan” – that is, not included in the MCO but covered under Medicaid. Fee-for-service benefits may be furnished by any participating provider. Rules of prior authorization apply to any service required by EOHHS. Each RIte Care member selects a primary care provider (PCP) who performs the necessary medical care and coordinates referrals to specialty care. The primary care provider orders treatment determined to be medically necessary in accordance with MCO policies. Beneficiaries in the Extended Family Planning (EFP) coverage group do not require a PCP. The extended family planning group is entitled only to family planning services. 1. Access to Benefits – Unless otherwise specified, members of all RIte Care coverage groups (MACC, Non-MAGI) are entitled to a comprehensive benefit package that includes both in-plan and specific out-of-plan services. Categories of eligibility for the extended family planning benefit package are as follows: a. Women otherwise Medicaid ineligible. The package of services is available without the comprehensive benefit package. Women who have given birth and are not eligible for Medicaid under another coverage group lose the full scope of covered services twelve (12) months postpartum or post-loss of pregnancy. Women in this category are eligible for RIte Care for a period of up to twenty-four (24) months for the full family planning benefit package. The benefit package includes interpreter services but does not include transportation benefits. Renewal is required at twelve (12) months. b. Women who are otherwise eligible for Medicaid. Women enrolled in RIte Care are eligible for family planning services. Participation is voluntary. Members continue to be enrolled with the same MCO they selected or were assigned to for comprehensive health service delivery but for family planning services only for a twelve (12) month period. Upon renewal at twelve (12) months, a participant may qualify for up to an additional twelve (12) months. Services are covered on an outpatient basis only. Non-prescription contraceptives are covered for members in this category with a provider’s order (i.e., prescription). 2. Delivery of Benefits – The coverage provided through RIte Care is categorized as follows: a. In-Plan Benefits
b. Out-of-Plan Benefits. 3. Medical necessity – The standard of "medical necessity" is used as the basis for determining whether access to Medicaid-covered services is required and appropriate. A "medically necessary service" means medical, surgical or other services required for the prevention, diagnosis, cure, or treatment of a health-related condition including any such services that are necessary to prevent a detrimental change in either medical or mental health status or substance use disorder or services needed to achieve age-appropriate growth and development or to attain, maintain, or regain functional capacity. Medically necessary services must be provided in the most cost-efficient and appropriate setting and must not be provided solely for the convenience of the member or service provider. 4. Early Periodic Screening, Diagnosis and Treatment (EPSDT) -- The EPSDT provision in Title XIX mandates that state Medicaid programs must provide coverage for all follow-up diagnostic and treatment services deemed medically necessary to ameliorate or correct defects and physical and mental illnesses and conditions discovered through screening or at any other occasion, whether or not those services are covered by Rhode Island's Medicaid State Plan or the State’s Medicaid Section 1115 waiver. This applies to members of the MACC group up to age nineteen (19), SSI- eligible children and young adults up to age twenty-one (21), including adults aging out of foster care up to age twenty-one (21). A young adult over age nineteen (19) who transitions from the MACC group for children to the MACC group for adults from age nineteen (19) to sixty-four (64) also receives EPSDT services until age twenty-one (21). 2.9 RIte Care In-Plan Capitated Benefits A. The benefits which the MCO provides or arranges within the capitated (fixed cost per enrollee per month) benefit are set forth below. B. In-Plan benefits subject to the capitated rate are organized as follows: the RIte Care comprehensive benefit package and the extended family planning benefit package. Adults who are found to be severely and persistently mentally ill have access to a comprehensive benefit package. All elements of the comprehensive benefit package are the responsibility of the MCO when beneficiaries in this group receive coverage through the RIte Care managed care delivery system. C. RIte Care comprehensive benefit package --The following benefits are included in the capitated rate on an annual basis, based on medical necessity:
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: Inpatient Hospital Care As medically necessary. EOHHS shall be responsible for inpatient admissions or authorizations while Member was in Medicaid fee-for-service, prior to Member’s enrollment in an MCO. Contractor shall be responsible for inpatient admissions or authorizations, even after the Member has been disenrolled from Contractor’s MCO and enrolled in another MCO or re-enrolled into Medicaid fee-for-service, until the management of the Member’s care is formally transferred to the care of another MCO, another program option, or fee-for-service Medicaid. Outpatient Hospital Services Covered as needed, based on medical necessity. Includes physical therapy, occupational therapy, speech therapy, language therapy, hearing therapy, respiratory therapy, and other Medicaid covered services delivered in an outpatient hospital setting. Therapies Covered as medically necessary, includes physical therapy, occupational therapy, speech therapy, hearing therapy, respiratory therapy and other related therapies. Physician/Provider Services Covered as needed, based on medical necessity, including primary care, specialty care, obstetric and newborn care. Family Planning Services Enrolled female members have freedom of choice of providers for family planning services. Prescription Drugs Covered when prescribed by an MCO physician/provider. Generic substitution only unless provided for otherwise as described in the Managed Care Pharmacy Benefit Plan Protocols.
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: Non-Prescription Drugs Covered when prescribed by a Health Plan physician/provider. Limited to non-prescription drugs, as described in the Medicaid Managed Care Pharmacy Benefit Plan Protocols. Includes nicotine cessation supplies ordered by an MCO physician. Includes medically necessary nutritional supplements ordered by an MCO physician. Laboratory Services Covered when ordered by an MCO physician/provider including urine drug screens. Radiology Services Covered when ordered by an MCO physician/provider. Diagnostic Services Covered when ordered by an MCO physician/provider. Mental Health and Substance Use –Outpatient& Inpatient Covered as needed for all members, including residential substance use treatment for youth. Covered services include a full continuum of mental health and substance use disorder treatment, including but not limited to, community-based narcotic treatment, methadone, and community detox. Covered residential treatment includes therapeutic services but does not include room and board, except in a facility accredited by the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO"). Also includes, DCYF ordered administratively necessary days, or hospital-based detox, MH/SUD residential treatment (including minimum six (6) month SSTAR birth residential services), Mental Health Psychiatric Rehabilitative Residence (MHPRR), psychiatric rehabilitation day programs, Community Psychiatric Supportive Treatment (CPST),Crisis Intervention for individuals with severe and persistent mental illness (SPMI) enrolled in the Community Support Program
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: (CSP), Opioid Treatment Program Health Homes (OTP), Assertive Community Treatment (ACT), Integrated Health Home (IHH), and services for individuals at CMHCs. Home Health Services Covered services include those services provided under a written plan of care authorized by a physician/provider/APP including full-time, part-time, or intermittent skilled nursing care and certified nursing assistant services as well as physical therapy, occupational therapy, respiratory therapy and speech-language pathology. This service also includes medical social services, durable medical equipment and medical supplies for use at home. Home health services do not include respite care, relief care or day care. Home Care Services Covered services include those provided under a written plan of care authorized by a physician/provider including full-time, part-time or intermittent care by a licensed nurse or certified nursing assistant as well as; physical therapy, occupational therapy, respiratory therapy and speech therapy. Home care services include laboratory services and private duty nursing for a patient whose medical condition requires more skilled nursing than intermittent visiting nursing care. Home care services include personal care services, such as assisting the client with personal hygiene, dressing, feeding, transfer and ambulatory needs. Home care services also include homemaking services that are incidental to the client’s health needs such as making the client’s bed, cleaning the client’s living areas such as bedroom and bathroom, and doing the client’s laundry and shopping. Home care services do not include respite care, relief care or day care.
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: Preventive Services Covered when ordered by a health plan physician/provider. Services include homemaker services, minor environmental modifications, physical therapy evaluation and services, and personal care services. EPSDT Services Provided to all children and young adults up to age twenty-one (21). Includes tracking, follow- up and outreach to children for initial visits, preventive visits, and follow-up visits. Includes inter-periodic screens as medically indicated. Includes multi-disciplinary evaluations and treatment, including, PT/OT/ST, for children with significant disabilities or developmental delays. Emergency Room Service and Emergency Transportation Services Covered both in- and out-of-State, for Emergency Services or when authorized by an MCO Provider, or in order to assess whether a condition warrants treatment as an emergency service. Nursing Home Care and Skilled Nursing Facility Care Covered when ordered by an MCO physician/provider. For Rhody Health Partners/Expansion members, the Contractor payments are limited to thirty (30) consecutive days. All skilled and custodial care covered. Contractor is responsible for notifying the State to begin disenrollment process. For RIte Care members, please refer to stop-loss provisions. School-Based Clinic Services Covered for RIte Care members as Medically Necessary at all designate sites. Services of Other Practitioners Covered if referred by an MCO physician or APP. Practitioners certified and licensed by the State of Rhode Island including social workers, licensed dietitians, psychologists and licensed nurse midwives.
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: Court-ordered mental health and substance use services – criminal court Covered for all members. Treatment must be provided in totality, as directed by the Court or other State official or body, such as a Probation Officer, the Rhode Island State Parole Board. If the length of stay is not prescribed on the court order, the MCOs may conduct Utilization Review on the length of stay. The MCOs must offer appropriate transitional care management to persons upon discharge and coordinate and/or arrange for in-plan medically necessary services to be in place after a court order expires. The following are examples of Criminal Court Ordered Benefits that must be provided in totality as an in-plan benefit: Bail Ordered: Treatment is prescribed as a condition of bail/bond by the court. Condition of Parole: Treatment is prescribed as a condition of parole by the Parole Board. Condition of Probation: Treatment is prescribed as a condition of probation Recommendation by a Probation State Official: Treatment is recommended by a State official (Probation Officer, Clinical social worker, etc.). Condition of Medical Parole: Person is released to treatment as a condition of their parole, by the Parole Board. Court-ordered mental health and substance use treatment – civil court All Civil Mental Health Court Ordered Treatment must be provided in totality as an in-plan benefit. All regulations in the R.I. Gen. Laws § 40.1-5-5 must be followed. If the length of stay is not prescribed on the court order, the MCOs may conduct Utilization Review on the length of stay. The MCOs must offer appropriate transitional care management to persons upon discharge and coordinate and/or arrange for in- plan medically necessary services to be in place
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: after a court order expires. Note the following are facilities where treatment may be ordered: The Eleanor Slater Hospital, Our Lady of Fatima Hospital, Rhode Island Hospital (including Hasbro), Landmark Medical Center, Newport Hospital, Roger Williams Medical Center, Butler Hospital (including the Kent Unit), Bradley Hospital, Community Mental Health Centers, Riverwood, and Fellowship. Any persons ordered to Eleanor Slater Hospital for more than seven (7) calendar days, will be disenrolled from the Health Plan at the end of the month, and be re-assigned into Medicaid FFS. Civil Court Ordered Treatment can be from the result of: Voluntary Admission Emergency Certification Civil Court Certification Court-ordered treatment that is not an in-plan benefit or to a non-network provider, is not the responsibility of the Contractor. Court ordered treatment is exempt from the fourteen (14) day prior authorization requirement for residential treatment. Podiatry Services Covered as ordered by an MCO physician/provider. Optometry Services For children under twenty-one (21): Covered as medically necessary with no other limits. For adults twenty-one (21) and older: Benefit is limited to examinations that include refractions and provision of eyeglasses if needed once every two years. Eyeglass lenses are covered more than once in two (2) years
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: only if medically necessary. Eyeglass frames are covered only every two (2) years. Annual eye exams are covered for members who have diabetes. Other medically necessary treatment visits for illness or injury to the eye are covered. Oral Health Inpatient: Contractor is responsible for operating room charges and anesthesia services related to dental treatment received by a Medicaid beneficiary in an inpatient setting. Outpatient: Contractor is responsible for operating room charges and anesthesia services related to dental treatment received by a Medicaid beneficiary in an outpatient hospital setting. Oral Surgery: Treatment covered as medically necessary. As detailed in the Schedule of In-Plan Oral Health Benefits updated January 2017. Hospice Services Covered as ordered by an MCO physician/provider. Services limited to those covered by Medicare. Durable Medical Equipment Covered as ordered by an MCO physician/provider as medically necessary. Adult Day Health Day programs for frail seniors and other adults who need supervision and health services during the daytime. Adult Day Health programs offer nursing care, therapies, personal care assistance, social and recreational activities, meals, and other services in a community group setting. Adult Day Health programs are for
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: adults who return to their homes and caregivers at the end of the day. Children’s Evaluations Covered as needed, child sexual abuse evaluations (victim and perpetrator); parent child evaluations; fire setter evaluations; PANDA clinic evaluations; and other evaluations deemed medically necessary. Nutrition Services Covered as delivered by a registered or licensed dietitian for certain medical conditions and as referred by an MCO physician or APP. Group/Individual Education Programs Including childbirth education classes, parenting classes, wellness/weight loss and tobacco cessation programs and services. Interpreter Services Covered as needed. Transplant Services Covered when ordered by an MCO physician. HIV/AIDS Non-Medical Targeted Case Management for People Living with HIV/AIDS (PLWH/As) and those at High Risk for acquiring Risk for Acquiring HIV This program may be provided for people living with HIV/AIDS and for those at high risk for acquiring HIV (see provider manual for distinct eligibility criteria for beneficiaries to qualify for this service). These services provide a series of consistent and required “steps” such that all clients are provided with and Intake, Assessment, Care Plan. All providers must utilize an acuity index to monitor client severity. Case management services are specifically defined as services furnished to assist individuals who reside in a community setting or are transitioning to a community setting to gain access to needed medical, social, educational and other services, such as housing and transportation. Targeted case management can be furnished without regard to Medicaid’s state- wideness or comparability requirements. This means that case management services may be
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: limited to a specific group of individuals (e.g., HIV/AIDS, by age or health/mental health condition) or a specific area of the State. (Under EPSDT, of course, all children who require case management are entitled to receive it.) May include: Benefits/entitlement counseling and referral activities to assist eligible clients to obtain access to public and private programs for which they may be eligible All types of case management encounters and communications (face-to-face, telephone contact, other) Categorical populations designated as high risk, such as, transitional case management for incarcerated persons as they prepare to exit the correctional system; adolescents who have a behavioral health condition; sex workers; etc. A series of metrics and quality performance measures for both HIV case management for PLWH/s and those at high risk for HIV will be collected by providers and are required outcomes for delivering this service. Does not involve coordination and follow up of medical treatments. AIDS Medical Case Management Medical Case Management services (including treatment adherence) are a range of client - centered services that link clients with health care, psychosocial, and other services. The coordination and follow-up of medical treatments are components of medical case management. These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care, through ongoing assessment of the beneficiary's and other key family
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: members' needs and personal support systems. Medical case management includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIVIAIDS treatments. Key activities include 1) Initial assessment of service needs; 2) Development of a comprehensive, individualized service plan; 3) Coordination of services required to implement the plan; 4) Monitoring the care; 5) Periodic re-evaluation and adaptation of the plan as necessary over the time beneficiary is enrolled in services. It includes beneficiary-specific advocacy and/or review of utilization of services. This includes all types of case management including face-to- face, phone contact, and any other form of communication. Treatment for Gender Dysphoria Comprehensive benefit package. Early Intervention Covered for RIte Care members as included within the Individual Family Service Plan (IFSP), consistent with R.I. Gen. Laws §§ 27-18-64, 27- 19-55, 27-20-50, and 27-41-68. Subject to stop loss greater than five thousand dollars ($5,000.00). Rehabilitation Services Physical, occupational and speech therapy services may be provided with physician orders by Rhode Island Department of Health-licensed outpatient rehabilitation centers. These services supplement home health and outpatient hospital clinical rehabilitation services when the individual requires specialized rehabilitation services not available from a home health or outpatient hospital provider. See also EPSDT.
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: In Lieu of Service All services as provided in § 2.9(C) of this Part can be utilized as an in Lieu of Service if alternative service or setting is a medically appropriate and cost-effective substitute for the covered service or setting. Value Add Services Services/equipment which are not in the State Plan but are cost effective, improve health and clinically appropriate. Neonatal Intensive Care Unit (NICU) Covered under the following circumstances: Admitted to Women and Infants (W&I) from home after discharge, admitted to W&I NICU from home after discharge from W&I Normal Newborn Nursery, Admission to non-W&I level 2 Nursery, Admission to W&I NICU from home following delivery at and discharge from non- W&I facility or discharge from non-W&I NICU with admission to W&I for continued care. D. Extended family planning services – The extended family planning group benefit package includes: 1. Gynecological Services. Limited to no more than four (4) office visits annually – One (1) comprehensive gynecological annual exam and up to three (3) additional family planning method related office visits if indicated. 2. Laboratory. Includes annual Pap smear; STD screening if indicated; anemia testing; dipstick urinalysis and urine culture if indicated; pregnancy testing. 3. Procedures. Limited to the following office/clinic/outpatient procedures if indicated tubal ligation; treatment for genital warts; Norplant insertion and removal; IUD insertion and removal; incision and drainage of a Bartholin's gland cyst or abscess. 4. Includes generic-first prescriptions and non-prescription family planning methods (Limited to twelve (12) thirty (30) day supplies per year) when prescribed by a health plan physician or APP.
5. Contraceptives. Includes oral contraceptives, contraceptive patch, contraceptive vaginal, contraceptive implant, contraceptive IUD, contraceptive injection, cervical cap, diaphragm, and emergency contraceptive pills, when prescribed by a health care physician. Covered non-prescription methods include foam, condoms, spermicidal cream/jelly, and sponges. 6. Referrals for other medically necessary services as appropriate/indicated, including: referral to State STD clinic for treatment if indicated. 7. Referral to State confidential HIV testing and counseling sites, if indicated. 8. Inpatient services are not a covered benefit, except as medically necessary follow-up treatment of a complication from provision of a covered procedure or service. 9. Categories of eligibility for this extended family planning benefit package are as follows: a. Women otherwise Medicaid ineligible. The package of services is available without the comprehensive benefit package. Women who have given birth and are not eligible for Medicaid under another coverage group, lose the full scope of covered services twelve (12) months postpartum or post-loss of pregnancy. Women in this category are eligible for RIte Care for a period of up to twenty-four (24) months for the full family planning benefit package. The benefit package includes interpreter services but does not include transportation benefits. Re-certification is required at twelve (12) months. b. Women who are otherwise eligible for Medicaid. Women enrolled in RIte Care are eligible for family planning services. Participation is voluntary. Members continue to be enrolled with the same health plan they selected or were assigned to for comprehensive health service delivery but for family planning services only for a twelve (12) month period. Upon re-certification at twelve (12) months, a participant may qualify for up to an additional twelve (12) months. Services are covered on an outpatient basis only. Non-prescription contraceptives are not covered for members in this category. E. EOHHS policy affects the access to and/or the scope and amount of several benefits as follows: 1. Prescriptions: Generic Policy. For RIte Care enrolled members, prescription benefits must be for generic drugs. Exceptions for limited brand coverage for certain therapeutic classes may be granted if approved by EOHHS, or the MCO acting in compliance with their contractual
agreements with EOHHS, and in accordance with the criteria described below: a. Availability of suitable within-class generic substitutes or out-of- class alternatives. b. Drugs with a narrow therapeutic range that are regarded as the standard of care for treating specific conditions. c. Relative disruptions in care that may be brought on by changing treatment from one drug to another. d. Relative medical management concerns for drugs that can only be used to treat patients with specific co-morbidities. e. Relative clinical advantages and disadvantages of drugs within a therapeutic class. f. Cost differentials between brand and generic alternatives. g. Drugs that are required under Federal and State Regulations. h. Demonstrated medical necessity and lack of efficacy on a case by case basis. 2. Non-emergency transportation (NEMT) policy. Responsibility for transportation services rests first with the member. If the member's condition, place of residence, or the location of medical provider does not permit the use of bus transportation, NEMT for the Medicaid enrollee may be arranged for by EOHHS or its agent for transportation to a Medicaid- covered service from a Medicaid-participating provider. NEMT service includes bus passes, and other RIPTA fare products, if authorized by EOHHS or its agent. 3. Interpretation services policy. EOHHS will notify the health plan when it knows of members who do not speak English as a first language who have either selected or been assigned to the plan. If the health plan has more than fifty (50) members who speak a single language, it must make available general written materials, such as its member handbook, in that language. a. Written material must be available in alternative formats, such as audio and large print, and in an appropriate manner that takes into consideration the special needs of those who are visually limited or have limited reading proficiency. All written materials for potential enrollees must include taglines in the prevalent non-English languages in the State, as well as large print, explaining the availability of written translations or oral interpretation to understand
the information provided and the toll-free telephone number of the entity providing choice counseling services. All enrollees must be informed that information is available in alternative formats and how to access those formats. 4. Tracking, Follow-up, Outreach. These services are provided by the MCO in association with an initial visit with member's PCP; for preventive visits and prenatal visits; referrals that result from preventive visits; and for preventive dental visits. Outreach includes mail, phone, and home outreach, if necessary, for members who miss preventive and follow-up visits, and to resolve barriers to care such as language and transportation barriers. 2.10 Out-of-Plan Benefits A. Out-of-plan benefits are not included in the capitated rate paid to the MCOs and are not the responsibility of the MCO to provide. These services are provided by existing Medicaid-approved providers who are reimbursed directly by EOHHS on a fee-for-service basis. Out-of-plan benefits are provided to all Rite Care enrollees with the following exceptions: Individuals eligible for Extended Family Planning only; Pregnant women who are otherwise ineligible for Medicaid and post-partum women with income up to the threshold for that eligiblity group described in Part 30-00-1 of this Title; and anyone enrolled in the guaranteed enrollment period but otherwise ineligible for Medicaid. The covered benefits are as follows: ELIGIBLE GROUP BENEFIT(S) PROVIDED OUT-OF-PLAN All Rhody Health Partners, RIte Care and Expansion members Dental services Court-ordered mental health and substance use services ordered to a non- network facility or provider Non-Emergency Transportation Services (Non-Emergency transportation is coordinated by the contracted Health Plans). Nursing home services in excess of thirty (30) consecutive days (RHP members only) Residential services for MR/DD clients that are paid by the State’s BHDDH Respite (Adult)
Neonatal intensive care Unit (NICU) Services at Women’s and Infants Hospital. Except as specified in § 2.9(C) of this Part Special Education services as defined in the child’s Individual Education Plan (IEP) for children with special health needs or developmental delays Lead Program home assessment and non-medical case management provided by Department of Health or Lead Centers for lead poisoned children Cedar Family Center Services Centers of Excellence Programs 2.11 Limits on Services A. The following services are not covered under the RIte Care program: 1. Experimental procedures, except as required by Rhode Island State law; 2. Private rooms in hospitals (unless medically necessary); 3. Cosmetic surgery; 4. Medications that treat erectile dysfunction or other sexual disorders; 5. Infertility treatment services; and 6. Any portion of services that exceeds fifteen (15) days provided in an Institution for Mental Diseases (IMD) for individuals between the ages of twenty-one (21) to sixty-four (64). B. Out-of-State Coverage 1. Out-of-State Benefits — EOHHS does not routinely provide coverage for out-of-State services with certain exceptions: Medicaid services provided in border communities are covered and emergency services are covered, within limits, at the discretion of EOHHS or the MCO.
2.12 Scope of Provider Networks A. The MCO must maintain provider networks in locations that are geographically accessible to the populations to be served, comprised of hospitals, physicians, advanced practice practitioners, mental health providers, substance use disorder providers, pharmacies, transportation services, dentists, school based health centers, etc. in sufficient numbers to make available all services in a timely manner. 2.13 Mainstreaming/Selective Contracting A. The mainstreaming of Medicaid beneficiaries into the broader health delivery system is an important objective of the Medicaid program. The MCO must ensure that all of its network providers accept RIte Care members for treatment. The MCO also must accept responsibility for ensuring that network providers do not intentionally segregate RIte Care members in any way from other persons receiving services. B. Health plans may develop selective contracting arrangements with certain providers for the purpose of cost containment, but must still adhere to the access standards as defined in the health plan contracts. 2.14 Primary Care Providers (PCPs) A. The MCO has written policies and procedures allowing every member to select a primary care provider (PCP). If a member does not select a PCP during enrollment, the MCO shall make an automatic assignment, taking into consideration such factors as current provider relationships, language needs, and the relative proximity of the PCP to the member’s area of residence. The health plan must notify the member in a timely manner of his/her PCP’s name, location, and office telephone number, and how to change PCPs, if desired. The PCP serves as the member's initial and most important point of interaction with the MCO network. In addition to performing primary care services, the PCP coordinates referrals and specialty care. As such, PCP responsibilities include at a minimum: 1. Serving as the member's primary care provider; 2. Ensuring that members receive all recommended preventive and screening care appropriate for their age group and risk factors; 3. Referring for specialty care and other medically necessary services both in and out-of-plan; 4. Maintaining a current medical record for the member; and
5. Adhering to the EPSDT periodicity schedule for members under age twenty-one (21). B. In addition, the MCO retains responsibility for monitoring PCP actions to ensure they comply with health plan and Medicaid program policies. 2.15 Service Accessibility Standards A. The service accessibility standards which the health plan must meet are: 1. Twenty-four (24) hour coverage; 2. Travel time or distance; 3. Days to appointment for non-emergency services. B. In addition, MCOs must staff both a member services and a provider services function. 1. Twenty-Four Hour Coverage – The MCO must provide coverage, either directly or through its PCPs, to members on a twenty-four (24) hours per day, seven (7) days a week basis. The MCO must also have available written policy and procedures describing how members and providers can contact it to receive instruction or prior authorization for treatment of an emergent or urgent medical problem. 2. Travel Time – The MCO must make available to every member a PCP whose office is located within twenty (20) minutes or twenty (20) miles driving time from the member's place of residence. Members may, at their discretion, select PCPs located farther from their homes. 3. Appointment for Non-Emergency Services – The MCO must make services available within twenty-four (24) hours and seven (7) days per week, including services for mental health and substance use disorders for treatment of an urgent medical problem. The MCO must make services available within thirty (30) days for treatment of a non-emergent, non- urgent medical problem. This thirty (30) day standard does not apply to appointments for routine physical examinations, nor for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every thirty (30) days. Non- emergent, non-urgent mental health or substance use appointments for diagnosis and treatment must be made available within ten (10) days. 4. Member Services – The MCO must staff a member services function operated at least during regular business hours and responsible for the following:
a. Orienting the member to the health plan and assisting members in the selection of a PCP; b. Assisting members to make appointments and obtain services; c. Assisting in arranging medically necessary transportation for members; d. Arranging interpreter services; e. Assisting in reporting fraud, waste, and abuse; f. Assisting members with coordination of out-of-plan services; g. Ordering member materials, such as handbooks and provider directories; h. Explaining to members what to do in an emergency or urgent medical situation; i. Assisting members with questions regarding benefits and how to access services; j. Handling members' complaints, grievances, and appeals; and k. Providing a toll-free telephone number. C. The MCO must maintain a toll-free Member Services telephone number. Although the full Member Services function is not required to operate after regular business hours, this or another toll-free telephone number must be staffed twenty-four (24) hours per day to provide prior authorization of services during evenings and weekends, including pharmacy services. D. Provider Services – The MCO must staff a provider Services function operated at least during regular business hours and responsible for the following: 1. Assisting providers with questions concerning member eligibility status and benefits; 2. Assisting providers with plan prior authorization, care coordination, network questions, and referral procedures; 3. Assisting providers with claims payment procedures; 4. Handling provider complaints.
2.16 Mandatory Participation in Managed Care A. Participation in managed care is mandatory for the members of the MACC, non- MAGI and non-Medicaid funded coverage groups identified in § 2.1 of this Part except as specified in § 2.34 of this Part. Medicaid members in these coverage groups with third (3rd) party medical coverage or insurance may be exempt from this mandate only as indicated in § 2.38 of this Part at the discretion of the EOHHS. 2.17 Enrollment Procedures, Rights and Responsibilities A. The enrollment process for MACC groups is set forth in § 2.34 of this Part. 2.18 Rhody Health Partners – Program Overview A. Rhody Health Partners (RHP) is a managed care delivery system for adult Medicaid beneficiaries ages nineteen (19) to sixty-four (64) eligible under the ACA expansion as well as adults with disabilities eligible under Part 40-00-1 of this Title. B. As with RIte Care, beneficiaries under this Rule who have access to a Medicaid approved employer-sponsored health insurance plans are evaluated for participation in the RIte Share Premium Assistance Program and are required to enroll in an employer plan approved by EOHHS as a condition of retaining Medicaid eligibility. 2.19 Scope and Purpose A. Eligible members of the MACC group for adults ages nineteen (19) to sixty-four (64) and must not be eligible for or enrolled in Medicare will be enrolled in a RHP health plan or, as applicable, RIte Share. The purpose of this section is to describe the RHP delivery system for members of this MACC coverage group and the respective roles and responsibilities of EOHHS and the individuals receiving affordable coverage through RHP. 2.20 Applicability A. The provisions governing RHP for persons who are eligible for Medicaid on the basis of being aged, blind, or with a disability are located in Part 40-10-1 of this Title. 2.21 MACC Group in Rhody Health Partners A. The MACC group participating in RHP is adults, ages nineteen (19) to sixty-four (64), who are not: pregnant, entitled to received Medicare Part A or B, or otherwise eligible for or enrolled in a Medicaid State Plan mandatory coverage
group. See: Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways (Subchapter 00 Part 1 of this Chapter). 2.22 Overview of RHP A. Individuals enrolled in RHP receive the full scope of services covered under the Medicaid State Plan and the State’s Section 1115 waiver, unless otherwise indicated. Covered services may be provided through the MCO or through the fee-for-service delivery system if the service is “out-of-plan” – that is, not included in the MCO but covered under Medicaid. Fee-for-service benefits may be furnished either by the managed care provider or by any participating provider. Rules of prior authorization apply to any service required by EOHHS. Each RHP member selects a primary care provider (PCP) who performs the necessary medical care and coordinates referrals to specialty care. The primary care provider orders treatment determined to be medically necessary in accordance with MCO policies. 2.23 Access to Benefits A. Unless otherwise specified, MACC group adults coverage groups entitled to a comprehensive benefit package that includes both in-plan and out-of-plan services. In-plan services are paid for on a capitated basis. The State may, at its discretion, identify other services paid for on a fee-for-service basis rather than at a capitated rate. B. Delivery of Benefits – The coverage provided through the RHP is categorized as follows: 1. In-Plan Benefits 2. Out-of-Plan Benefits C. Medical necessity – The standard of "medical necessity" is used as the basis for determining whether access to a Medicaid covered services is required and appropriate. A "medically necessary service" means medical, surgical or other services required for the prevention, diagnosis, cure, or treatment of a health- related condition including any such services are necessary to prevent a decremental change in either medical or mental health status or substance use disorder or services needed to achieve age-appropriate growth and development or to attain, maintain, or regain functional capacity. D. Medically necessary services must be provided in the most cost-efficient and appropriate setting and must not be provided solely for the convenience of the member or service provider.
2.24 RHP In-Plan Capitated Benefits A. The benefits which the MCO provides within the capitated (fixed cost per enrollee per month) benefit. B. RHP comprehensive benefit package – The following benefits are included in the capitated rate on an annual basis, based on medical necessity: SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: Inpatient Hospital Care As medically necessary. EOHHS shall be responsible for inpatient admissions or authorizations while Member was in Medicaid fee-for-service, prior to Member’s enrollment in Health Plan. Contractor shall be responsible for inpatient admissions or authorizations, even after the Member has been disenrolled from Contractor’s Health Plan and enrolled in another MCO or re-enrolled into Medicaid fee-for-service, until the management of the Member’s care is formally transferred to the care of another MCO, another program option, or fee-for-service Medicaid. Outpatient Hospital Services Covered as needed, based on medical necessity. Includes physical therapy, occupational therapy, speech therapy, language therapy, hearing therapy, respiratory therapy, and other Medicaid covered services delivered in an outpatient hospital setting. Therapies Covered as medically necessary, includes physical therapy, occupational therapy, speech therapy, hearing therapy, respiratory therapy and other related therapies. Physician/Provider Services Covered as needed, based on medical necessity, including primary care, specialty care, obstetric and newborn care. Family Planning Services Enrolled female members have freedom of choice of providers for family planning services. Prescription Drugs Covered when prescribed by an MCO physician/provider. Generic substitution only unless provided for otherwise as
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: described in the Managed Care Pharmacy Benefit Plan Protocols. Non-Prescription Drugs Covered when prescribed by a Health Plan physician/provider/APP. Limited to non-prescription drugs, as described in the Medicaid Managed Care Pharmacy Benefit Plan Protocols. Includes nicotine cessation supplies ordered by an MCO physician or APP. Includes medically necessary nutritional supplements ordered by an MCO physician or APP. Laboratory Services Covered when ordered by a Health Plan physician/provider including urine drug screens. Radiology Services Covered when ordered by a Health Plan physician/provider. Diagnostic Services Covered when ordered by a Health Plan physician/provider. Mental Health and Substance Use – Outpatient & Inpatient Covered as needed for all members, including residential substance use treatment for youth. Covered services include a full continuum of mental health and substance use disorder treatment, including but not limited to, community-based narcotic treatment, methadone, and community detox. Covered residential treatment includes therapeutic services but does not include room and board, except in a facility accredited by the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO"). Also includes, DCYF ordered administratively necessary days, or hospital-based detox, MH/SUD residential treatment (including minimum six (6) month SSTAR birth residential services), Mental Health Psychiatric Rehabilitative Residence (MHPRR), psychiatric rehabilitation day programs, Community Psychiatric Supportive Treatment (CPST),Crisis Intervention for individuals with severe and persistent mental illness (SPMI) enrolled in the Community Support Program (CSP), Opioid Treatment Program Health Homes (OTP),
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: Assertive Community Treatment (ACT), Integrated Health Home (IHH), and services for individuals at CMHCs. Home Health Services Covered services include those services provided under a written plan of care authorized by a physician/provider including full-time, part-time, or intermittent skilled nursing care and certified nursing assistant services as well as physical therapy, occupational therapy, respiratory therapy and speech-language pathology, as ordered by an MCO physician. This service also includes medical social services, durable medical equipment and medical supplies for use at home. Home health services do not include respite care, relief care or day care. Home Care Services Covered services include those provided under a written plan of care authorized by a physician/provider including full-time, part-time or intermittent care by a licensed nurse or certified nursing assistant as well as; physical therapy, occupational therapy, respiratory therapy and speech therapy. Home care services include laboratory services and private duty nursing for a patient whose medical condition requires more skilled nursing than intermittent visiting nursing care. Home care services include personal care services, such as assisting the client with personal hygiene, dressing, feeding, transfer and ambulatory needs. Home care services also include homemaking services that are incidental to the client’s health needs such as making the client’s bed, cleaning the client’s living areas such as bedroom and bathroom, and doing the client’s laundry and shopping. Home care services do not include respite care, relief care or day care. Preventive Services Covered when ordered by a health plan physician/provider. Services include homemaker services, minor environmental modifications, physical therapy evaluation and services, and personal care services. EPSDT Services Provided to all children and young adults up to age twenty-one (21). Includes tracking, follow-up and outreach to children for initial visits, preventive visits, and follow-up visits. Includes inter-periodic screens as medically
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: indicated. Includes multi-disciplinary evaluations and treatment, including, PT/OT/ST, for children with significant disabilities or developmental delays. Emergency Room Service and Emergency Transportation Services Covered both in- and out-of-State, for Emergency Services or when authorized by an MCO Provider, or in order to assess whether a condition warrants treatment as an emergency service. Nursing Home Care and Skilled Nursing Facility Care Covered when ordered by a Health Plan physician/provider. For Rhody Health Partners/Expansion members, the Contractor payments are limited to thirty (30) consecutive days. Please refer to the Nursing Home Status Form Policy. All skilled and custodial care covered. Contractor is responsible for notifying the State to begin dis-enrollment process. For RIte Care members, please refer to stop-loss provisions. School-Based Clinic Services Covered for RIte Care members as Medically Necessary at all designate sites. Services of Other Practitioners Covered if referred by an MCO physician. Practitioners certified and licensed by the State of Rhode Island including nurse practitioners, physicians’ assistants, social workers, licensed dietitians, psychologists and licensed nurse midwives. Court-ordered mental health and substance use services – criminal court Covered for all members. Treatment must be provided in totality, as directed by the Court or other State official or body, such as a Probation Officer, the Rhode Island State Parole Board. If the length of stay is not prescribed on the court order, the MCOs may conduct Utilization Review on the length of stay. The MCOs must offer appropriate transitional care management to persons upon discharge and coordinate and/or arrange for in-plan medically necessary services to be in place after a court order expires. The following are examples of Criminal Court Ordered Benefits that must be provided in totality as an in- plan benefit:
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: Bail Ordered: Treatment is prescribed as a condition of bail/bond by the court. Condition of Parole: Treatment is prescribed as a condition of parole by the Parole Board. Condition of Probation: Treatment is prescribed as a condition of probation. Recommendation by a Probation State Official: Treatment is recommended by a State official (Probation Officer, Clinical social worker, etc.). Condition of Medical Parole: Person is released to treatment as a condition of their parole, by the Parole Board. Court-ordered mental health and substance use treatment – civil court All Civil Mental Health Court Ordered Treatment must be provided in totality as an in-plan benefit. All Regulations in the R.I. Gen. Laws § 40.1-5-5 must be followed. If the length of stay is not prescribed on the court order, the MCOs may conduct Utilization Review on the length of stay. The MCOs must offer appropriate transitional care management to persons upon discharge and coordinate and/or arrange for in-plan medically necessary services to be in place after a court order expires. Note the following are facilities where treatment may be ordered: The Eleanor Slater Hospital, Our Lady of Fatima Hospital, Rhode Island Hospital (including Hasbro), Landmark Medical Center, Newport Hospital, Roger Williams Medical Center, Butler Hospital (including the Kent Unit), Bradley Hospital, Community Mental Health Centers, Riverwood, and Fellowship. Any persons ordered to Eleanor Slater Hospital for more than seven (7) calendar days, will be dis-enrolled from the MCO at the end of the month, and be re-assigned into Medicaid FFS. Civil Court Ordered Treatment can be from the result of: a) Voluntary Admission b) Emergency Certification
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: c) Civil Court Certification Court-ordered treatment that is not an in-plan benefit or to a non-network provider, is not the responsibility of the Contractor. Court ordered treatment is exempt from the fourteen (14) day prior authorization requirement for residential treatment. Podiatry Services Covered as ordered by Health Plan physician/provider. Optometry Services For children under twenty-one (21): Covered as medically necessary with no other limits. For adults twenty-one (21) and older: Benefit is limited to examinations that include refractions and provision of eyeglasses if needed once every two (2) years. Eyeglass lenses are covered more than once in two (2) years only if medically necessary. Eyeglass frames are covered only every two (2) years. Annual eye exams are covered for members who have diabetes. Other medically necessary treatment visits for illness or injury to the eye are covered. Oral Health Inpatient: Contractor is responsible for operating room charges and anesthesia services related to dental treatment received by a Medicaid beneficiary in an inpatient setting. Outpatient: Contractor is responsible for operating room charges and anesthesia services related to dental treatment received by a Medicaid beneficiary in an outpatient hospital setting. Oral Surgery:
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: Treatment covered as medically necessary. As detailed in the Schedule of In-Plan Oral Health Benefits updated January 2017. Hospice Services Covered as ordered by an MCO physician/provider. Services limited to those covered by Medicare. Durable Medical Equipment Covered as ordered by an MCO physician/provider as medically necessary. Adult Day Health Day programs for frail seniors and other adults who need supervision and health services during the daytime. Adult Day Health programs offer nursing care, therapies, personal care assistance, social and recreational activities, meals, and other services in a community group setting. Adult Day Health programs are for adults who return to their homes and caregivers at the end of the day. Children’s Evaluations Covered as needed, child sexual abuse evaluations (victim and perpetrator); parent child evaluations; fire setter evaluations; PANDA clinic evaluations; and other evaluations deemed medically necessary. Nutrition Services Covered as delivered by a registered or licensed dietitian for certain medical conditions and as referred by an MCO physician. Group/Individual Education Programs Including childbirth education classes, parenting classes, wellness/weight loss and tobacco cessation programs and services. Interpreter Services Covered as needed. Transplant Services Covered when ordered by an MCO physician. HIV/AIDS Non-Medical Targeted Case This program may be provided for people living with HIV/AIDS and for those at high risk for acquiring HIV (see provider manual for distinct eligibility criteria for
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: Management for People Living with HIV/AIDS (PLWH/As) and those at High Risk for acquiring HIV beneficiaries to qualify for this service). These services provide a series of consistent and required “steps” such that all clients are provided with and Intake, Assessment, Care Plan. All providers must utilize an acuity index to monitor beneficiary severity. Case management services are specifically defined as services furnished to assist individuals who reside in a community setting or are transitioning to a community setting to gain access to needed medical, social, educational and other services, such as housing and transportation. Targeted case management can be furnished without regard to Medicaid’s state-wideness or comparability requirements. This means that case management services may be limited to a specific group of individuals, such as HIV/AIDS, by age or health/mental health condition, or a specific area of the state. (Under EPSDT, of course, all children who require case management are entitled to receive it.) May include: Benefits/entitlement counseling and referral activities to assist eligible beneficiaries to obtain access to public and private programs for which they may be eligible All types of case management encounters and communications (face-to-face, telephone contact, other) Categorical populations designated as high risk, such as, transitional case management for incarcerated persons as they prepare to exit the correctional system; adolescents who have a behavioral health condition; sex workers; etc. A series of metrics and quality performance measures for both HIV case management for PLWH/s and those at high risk for HIV will be collected by providers and are required outcomes for delivering this service. Does not involve coordination and follow up of medical treatments. AIDS Medical Case Management Medical Case Management services (including treatment adherence) are a range of beneficiary-centered services that link beneficiaries with health care, psychosocial, and
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: other services. The coordination and follow-up of medical treatments are components of medical case management. These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care, through ongoing assessment of the client's and other key family members' needs and personal support systems. Medical case management includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIVIAIDS treatments. Key activities include 1) Initial assessment of service needs; 2) Development of a comprehensive, individualized service plan; 3) Coordination of services required to implement the plan; 4) Monitoring the care; 5) Periodic re-evaluation and adaptation of the plan as necessary over the time beneficiary is enrolled in services. It includes beneficiary-specific advocacy and/or review of utilization of services. This includes all types of case management including face-to-face, phone contact, and any other form of communication. Treatment for Gender Dysphoria Comprehensive benefit package. Rehabilitation Services Physical, Occupational and Speech therapy services may be provided with physician orders by RI DOH licensed outpatient Rehabilitation Centers. These services supplement home health and outpatient hospital clinical rehabilitation services when the individual requires specialized rehabilitation services not available from a home health or outpatient hospital provider. See also EPSDT. In Lieu of Service All services as provided in § 2.9(C) of this Part can be utilized as an in Lieu of Service if alternative service or setting is a medically appropriate and cost-effective substitute for the covered service or setting.
SERVICE SCOPE OF BENEFIT (ANNUAL) Including but not limited to: Value Add Services Services/equipment which are not in the State Plan but are cost effective, improve health and clinically appropriate. C. EOHHS policy affects the access to and/or the scope and amount of several benefits as follows: 1. Prescriptions: Generic Policy. For RHP enrolled members, prescription benefits must be for generic drugs. Exceptions for limited brand coverage for certain therapeutic classes may be granted if approved by EOHHS, or the MCO acting in compliance with their contractual agreements with EOHHS, and in accordance with the criteria described below: a. Availability of suitable within-class generic substitutes or out-of- class alternatives. b. Drugs with a narrow therapeutic range that are regarded as the standard of care for treating specific conditions. c. Relative disruptions in care that may be brought on by changing treatment from one drug to another. d. Relative medical management concerns for drugs that can only be used to treat patients with specific co-morbidities. e. Relative clinical advantages and disadvantages of drugs within a therapeutic class. f. Cost differentials between brand and generic alternatives. g. Drugs that are required under Federal and State Regulations. h. Demonstrated medical necessity and lack of efficacy on a case by case basis. 2. Non-emergency medical transportation (NEMT) policy. Responsibility for transportation services rests first with the member. If the member's condition, place of residence, or the location of medical provider does not permit the use of bus transportation, NEMT for the Medicaid enrollee may be arranged for by EOHHS or its agent for transportation to a Medicaid covered service from a Medicaid participating provider, including medical,
dental, and behavioral health care services. NEMT services include bus passes, other RIPTA fare products, if authorized by EOHHS or its agent. 3. Interpretation services policy. EOHHS will notify the MCO when it knows of members who do not speak English as a first (1st) language who have either selected or been assigned to the MCO. If the MCO has more than fifty (50) members who speak a single language, it must make available general written materials, such as its member handbook, in that language. a. Written material must be available in alternative formats, such as audio and large print, and in an appropriate manner that takes into consideration the special needs of those who are visually limited or have limited reading proficiency. All written materials for potential enrollees must include taglines in the prevalent non-English languages in the State, as well as large print, explaining the availability of written translations or oral interpretation to understand the information provided and the toll-free telephone number of the entity providing choice counseling services. All enrollees must be informed that information is available in alternative formats and how to access those formats. 4. Tracking, Follow-up, Outreach. These services are provided by the MCO in association with an initial visit with member's PCP; for preventive visits and prenatal visits; referrals that result from preventive visits; and for preventive dental visits. Outreach includes mail, phone, and home outreach, if necessary, for members who miss preventive and follow-up visits, and to resolve barriers to care such as language and transportation barriers. 2.25 SPMI Modifications A. SPMI adults have access to a comprehensive benefit package. All elements of the comprehensive benefit package are the responsibility of the MCO when a beneficiary is enrolled in the Rhody Health Partners delivery system. 2.26 Out-of-Plan Benefits A. Out-of-plan benefits are not included in the managed care contracts and are not the responsibility of the MCO to provide. These services are provided by existing Medicaid-approved providers who are reimbursed directly by EOHHS on a fee- for-service basis. Out-of-plan benefits are provided to all RHP enrollees with the following exceptions: anyone enrolled in the guaranteed enrollment period but otherwise ineligible for Medicaid. The covered benefits are as follows: ELIGIBLE GROUP BENEFIT(S) PROVIDED OUT-OF-PLAN
All Rhody Health Partners and Expansion members Dental services Court-ordered mental health and substance use services ordered to a non- network facility or provider Non-Emergency Transportation Services (Non-Emergency transportation is coordinated by the contracted Health Plans) Nursing home services in excess of thirty (30) consecutive days Residential services for MR/DD clients that are paid by the State’s BHDDH Respite (Adult) Neonatal intensive care Unit (NICU) Services at Women’s and Infants Hospital. Except as specified in § 2.9(C) of this Part Special Education services as defined in the child’s Individual Education Plan (IEP) for children with special health needs or developmental delays Lead Program home assessment and non-medical case management provided by Department of Health or Lead Centers for lead poisoned children Cedar Family Center Services (RIte Care) Centers of Excellence Programs 2.27 Services that are Not Covered by Medicaid A. Non-covered services – The following services are not covered under the Medicaid program: 1. Experimental procedures, except as required by Rhode Island State law; 2. Private rooms in hospitals (unless medically necessary);
3. Cosmetic surgery; 4. Medications that treat erectile dysfunction or other sexual disorders; 5. Infertility treatment services; and 6. Any portion of services that exceeds fifteen (15) days provided in an Institution for Mental Diseases (IMD) for individuals between the ages of twenty-one (21) to sixty-four (64). RHP managed care enrollees may access IMDs. B. Out-of-State Coverage – EOHHS does not routinely provide coverage for out-of- State services with certain exceptions: Medicaid services provided in border communities are covered and emergency services are covered, within limits, at the discretion of EOHHS or the managed care organization. 2.28 Scope of Provider Networks A. The MCO must maintain provider networks in locations that are geographically accessible to the populations to be served, comprised of hospitals, physicians, advanced practice practitioners, mental health providers, substance use disorder providers, pharmacies, transportation services, dentists, school based health centers, etc. in sufficient numbers to make available all services in a timely manner. 2.29 Mainstreaming/Selective Contracting A. The mainstreaming of Medicaid beneficiaries into the broader health delivery system is an important objective of EOHHS. The MCO must ensure that all of its network providers accept RHP members for treatment. The MCO also must accept responsibility for ensuring that network providers do not intentionally segregate RHP members in any way from other persons receiving services. B. Health plans may develop selective contracting arrangements with certain providers for the purpose of cost containment, but must still adhere to the access standards as defined in the health plan contracts. 2.30 Primary Care Providers (PCPs) A. The MCO has written policies and procedures allowing every member to select a primary care provider (PCP). If a member does not select a PCP during enrollment, the MCO shall make an automatic assignment, taking into consideration such factors as current provider relationships, language needs, and the relative proximity of the PCP to the member’s area of residence. The MCO must notify the member in a timely manner of his/her PCP’s name, location, and office telephone number, and how to change PCPs, if desired. The PCP serves as the member's initial and most important point of interaction with
the health plan network. In addition to performing primary care services, the PCP coordinates referrals and specialty care. As such, PCP responsibilities include at a minimum: 1. Serving as the member's primary care provider; 2. Ensuring that members receive all recommended preventive and screening care appropriate for their age group and risk factors; 3. Referring for specialty care and other medically necessary services both in and out-of-plan; 4. Maintaining a current medical record for the member; and B. In addition, the MCO retains responsibility for monitoring PCP actions to ensure they comply with health plan and Medicaid program policies. 2.31 Service Accessibility Standards A. The service accessibility standards which the MCO must meet are: 1. Twenty-four (24) hour coverage; 2. Travel time or distance; 3. Days to appointment for non-emergency services. B. In addition, MCOs must staff both a member services and provider services function. 1. Twenty-Four Hour Coverage – The MCO must provide coverage, either directly or through its PCPs, to members on a twenty-four (24) hour per day, seven (7) days a week basis. The MCO must also have available written policy and procedures describing how members and providers can contact it to receive instruction or prior authorization for treatment of an emergent or urgent medical problem. 2. Travel Time – The MCO must make available to every member a PCP whose office is located within twenty (20) minutes or twenty (20) miles driving time from the member's place of residence. Members may, at their discretion, select PCPs located farther from their homes. 3. Appointment for Non-Emergency Services – The MCO must make services available within twenty-four (24) hours and seven (7) days per week, including services for mental health and substance use disorders for treatment of an urgent medical problem. The MCO must make services available within thirty (30) days for treatment of a non-emergent, non- urgent medical problem. This thirty (30) day standard does not apply to
appointments for routine physical examinations, nor for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every thirty (30) days. Non- emergent, non-urgent mental health or substance use disorder appointments for diagnosis and treatment must be made available within ten (10) days. 4. Member Services – The MCO must staff a member services function operated at least during regular business hours and responsible for the following: a. Orienting the member to the health plan and assisting members in the selection of a PCP; b. Assisting members to make appointments and obtain services; c. Assisting in arranging medically necessary transportation for members; d. Arranging interpreter services; e. Assisting in reporting fraud, waste, and abuse; f. Assisting members with coordination of out-of-plan services; g. Ordering member materials, such as handbooks and provider directories; h. Explaining to members what to do in an emergency or urgent medical situation; i. Assisting members with questions regarding benefits and how to access services; j. Handling members' complaints, grievances, and appeals; and k. Providing a toll-free telephone number. 5. The MCO must maintain a toll-free member services telephone number. Although the full Member Services function is not required to operate after regular business hours, this or another toll-free telephone number must be staffed twenty-four (24) hours per day to provide prior authorization of services during evenings and weekends, including pharmacy services. 6. Provider Services – The MCO must staff a provider services function operated at least during regular business hours and responsible for the following:
a. Assisting providers with questions concerning member eligibility status and benefits; b. Assisting providers with plan prior authorization, care coordination, network questions, and referral procedures; c. Assisting providers with claims payment procedures; and d. Handling provider complaints. 2.32 Mandatory Participation in Managed Care A. Participation in managed care is mandatory for the members of the MACC, non- MAGI and non-Medicaid funded coverage groups identified in § 2.1 of this Part except as specified in § 2.34 of this Part. Medicaid members in these coverage groups with third (3rd) party medical coverage or insurance may be exempt from this mandate only as indicated in § 2.38 of this Part, at the discretion of the EOHHS. 2.33 Enrollment Procedures, Rights, and Responsibilities A. The enrollment process for MACC groups using the RHP delivery system is set forth in § 2.34 of this Part. 2.34 Enrollment Processes for RIte Care and Rhody Health Partners Managed Care Plans Overview A. With the approval of the State’s Section 1115 waiver in 2009, enrollment in an MCO became mandatory for all individuals covered in the Rhode Island Medicaid program who do not require long term services and supports. The State’s goal in implementing this policy is to assure that all Rhode Islanders enrolled in Medicaid have access to an organized system of high quality services that provides a medical home focusing on primary care and prevention services. 2.35 Scope and Purpose A. The Medicaid eligible Medicaid Affordable Care Coverage (MACC) groups identified in the “Affordable Care Coverage Groups” (Subchapter 00 Part 1 of this Chapter) must enroll for coverage in a RIte Care ( parent/caretaker, children and pregnant women) or Rhody Health Partners (adults nineteen (19) to sixty-four (64) without children) managed care plan, as described above. There are other Medicaid coverage groups enrolled in both service delivery systems. B. This Rule applies to all RIte Care coverage groups identified in § 2.1 of this Part. It does not apply to adults eligible on the basis of age, blindness, or disability subject to the provisions for RIte Care unless the beneficiary qualifies for and
chooses the eligibility pathway for parents/caretakers. See Part 40-10-1 of this Title for a description of these groups. C. EOHHS must ensure that enrollment in RIte Care and Rhody Health Partner (RHP) MCOs function in a timely and efficient manner that respects the rights of Medicaid eligible individuals and the State’s interest in assuring that they have ready access to an organized system of high quality health care. D. The provisions of this rule also apply to any applicants in these coverage groups who have access to employer-sponsored (ESI) health plans who may be qualified for the RIte Share premium assistance program, as specified in Part 3 of this Subchapter, until further notice from the EOHHS. 2.36 Initiating Enrollment: No Wrong Door A. The enrollment process begins at the point in which an eligibility determination has been made and the applicant is notified. Once determined eligible, a Medicaid member must select an MCO at the time a determination is made if applying online through the web-portal either alone or with assistance. Notice of eligibility provided by EOHHS, whether electronically or on paper, must inform the Medicaid member of whether enrollment in a RIte Care versus Rhody Health Partners plan is required. The Medicaid coverage group that is the basis of eligibility for an individual determines the delivery system – RIte Care or RHP – in which a person must enroll (see Subchapter 00 Part 1 of this Chapter). 1. Enrollment channels – Once determined eligible, a Medicaid eligible person may enroll in a RIte Care or Rhody Health Partners Plan, as appropriate: a. Online through the eligibility portal independently or with a navigator's assistance; b. Over the phone with a Contact Center representative; or c. In-person at the Contact Center or a DHS office. (Contact information located in § 2.67 of this Part). 2. Information on enrollment options – The EOHHS and the RIte Care and RHP MCOs share responsibility for ensuring Medicaid applicants and prospective and current enrollees have access to accurate up-to-date information about their enrollment options. This information is available online if applying through the eligibility web portal, as well as through the Contact Center, EOHHS, DHS and the participating MCOs. The information available must include: a. Materials describing the Medicaid managed care delivery system.
b. A written explanation of enrollment options including information about the applicable service delivery system – RIte Care versus RHP – and choice of participating MCOs therein. c. Upon requested, an indication of whether a prospective enrollee’s existing physician is a participant in each of the respective MCOs. d. Non-biased enrollment counseling through the Contact Center or a Navigator. e. A chart comparing participating MCOs. f. Detailed instructions on how to enroll. g. Full disclosure of any time limits and consequences for failing to meet those time limits. h. Access to interpreter services. i. Notification in writing of the right to challenge auto-assignment for good cause through EOHHS. 3. Non-biased enrollment counseling – Non-biased enrollment navigators who are not affiliated with any participating MCO help enrollees choose an MCO and a primary care provider (PCP) capable of meeting their needs. Factors that may be considered when making this choice are whether an existing PCP participates in a particular MCO, as well as language preferences or limitation, geographic proximity, and so forth. Enrollment navigators are available by telephone or in-person at the Contact Center and DHS offices during regular hours of operation. They also are available in-person and by telephone at these locations to assist enrollees who would like to change MCO, such as, during open enrollment or due to good cause). 4. Voluntary selection of MCO – Prospective enrollees are given fourteen (14) calendar days from the completion of their eligibility determination to select an MCO. All members of a family must select the same MCO. If an individual or family does not select an MCO within the time allowed, the individual or family is automatically assigned to an MCO. 5. Automatic assignment into an MCO – The State employs a formula, or algorithm, to assign prospective enrollees who do not make a voluntary selection into an MCO. This algorithm considers quality and financial performance. 6. Requests for reassignment – Medicaid enrollees who have selected an MCO voluntarily or have been auto-assigned may request to be reassigned within certain limits. Such requests are categorized as follows:
a. Requests made within ninety (90) days of enrollment. Medicaid members may be reassigned to the MCO of their choice if their oral or written request for reassignment and their choice of an alternative MCO is received by EOHHS within ninety (90) days of the voluntary or auto-assigned enrollment and the MCO selected is open to new members. The effective date of an approved enrollment must be no later than the last day of the second (2nd) month following the month in which the enrollee requests disenrollment or the MCO requests. b. Requests made ninety (90) days or more after enrollment. Medicaid enrollees who challenge an auto-assignment decision or seek to change MCOs more than ninety (90) days after enrollment in the health plan must submit an oral or written request to EOHHS and show good cause, as provided in § 2.48(A)(4) of this Part, for reassignment to another MCO. A written decision must be rendered by EOHHS within ten (10) days of receiving the request and is subject to appeal. c. Open Enrollment. A Medicaid enrollee may request to be reassigned to another MCO once every twelve (12) months without good cause shown. 7. Auto-assignment and resumption of eligibility – Medicaid members who are disenrolled from an MCO due to loss of eligibility and who regain eligibility within sixty (60) calendar days of disenrollment are automatically re-enrolled, or assigned, into the same MCO if they do not make an MCO selection upon reinstatement of their Medicaid eligibility. If more than sixty (60) days has elapsed and the Medicaid member does not make an MCO selection at the time eligibility was reinstated, the Medicaid member will be auto-assigned to an MCO based on EOHHS’s algorithm referenced in § 2.36(A)(5) of this Part. 8. Open-enrollment – To the extent feasible, EOHHS must coordinate open enrollment periods with those established for affordable care more generally through the State’s health insurance exchange – HealthSource RI. 9. EOHHS reserves the discretion to provide Medicaid wrap around coverage, as an alternative to coverage in a Medicaid MCO to any eligible individual who has comprehensive health insurance through a liable third party, including (but not limited to) absent parent coverage. Such wrap around coverage must be equivalent in scope, amount and duration to that provided to Medicaid eligible individuals enrolled in in a qualified health plan, including ESI, through the RIte Share program. See Part 3 of this Subchapter.
2.37 Enrollment of Newborns and Adopted Children A. RHP members remain enrolled in their current plan until the time of renewal or the birth of the child or the end of the pregnancy, whichever comes first. 1. Newborns – Infants born to mothers who are enrolled in an MCO on the date of their baby's birth are automatically enrolled into a RIte Care MCO. If the newborn’s mother is enrolled in a RIte Care MCO, the child is automatically enrolled in the mother's MCO. If the newborn’s mother is enrolled in a RHP MCO, the baby and the mother will be enrolled in a RIte Care MCO, effective on the date of birth, once certification of the birth has been received. If the newborn’s mother is enrolled in an ESI or other qualified health plan (QHP) with a Medicaid wrap, the baby is enrolled in RIte Care or RIte Share if the plan meets the cost-effectiveness test set forth in Part 3 of this Subchapter. See Part 30-00-1 of this Title for newborn deeming provisions. 2. Adopted children – Enrollment of adopted children who are eligible on the basis of their status as an adopted child or as a member of the child group with income under the limit described in Part 30-00-1 of this Title also varies depending on the basis of Medicaid coverage. Legally adopted children are enrolled as of the date the adoption becomes final. This date cannot be prior to the date Medicaid eligibility is established. The applicable provisions on eligibility and enrollment of child participating the State’s adoption subsidy program are located in, Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways (Subchapter 00 Part 1 of this Chapter). A parent, caretaker or guardian must notify EOHHS when a newborn deemed eligible is adopted. 3. Other Infants and Children –Infants and children with income up to the threshold for the MACC group for children are Medicaid eligible, irrespective of the eligibility of any other member of the household (Subchapter 00 Part 1 of this Chapter). Any infants and children determined eligible on this basis are enrolled in a RIte Care or, as applicable, RIte Share-approved ESI health plan in accordance with the provisions of this rule applicable to all other Medicaid members. 2.38 Medicaid Members Exempt from Enrollment Managed Care A. Certain Medicaid members who would otherwise receive care through the RIte Care or RHP delivery systems may be granted exemptions from mandatory enrollment in an MCO for good cause in narrow range of “extraordinary circumstances” upon approval of EOHHS. An extraordinary circumstance, as defined for these purposes, is a situation, factor or set of factors that preclude a Medicaid member from obtaining the appropriate level of medically necessary care through the managed care delivery system – RIte Care or RHP – designated for the Medicaid member’s coverage group.
1. Types of extraordinary circumstances – Such a situation, factor or set of factors may include the existence of a chronic, severe medical condition for which the member has a longstanding treatment relationship with a licensed health care practitioner who does not participate in any of the Medicaid MCOs in the delivery system designated to provide care to the member. 2. Limits – A Medicaid member's preference to continue a treatment relationship with a particular physician or other health care practitioner who does not participate with an MCO in the member’s designated delivery system does not constitute an "extraordinary circumstance" in and of itself. 3. Exemption requests – Requests for exemption to mandatory enrollment in managed care due to extraordinary circumstances must be made in writing, include appropriate documentation (letter from physician, medical records, or other as indicated), and signed. Exemption requests should be routed to EOHHS. 4. Agency actions and duration of exemption – EOHHS makes enrollment exemption determinations based on a consideration of the circumstances of each member’s individual request. Once exempted, an individual can be exempt for as long as the extraordinary circumstance exists. Non- exempt Medicaid members in a household must follow the regular Medicaid MCO enrollment process. 2.39 MCO Lock-In A. Following initial enrollment into an MCO, Medicaid members are restricted to that MCO until the next open enrollment period. During this health plan lock-in, a Medicaid member may request to be reassigned to another MCO only under one of a set of specific allowed conditions. 1. Allowed conditions for reassignment requests – Members may request to be reassigned to another MCO for any of the following reasons: a. Substandard or poor quality care; b. Inadequate access to necessary specialty services; c. Lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the enrollee's care needs; d. The MCO does not, because of moral or religious objections, cover the services the enrollee seeks;
e. The enrollee needs related services to be performed at the same time; not all related services are available within the provider network; and the enrollee's primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk; f. Insufficient transportation; g. Discrimination; h. Member relocation; i. Good cause as defined in § 2.48(A)(4) of this Part. j. Without cause during the ninety (90) days following the effective date of the Medicaid member’s initial enrollment with the MCO. 2. Process for requesting reassignment – Medicaid members seeking MCO reassignment during the lock-in period must file a formal request with EOHHS. 3. Agency review – MCO reassignment can only be ordered by EOHHS after administrative review of the facts of the case. In the course of the review, EOHHS must examine the evidence it has compiled about the grounds that are the basis for the Medicaid member’s request for disenrollment. 4. Notice of agency action – EOHHS must provide the member with written notice of the action taken on the request for MCO reassignment. If EOHHS determines that there is sufficient evidence to reassign the Medicaid member, the notice must be sent to the member at least ten (10) days prior to the date the proposed reassignment would be effective. The Medicaid member must submit a plan change form to select another MCO. 2.40 Open Enrollment A. During an open enrollment period, Medicaid members have an opportunity to change MCOs. Open enrollment extends to all RHP enrollees and RIte Care enrollees, with the exception of members in the Extended Family Planning coverage group and foster care children who are receiving foster care or adoption subsidy assistance (Title IV-E), are in foster care, or are otherwise in an out-of-home placement. 2.41 Membership Handbook A. The Medicaid MCO must provide a Medicaid enrollee with a membership handbook and information on how to select a primary care provider member.
This information must be sent by mail within ten (10) days of the date of enrollment for all members excluding foster children. 2.42 Identification Cards A. Medicaid members are issued two identification cards – permanent MCO cards and permanent Rhode Island Medicaid cards. 1. MCO permanent cards – Medicaid MCOs must issue permanent identification cards to all Medicaid members within ten (10) days of the date the enrollment was received by the MCO. The card identifies the MCO name and a twenty-four (24) hour, toll-free telephone number for the Medicaid member to call in the event of an urgent or emergent health care problem. The card also includes the telephone number for the MCO’s membership services division and may include the name and telephone number of the recipient's primary care provider. 2. Medicaid cards – A Rhode Island Medicaid identification card is also issued to Medicaid members who are eligible for out-of-plan benefits through the State’s Medicaid Management Information System (MMIS). 2.43 Interim Fee-for-Service Coverage A. For RIte Care members only, there is a seven (7) day period between Medicaid MCO assignment and MCO enrollment during which services provided to a Medicaid member may be paid on a fee-for-service basis. To be reimbursed, the services must be delivered to the Medicaid member by a health provider or practitioner certified to participate in the Rhode Island Medicaid program. 2.44 Verification of Eligibility/Enrollment A. Medicaid MCO have the opportunity to contact EOHHS, a DHS office, the automated enrollment mailbox utilized by the health plans, or the automated eligibility verification system as necessary and appropriate to verify eligibility and plan enrollment if a Medicaid member requires immediate services. 2.45 Responsibility of Medicaid Members to Report Change in Status A. Medicaid members are responsible for reporting certain changes in status including any related to family size, residence, income, employment, third (3rd) party coverage, and child support. Such information must be filed with EOHHS, the Contact Center or a DHS field office within ten (10) days of the date the change occurs. In addition, EOHHS conducts periodic reviews to determine whether any changes in status have occurred that affect eligibility or health plan enrollment. Medicaid MCOs must also report to EOHHS any changes in the status of Medicaid members once they become known.
2.46 Transitioning Members between MCOs and Delivery Systems A. It may be necessary to transition a Medicaid member between MCOs or from one (1) delivery system – RHP to RIte Care or vice versa – for a variety of reasons: 1. Change in MCOs within a delivery system – The transition between Medicaid MCOs may occur as a result of change in MCO during open enrollment or a change that is ordered as part of a grievance resolution. The MCOs have written policies and procedures for transferring relevant patient information, including medical records and other pertinent materials, when transitioning a member to or from another MCO. The MCO must transfer this information at no cost to the member. 2. Change in delivery systems – Medicaid members may be transitioned from one managed care delivery system into another as a result of changes in eligibility status. Adults enrolled in RIte Care who are between the ages of nineteen (19) and sixty-four (64) may be eligible under the MACC group for adults when their dependent children age out of MACC group for children. Once a RHP member has given birth, both newborn and/or parents may be transitioned to RIte Care if income is within the eligibility thresholds set forth in Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways (Subchapter 00 Part 1 of this Chapter). Enrollment in MCOs during such transitions will strive to preserve the continuity of care to the full extent feasible. Accordingly, Medicaid members enrolled in a particular MCO subject to a delivery system transition will be enrolled in the same health plan, if participating, in the new delivery system. 2.47 Grievances, Appeals, and Hearings A. The State provides a grievance and appeals process that MCO providers and Medicaid enrollees must use when seeking redress against health plans. This is the same process that the MCOs must use when seeking to disenroll members who are habitually non-compliant or who pose a threat to plan employees or other members. See Part 10-05-2 of this Title, Appeals Process and Procedures for EOHHS Agencies and Programs, for additional information. 2.48 MCO Initiated Disenrollment A. The MCO may seek disenrollment of a member who is habitually non-compliant or poses a threat to MCO employees or other members. An MCO initiated disenrollment, is subject to an administrative review process by EOHHS and must follow the following requirements: 1. MCO disenrollment requests – For an MCO to disenroll a Medicaid member, the MCO must send a request, along with accompanying
documentation, to EOHHS. When the request is received, EOHHS sends a notice to the Medicaid member informing him or her that the MCO is seeking to take a disenrollment action and explaining the reason given by the MCO for taking such an action. The notice also informs the member that of the right to submit within ten (10) days any evidence establishing a good cause appeal rejecting the disenrollment action. 2. Additionally, the MCO must: a. Specify the reasons for which the MCO is requesting disenrollment of an enrollee; b. Not request disenrollment because of an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his/her special needs (except when his/her continued enrollment in the MCO seriously impairs the MCO’s ability to furnish services to either this particular enrollee or other enrollees). c. Specify the methods by which the MCO assures EOHHS that it does not request disenrollment for reasons other than those permitted under the managed care contract. 3. EOHHS action – EOHHS must investigate and render a decision within ten (10) days of receipt of evidence from both parties. EOHHS’s decision is subject to appeal. If, based upon the evidence submitted by the health plan, EOHHS determines that the Medicaid member should be disenrolled from the health plan, a notice is sent to the Medicaid member by EOHHS stating the decision and the basis thereof at least ten (10) days prior to the date the proposed disenrollment would be effective. 4. Good Cause appeal – A Medicaid member subject to a health plan request for disenrollment has the right to present evidence establishing good cause. Good cause must be filed prior to the end of the ten (10) day advance notice period. The filing of good cause is submitted in writing to EOHHS. Good cause includes circumstances beyond the Medicaid member’s control sufficiently serious to prevent compliance; an unanticipated household emergency; a court-required appearance; incarceration; breakdown in transportation arrangements; or inclement weather which prevented the Medicaid member and other persons similarly situated from traveling to, or participating in, the required appointment. A member's preference to remain in fee-for-service does not constitute good cause for an appeal of the request for disenrollment.
2.49 EOHHS Authority A. EOHHS has sole authority as the Medicaid Single State Agency for disenrolling Medicaid members from an MCO. Requests for disenrollment, either as the result of a formal grievance filed by the Medicaid member against the MCO, or by the MCO against the Medicaid member, is subject to an administrative review process by EOHHS. 2.50 Reasons for Disenrollment A. EOHHS may disenroll Medicaid eligible MCO members for a variety of reasons including, but not limited to, any of the following: 1. Death; 2. Loss of eligibility; 3. Selection of another MCO during open enrollment; 4. Change of residence outside of the MCO’s service area; 5. Non-payment of premium share; 6. Incarceration; 7. Permanent placement in Eleanor Slater Hospital; 8. Long-term placement in a nursing facility for more than thirty (30) days (does not apply to RIte Care members); 9. Disenrollment as the result of a formal grievance filed by the member against the MCO; or 10. Disenrollment as the result of a formal grievance filed by the MCO against the member. 2.51 Disenrollment Effective Dates A. Member disenrollments outside of the open enrollment process become effective on the date specified by EOHHS, but not fewer than six (6) days after the MCO has been notified, unless the MCO waives this condition. The MCOs have written policies and procedures for complying with EOHHS disenrollment orders. 2.52 Right to Appeal A. All notifications of disenrollment must include information regarding the Medicaid member’s right to appeal the decision and the procedures for requesting an EOHHS administrative fair hearing.
2.53 Medicaid Member Rights and Protections A. All Medicaid members are guaranteed access to quality health care delivered in a timely and respectful manner. To ensure this goal is met, the following rights and protections must be clearly stipulated by both EOHHS and the MCO. 1. Enrollment – EOHHS will make every effort to provide the following: a. Multilingual services to all people who do not speak English; b. Written enrollment information will be provided in a clear and easy- to-understand format; c. Enrollment information provided by the MCO must include detailed information on how to obtain transportation services, second opinions, interpreter services, referrals, emergency services and out-of-State services unavailable in Rhode Island. Information must also be provided regarding switching primary care providers, disenrollment for good cause, the in-plan grievance process and the EOHHS appeals process; d. The State will conduct a special enrollment outreach effort for beneficiaries who are homeless or who live in transitional housing; e. Once a Medicaid member is enrolled, the MCO will conduct a special enrollment outreach effort for any enrollees who are homeless or who live in transitional housing; f. The MCO is prohibited from engaging in any door-to-door or telemarketing or any other similar unfair marketing practices; g. Enrollees will be provided with counseling assistance in the selection process for their primary care providers; h. Medicaid members who receive on-going care from a primary care provider or specialist will be advised by the non-biased enrollment counselor which providers are participating in each MCO option so as to promote continuity of care; i. If a Medicaid member is auto-assigned to an MCO, the member, within ninety (90) days, may dispute that assignment through the right to rebuttal. A decision by EOHHS must be rendered within ten (10) days of the filing of the rebuttal and is subject to appeal. 2. Second Opinions and Switching Doctors – Every Medicaid member must be informed of the following:
a. MCOs must provide, at their expense, a second (2nd) opinion within the MCO upon an enrollee’s request. A decision on the request for a second (2nd) opinion will be made in a timely manner and approval shall not be unreasonably withheld; b. A Medicaid member is entitled to a second (2nd) surgical opinion by a plan physician, or if the referral is made by a plan physician, to a second (2nd) surgical opinion by a non-participating physician; c. Medicaid members have the right to switch providers within the MCO, upon request. d. Members who are denied a second (2nd) opinion or denied the right to switch providers will have the right to appeal, as set forth in Part 10-05-2 of this Title, Appeals Process and Procedures for EOHHS Agencies and Programs for additional information. 3. Disenrollment – The following apply to requests for disenrollment, as indicated: a. Medicaid members may request to disenroll from any MCO for the remainder of an enrollment period for any of the reasons established in § 2.34 of this Part; b. A rapid disenrollment process must be provided for individuals and families who are dislocated and move to another area due to homelessness, domestic abuse, or other similar crises, if they cannot access in-plan services within a reasonable distance from their new location; 4. Interpreter Services – Plans are encouraged to provide availability to twenty-four (24) hour interpreter services for every language group enrolled by the health plan for all points of contact, especially telephone contact. In addition, reasonable attempts must be made by the plans to have written materials, such as forms and membership manuals, translated into other languages. If the health plan has more than fifty (50) members who speak a single language, it must make available general written materials, such as its member handbook, in that language. Interpreter services are provided if a plan has more than one hundred (100) members or ten percent (10%) of its Medicaid membership, whichever is less, who speak a single language other than English as a first language. a. Written material must be available in alternative formats, such as audio and large print, and in an appropriate manner that takes into consideration the special needs of those who are visually limited or have limited reading proficiency. All written materials for potential enrollees must include taglines in the prevalent non-English
languages in the State, as well as large print, explaining the availability of written translations or oral interpretation to understand the information provided and the toll-free telephone number of the entity providing choice counseling services. All enrollees must be informed that information is available in alternative formats and how to access those formats. 5. Exceptions Based on Safety Needs – Providers, MCOs and the State must consider the personal safety of a beneficiary in instances of domestic violence in all of the following matters: a. Enrollment policies; b. Disenrollment policies; c. Second (2nd) opinions; d. Switching primary care physicians/practitioners; and e. Grievance procedures. 6. Referral to Rhode Island Legal Services – Notices to Medicaid members must include information indicating that they may represent themselves or be represented by someone else such as a lawyer, relative, or another person in the hearing and appeal process. Notices must also provide information regarding free legal help available at Rhode Island Legal Services. 2.54 Pharmacy Home Program A. The objective of the Pharmacy Home Program is to prevent members from obtaining excessive quantities of prescribed medications through visits to multiple prescribers and pharmacies and improving health outcomes. Participants enrolled in the program are required to obtain all medications from a specific pharmacy location otherwise known as a “Pharmacy Home” for a period of two (2) years. B. The EOHHS, or its contracted MCO, will establish criteria to identify members for inclusion in the Pharmacy Home Program. Members will be notified at least thirty (30) days prior to enrollment in the program. C. Select provider referrals are available as part of the Pharmacy Home Program. The EOHHS, or its contracted MCO, will ensure that members with complex medical and/or behavioral health needs are connected with high quality select providers to meet those needs. Members who use multiple providers and have one or more complex medical conditions and chronic diseases shall be referred as needed to a select provider.
2.55 Rite Smiles Dental Plan Overview A. The RIte Smiles Program is a statewide dental benefits managed care delivery system established under a Federal waiver. The program's goal is to improve access to oral health services for Rhode Island children who receive Medicaid. Emphasis is placed on preventive and primary care dental services and education. B. Children born on or after May 1, 2000 who are receiving dental benefits through Medicaid are enrolled in a RIte Smiles dental plan. EOHHS contracts with one (1) or more dental plans to provide oral health services to these Medicaid-eligible children. 2.56 Legal Authority A. Title XIX of the Social Security Act, 42 U.S.C. §§ 1396-1396w-8, provides the legal authority for the Medicaid Program. The RIte Smiles Program operates under the State's Section 1115 waiver. 2.57 Coverage Groups A. Participation in the RIte Smiles Program is mandatory for all children in the following populations who were born on or after May 1, 2000 and who are receiving Medicaid: 1. Section 1931 children and related populations (including poverty level groups and RI Works cash recipients); 2. Blind and/or disabled children; 3. Foster care children who are receiving foster care or adoption subsidy assistance (Title IV-E), are in foster care, or are otherwise in an out-of- home placement; 4. Section 1115 Waiver Children. 2.58 Excluded Coverage Groups A. The following groups are excluded from participation in the RIte Smiles Program: 1. Children born on or before April 30, 2000; 2. Children who have access to third (3rd) party dental benefits; 3. Children who reside in nursing facilities or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/ID).
4. Children who reside outside of the State of Rhode Island. Those children who are not eligible to participate in the RIte Smiles Program receive dental benefit coverage under the fee-for-service system. 2.59 Retroactive Eligibility A. If a member is eligible for retroactive eligibility, the dental plan does not provide coverage to Medicaid beneficiaries during the period of retroactive eligibility. 2.60 Enrollment Process A. All children determined eligible for Medicaid who were born on or after May 1, 2000 must enroll in a RIte Smiles Program dental plan. The parent(s) or guardian(s) of the eligible children may have a choice of dental plans, if more than one (1) plan is available, in which to enroll. B. The enrollment process ensures that applicants/beneficiaries are provided with sufficient information (if a choice of dental plan is available) in order to make an informed choice when deciding upon which RIte Smiles plan to choose. 2.61 Voluntary Selection of a Dental Plan A. Newly eligible children for RIte Care, RIte Share, or fee-for service Medicaid will be given a choice of RIte Smiles plans on their Medicaid application. 2.62 Auto Re-Enrollment Following Resumption of Eligibility A. Members of families who receive Medicaid and who are disenrolled from a dental plan due to loss of eligibility are automatically re-enrolled, or assigned, into the same plan should they regain eligibility within sixty (60) calendar days. If more than sixty (60) days has elapsed, the family is permitted to select a plan from those open for enrollment at that time. 2.63 Rite Smiles Lock-In A. After initial enrollment into a RIte Smiles plan, enrollees are restricted to that dental plan until the next open enrollment period, unless disenrolled under one (1) of the conditions described below: 1. Loss of Medicaid eligibility, including for non-payment of applicable premium shares for RIte Care or RIte Share; 2. Selection of another dental plan during open enrollment, if another plan exists; 3. Death; 4. Relocation out-of-State;
5. Adjudicative actions; 6. Change of eligibility status; 7. Eligibility determination error; 8. As the result of a formal grievance filed by the member against the dental plan or by the dental plan against the member; 9. Just cause (as determined by EOHHS). 2.64 Open Enrollment A. During open enrollment members have an opportunity to change RIte Smiles dental plans, if more than one (1) dental plan is available. 2.65 Voluntary Disenrollment A. RIte Smiles members seeking disenrollment during the lock-in period must first file a formal appeal pursuant to appeal procedures with the dental plan (with the exception that members are permitted to disenroll without cause during the ninety (90) days following the effective date of the individual's initial enrollment, if more than one (1) dental plan is available). B. Disenrollment can only be ordered by EOHHS after administrative review of the facts of the case. In order for disenrollment to occur, EOHHS must first find in favor of the member, and then determine that the appropriate resolution to the member's complaint is the member's disenrollment. 2.66 Member Disenrollment A. Unless the member's continued enrollment in the dental plan seriously impairs the dental plan's ability to furnish services to either the particular member or other members, a RIte Smiles dental plan may not request disenrollment of a member because of: 1. An adverse change in the member's health status; 2. The member's utilization of medical/dental services; or 3. Uncooperative or disruptive behavior resulting from the member's special needs. All disenrollments are subject to approval by EOHHS. 2.67 Information and Referral A. For Further Information or to Obtain Assistance: 1. www.eohhs.ri.gov
2. www.dhs.ri.gov 3. www.HealthSourceRI.com B. Applicants may also apply in person at one of the Department of Human Services offices or by U.S. Mail. Request an application by calling 1-855-609- 3304 and TTY 1-888-657-3173. C. For assistance finding a place to apply or for assistance completing the application, please call: 1-855-609-3304 or 1- 855-840-HSRI (4774). 2.68 Severability A. If any provisions of these Regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable.
210-RICR-30-05-2 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 05 - SERVICE DELIVERY OPTIONS PART 2 - MEDICAID MANAGED CARE DELIVERY OPTIONS (210-RICR-30-05-2) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 08/17/2025 July 28, 2025 E-SIGNED by Richard Charest on 2025-07-28 10:40:24 EDT July 28, 2025 E-SIGNED by Department of State on 2025-07-28 10:43:44 EDT
210-RICR-30-05-3 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 – MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 05 – SERVICE DELIVERY OPTIONS PART 3 – RIte Share Premium Assistance Program 3.1 Overview / Legal Authority A. This Part is promulgated pursuant to Federal authorities as follows: 1. Federal Law: § 701(f)(3) of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1181(f)(3); § 1115 of the Social Security Act, 42 U.S.C. § 1315; Title XIX of the Social Security Act, 42 U.S.C §§ 1396a-1396w-8; Title XXI of the Social Security Act, 42 U.S.C. §§ 1397aa- 1397mm; 42 U.S.C. § 1396k 2. The Medicaid State Plan and the Section 1115 Demonstration Wavier granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315 B. Applicable State authority is derived from R.I. Gen. Laws Chapters 40-6, 42-7.2, 40-8, 40-8.4, 40-8.12, and 42-12.3. 3.2 Scope and Purpose A. This Part applies to individuals determined to be Medicaid-eligible under Chapter 30 of this Title. If these individuals have access to employer sponsored insurance (ESI) and the employed person works thirty (30) or more hours per week, EOHHS must conduct a review of the coverage to determine if the benefits are comparable to Medicaid benefits and if the cost of the ESI is less expensive than Medicaid managed care (in the aggregate). When ESI is found to be cost- effective, the State will pay the employee’s premium for that coverage as well as wrap-around costs such as deductibles, co-insurance, etc. B. The purpose of this rule is to set forth the provisions governing participation in the RIte Share Program, the Buy-in requirement, and the process for determining whether an ESI plan meets the cost-effectiveness criteria established by EOHHS, the Medicaid agency. The rule also identifies the respective roles and responsibilities of Medicaid-eligible individuals and the Medicaid agency.
3.3 Incorporated Materials A. These regulations hereby adopt and incorporate 42 CFR § 447.15 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. 3.4 Definitions A. For the purposes of this section, the following definitions apply: 1. “Applicant” means a person seeking Medicaid coverage under this Part, in accordance with the provisions established in Rhode Island General Laws and Public Laws. 2. “Cost-effective” means that the portion of the ESI that the State would subsidize, as well as wrap-around costs, would, on average, cost less to the State than enrolling that same individual/family in a Medicaid managed care plan. 3. “Cost-sharing” means the amount of money the RIte Share Buy-in recipients must pay monthly for their monthly RIte Share coverage. 4. “Employee premium” means the monthly amount an individual or family is required to pay to the employer to obtain and maintain ESI coverage. 5. “Employer-sponsored insurance” or “ESI” means health insurance or a group health plan offered to employees by an employer. This includes plans purchased by small employers through HealthSource RI, the State’s health insurance marketplace. 6. “Federal poverty level” or “FPL”, as used herein, means the most recently published federal poverty level by the U.S. Department of Health and Human Services. 7. “Group health plan” means an employee benefits plan as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974 as qualified in R.I. Gen. Laws §§ 27-50-3(t)(1) and 27-18.6-2(15). 8. “Health insurance coverage” or “Health benefit plan” means a policy, contract, certificate or agreement offered by a health insurance carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services as defined and qualified in R.I. Gen. Laws §§ 27- 18.5-2(7), 27-18.6-2(14) and 27-50-3(u)(1). 9. “Medicaid member” means a person who has been determined to be eligible for Medicaid benefits.
10. “Modified Adjusted Gross Income” or “MAGI” means income, adjusted by any amount excluded from gross income under Section 911 of the IRS Code, and any interest accrued. Social Security benefits are not included in gross income. The MAGI methodology is the standard for determining income eligibility for all Medicaid affordable care coverage groups, which are described in further detail in Part 1 of this Chapter. 11. “Policy holder” means the employee with access to ESI. 12. “Rhode Island Works” or “RI Works” means the State’s Temporary Assistance for Needy Families (TANF) program that provides assistance to low income needy families on the path to full employment and financial independence. The Program is administered by the Rhode Island Department of Human Services, one of the four State agencies under the Executive Office of Health and Human Services (EOHHS) umbrella. 13. “RIte Share-approved employer-sponsored insurance” means an ESI plan that meets the coverage and cost-effectiveness criteria for RIte Share. 14. “RIte Share Buy-In” means, the requirement that applies to a household with MAGI-based income above 150% of the FPL where only the child(ren) is Medicaid eligible and the parent/caretaker has access to ESI that is RIte Share-approved. These families are required to enroll in RIte Share, the State will pay the premium for a family plan, and the parent/caretaker will be responsible for a small monthly cost share to the State. 15. “RIte Share Premium Assistance Program” means the Rhode Island Medicaid premium assistance program in which the State pays the eligible Medicaid member’s share of the cost of enrolling in a RIte Share-approved ESI plan. This allows the State to share the cost of the health insurance coverage with the employer. 16. “RIte Share Unit” means the entity within EOHHS responsible for assessing the cost-effectiveness of ESI, contacting employers about ESI as appropriate, initiating the RIte Share enrollment and disenrollment processes, handling member communications, and managing the overall operations of the RIte Share Program. 17. “Third-party liability” or “TPL” means other health insurance coverage. This insurance is in addition to Medicaid and is usually provided through an employer. Since Medicaid is always the payer of last resort, the TPL is always the primary coverage. 18. “Wrap-around services or coverage” means any health care services not included in the ESI plan that would have been covered had the Medicaid member been enrolled in a Medicaid managed care plan (see Part 2 of this Subchapter for details). Coverage of deductibles, co-insurance and
benefits covered by Medicaid but not the commercial plan are included in the wrap (co-payments to providers are not covered, however, pursuant to 42 CFR § 447.15, Medicaid enrolled providers must accept Medicaid payment as payment in full and cannot charge the member a co-pay). 3.5 RIte Share Populations A. The income of Medicaid members affects whether and in what manner they must participate in RIte Share. RIte Share populations are determined pursuant to R.I. Gen. Laws § 40-8.4-12(c). 1. RIte Share includes: children, parents and caretakers, and individuals who are pregnant, who are eligible for Medicaid, or the Children’s Health Insurance Program (CHIP), and childless adults between the ages of nineteen (19) and sixty-four (64) who are not receiving or eligible to receive Medicare but are Medicaid-eligible. 3.6 RIte Share Enrollment as a Condition of Eligibility A. Medicaid members over the age of nineteen (19), who have access to RIte Share-approved ESI must enroll in that ESI as a condition of continuing Medicaid eligibility. This requirement also applies to any individuals who have, or previously have had the option to waive ESI coverage to receive financial compensation, including but not limited to, an increase in hourly wage, an increase in weekly salary, and/or a lump sum payment. (An increase in wages for waiving coverage is also known as "pay in lieu of benefits.") 1. Mandatory ESI Enrollment – Once EOHHS has determined that the ESI offered by a particular employer is RIte-Share-approved, all eligible Medicaid members with access to that ESI are required to enroll in that coverage. a. Failure to meet the mandatory enrollment requirement results in the termination of the Medicaid eligiblity of the policy holder and other Medicaid members nineteen (19) or older in the household who would have been covered under the ESI. These individuals will remain terminated until the policy holder complies with the RIte Share participation and enrollment procedures established in § 3.18 of this Part. b. Children under age nineteen (19) will not be sanctioned if the policy holder does not comply and, instead, will remain/be enrolled in Medicaid managed care. c. Pregnant individuals in the household will not be sanctioned if the policy holder does not comply and instead will remain/be enrolled in Medicaid managed care.
d. Individuals enrolled in RI Works (TANF) are exempt from the mandatory enrollment requirement for the first six (6) months of employment. See § 3.7 of this Part below. 2. Reinstatement – The period of ineligibility may be shortened and Medicaid eligibility reinstated if: a. the policy holder complies with RIte Share’s request to enroll in ESI; b. the employer’s plan is no longer RIte Share-approved; or c. the policy holder no longer has access to that ESI (e.g., left employment, decrease in work hours, etc.). 3.7 RI Works Participants (TANF) A. RI Works (TANF) participants who are Medicaid-eligible are not required to enroll in a RIte Share plan for their first six (6) months of employment. This six-month exemption also applies to families losing eligibility for RI Works due to employment. Specifically, to be subject to enrollment in a RIte Share approved ESI plan, the RI Works participant must be: 1. Age nineteen (19) or older; and 2. Employed for a period of six (6) consecutive months or more by the same employer. B. RI Works participants who do not meet both of these criteria at the time Medicaid eligibility is renewed in accordance with § 3.15 of this Part are exempt from mandatory participation in RIte Share. 3.8 RIte Share Premium Assistance Payments A. Under the RIte Share Premium Assistance Program, the State pays the employee’s share of their ESI premium and provides wrap-around coverage under Medicaid fee-for-service. 1. For the majority of those enrolled in RIte Share, EOHHS pays the employee directly for their share of the ESI prior to the anticipated date on which the premium is deducted from the employee’s paycheck. The RIte Share Unit or its agent mails a check or electronically transfers payment to the policy holder, on a monthly basis, to cover the premium cost deducted from the policy holder’s check. 2. For a limited number of those enrolled in RIte Share, the State pays the employer directly for the employee’s share of the premium, thereby foregoing the need to deduct the premium from the employee’s paycheck.
This payment method is limited to employers who have been grandfathered into this option. B. Cost-sharing – With the exception of the Buy-In Program (see § 3.9), Medicaid members enrolled in ESI are not obligated to pay any cost- sharing that is not otherwise applicable to Medicaid. C. Wrap-around coverage – This includes deductibles, co-insurance and services and benefits that are covered by Medicaid, but are not offered through the ESI plan. Wrap-around coverage is only available for services provided by Medicaid enrolled providers. 4. Repayment and recoupment – EOHHS has the authority to recover Medicaid benefit overpayment claims and cost-share arrearages through offset of the individual State income tax refund in accordance with R.I. Gen. Laws §§ 44-30.1-1, 44-30.1-3, 44-30.1-4 and 44-30.1-8 in R.I. Gen. Laws Chapter 44-30.1 entitled ‘Setoff of Refund of Personal Income Tax.’ 3.9 RIte Share Buy-in Requirement A. In certain instances, Medicaid members participating in RIte Share are subject to a Buy-in requirement. This requirement applies to a household with MAGI-based income above 150% of the FPL where only the child(ren) is Medicaid eligible, and the parent/caretaker has access to ESI that is RIte Share-approved. 1. Buy-in amount – The parent/caretaker is required to pay a monthly Buy-in amount that varies with income as follows: Monthly Family Income Monthly Buy-In Amount Over 150% and not greater than 185% FPL $ 61.00 Over 185% and not greater than 200% FPL $ 77.00 Over 200% and not greater than 250% FPL $ 92.00 2. Notice – EOHHS must provide the adult in the family subject to the Buy-in requirement with timely notice. This may be done separately or in conjunction with the notice of RIte Share participation. The notice must include the amount of the buy-in, the process for making payments, the consequences for non-payment and a statement of the right to appeal and request a hearing. 3. Payment – Buy-in amounts are not prorated. Therefore, a full monthly Buy-in amount is due if RIte Share enrollment is effective for any portion of a coverage month.
4. Method of payment – EOHHS deducts the Buy-in amount from the State’s premium payment to the member. For the limited number of RIte Share members described in § 3.8(A)(2), the member receives an invoice and pays the state directly. 5. Non-compliance – Individuals subject to the buy-in requirements must cooperate in making monthly Buy-in payments in accordance with § 3.8 of this Part to remain enrolled in ESI. Failure to make a required premium payment for three consecutive months will result in Medicaid termination of all adults enrolled in RIte Share. Children will be transitioned to managed care. 3.10 Basis for Approving ESI Plans A. Only ESI or group health plans that meet the cost-effectiveness and benefits criteria specified in this Part are approved for the RIte Share Premium Assistance Program. 1. Sources of information for determining cost-effectiveness – Determinations of ESI cost-effectiveness are based on information gathered from the following sources: a. Application materials. When applying for Medicaid, applicants must indicate: current health insurance coverage status; relationship to policy holder; plan name; policy number. Subchapter 00 Part 3 of this Chapter explains the process for applying for Medicaid through the State’s affordable care eligibility system and the manner in which this information is collected and maintained. b. The RIte Share Unit. This EOHHS unit collects employer data from the Medicaid member, employer, broker and/or insurance carrier about the ESI plans offered by the employer. Information includes rates and benefit summaries which are necessary to determine whether the employer’s ESI meets EOHHS’s cost-effectiveness criteria. 2. EOHHS reserves the right to request additional information about the ESI from the Medicaid member, the policy holder (even if the policy holder is not Medicaid-eligible), the employer, broker and/or insurance carrier. 3.11 Methodology for Determining Cost-Effectiveness A. The RIte Share Unit uses the information about the ESI to compare the cost of the employee's share of the ESI, as well as wrap-around costs, to the cost of enrollment in Medicaid managed care. An ESI plan is determined to be cost- effective when, on the aggregate, the total cost of medical coverage through RIte Share is less than the cost of coverage if enrolled in a Medicaid managed care
plan. RIte Share participants receive coverage comparable in scope, amount, and duration to coverage provided in a Medicaid managed care plan. 1. Cost-effectiveness test – To be cost-effective, the policy holder’s monthly ESI premium share, deductibles, co-insurance, plus any Medicaid covered services not covered by the ESI plan (such as services covered under the managed care contracts, but not under the ESI plan), must be less than the average capitation payment for a member enrolled in a Medicaid managed care plan. These average costs must be actuarially determined at such intervals as deemed appropriate by EOHHS. 2. The analysis of cost effectiveness is dependent on the Medicaid eligibility status of each member of the household. Cost effectiveness determinations will be based on one of the following scenarios as applicable: a. Household in which all individuals are Medicaid-eligible; b. Household in which only child(ren) and/or pregnant women in the family are Medicaid-eligible; c. Household in which childless adult is Medicaid-eligible; or B. The figures used as the basis for assessing cost-effectiveness shall be made available, upon request, by EOHHS. 3.12 Scope and Consequence of Approving an ESI Plan
RIte Share-approved ESI plans need to be reevaluated on an annual basis, in alignment with annual renewals of employer insurance, to ensure that the ESI remains cost-effective. From the date an ESI plan is approved until the date it is reevaluated, any Medicaid members who work for that employer, and their Medicaid-eligible dependents, must enroll in the ESI through RIte Share. 3.13 Member Enrollment Process A. Medicaid members who are required to participate in RIte Share must enroll in the ESI plan as directed by EOHHS. Enrollment into RIte Share may occur upon initial determination or at the time of Medicaid annual renewal, or as deemed appropriate by EOHHS. Enrollment in RIte Share is considered to be a “qualifying event” and may occur at any time, including outside of the employer’s open enrollment period. Additionally, according to section 701(f)(3) of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1181(f)(3), a group health plan must permit an employee (or dependent) who is: 1 eligible for but not enrolled in the ESI, and
2 determined eligible for an ESI premium assistance program under Medicaid or CHIP, to enroll in ESI coverage no later than 60 days after the date the employee (or dependent) is determined eligible for the premium assistance program. 3. Eligibility determination and RIte Share referral – The referral for RIte Share participation is based on employment information provided by the Medicaid member, as well as information available about the employer’s ESI offering (i.e. whether the employer offers RIte Share-approved coverage). 4. Notice of RIte Share requirement: a. Upon determining that a Medicaid member is eligible for RIte Share, EOHHS sends a “Go Enroll” letter stating the employee must enroll in a RIte Share-approved ESI plan through their employer’s personnel or human resources office within fourteen (14) calendar days of the date on which the letter was generated. b. If no response is received, a second letter is sent. c. If no response is received thirty (30) days after the initial “Go Enroll” letter was sent, a sanction notice is generated informing the adults in the household that they will lose Medicaid eligiblity and their children will remain/be enrolled in managed care. 3.14 Continuing Eligibility – Medicaid Renewals A. For Medicaid members renewing eligibility, EOHHS must assess as part of the redetermination process whether anyone in the household is a RIte Share participant and if there has been any change in access to ESI. 1. Notice of renewal – Medicaid members must be provided with a notice at the time of renewal specifying the terms for continuing eligibility. The terms for continuing coverage vary as follows: a. Medicaid managed care enrollees without access to ESI continue enrollment in the Medicaid managed care plan that provided coverage in the previous period of eligibility in accordance with Part 2 of this Subchapter. b. Medicaid managed care enrollees who have gained access to a RIte Share-approved ESI plan continue to be enrolled in the Medicaid managed care plan that provided coverage in the previous period of eligibility pending review by the RIte Share Unit. c. RIte Share participants who retain access to the RIte Share- approved ESI plan that provided coverage during the during the
previous period of eligibility, continue to be enrolled in the ESI plan pending review by the RIte Share Unit of any changes that might result in withdrawal of approval of the ESI plan, disenrollment, and subsequent enrollment in a Medicaid managed care plan. 2. Loss of ESI – RIte Share participants who involuntarily lose access to an approved ESI plan that provided coverage during the previous period of eligibility for any of the reasons stated in § 3.19 of this Part receive coverage as follows: a. Any Medicaid-eligible individuals in the family will receive coverage through fee-for-service pending either enrollment in a Medicaid managed care plan, or if the Medicaid member gained access to another ESI plan, approval of that plan by the RIte Share Unit. 3. Notice of renewal – In all such cases, the notice of renewal for continuing eligibility sent by EOHHS to the Medicaid members shall include a statement of the applicable terms for continuing eligibility including any Buy-in requirement, the reason(s) for establishing the terms, and the right to appeal and request a hearing with respect to either (See Part 10-05-2 of this Title), as well as all other information required in this section. The enrollment referral transmitted to the RIte Share Unit shall also indicate which terms apply and shall be sent at the time the redetermination is made. 3.15 Renewal of RI Works Participants (TANF) A. At the time eligibility renewals are completed, EOHHS is responsible for assessing whether RI Works participants are subject to enroll in a RIte Share- approved plan as a condition of continuing Medicaid eligibility. 1. Employed under six (6) months – Only those RI Works participants, age nineteen (19) or older, who have access to ESI and have been steadily employed for a period of six (6) consecutive months or more, shall be subject to enrollment in RIte Share. All other RI Works participants continue enrollment in the Medicaid managed care plan which provided coverage until the next scheduled redetermination of eligibility. 2. Employed six (6) months or over – If the RI Works participant has been employed for over six (6) months, the notice of renewal sent by EOHHS must state that enrollment in the Medicaid managed care plan that provided coverage during the previous period of eligibility is continued, pending review of the ESI plan by the RIte Share Unit. If enrollment in an approved ESI plan is a condition of retaining continuing eligibility, Medicaid members shall receive notice from the RIte Share Unit at least fourteen (14) days prior to enrollment in an ESI plan.
3.16 Role of RIte Share Unit A. The RIte Share Unit is responsible for overseeing the operations of the program as follows: 1. Gathering information from employers and employees about the health plans they offer to workers on an ongoing basis; 2. Evaluating health plans for RIte Share approval; 3. Entering cost-effective information into the RI Bridges system; and 4. Contacting employers and employees to make RIte Share enrollment decisions. B. Upon receipt of member referral information, the RIte Share Unit verifies employment and access to a RIte Share-approved ESI plan. Based on this review, the RIte Share Unit determines: 1. Whether the Medicaid member is approved for RIte Share; and 2. The date that individual or family must enroll in the ESI in order to maintain Medicaid eligibility. C. The specific procedures for making such determinations vary depending on the enrollment status of the Medicaid member and the employer’s customary enrollment process. 3.17 ESI Enrollment Verification A. Verification of enrollment in a RIte Share-approved ESI plan is required. 1. For Medicaid members working for an employer who offers RIte Share approved coverage, the employer is required to submit verification to the RIte Share Unit that initial enrollment in the ESI has been made in the manner prescribed by EOHHS. 2. The individual or employer must submit verification of enrollment by completing the Employer Verification form, which requires the signature of both a representative of the employer and the member. 3.18 Failure to Enroll A. Failure to enroll in the ESI plan is grounds for termination of Medicaid eligibility for the non-pregnant parent(s) or caretaker over the age of nineteen (19) in the household who would have been enrolled in RIte Share (see § 3.6 of this Part for details).
1. Discontinuation – EOHHS sends an “Ineligible for Medicaid Notice”, stating that Medicaid eligibility has been terminated for adults in the household due to the failure to enroll in the RIte Share-approved plan. Anyone in the household subject to the notice may reapply (for inactive cases) or request reinstatement (for active Medicaid cases) if: a. they choose to comply with RIte Share; b. an exemption from participation is granted; or c. the individual no longer has access to the ESI. B. The “Ineligible for Medicaid Notice” shall include a statement indicating that any affected Medicaid-eligible individuals in the household have the right to appeal and to request a hearing to contest the change in eligibility and the enrollment decision. 3.19 Disenrollment from RIte Share-Approved Plan A. Pursuant to Part 30-00-3 of this Title, RIte Share members who are voluntarily or involuntarily disenrolled from an approved ESI plan must report the change in enrollment status to EOHHS in no more than ten (10) days from the date the disenrollment action occurs. The type of disenrollment will determine EOHHS’s action as follows: 1. Voluntary disenrollment – Medicaid-eligible RIte Share members age nineteen (19) or older who voluntarily disenroll from an approved ESI will be terminated for coverage based on the failure to meet the non-financial cooperation requirements set forth in this Part. Voluntary disenrollment includes, but is not limited to, instances in which a RIte Share member: a. Requests that the employer drop coverage or cease enrollment for the entire family or a Medicaid-eligible individual in the family; b. Fails to meet the requirements established by the employer to maintain enrollment in the approved plan such as, submit required documentation or forms. c. Engages in unlawful or fraudulent acts, such as submitting false claims that violate the terms for continuing enrollment in the ESI plan. Please refer to § 3.6 of this Part. 2. Involuntary disenrollment – Involuntary disenrollment includes the loss of access to ESI as a result of change in employment, termination of coverage by the employer for an entire class of workers, death, separation, divorce, disability of the policy holder, or any other factors that
could be reasonably construed as involuntary disenrollment as defined in this Part. 3. RIte Share Unit responsibilities – Upon receiving a report from the employer, broker and/or the insurance provider, or Medicaid member indicating that disenrollment has occurred, the RIte Share Unit verifies the accuracy of the report and assesses whether it is voluntary or involuntary in nature. a. Voluntary Disenrollment – Once the report has been verified and it is determined to be voluntary disenrollment, EOHHS sends a “Ineligible for Medicaid Notice” noting termination of the Medicaid eligibility of the policy holder, parent(s) or caretaker relative in the applicant’s household until the individual demonstrates compliance with enrollment procedures established by EOHHS. The “Ineligible for Medicaid Notice” must also include any remedies for shortening the period of ineligibility as well as the right to request a hearing and appeal the decision: (1) All Medicaid-eligible pregnant women and children must be automatically enrolled in a Medicaid managed care plan. (3) This period of Medicaid ineligibility may be shortened and Medicaid eligibility established if such individual complies, becomes exempt from RIte Share enrollment, or no longer has access to ESI for reasons such as a change in employment. (See § 3.18 of this Part). b. Involuntary disenrollment – There is no adverse action taken against Medicaid members required to participate in RIte Share if disenrollment from an approved ESI plan is involuntary. 3.20 Cooperation Requirements A. All Medicaid applicants and members must cooperate with the non-financial requirements for eligibility as follows: 1. Requirement to provide information – All applicants/members are required to provide information about other health coverage they may have (TPL – Third Party Liability) including: a. The names of any family members in the household currently covered by other insurance; b. The name of the policy holder and the employer offering the insurance coverage; and
c. When requested, verification of monthly enrollment costs via a paycheck stub if the policy holder is currently enrolled or, if available, enrollment information provided by the employer indicating the policy holder's monthly premium for the appropriate family composition. 2. Requirement to enroll in ESI – Medicaid members required to enroll in the ESI must cooperate as follows: a. Enroll in the ESI in the manner, and within the timelines, established by EOHHS. Failure to do so will result in the termination of Medicaid for any eligible parents/caretaker age nineteen (19) and older in the family who would otherwise have been enrolled in RIte Share. Children and/or individuals who are pregnant will not be terminated from Medicaid. See § 3.18 of this Part. b. Submit verification of enrollment in accordance with § 3.17 of this Part when the employer does not participate in RIte Share. c. Provide reports to EOHHS indicating any changes in enrollment status of Medicaid-eligible family members, enrollment costs, household composition, employment, income, residence, and access to ESI within ten (10) days from the date the change occurs. 3. Requirement to notify both DHS and EOHHS of loss of employment – Pursuant to Part 30-00-3 of this Title, Medicaid members must notify the State that they are no longer employed or no longer have access to ESI so that payment can be stopped. Payments are NOT transferrable from one employer to another (i.e., payment is employer-specific). If a member receives payment for coverage for which they are no longer eligible, they will be responsible for paying those premiums back to EOHHS. Pursuant to Part 10-00-6 of this Title, If a member does not pay back those overpayments, the State has a right to recoup those dollars from the member’s RI tax refund (see § 3.8). 3.21 Good Cause A. EOHHS is responsible for determining whether good cause exists for an exception to the non-financial cooperation requirements for Medicaid eligibility contained in Subchapter 00 Part 1 of this Chapter and, more specifically, for participation in RIte Share, except as noted below: 1. Extraordinary circumstances – EOHHS must exempt a Medicaid member from RIte Share participation only when there are extraordinary circumstances which preclude the individual from receiving medically necessary care through the RIte Share-approved plan. For purposes of
this exemption, "extraordinary circumstances" may include but not be limited to: a. The existence of an unusual and life-threatening medical condition which requires medical treatment that cannot be provided or arranged by the ESI plan; b. The existence of a chronic, severe medical condition for which the Medicaid member has a long-standing treatment relationship for that condition with a provider who does not participate in the ESI plan and/or refuses to enroll as a Medicaid participating provider. 3. Other programs – If good cause has been granted for any other benefit program administered by EOHHS or DHS, the good cause exemption will be honored by the RIte Share Program. 4. Nature of request – Enrollment exemptions requested due to extraordinary circumstances must be in writing, with appropriate documentation (letter from physician, medical records, restraining orders, or others as indicated), and signed by the Medicaid member, parent/caretaker or person designated to make the request on their behalf. 5. Basis of the determination – EOHHS makes RIte Share participation exemption determinations on a case-by-case basis after considering all required documentation and any other relevant information pertaining to the request. An exemption may be granted for any length of time during the period in which the extraordinary circumstances exist. When an exemption is granted, Medicaid member is enrolled in the appropriate Medicaid managed care plan in accordance with Part 2 of this Subchapter. 6. Limits – An individual's preference to continue a treatment relationship with a doctor or other health care provider who does not participate in the RIte Share plan or Medicaid program does not in and of itself constitute an "extraordinary circumstance." 3.22 Notice and Appeal Rights
Medicaid applicants and recipients shall receive timely notification of eligibility and enrollment determinations and the right to appeal. EOHHS shall also provide timely notification, including appeal rights, of any adverse decisions that reduce or terminate benefits. See Part 10-05-2 of this Title for full statement of these rights. 3.23 Severability
If any provisions of these regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions
or application of these regulations which can be given effect, and to this end the provisions of these regulations are declared to be severable.
210-RICR-30-05-3 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 05 - SERVICE DELIVERY OPTIONS PART 3 - RITE SHARE PREMIUM ASSISTANCE PROGRAM (210-RICR-30-05-3) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 08/17/2025 July 28, 2025 E-SIGNED by Richard Charest on 2025-07-28 10:39:57 EDT July 28, 2025 E-SIGNED by Department of State on 2025-07-28 10:44:47 EDT
210-RICR-30-10-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 10 - PREMIUM ASSISTANCE PROGRAM Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program 1.1 Overview and legal authority
R.I. Gen. Laws § 40-8.12-3 mandated the Executive Office of Health and Human Services (EOHHS) to establish a fund to ensure insurance coverage through HealthSource RI is affordable for parents and caretakers of Medicaid-eligible children in households with incomes below 175% of the Federal Poverty Level (FPL). The fund is available to assist caretakers who are not otherwise eligible for Medicaid through the RI Affordable Health Care Coverage Assistance Program (AHCCA). 1.2 Scope and Purpose A. Caretakers of Medicaid-eligible children in households with incomes below 175% FPL who are not Medicaid eligible themselves can apply for financial assistance for paying for health insurance coverage accessed through HealthSource RI. B. The purpose of this rule is to set forth the provisions governing this financial assistance. The rule describes the scope of the Affordable Health Care Coverage Assistance (AHCCA) Program, the basis for determining eligibility, and the respective responsibilities of the State and the individuals seeking assistance through the Program. 1.3 Definitions A. For the purposes of this rule, the following definitions apply: 1. “Affordable Care Act” or “ACA” means the federal Patient Protection and Affordable Care Act of 2010. The law is also sometimes referred to as “Obamacare” and federal health reform. 2. “APTC/CSR eligibility” means the application of the IRS-based measure of income known as “Modified Adjusted Gross Income” (MAGI) for determining eligibility for affordable health care through health insurance exchanges/marketplaces established under the ACA. Also, “APTC” means advanced premium tax credits and “CSR” means cost-sharing reductions.
3. “Caretaker” means any adult over age nineteen (19) living with a Medicaid-eligible dependent child who has assumed primary responsibility for that child as defined in MCAR section 1305.13, “Eligibility Requirements.” This term includes relatives and non-relatives. 4. “HealthSource RI” means the state-based health insurance marketplace (also referred to as a “benefit exchange”) established in conjunction with implementation of the federal Affordable Care Act of 2010. 5. “Qualified Health Plan” means a health plan certified by HealthSource RI that provides essential benefits and meets all other related ACA requirements to be offered through the State’s health benefits exchange. 6. “Silver Plan” means a Qualified Health Plan offered through HealthSource RI that covers approximately 70% of an enrollee’s medical costs. There are federal subsidies for certain Silver Plan enrollees to help cover co- payments and other out-of-pocket expenses. 1.4 Eligibility Requirements A. Caretakers must meet certain requirements related to income, health coverage, and relationship to be eligible to participate in the AHCCA Program. Coverage through HealthSource RI is also a condition of eligibility. 1. Eligibility – The requirements are as follows: a. Income. Household income at or under 175% of the FPL. b. Health coverage. Caretakers must not be otherwise eligible for Medicaid. c. Relationship. Caretakers need to have primary responsibility for a Medicaid-eligible child who is under the age of nineteen (19). d. Must pay their monthly Silver Plan premium on-time. 2. Plan enrollment – AHCCA financial assistance will be available only if the applicant has enrolled in a Silver Plan through HealthSource RI. 1.5 Application Process A. Caretakers must submit an application for AHCCA through EOHHS. 1. Application forms will be available at the HealthSource RI Contact Center located at: 401 Wampanoag Trail, Riverside, RI 02915 or at EOHHS, Virks Building, 3 West Road, Cranston, RI 02920 or at www.eohhs.ri.gov or www.HealthSourceRI.com. Applicants must also provide basic
demographic information and information regarding enrollment in a Qualified Health Plan through HealthSource RI. 2. State’s Responsibilities – EOHHS must review and determine eligibility for financial assistance within sixty (60) days. If additional information is needed by EOHHS, a new review period will begin once the additional information has been received. 1.6 Eligibility Approval – Premium Amount A. If a caretaker is approved, EOHHS calculates the AHCCA subsidy amount in accordance with the following chart: Rhode Island Affordable Health Care Coverage Assistance Program Assistance Total Family Size 138 % FPL to 150% FPL 151% FPL to 175 % FPL 2 $39 $28 3 $49 $43 4 $59 $58 5 $69 $73 6 $79 $88 1.7 Notice
EOHHS, or its agent, must send a notice to the caretaker with an eligibility determination for AHCCA. All notices must include a statement of the rights of the caretaker applying. 1.8 Payment of Subsidies
The payment option for the AHCCA subsidy includes the following: The caretaker pays the premium due to the insurer to HealthSource RI. EOHHS or its agent mails a check to the caretaker monthly. 1.9 Duration and Continuing Eligibility A. Period of eligibility – Eligibility for the AHCCA subsidy is on a month-to-month basis. The subsidy may be curtailed sooner if there is a change in any eligibility factor that affects household or enrollment in the Qualified Health Plan selected
by the caretaker. Continuation of the subsidy must be reconsidered if such a change occurs, if eligibility under § 1.4 of this Part still applies, AHCCA financial assistance continues. B. Notice – EOHHS must provide notice to the eligible caretaker sixty (60) days prior to termination. The notice must include guidance on how to apply for continued financial assistance as well as the right to appeal EOHHS actions as indicated in § 1.10 of this Part. 1.10 Termination or Denial of Participation
Eligibility for the AHCCA must be denied or terminated, as appropriate, upon determining that an applicant has provided false information on an application for assistance or has not provided timely notification of changes that would affect the eligibility factors set forth in § 1.4 of this Part. 1.11 Hearing and the Right to Appeal A. EOHHS must provide applicants and recipients of AHCCA subsidies with notice of the right to appeal and request a hearing with regard to the following agency actions: 1. A determination that an applicant disapproved for AHCCA participation and the basis for the decision of ineligibility; 2. The amount of assistance determined; 3. Termination of eligibility to participate in the AHCCA. (See regulations contained in Part 10-05-2 of this Title). 1.12 For Further Information or to Obtain Assistance A. See the following websites: 1. www.eohhs.ri.gov 2. www.HealthSourceRI.com B. For assistance finding a place to apply or for assistance completing the application, please call: 1-855-609-3304 or 1-855-840-HSRI (4774) or the Premium Assistance Program at 401-462-0311. 1.13 Severability
If any provisions of these regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these regulations which can be given effect, and to this end the provisions of these regulations are declared to be severable.
210-RICR-30-10-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 10 - PREMIUM ASSISTANCE PART 1 - RHODE ISLAND AFFORDABLE HEALTH CARE COVERAGE ASSISTANCE PROGRAM (210-RICR-30-10-1) Type of Filing: Refile Capabilities Department of State _________________________________________________________________ Regulation Effective Date Original Signing Date _________________________________________________________________ Department of State Initials Department of State Date 01/04/2022 N/A December 15, 2021 E-SIGNED by Department of State on 2021-12-15 15:18:59 EST
210-RICR-30-15-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 15 - EARLY INTERVENTION Part 1 - Early Intervention Program 1.1 Purpose A. The purpose of the Rhode Island Early Intervention (EI) Program is to provide a comprehensive, and coordinated, system of home and community based services and supports for families of infants and toddlers with developmental disabilities or delays. B. The purpose of Early Intervention is to: 1. Enhance the capacity of families to meet the special needs of their infant or toddler. 2. Enhance the developmental functioning of infants and toddlers with special needs. C. The intent of Rhode Island’s Early Intervention system is to establish and support a service delivery model that supports the development of infants and toddlers and utilizes evidence-based practices known to promote learning in young children. This service delivery model identifies the parent/adult caregiver as the primary consumer of Early Intervention services because he/she is the primary agent(s) of change for the child’s well-being and development. 1.2 Statewide Equity
Children and families must have equal access to comprehensive Early Intervention services, as defined in these regulations, irrespective of geographic location. The provision of Early Intervention must be fully compliant with all provisions of the regulations. Early Intervention must be made available to all children referred irrespective of gender, race, ethnicity, religious beliefs, cultural orientation, citizenship, economic status, and educational or medical diagnosis. 1.3 Definitions A. For the purposes of this rule, the following definitions apply: 1. "Act" means R.I. Gen. Laws Chapter 23-13, as amended.
2. "Children" means infants and toddlers from birth through age two (2), who need early intervention services. 3. "Council" means the state Interagency Coordinating Council. 4. "Days" means calendar days. 5. "Department" means the Rhode Island Executive Office of Health and Human Services. 6. "Developmental delay" means significant delay in the developmental areas of cognition, communication development, and physical development, including vision and hearing, social or emotional development, and/or adaptive behavior. 7. "Early Intervention System" means the total effort in the state that is directed at identifying and meeting the needs of eligible children and families. 8. "Early Intervention provider" means an entity (whether public, private or nonprofit) or an individual that provides early intervention services. 9. "Early Intervention services" (here and after referred to as "EIS") means services that are designed to meet the unique developmental needs of the eligible child and the needs of the family related to enhancing the child's development. 10. "Evaluation" means the procedures used by qualified personnel to determine the child's eligibility. 11. "Infants and toddlers with disabilities" means individuals from birth through age two (2) who: a. Have a diagnosed physical or mental condition that has a high probability of resulting in developmental delay; b. Are experiencing developmental delays as measured by a norm- referenced standardized tool that identifies a delay that is 2 standard deviations below the mean in at least one area of development, or 1.5 standard deviations below the mean in two or more areas of development. Areas of development include: cognitive development, physical development (including vision and hearing), communication development, social or emotional development, adaptive development; or
c. Through the use of informed clinical opinion, the multidisciplinary team identifies a significant delay not captured by test scores, significant, atypical behaviors, or significant circumstance. d. In order to be eligible under informed clinical opinion, there must be an impact on child/family functioning to the degree that without intervention developmental delay would result. 12. “Lead agency” means the Rhode Island Executive Office of Health and Human Services (EOHHS). 13. Multidisciplinary" means involvement of two or more disciplines or professions in the provision of integrated and coordinated services, including evaluation and assessment and development of an IFSP (Individualized Family Service Plan). 14. "Parent" means: a. General: (1) A biological or adoptive parent of a child; (2) A guardian generally authorized to act as the child’s parent, or authorized to make early intervention, educational, health or developmental decisions for the child (but not if the child is ward of the state); (3) A person acting in the place of a biological or adoptive parent (such as a grandparent or stepparent with whom the child lives, or a person who is legally responsible for the child's welfare); (4) A surrogate parent who has been assigned in accordance with existing state law and procedures outlined in the Rhode Island Early Intervention Certification Standards. The term does not include the state if the child is a ward of the state. (5) Foster parent. If the biological parents' authority to make the decisions required of parent under the Act has been extinguished under state law. b. The term does not include the state if the child is a ward of the state. 15. “Part C” means Part C of the Individuals with Disabilities Education Improvement ACT of 2004 that addresses infants and toddlers, birth through two (2) years of age with developmental delays or disabilities or
physical or mental conditions with a high probability of resulting in significant delay in development in accordance with 34 C.F.R. 303. 16. Person" means any individual, trust or estate, partnership, corporation (including associations, joint stock companies), limited liability companies, state or political subdivision or instrumentality of a state. 17. "Qualified personnel" means personnel who provide Early Intervention services and who have met state approved or recognized certification, licensing, registration, or other comparable requirements that apply to the area in which the person is providing EIS as outlined in the Rhode Island Early Intervention Certification Standards. 18. “Rhode Island EI Certification Standards” means the policies and procedures defined by the EOHHS to ensure compliance with Part C of IDEA (Individuals with Disabilities Education Act), state regulations and to ensure the provision of quality services and supports to eligible families of infants and toddlers with developmental disabilities and delays in Rhode Island. 19. "Secretary" means the Secretary of the Rhode Island Executive Office of Health and Human Services. 1.4 Lead Agency
The EOHHS is the lead agency responsible for Early Intervention services for infants, toddlers, and their families consistent with final Part C of IDEA regulations effective September 6, 2011 and R.I. Gen. Laws § 23-13-22, as amended. 1.5 Interagency Coordinating Council (ICC) 1.5.1 COMPOSITION OF ICC A. The lead agency shall establish a State Interagency Council and shall provide assistance and resources to the council. The composition of the Council is specifically determined by criteria set forth in Part C of IDEA and in accordance with bylaws. Members of the Council are appointed by the Governor. The Governor shall ensure that the membership of the Council reasonably represents the population of the state. B. The Governor shall designate a member of the Council to serve as the chairperson of the Council. Any member of the Council who is a representative of the Department may not serve as the chairperson. C. Appointments to the Council are for a two-year term. Composition of the Council shall include, but not be limited to:
1. At least twenty percent (20%) of parents of infants or toddlers including minority parents who have been enrolled in the Early Intervention Program within the past three (3) years [minimum 20%]; 2. At least twenty percent (20%) of providers of early intervention services [minimum 20%]; 3. One (1) representative from the legislature; 4. One (1) college or university member involved in personnel preparation; 5. One (1) pediatrician; 6. One (1) representative from each of the state human service agencies involved in the provision of or payment for EIS to infants and toddlers with disabilities and their families (Children, Youth and Families; Education; Health; Human Services; Behavioral Healthcare, Developmental Disabilities, and Hospitals) having sufficient authority to do policy planning or implementation on behalf of the agency; 7. One (1) representative from the advocacy community for children with special needs and their families; 8. At least one (1) representative from the Department of Business Regulation, the agency responsible for state governance of health insurance; 9. At least one (1) representative from the Rhode Island Department of Education, Director of Special Education, responsible for preschool services to children with disabilities. This may or may not be the same representative of the Department of Education as required in subsection (f); 10. At least one (1) member from Head Start / Early Head Start; 11. At least one (1) member from a state agency responsible for child care. This may or may not be the same representative of the Department of Children, Youth, and Families as required in subsection (f); 12. At least one (1) member from the State Medicaid Agency; 13. At least (1) member from the Office of the Coordinator of Education for Homeless Children and Youth; 14. At least one (1) member from the state child welfare agency responsible for foster care. This may or may not be the same representative of the Department of Children, Youth, and Families as required in subsection (f);
15. At least one (1) member from the state agency responsible for children's mental health. D. The Council may include other members selected by the Governor. E. Council shall assume the following responsibilities consistent with the provisions of Part C of IDEA: F. The Council will meet at least quarterly as stated in the by-laws; G. The Council shall announce meetings in sufficient time as to ensure attendance; H. Council meetings shall be open and accessible to the general public; I. Interpreters for the deaf and other services needed to support participation of all interested parties will be provided as necessary; J. No member of ICC may vote on any matter providing direct financial benefit to self or give appearance of conflict, and must conform to the provisions of R.I. Gen. Laws Chapter 36-14, as amended, entitled "Code of Ethics"; K. Advise and assist the EOHHS in the development and implementation of the policies that constitute the statewide system; L. Assist the EOHHS in achieving the full participation, coordination, and cooperation of all appropriate public agencies in the state; M. Assist EOHHS in implementation of the statewide system by establishing a process that includes seeking information from service providers, service coordinators, parents, and others about any federal or state or local policies that impede timely service delivery, and taking steps to ensure that policy problems are identified and resolved; N. Assist EOHHS in resolution of disputes to the extent deemed appropriate; O. Advise and assist EOHHS and state education agency (SEA) in obtaining appropriate services for children ages birth-5 inclusive; P. Advise and assist SEA regarding transition of toddlers with disabilities to services under Part B to preschool and other appropriate services; Q. Advise or assist EOHHS in the preparation of applications and amendments for applications; R. Assist EOHHS in the identification of fiscal sources of support for early intervention programs; S. Assist in the assignment of financial responsibility to the appropriate agency;
T. Assist in the promotion of interagency agreements; U. Submit an annual report to the Governor and to the Secretary of Education on the status of early intervention programs within the state. 1.6 Rhode Island Early Intervention Certification Standards A. The EOHHS shall establish and implement Rhode Island Early Intervention Certification Standards. B. The certification process provides the basis for EOHHS to determine that providers are eligible to participate in and receive payment for the provision of Early Intervention services. Providers must be in conformity with EOHHS’ Rhode Island Certification Standards. C. The Rhode Island Early Intervention Certification Standards establish the policies and procedures required of an Early Intervention program in Rhode Island. D. Full compliance with the Rhode Island Early Intervention Certification Standards is required of all certified Early Intervention programs. E. The EOHHS is responsible for the oversight and monitoring of compliance with these standards. F. Changes to the standards may be made by the EOHHS in order to comply with federal or State regulations and/or to ensure funding, with reasonable notice to providers. Substantial changes to the standards will require certified providers to submit revised or new program policies and an agreement to comply with any changes. G. The EOHHS will hold public hearings on any new or revised policy or procedure outlined in the Rhode Island Early Intervention Certification Standards and provide notice of the hearing held in accordance with 34 C.F.R. § 303.208(b)(1) at least 30 days before the hearing is conducted in order to enable public participation. The EOHHS will also provide opportunities for the general public, including individuals with disabilities, parents of infants and toddlers with disabilities, Early Intervention providers, and members of the Interagency Coordinating Council, to comment for at least 30 days on the new or revised policy or procedure needed to comply with Part C of IDEA. H. No person shall provide EI services as an EI service provider without first becoming certified by the EOHHS. I. In order to become certified as an EI service provider, an agency or organization shall submit notice of intent to apply for certification status to the EOHHS. Required documentation includes the submission of an Implementation Plan demonstrating compliance with the regulations herein, and the Rhode Island Early Intervention Certification Standards.
1. The Implementation Plan must include at a minimum: a. Initial Staffing and Supervision Plan; b. Initial Budget; c. Initial Organizational Plan including how Early Intervention fits into the agency structure; d. Evidence of an understanding of RI Early Intervention Principles and Practices; e. Evidence of understanding and the ability to comply with all state and federal requirements and RI Certification Standards. J. Organizations must submit any change to program policies and procedures or organizational changes (impacting Early Intervention) to the EOHHS. K. Certification shall be granted for a one-year period. Early Intervention Certification is valid and renewed annually, contingent upon continuing compliance with federal and state regulations and with the Rhode Island Early Intervention Certification Standards. L. The EOHHS shall certify applicants as it deems appropriate and necessary in order to assure a viable statewide early intervention system that provides quality services to infants and toddlers with disabilities and developmental delay. Factors reviewed to ensure that Rhode Island has the capacity to meet the need for Early Intervention include changes in population, performance indicators, or in the number of certified providers. M. The EOHHS determines the structure of the Rhode Island Early Intervention system and shall make changes as needed. N. The EOHHS will continually monitor compliance with Rhode Island Early Intervention Certification Standards. Technical assistance is available. The EOHHS may apply sanctions for non-compliance which may include but not be limited to: 1. Corrective action plans/Performance Improvement Plans; 2. Mandatory technical assistance; 3. Additional reporting requirements; 4. Suspension of new referrals; 5. Recoupment of funds; 6. Provisional certification status, suspension or termination of certification.
1.7 Monitoring A. The EOHHS is responsible for the general administration, supervision and monitoring of certified Early Intervention programs and activities to carry out Part C of the Act. B. The EOHHS shall establish and implement a system of general supervision that includes multiple methods to ensure implementation of Part C of the ACT, and compliance with Rhode Island Early Intervention Certification Standards, identify and correct noncompliance, facilitate improvement, and support practices that improve results and functional outcomes for children and their families. C. Monitoring activities shall include annual determination about the performance of each certified Early Intervention provider. 1.8 Eligible Population 1.8.1 DEFINITION OF THE ELIGIBLE POPULATION A. Children eligible for early intervention include: 1. Children with a single established condition. Criteria: The child has a diagnosed physical or mental condition that has a high probability of resulting in developmental delays including, but not limited to, chromosomal abnormalities; genetic or congenital disorders; neurological, metabolic disorders; hearing impairments and visual impairments not corrected by medical intervention or prosthesis; congenital infections; severe attachment disorders and disorders secondary to exposure to toxic substances including fetal alcohol syndrome. Evidence of diagnosis must be in the child’s record. a. Children with established developmental delays. Criteria: The child exhibits a delay in one or more areas of development as measured by a norm referenced standardized tool that identifies a delay that is 2 standard deviations below the mean in one area of development, or 1.5 standard deviations below mean in two or more areas of development).
Or b. Through the use of informed clinical opinion, the multidisciplinary team identifies a significant delay not captured by test scores, significant atypical behaviors or significant circumstances. In order to be eligible under informed clinical opinion, there must be an impact on child/family functioning to the degree that, without intervention, developmental delay would result.
1.9 State Interagency Coordination
It is the responsibility of the EOHHS to identify and coordinate all available resources for Early Intervention in the state including developing formal interagency agreements, assigning financial responsibility to the appropriate agencies and developing procedures for securing timely reimbursement of funds. Additional responsibilities include resolving intra- and interagency disputes and developing procedures to ensure that services are provided in a timely manner pending resolution of any disputes. 1.10 Central Directory of Services A. The EOHHS shall oversee a central directory that is accessible to the general public (i.e., through the EOHHS’s web site and other appropriate means) that is accurate and up to date and includes: 1. Information on research and demonstration projects in the state; 2. Professionals and other groups providing assistance to infants and toddlers with disabilities eligible for early intervention and their families; 3. Public and private early intervention services. 1.11 Comprehensive Child Find System A. Child Find efforts shall be coordinated by the EOHHS with all state agencies and relevant community programs (e.g., Department of Education, Department of Human Services, Maternal and Child Health, Newborn Hearing Screening, Medicaid EPSDT, Department of Children, Youth and Families, Head Start, Early Head Start and First Connections Program). Screening (by Primary Care Providers, DOH Family Visiting Programs, and other community programs), direct referrals and public awareness, shall be implemented concurrently on a statewide basis to ensure that all infants and toddlers in the state who are eligible for services are identified, located, and evaluated. B. Newborn screening shall occur for every child born in Rhode Island and includes screening at birth for risk factors related to developmental delay, or adverse developmental consequences. Follow-up screening shall occur at periodic intervals between birth and through age two (2). This initial screening may occur in the hospital and will continue via other health care providers in the community. C. In-home screening, for all those identified as having risk factors, is a comprehensive process that is intended to identify children in need of additional services. After in-home screening is completed, and on-going risk factors have been identified, the child and family's needs will be addressed through a community based review process. Alternatively, children who are determined to have probable eligibility for EIS shall be referred to an EI service provider.
D. All early intervention service providers certified by the EOHHS shall implement a standard direct referral process as outlined in the Rhode Island Certification Standards which permits families and community-based agencies to refer infants and toddlers directly to programs for screening, evaluation and assessment to determine eligibility for EIS. E. Referrals will be made by primary referral sources (i.e., hospitals, physicians, parents, child care centers, LEAs, public health facilities, other social service agencies and other health care providers) within seven (7) working days after the child is identified. F. All children under the age of three who are involved in a substantiated case of child abuse or neglect or are identified as affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure shall be referred to EI. G. The EOHHS shall establish and implement a public awareness program that focuses on the early identification of infants and toddlers with disabilities and provides information to parents of infants and toddlers through primary referral sources. Information is made available to families and the general public as well as primary referral sources. 1.12 Comprehensive System of Personnel Development A. The EOHHS shall establish and implement a comprehensive system of personnel development including training paraprofessionals, and primary referral sources with respect to the basic components of early intervention and training personnel to coordinate transition services for infants and toddlers with disabilities. Functions of the Rhode Island Comprehensive System of Personnel Development shall include: 1. Recruitment and retention of qualified personnel; 2. Increased workforce capacity; 3. Professional development and technical assistance for the current workforce; 4. Implementation of evidence based practices; 5. Leadership development across the Rhode Island Early Intervention systems. 1.13 System of Payments A. The Rhode Island Early Intervention system of payments includes a combination of state and federal funds and the use of public and private insurance. Early Intervention is a state-required benefit for all insurance plans issued in Rhode
Island. RI General Laws §§ 27-18-64, 27-20-50, and 27-41-68 require private and public insurers based in Rhode Island and providing coverage for dependent children to cover the cost of Early Intervention services. Plans may not include deductibles, co-pays, or co-insurance. Rhode Island residents may have employer-sponsored health benefit plans or “self- insured” plans that are exempt from Rhode Island State law but these plans must follow federal law. These plans and other out-of-state plans may provide “essential benefits”, including “rehabilitative and habilitative services and devices” depending on the plan design, which may cover early intervention services. Any Early Intervention service not covered by health insurance or health benefit plans exempt from Rhode Island State law including deductibles, co-pays or co-insurance is funded through the use of public and Part C funds. B. The Rhode Island Early Intervention system of payments does not include any family fees, co-payments or deductibles. Therefore, there is no family payment system; no sliding or cost participation fees; no basis for determining fees; and no definitions regarding ability and inability to pay. C. The Rhode Island Early Intervention system will ensure that parents are not charged any out-of-pocket costs for any Part C services. Fees will not be charged for the services that a child is otherwise entitled to receive at no cost to the parents including: 1. Implementation of the child find requirements; 2. Evaluation and assessment; 3. Service coordination; 4. Administrative and coordinative activities related to: a. The development, review, and evaluation of IFSPs; b. The implementation of procedural safeguards; c. All Early Intervention services authorized on the IFSP, including any co-payments or deductibles related to these services. D. The Rhode Island Early Intervention system does not charge any fees to parents, copayments or deductibles, therefore: 1. The inability of the parents to pay for services will not result in the delay or denial of services to the child or the child’s family; 2. Families will not be charged any more than the actual cost of an Early Intervention service;
3. Parents with public insurance or benefits or private insurance will not be charged disproportionately more than those who do not; and 4. No fees will be charged to parents for failure to provide income information. E. Parents are only responsible for the cost of their health insurance premiums. F. No service a child is entitled to receive will be delayed or denied due to disputes between agencies regarding financial or other responsibilities. G. All Part C services on the IFSP are available to the child and family whether or not consent to use insurance or Medicaid is required or provided. H. Payor of Last Resort 1. Part C funds may be used for activities or expenses that are reasonable and necessary for implementing the Rhode Island Early Intervention system including direct Part C services for children and families and the cost of co-pays and deductibles. Part C funds will be used as the payor of last resort and cannot be used to satisfy a financial commitment for services that would otherwise have been paid for from another public or private source. However, if necessary to prevent a delay in the timely provision of appropriate Part C services to an infant/toddler or the family, funds may be used to pay the provider of services for services and functions authorized under Part C pending reimbursement from the insurance provider that has ultimate responsibility for the payment. I. The Use of Private Insurance to Pay for Part C Services 1. Consent for the use of private insurance is not required because the Part C required specific protections are provided by Rhode Island state statutes governing insurance in Rhode Island. Parents who have insurance plans exempt from RI law are also afforded the required specific protections under Federal law. a. Required Protection C.F.R. § 303.520(b)2(i) (1) The use of private health insurance to pay for Part C services cannot count towards or result in a loss of benefits due to the annual or lifetime health insurance coverage caps for the infant or toddler with a disability, the parent or the child’s family members who are covered under that health policy. b. Required Protection C.F.R. § 303.520(b)2(ii)
(1) The use of private health insurance to pay for Part C services cannot negatively affect the availability of health insurance to the infant or toddler with a disability, the parent, or the child’s family members who are covered under that health policy and health insurance may not be discontinued for these individuals due to the use of the health insurance to pay for Part C services. c. Required Protection C.F.R. § 303.520(b)2(iii) (1) The use of private health insurance to pay for Part C services cannot be the basis for increasing the health insurance premiums of the infant and toddler with a disability, the parent, or the child’s family members covered under that health insurance policy. J. Notification prior to the initial use of the parent’s private insurance is required as well as consent to release personally identifiable information for billing purposes. Consent to release personally identifiable information can be revoked at any time without the risk of losing Early Intervention services. K. The Use of Public Benefits or Public Insurance to Pay for Part C Services – Medicaid/RIte Care: 1. The use of public benefits or public insurance is allowed to pay for Part C services, however the following provisions must be followed: a. Parents are not required to sign up or enroll in a public benefits or public insurance program as a condition for their child to receive Part C services. b. Parental notification must be provided prior to using public benefits or public insurance of a child or parent if that child or parent is enrolled in a public benefits or public insurance program. Parental notification must include the following: (1) A statement that in Rhode Island when using public insurance, parents have no out-of-pocket costs except for insurance premiums. Co-pays, co-insurance and deductibles are not charged to parents. (2) Consent for disclosure of personally identifiable information to bill public insurance is not required because EOHHS administers both Part C and Medicaid. (3) A statement that parents, who have both private insurance and public insurance, state Medicaid regulations require the use of private insurance as the primary insurance.
(4) In Rhode Island, consent is not required to bill private insurance because of specific protections provided in state statute and federal law. However, notification prior to the initial use of the parent’s private insurance is required as well as consent to release personally identifiable information for billing purposes. (For parents with public insurance, consent to release personally identifiable information was provided upon enrollment in Medicaid). Consent to release personally identifiable information can be revoked at any time without the risk of losing Early Intervention services. L. If an infant or toddler or parent is enrolled in a public benefits or public insurance program, written parental consent is not required because the use of these benefits to pay for Part C services does not: 1. Decrease available lifetime coverage or any other insured benefit for the child or parent; or 2. Result in the child’s parents paying for services that would otherwise be covered by public benefits or insurance; or 3. Result in any increase in premiums or cancellation of public benefits or insurance for the child or parent; or 4. Risk the loss of eligibility for the child or the child’s parents for home and community-based waivers based on total health-related costs. 5. Prior to the initial use of private or public insurance, the EI provider must provide families with the following: a. Procedural safeguards including the right to participate in mediation; request a due process hearing; or file a state complaint; b. Written notice related to the use of private insurance and Medicaid. 1.14 Resolving Complaints A. The Rhode Island EOHHS, as lead agency, is responsible to review, investigate and act on any complaints or allegations of noncompliance with Part C of IDEA or with Rhode Island Early Intervention Certification standards, policies, or procedures by a certified Early Intervention Provider. The complaint procedure is publicly available on the EOHHS website. B. Any public agency, public employee, parent, private individual or organization may file a written complaint alleging that there has been an instance of noncompliance with IDEA Part C or with Rhode Island Certification Standards, policies, or procedures by any certified Early Intervention Provider.
C. The parent, organization, or individual filing the complaint must submit a signed written complaint to the Part C Coordinator and simultaneously forward a copy of the complaint to the EI provider serving the child. D. The complaint must be completed, signed, dated and submitted to the Part C Coordinator. The Early Intervention Complaint form is given to parents at Intake and is available on line at: http://www.eohhs.ri.gov E. The EI provider will assist the parent in filing a written complaint if requested. F. The Early Intervention Complaint Form (or facsimile) shall be used and must include: 1. A statement that the EI provider has violated a requirement of Part C of the IDEA; 2. The facts on which the statement is based; 3. The signature and contact information for the individual filing the complaint; and 4. The name and address of the child; 5. The name of the EI provider serving the child; 6. A description of the nature of the problem of the child, including facts relating to the problem; and 7. A proposed resolution of the problem to the extent known and available to the party at the time the complaint is filed. G. The violation must have allegedly occurred not more than one (1) year prior to the date that the complaint is received. H. The lead agency will conduct an investigation of the complaint through interviews and a review of the early intervention record(s) or may determine that an independent on-site investigation is necessary. The complainant will be given the opportunity to submit additional information orally or in writing within the required timeline. I. The EI provider will be given an opportunity to respond to the complaint; including at the discretion of the lead agency, a proposal to resolve the complaint. J. A parent who has filed a complaint will be given an opportunity to voluntarily engage in mediation with the EI provider.
K. EI programs shall cooperate with the lead agency by providing full access to all records and personnel involved. L. The lead agency will review all relevant information and determine whether there has been a violation of a requirement of the Rhode Island Early Intervention system and will issue a written decision within sixty (60) days. A time extension may be permitted only if exceptional circumstances exist with respect to the complaint or if the parent and the EI provider agree to extend the time to engage in mediation. M. The written decision will address each allegation in the complaint and will contain the following: 1. Findings of facts and conclusions: 2. The reasons for the final decision; 3. The procedures to effectively implement the decision including corrective actions needed to achieve compliance, negotiations and technical assistance; N. If the lead agency has found that the EI provider failed to provide appropriate services, the lead agency must address corrective actions required to correct the cause of the complaint. This includes corrective actions required of the system or of the EI program which impact the future provision of service for children with disabilities and their families, and compensatory services or monetary reimbursement as appropriate to the needs of the child and the child’s family. O. Final decisions are binding and enforceable. The lead agency may monitor the EI provider regarding implementation of corrective actions and if corrective actions are not implemented the lead agency may terminate the EI provider’s certification agreement. P. If an issue is raised in the written complaint, or there are multiple issues in which one or more are also part of a due process hearing request, the issue(s) must be set aside until the conclusion of the due process hearing. The remaining issues must be resolved using the written complaint time limits. Q. If an issue is raised in the written complaint, which has already been decided in a due process hearing, the previous decision is binding and the complainant must be so informed. R. A written complaint alleging a failure of the EI provider to implement a decision made pursuant to a “Request for Due Process Hearing” must be resolved by the lead agency. S. If a parent is not satisfied with the final decision issued by the lead agency, a “Request for a Due Process Hearing” may be filed by the parent if the written
complaint was about a proposal to initiate or change the identification, evaluation or early intervention services of their child; or the refusal to initiate or change the child’s identification, evaluation or early intervention services of their child. 1.15 Mediation A. When filing a written complaint or a request for a due process hearing, families must be offered mediation as a formal method for resolving any dispute. Parents will be notified of mediation procedures in writing, initially and annually from the EI provider. Parents also receive written notice of all rights available to them whenever prior written notice is given. B. The EOHHS will offer mediation to the parent as a first step in resolving a disagreement when the parent(s) file: 1. A written complaint; 2. A request for a due process hearing. C. Mediation is voluntary on the part of all parties. The EOHHS identifies individual mediators to provide EI mediation services. EOHHS maintains a list of qualified and impartial mediators who are required to undergo training in effective mediation techniques and are knowledgeable in laws, regulations, policies and procedures related to the provision of EI services. D. Mediation cannot be used to deny or delay the parent’s right to a due process hearing or any other rights. E. The parent may refuse or withdraw from the mediation process at any time. F. The mediation process, including a written mediation agreement, must be completed to ensure enough time for completion of a due process hearing or complaint investigation by the lead agency, unless an extension of time has been granted by the EOHHS in the case of a written complaint or the hearing officer in the case of a due process hearing. G. Each session in the mediation process must be scheduled in a timely manner and must be held in a location that is convenient to the parties (parent and EI service provider) to the dispute. The lead agency must bear the cost of the mediation process, including the costs of meetings or sessions described above. H. If the parties resolve a dispute through the mediation process, the parties must execute a legally binding agreement that sets forth the resolution of the dispute and: I. States that all discussions that occurred during the mediation process shall remain confidential and may not be used as evidence in any subsequent due process hearing or civil proceeding; and
J. Is signed by both the parent and a representative of the lead agency to bind the agency to what has been agreed upon; K. A written, signed mediation agreement is enforceable in any state court of competent jurisdiction or in a district court of the United States. 1.16 Due Process Hearing A. A due process hearing is a formal review of a complaint identified by the parent, all data related to the problem, and testimony from the parties concerned. B. Parents may request a hearing with regard to: 1. A proposal to initiate or change the identification, evaluation or early intervention services of their child; 2. Refusal to initiate or change the child’s identification, evaluation, or early intervention services of their child. 3. A request that information in their child’s record be amended and the Early Intervention provider refuses to amend the record in accordance with the request (see Access to Records procedure). C. A “Request for a Due Process Hearing” form must be completed, signed and dated by the parent or the parent’s representative and submitted to the Part C Coordinator. This form is given to parents at intake and is also available online at: http://www.eohhs.ri.gov/ProvidersPartners/ProviderManualsGuidelines/Medicaid ProviderManual/EarlyInterventionProviders/EarlyInterventionProgram.aspx D. The EI provider will assist the parent in filing a “Request for a Due Process” Hearing upon parent request. E. When a hearing is requested by the parent, the lead agency will inform the parent of the right to mediation and of any free or low cost legal services available to the parent. F. The hearing will be scheduled at a time and in a location that is convenient for the parents. G. The due process hearing must be completed, and a written decision mailed to each of the parties within thirty (30) calendar days of the receipt of the request. Mediation, if attempted, must occur within the same thirty (30) days. A hearing officer may grant specific extensions of time beyond the period set, at the request of either party. H. The hearing officer:
1. Shall not be an employee of the lead agency or program involved in the provision of early intervention services or care of the child, nor have a personal or professional interest that would conflict with his or her objectivity in implementing the process. A hearing officer cannot be an employee of an agency solely because the person is paid by the agency to implement hearing or mediation procedures under this part. 2. Shall have knowledge about the provision of early intervention and services available for infants and toddlers with disabilities and their families. 3. Shall listen to the presentation of viewpoints concerning the matter under review, examine all information relevant to the issues, and seek to reach a timely resolution of the matter. I. Parents have the right to: 1. Be accompanied and advised by counsel and or individuals with special knowledge or training with respect to early intervention services for eligible children. 2. Present evidence and confront, cross-examine, and compel the attendance of witnesses. 3. Prohibit the introduction of any evidence at the hearing that has not been disclosed to them at least five (5) days before the proceeding. 4. Obtain a written or electronic verbatim transcription of the proceedings. 5. Obtain written findings of fact, conclusions of law, and decisions at no cost. J. The hearing officer shall inform the parents or guardians and lead agency of their decision in writing within thirty (30) days of the request. K. Any party disagreeing with the results of the hearing has the right to bring civil action in State or Federal court. L. The lead agency shall ensure that the results of the hearing are implemented. M. A child must continue to receive IFSP services consented to by the parent pending a hearing unless the parent and the EOHHS agree otherwise. If the hearing involves agreement on the initial IFSP, the child shall receive those services that are not in dispute.
1.17 Severability
If any provisions of these rules and regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of the rules and regulations which can be given effect, and to this end the provisions of the rules and regulations are declared to be severable.
210-RICR-30-15-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 15 - EARLY INTERVENTION PART 1 - EARLY INTERVENTION PROGRAM (210-RICR-30-15-1) Type of Filing: Refile Capabilities Department of State _________________________________________________________________ Regulation Effective Date Original Signing Date _________________________________________________________________ Department of State Initials Department of State Date 01/04/2022 N/A December 15, 2021 E-SIGNED by Department of State on 2021-12-15 15:19:23 EST
210-RICR-40-00-1 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 – MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 00 – INTEGRATED HEALTH CARE COVERAGE GROUPS PART 1 – OVERVIEW OF MEDICAID INTEGRATED HEALTH CARE COVERAGE 1.1 Overview of this Chapter A. This Chapter establishes the Medicaid Integrated Health Care Coverage (IHCC) groups for elders, adults with disabilities, and certain individuals who qualify as medically needy (MN) due to high health care expenses. In addition, sections of this Chapter set forth the basic tenets of the Supplemental Security Income (SSI) methodology for determining Medicaid eligibility in general and, specifically, for those applicants and beneficiaries seeking coverage through an IHCC Community Medicaid eligibility pathway. B. The term Community Medicaid refers hereinafter to anyone applying for or renewing eligibility for non-LTSS Medicaid health coverage as MN or through a pathway for elders and adults with disabilities on the basis of SSI, an SSI-related characteristic (that is, age, blindness or disability), or special requirements related to a particular characteristic, condition or circumstances. Community Medicaid also encompasses Medicare beneficiaries seeking financial assistance through the State’s Medicare Premium Payment Program (MPPP). C. Although all the IHCC groups for MN and elders and adults with disabilities are described in this Chapter – both Community Medicaid and LTSS – there are separate sections, as indicated below, that provide more in-depth provisions related to IHCC groups, as follows: 1. The Sherlock Plan and Ticket to Work Plan provide eligibility pathways for adults with disabilities who are working. Although referenced in this Section as two of the IHCC groups subject to the SSI methodology, the Sherlock Plan and Ticket to Work Plan are covered in detail in a separate section (Subchapter 15, Part 1 of this Chapter) along with other eligibility opportunities for persons with disabilities who are working. 2. An overview of the LTSS coverage groups subject to the SSI methodology is included in this Chapter to show areas of overlap in the application process and determination of financial eligibility. However, LTSS eligibility and services are covered in detail in Chapter 50 of this Title.
3. Children and families in the IHCC category who are eligible on the basis of their participation in other programs – e.g., children in foster care or SSI- eligible – are addressed in Part 30-00-1 of this Title. 1.2 Authority A. This Part is promulgated pursuant to Federal authorities as follows: 1. Federal Law: Title XIX of the U.S. Social Security Act, 42 U.S.C. §§ 1396- 1396w-7; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148; and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-115. 2. The Medicaid State Plan and the Section 1115 Waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. B. Applicable State authority is derived from R.I. Gen. Laws Title 40 and R.I. Gen. Laws Chapter 42-7.2.
1.3 Scope and Purpose A. This Part provides an overview of the IHCC groups included in this Chapter. The rules governing the IHCC groups have been amended and revised as set forth herein to reflect programmatic changes resulting from the following State and federal Medicaid initiatives: 1. Section 1115 Waiver – The rules in this Chapter implement Section 1115 Waiver authorities that streamline and refine SSI-based eligibility determinations, enhance the availability of cost-effective primary care, and improve the integration of services and a wider range of supports across the care continuum. 2. ACA Implementation – The federal Patient Protection and Affordable Care Act (ACA), Pub. L. No. 111-148, mandated changes in the way states organize Medicaid coverage groups, the standards they use for determining income-based eligibility, and the application and renewal processes for all eligible populations. This Chapter establishes administrative rules that implement ACA reforms related to eligibility and the application and renewal process for the IHCC groups to ensure they match those already in effect for MACC groups. 3. Integrated Eligibility System – RI Bridges is the State’s integrated health and human services eligibility system (IES). The State’s IES provides the State with the system capacity to implement all programmatic changes required by the ACA and authorized under the Section 1115 Waiver. In addition to automating most facets of the application, eligibility determination and enrollment processes, the State’s IES also conducts a
multi-tiered evaluation of eligibility that makes it possible to consider applicants for most forms of publicly financed health coverage and various other State-administered health and human services through a single application process. 1.4 Definitions A. For the purposes of this Chapter, the following definitions apply: 1. “Affordable Care Act” or “ACA” means the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, and the Three Percent Withholding Repeal and Job Creation Act, Pub. L. No. 112- 56. 2. “Applicant” means the person in the household who, if determined eligible, would qualify for Medicaid in one of the Integrated Health Care Coverage groups on the basis of the provisions set forth herein. 3. “Calendar quarter” means a period of three (3) full calendar months beginning with January, April, July, or October. 4. “Community Medicaid” means the term used to refer to IHCC groups that are provided with Medicaid health coverage for essential primary care and limited preventive services in some circumstances, but does not include more than thirty (30) days of continuous LTSS. 5. “Executive Office of Health and Human Services” or “EOHHS” means the state agency established under the provisions of R.I. Gen. Laws Chapter 42-7.2 designated as the single State agency for the Medicaid program. 6. “Dual Eligible Beneficiary” means a person who is enrolled in Medicaid and Medicare. The term includes elders and adults with disabilities who are enrolled in Medicare and receive Medicaid health coverage and/or financial assistance through the State’s Medicare Premium Payment Program (MPPP). 7. “Income Standard” or “Income Limit” means the maximum amount of countable income a person can have to qualify for Medicaid health coverage through an eligibility pathway or coverage group after all required exclusions, disregards, and deductions. 8. “Long-Term Services and Supports” or “LTSS" means a spectrum of services covered by the Rhode Island Medicaid program for persons with clinical and functional impairments and/or chronic illness that require the level of care typically provided in a health care institution. Medicaid LTSS includes skilled or custodial nursing facility care, therapeutic day services, and personal care as well as various home and community-based
services. Medicaid beneficiaries eligible for LTSS are also provided with primary care essential benefits. 10. “Medicaid Affordable Care Coverage (MACC) Groups” means the populations whose income eligibility for Medicaid is determined on the basis of the Modified Adjusted Gross Income (MAGI) standard. This includes children up to age nineteen (19), parents/caretakers, pregnant people, and otherwise ineligible adults age nineteen (19) to sixty-four (64) in accordance with the provisions established in Part 30-00-1 of this Title. 12. “Primary Care Essential Benefits” means non-LTSS Medicaid health coverage, and includes an array of acute, subacute, and specialty essential benefits, as identified under the Medicaid State Plan and Section 1115 Waiver, provided by licensed health professionals. These essential benefits include, but are not limited to: health promotion, disease prevention, health maintenance, counseling, patient education, various specialty services, and diagnosis and treatment of acute and chronic medical and behavioral health illnesses and conditions in a variety of health care settings (e.g., office visits, inpatient, home care, day care, etc.). 13. “Primary Care Provider” means a health care practitioner who is licensed as: a. a physician with a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine and is responsible for monitoring a beneficiary’s overall health; or b. a nurse practitioner, clinical nurse specialist, or physician assistant and, to the extent licensure allows, is responsible for, or collaborates with a physician, monitoring a beneficiary’s overall health. 14. “Resource Standard” or “Resource Limit” means the maximum amount of resources a person can have to qualify for Medicaid health coverage through an eligibility pathway or coverage group after all required exclusions. 15. "Section 1115 Waiver" means the waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. 16. “Title XIX” means Title XIX of the U.S. Social Security Act, 42 U.S.C. §§ 1396-1396w-7, that established the Medicaid program and provides the legal basis for providing services and benefits to certain populations in each IHCC group. 17. “Wrap-around Coverage” means the Medicaid benefits provided to a beneficiary who has another form of health insurance – e.g., Medicare or a
commercial plan – that serves as the principal payer for their health care, but that does not cover those benefits. 1.5 IHCC Groups Subject to the SSI Methodology A. The provisions of this Chapter govern the following eligibility pathways that use the SSI methodology in whole or in part to determine eligibility for Medicaid benefits: 1. Elders and Adults with Disabilities (EAD) – Low-income elders who are sixty-five (65) and older and adults living with disabilities who have income at or below one hundred percent (100%) of the Federal Poverty Level (FPL) and resources at or under $4,000 for an individual or $6,000 for a couple. 2. Medically Needy (MN) – Elders, adults with disabilities, children, parents and caretakers of Medicaid-eligible children, and pregnant people who do not qualify for eligibility on the basis of income but have high health expenses and must spend or contribute income and/or resources above the applicable income standard to obtain or retain Medicaid eligibility. Subchapter 05 Part 2 of this Chapter pertains to the MN eligibility pathway for Community Medicaid. 3. Supplemental Security Income (SSI) Recipients – All persons receiving SSI cash assistance based on age or as an adult with a disability, as determined by the federal Social Security Administration (SSA). SSI recipients are automatically eligible for Medicaid on this basis and are not required to apply for Medicaid health coverage through the State. Program-specific provisions for SSI recipients twenty-one (21) and older are included in this Chapter. The relevant provisions for Medicaid beneficiaries under twenty-one (21) are located in the sections pertaining to coverage for children and families. 4. State Supplement Payment (SSP) – Persons who qualify to receive the optional state-funded supplemental payment under 218-RICR-20-00-5 are automatically eligible for Medicaid health coverage under the Medicaid State Plan. 5. SSI Protected Status Beneficiaries – This group, sometimes referred to as “SSI-lookalikes,” includes persons who meet the age or disability criteria for SSI, but are ineligible for full SSI cash benefits or qualify for special treatment. To protect Medicaid health coverage for members of these coverage groups, federal law requires the application of special rules that confer or preserve Medicaid eligibility. 6. Medicaid Premium Payment Program (MPPP) for Medicare beneficiaries with income at or below one hundred thirty-five percent (135%) of the FPL.
The MPPP provides financial help through Medicaid to assist in paying Medicare costs including premiums, deductibles, and coinsurance in amounts that vary depending on income and resources. 7. Sherlock Plan for Working Adults with Disabilities – The State’s program for working adults with disabilities age sixty-five (65) and older. The Sherlock Plan provides Medicaid health coverage and/or LTSS to persons with disabilities who are working. As set forth in greater detail in Subchapter 15, Part 1 of this Title, Sherlock beneficiaries age sixty-five (65) or older in this group may have countable income at or below two- hundred fifty percent (250%) of the FPL and resources less than or equal to $10,000 for an individual and $20,000 for a couple. 8. Ticket to Work Plan for Working Adults with Disabilities – The State’s program for working adults with disabilities ages sixteen (16) to sixty-four (64). The Ticket to Work Plan provides Medicaid health coverage and/or LTSS to persons with disabilities who are working. As set forth in greater detail in Subchapter 15, Part 1 of this Title, Ticket to Work beneficiaries are not required to meet an income or resource standard in order to qualify for coverage. 9. IHCC Medicaid LTSS -- Consists of new applicants seeking Medicaid- funded LTSS and current IHCC group beneficiaries who develop a continuous need for the level of care typically provided in an institution (hospital, nursing facility, or intermediate care facility for person with intellectual disabilities). Beneficiaries eligible in the MACC groups who require LTSS are not subject to the SSI methodology; LTSS eligibility based on the SSI methodology and more generally is located in Chapter 50 of this Title. 1.6 IHCC Special Coverage Groups A. The IHCC category also includes members of the special coverage groups below who are subject to unique eligibility requirements waiving some or all facets of the SSI methodology due to specific conditions, circumstances, or characteristics. 1. Low-income, uninsured people with breast or cervical cancer – Medicaid coverage group for uninsured people under age sixty-five (65) who are screened under the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program and are found to need treatment for breast or cervical cancer or for precancerous conditions of the breast or cervix. 2. Refugee Medicaid Assistance (RMA) – Federally mandated coverage group for individuals and families operating under the auspices of the U.S. Department of Health and Human Services, Office of Refugee
Resettlement. Refugees who qualify for this program receive eight (8) months of Medicaid health coverage or commercial coverage with financial help through HealthSource RI (HSRI), depending on income. Eligibility is evaluated first using the MAGI methodology set forth Part 30- 00-1 of this Title, and the SSI standards for Community Medicaid in Part 40-05-1 of this Chapter. Only persons in this group who are ineligible for Medicaid or commercial plan with financial help and have income at or below two hundred percent (200%) of the FPL may qualify for MN coverage under this pathway. 3. Emergency Medicaid – Medicaid health coverage available to non-citizens who have emergency health care needs who meet all the general and income requirements for coverage with the exception of immigration status. 1.7 The State’s Integrated Eligibility System (IES) A. With the implementation of the State’s IES, all IHCC group members have the option of applying online, using a self-service portal, submitting a completed paper application, or in-person by visiting one of the field offices of the RI Department of Human Services (DHS). The IES also allows for the following important changes to the application and eligibility determination process: 1. Coverage Group Options – To maximize choice and ease of access, the State’s IES evaluates all applicants for Medicaid health coverage using multiple eligibility pathways, within and across the major coverage group categories. 2. Streamlined Document Submission and Verification – The State’s IES created the capacity for applicants and beneficiaries to upload important documents and verification materials online as well through more traditional means. The system also has capacity to access to a broader array of electronic data sources for verifying and updating critical eligibility information related to income and assets. 3. Modified Passive Eligibility Renewal – The eligibility renewal process for IHCC group members has been reformed to ease the burden on beneficiaries. The State’s passive renewal process requires beneficiaries to review the eligibility information in their accounts, including updates through electronic data sources, and notify the agency within a specified time period of any changes or discrepancies that may affect the continuation of coverage. The renewal process and variations across coverage groups are set forth in Part 2 of this Subchapter.
1.8 Medicaid Benefits A. The benefits that members of the IHCC groups receive are dictated by the Medicaid State Plan and the State’s Section 1115 Waiver. Medicaid benefits include health care services and supports or, if a beneficiary has third party coverage such as Medicare, wrap-around coverage and/or financial assistance in paying premiums, co-pays, and cost-sharing. 1. Premium Assistance/and Financial Help – Dual eligible beneficiaries, including those participating in the MPPP, may receive full Medicaid health coverage and/or financial help paying for Medicare. The scope of benefits dual eligible beneficiaries receive depends on their income and resources as set forth in Subchapter 05 Part 1 of this Chapter. Premium assistance is also available for some Community Medicaid beneficiaries who have access to employer-sponsored insurance through the RIte Share Premium Assistance Program as set forth in Part 30-05-3 of this Title. 2. Health Care Services and Supports – The scope of services and supports beneficiaries receive varies as follows: a. Community Medicaid. Beneficiaries eligible for health coverage receive the full scope of medically necessary primary care essential benefits – including acute, subacute and rehabilitative services – as well as thirty (30) days of LTSS and, based on need, a limited set of LTSS preventive services. Subchapter 10 Part 1 of this Chapter identifies the scope of covered services available through the managed care and fee-for-service delivery options for IHCC group beneficiaries eligible for full Medicaid benefits. Note: (1) The Medicaid benefits MPPP participants are eligible to receive may be limited to premium payment assistance only, depending on the basis of eligibility. See Subchapter 05 Part 1 of this Chapter. (2) For the scope of services covered under the Sherlock and Ticket to Work Plans, see Subchapter 15 Part 1 of this Chapter. b. Medicaid LTSS. Medicaid LTSS includes health supports, personal care, and social services in an institutional or home and community-based setting. The scope of Medicaid LTSS a beneficiary receives is based on need -- health status and functional ability -- and personal health preferences and goals. Persons eligible for Medicaid LTSS also receive the full scope of medically necessary primary care essential benefits. To be eligible for Medicaid LTSS, a person must meet a specific set of financial
and clinical criteria that do not apply to applicants seeking coverage through other Medicaid eligibility pathways. 3. Integrated Care -- The State’s Integrated Care Initiative (ICI) provides IHCC group members who have Medicare and other forms of third-party coverage who qualify for LTSS to obtain the coordinated services they need across the care continuum through a single plan. Subchapter 10 Part 1 of this Chapter covers these options and the process for managed care plan selection and enrollment. 4. Retroactive Eligibility – Up to three (3) months of Medicaid retroactive coverage is available for certain IHCC group beneficiaries. To qualify, the State must determine that a person would have met the applicable eligibility criteria for their coverage group if the application was submitted during the retroactive period. The State provides reimbursement to providers only for Medicaid covered services, however. The provisions in Subchapter 05 Part 3 of this Chapter explain the process for obtaining retroactive coverage in greater detail. 1.9 Service Delivery Options A. The service delivery options for IHCC group members are dictated in large part by type of Medicaid health coverage and eligibility pathway. B.
Overview IHCC Group Service Delivery Eligibility Pathway Service Delivery Option SSI, EAD with no Medicare Rhody Health Partners SSI, EAD with Medicare Rhody Health Options, PACE, Fee-for- Service (FFS) w/Community Health Team, or FFS-only LTSS No Medicare Same as above LTSS with Medicare Rhody Health Options, Medicare- Medicaid Plan II, PACE Sherlock/Ticket to Work Plan FFS
Overview IHCC Group Service Delivery Eligibility Pathway Service Delivery Option Medically Needy – non-LTSS FFS
210-RICR-40-00-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 - MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 00 - INTEGRATED COVERAGE GROUPS PART 1 - OVERVIEW OF MEDICAID INTEGRATED CARE COVERAGE (210-RICR- 40-00-1) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 01/02/2025 December 12, 2024 E-SIGNED by Richard Charest on 2024-12-12 19:53:33 EST December 13, 2024 E-SIGNED by Department of State on 2024-12-13 11:08:39 EST
210-RICR-40-00-2 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 - MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 00 – INTEGRATED HEALTH CARE COVERAGE GROUPS PART 2 – APPLICATION AND RENEWAL PROCESS FOR IHCC GROUPS 2.1 Scope and Purpose A. In September 2016, the State implemented its integrated eligibility system (IES) which has the capacity to crosswalk with the State’s health insurance marketplace, HealthsourceRI.com (HSRI) and, through a single application process, evaluate eligibility for publicly financed health coverage and needs- based programs administered by DHS and other EOHHS agencies. This Section focuses on the application and renewal processes for IHCC groups that have been established in conjunction with the implementation of the IES. 2.2 Authority A. This Part is promulgated pursuant to Federal authorities as follows: 1. Federal Law: Title XIX of the U.S. Social Security Act, 42 U.S.C. §§ 1396- 1396w-7; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148; and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-115. 2. The Medicaid State Plan and the Section 1115 Waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. B. Applicable State authority is derived from R.I. Gen. Laws Title 40 and R.I. Gen. Laws Chapter 42-7.2. 2.3 Incorporated Materials A. These regulations hereby adopt and incorporate 42 C.F.R. § 435.908 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. B. These regulations hereby adopt and incorporate 42 C.F.R. § 435.916 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations.
2.4 Access Points A. The State is committed to pursuing a “No Wrong Door” policy that offers consumers multiple application and renewal access points which all lead to the State’s IES. 1. Self-Service – Persons seeking initial or continuing eligibility have the option of accessing the eligibility system online using a self-service portal through links on the EOHHS (eohhs.ri.gov) and DHS (dhs.ri.gov) websites or directly through HSRI (HealthSourceRI.com). There are also kiosks located in DHS field offices that provide direct access to the self-service portal. The information applicants provide online is entered directly into the eligibility system and processed electronically in real-time. For these reasons, the Medicaid agency encourages all new applicants to select the self-service portal option and complete and submit the application electronically whenever feasible. 2. Assisted Service – Applicants and beneficiaries may also apply on paper and submit forms via mail, fax, or e-mail or deliver forms in person to DHS field offices. Agency eligibility specialists are available to provide help, as are HSRI representatives and various certified assisters located at community agencies. Applications that are completed on paper are scanned into the IES agency portal. 3. Applicants may submit paper applications in-person or by U.S. mail, e-mail transmissions, and facsimile transmissions to the address specified on the application. Paper applications are available online, through the U.S. mail upon written request, by telephone request, or in person at any DHS field office. Information provided on the paper application is directly scanned or entered into the eligibility system through an agency portal by eligibility or LTSS specialists on the applicant’s behalf. 2.5 Application and Renewal Assistance A. The State provides application and renewal assistance through eligibility specialists in the DHS field offices and HSRI Contact Center and trained assisters, certified in accordance with 42 C.F.R. § 435.908 (2023). This assistance must be provided in a manner that is accessible to persons with disabilities and persons with limited English proficiency. Information on obtaining application/renewal assistance is available by calling 855-MYRIDHS (1-855-697- 4347) as well as online through the DHS, HSRI and EOHHS websites. In addition, eligibility specialists and certified assisters are responsible for upholding the following rights of current and prospective Medicaid beneficiaries: 1. Eligibility and Renewal Help – Including help provided by DHS, EOHHS, and HSRI eligibility specialists and certified assisters in completing all necessary forms, obtaining and submitting required documentation, and
responding to inquiries or requests for information. Assisters may provide help or act on behalf of the applicant or beneficiary when interacting with agency representatives but are not permitted to make determinations of eligibility. 2. Translation Services – An interpreter or translator is available to assist in the application process upon request. 3. Protection of Privacy -- All information applicants provide is kept confidential unless the agency is otherwise authorized to share with other state and federal agencies for the purposes of verification and enrollment. 4. Timely Determinations – Eligibility determinations, including providing a notice of the agency’s decision, must be made in accordance with the timelines indicated in § 2.6 of this Part. 5. Appeals - EOHHS accepts appeals and holds hearings on actions related to eligibility decisions in accordance with Part 10-05-2 of this Title. 6. Non-discrimination – Applicants and beneficiaries are treated in a manner that is free from discrimination on the basis of race, color, national origin, sex, gender identity or sexual orientation, age or disability. 2.6 Completing and Submitting the Application A. In general, the process of completing and submitting an application proceeds in accordance with the following: 1. Account Creation – To initiate the application process, a person must create a login and establish an account in the eligibility system. This can be done through the self-service portal by the person alone or with the help of an eligibility specialist or certified assister. a. Identity proofing. The applicant must provide personally identifiable information for the purpose of creating an online account as a form of identify proofing during the process of applying for Medicaid. Verification of this information is automated. Documentation proving identity may be required if the automated verification process is unsuccessful. Acceptable forms of identity proof include a driver’s license, school registration, voter registration card, etc. Documents may be submitted via mail, fax, online upload, or to a DHS Office. b. Account matches. Once identity is verified, account matches are conducted to determine whether the applicant or members of the applicant’s household have other accounts or are currently receiving benefits.
2. Account Duration – An application account is open for a period of ninety (90) days. Applications may be started at any time. Once started, progress can be saved at any point and the application returned to at a later time. Incomplete applications not submitted within ninety (90) days are automatically deleted in the eligibility system. 3. Application Materials – The application materials a person seeking Medicaid coverage must provide may vary depending on the application processing flow: a. MAGI-based eligibility. As indicated in § 2.8.2 of this Part, applicants who are under sixty-five (65) are generally evaluated first for eligibility in one of the Medicaid Affordable Care Coverage (MACC) groups before being considered for the IHCC groups. The MACC group, MAGI-based application process is explained in greater detail in Part 30-00-3 of this Title. This eligibility process generally requires applicants to provide information used when filing federal tax forms and/or documents commonly used for identification and income verification purposes. b. SSI-based eligibility. The IHCC application process builds on the MAGI review unless a person is age sixty-five (65) or older. In all cases, self-attestation of income and resources begins the process. To the full extent feasible, electronic data matches are used to verify financial information. Documentation of certain information may be required, however. In addition, when using a paper application, access to certain types of materials may be necessary. (1) Materials that may be of assistance in completing the application include, but are not limited to: (AA) Federal tax filing status (BB) Social Security Numbers (CC) Birth Dates (DD) Passport or other immigration numbers (EE) Federal tax returns (FF) Information about any health coverage available to the applicant or the applicant's family, including any information the applicant has about the health insurance their current employer offers even if they are not covered by the employer’s insurance plan, Medicare and other forms of coverage
(GG) W-2 forms with salary and wage information if the beneficiary is employed (HH) 1099 forms, if the applicant is self-employed. (2) Common types of documentation that may be needed to verify income and resources include the wage and earning and tax forms noted above and: (AA) Copies of checks or receipts for unearned or irregular income (BB) Bank statements (CC) Annuity/retirement fund statements for insurance companies (DD) Copies of bonds (EE) Stock ownership statements (FF) Copies of life insurance policies (GG) Statements from insurance companies or companies providing annuities (HH) Copies of burial purchase agreements. (3) Common documents that may be required with respect to self-employment income include: (AA) Tax forms such as 1040 Schedule ES (Form 1040), Schedule C or comparable State form or federal return with the "Self-Employment Tax" line completed. (BB) Business records if the applicant has not been self- employed long enough to file taxes, including financial statements, gross receipts and expenses, quarterly reports, certified statement form licensed accountant. (CC) For royalties, honoraria, and stipends, the nature and amount of payments, any Social Security of Medicare withholding, dates of payments and frequency of payments, and/or tax forms above or 1099 MISC and the name of the issuer. (4) Common documents that are required related to health status or disability include:
(AA) Authorization to obtain medical and/or health care records, the names and addresses of the treating physicians and other providers, health care bills incurred or paid during the three (3) month retroactive eligibility period, or that remain unpaid from any previous period. 4. Application Filing Date – The filing date of an application is the date used to determine when eligibility begins if it is approved. The filing date is not necessarily the date an application is complete but is typically the date a signed completed application form is submitted through the self-service portal online or date-stamped as received by the agency or electronic means if uploaded, mailed, faxed or scanned, or delivered in-person. The filing date may be protected if the application is not complete due to outstanding verifications or required reforms. However, the timeline the agency must meet for making an eligibility determination does not begin until the date an application is complete, as indicated below. 5. Application Completeness – An application must be complete before a determination of eligibility can be made. An application is considered complete when all information requested, including any ancillary required forms and authorizations, are date-marked as received by the State. As the timelines for making a determination of eligibility specified below begin on the date the application is complete, applicants are informed and offered the opportunity to provide any additional documentation or explanations necessary to proceed to the determination of eligibility in a timely manner. Such information is provided to applicants immediately through an electronic notification from the IES when applying online either through the consumer self-service portal or with the assistance of an agency representative. In cases in which an agency eligibility specialist or assister is entering information into an applicant’s account or scanning a paper application, information about necessary documentation is generated immediately in the online account and must be made available as soon as feasible. 6. Voluntary Withdrawal – An applicant may request that an application for Medicaid health coverage be withdrawn at any time either through their secure online account or by submitting the request in writing via the U.S. mail or fax to the EOHHS or DHS agency representative. The Medicaid agency sends a notice to the applicant verifying the time and date of the voluntary withdrawal and indicating that the applicant may reapply at any time. 7. Self-Attestation of Application Information – All questions on the application must be answered in a truthful and accurate manner. Every applicant must attest to the truthfulness and accuracy by signing a paper application in ink or by providing an electronic signature online under
penalty of perjury. The IES verifies the information electronically to the fullest extent feasible and must verify applicant attestations in accordance with the procedures set forth in Part 10-00-3 of this Title. 8. Privacy of Application Information – Application information must only be used to determine eligibility and the types of coverage a person is qualified to receive. Accordingly, the EOHHS, the agencies under its umbrella, and all other entities serving as its agents in the Medicaid eligibility process maintain the privacy and confidentiality of all application information and in the manner required by applicable federal and state laws and regulations. 9. Eligibility Determination Timelines – Federal and State law set specific timelines for making determinations of Medicaid eligibility. The timelines vary in length depending on whether a clinical eligibility determination is required that necessitates a review of information from second parties (e.g., health practitioner or provider) and/or third parties (e.g., insurers). In accordance with R.I. Gen. Laws § 40-8.6(b)(2), the timeline for determining eligibility begins on the date a completed application, including any required forms and/or authorizations, is received by the EOHHS or its authorized eligibility agents, and ends on the date a notice is sent to the applicant explaining the agency’s decision. The EOHHS is responsible for processing applications within these time limits for IHCC group members who have not been deemed or determined eligible on the basis of participation in another federal program (e.g., SSI, DCYF Foster Child, etc.). The timelines are as follows: MACC and IHCC Eligibility Determination Timelines Coverage Group Determination Timeline MACC Groups 30 Days Community Medicaid – Elders 65 and over 30 Days Community Medicaid – Adults with Disabilities 90 Days Sherlock/Ticket to Work Plans If determination of disability has been made – 30 days If determination of disability is required – 90 days
MACC and IHCC Eligibility Determination Timelines Coverage Group Determination Timeline Medically Needy – Persons with Disabilities 90 Days Medically Needy – No Disability 30 Days LTSS 90 Days 2.7 Beneficiary Responsibilities A. Medicaid beneficiaries must provide accurate and complete information about any eligibility factors subject to change at the time of the application and annual renewal. Accordingly: 1. Consent – At the time of the initial application or first renewal, Medicaid beneficiaries are required to provide the State with consent to retrieve and review any information not currently on record pertaining to the eligibility factors subject to change through electronic data matches conducted through the State’s eligibility system. Once such consent is provided, the Medicaid agency may retrieve and review such information when conducting all subsequent annual renewals. 2. Duty to Report – Medicaid beneficiaries are required to report changes in eligibility factors to the Medicaid agency within ten (10) days from the date the change takes effect. Self-reports are permitted through the eligibility system consumer self-service portal as well as in person, via fax, or mail. Failure to report in a timely manner may result in the discontinuation of Medicaid eligibility. 3. Cooperation – Medicaid members must provide any documentation that otherwise cannot be obtained related to any eligibility factors subject to change when requested by the Medicaid agency. The information must be provided within the timeframe specified by the Medicaid agency in the notice to the Medicaid member stating the basis for making the agency’s request. 4. Voluntary Termination – A Medicaid beneficiary may request to be disenrolled from a Medicaid health plan or to terminate Medicaid eligibility at any time. Such requests must be made in writing and preferably two (2)
weeks prior to the date of disenrollment or the date a beneficiary seeks to end eligibility. 5. Reliable Information – Medicaid applicants and beneficiaries must sign under the penalty of perjury that all information provided at the time of application and any annual renewals thereafter is accurate and truthful. 6. Change of Service Delivery Options – Medicaid beneficiaries may change Medicaid health plans during the annual open enrollment period. Notice of the open enrollment period is provided to beneficiaries at least thirty (30) days prior to the date the period begins. Beneficiaries may also request to change service delivery options at any other time in accordance with the procedures set forth in Subchapter 10 Part 1 of this Chapter, or if MACC group eligible, Chapter 30, Subchapter 05 of this Title. 7. Alternative forms of Benefits/Assistance – Applicants and beneficiaries must, as a condition of eligibility, take any necessary steps to obtain annuities, pensions, retirement and disability benefits along with any other forms of assistance available for support and maintenance that may be identified by the agency, in writing, in accordance with Part 10-00-3 of this Title. Good cause exceptions are considered when requested in writing. 2.8 Application Review Process 2.8.1 Scope and Purpose A. This Section provides an overview of the application review process for all IHCC groups identified in this Chapter and the specific provisions that apply to Community Medicaid populations subject to eligibility determinations made by the State. As a result of programmatic changes in the State’s IES required by the ACA, people are no longer required to apply for one particular category of Medicaid eligibility. Instead, to maximize access and choice, applicants are evaluated across a variety of MACC and IHCC pathways which apply different eligibility standards, requirements, and criteria. In short, the denial or termination of eligibility in one category does not preclude eligibility through another pathway. The State must consider all bases of eligibility. 2.8.2 General Rules A. To the extent feasible, the person seeking initial or continuing eligibility is provided with the choice of eligibility pathways within and, in some instances, across the MACC and IHCC group categories. MACC group eligibility is primarily income-based and uses the MAGI standard established in conjunction with federal health care reform. IHCC group eligibility is much more varied and, when not automatic due to participation in another federal program or special requirements, is based on both the SSI methodology and SSI-related characteristics. As there are significant distinctions between these two categories
for obtaining eligibility, when choosing a pathway, the following should be taken into consideration: 1. Limits on Choice – Although the scope of primary care essential health coverage across Medicaid in the broad IHCC and MACC categories does not significantly vary, there are certain differences that may affect a person’s choice of or access to certain eligibility pathways. In addition, federal and State policies also impose restrictions. The most common include: a. Retroactive coverage. Under the State’s Section 1115 Waiver, retroactive coverage is not available to MACC group beneficiaries, including those who qualify for LTSS. Retroactive coverage is an included benefit through many of the IHCC pathways in which the State determines eligibility for Community Medicaid and Medicaid LTSS, as indicated in Subchapter 05 Part 3 of this Chapter. b. Other Health Coverage. Federal law precludes persons who are eligible for or enrolled in Medicare from obtaining coverage through the MACC group for adults, ages nineteen (19) to sixty-four (64). Other forms of health coverage, including both commercial insurance and government-sponsored, are generally not a bar to Medicaid eligibility through the MACC and IHCC pathways. In addition, the State’s health insurance payment program – RIte Share – makes it possible for beneficiaries who have access to cost-effective Employer-Sponsored Insurance (ESI) to maintain coverage through work once they become Medicaid-eligible. Part 30-05-3 of this Title provides details on RIte Share. The MPPP is also available to provide financial help to cover the costs of Medicare coverage for low-income elders and adults with disabilities. c. Former SSI Recipients. All former SSI recipients who lose cash benefits due to increases in income are evaluated first for the SSI protected status groups described in Subchapter 05 Part 1 of this Chapter. In instances in which eligibility in one of these groups is unavailable, the person will be evaluated for the MACC and/or IHCC Community Medicaid pathways, to the extent the other limiting factors in this Subsection allow, and provided with a choice of coverage options as appropriate. d. Age. In general, persons sixty-five (65) and older are ineligible for MAGI-based MACC group eligibility. Parents/caretakers of a Medicaid eligible child in this age group, including those enrolled in Medicare, are the only exceptions. Children and youth under nineteen (19) are generally not eligible in the IHCC groups. However, pregnant people, parents/caretakers and children with
high health care expenses who have family income above the MACC group limit may seek MN eligibility through Community Medicaid using the SSI methodology. IHCC resource and deeming rules apply unless the child is seeking LTSS through the Katie Beckett eligibility provision. e. LTSS Preventive Level Services. These services are only available to adults with disabilities and elders who are eligible through the Community Medicaid pathways as EAD or MN. f. Need for LTSS. All LTSS applicants are subject to a review of the transfer of assets, in accordance with applicable federal requirements, and State laws and regulations governing estate recoveries, irrespective of whether initial income eligibility is determined using the MAGI standard or the SSI methodology. LTSS beneficiaries who are eligible through the MACC group pathway are not subject to resource limits, however. g. Medically Needy (MN) Eligibility. For all non-LTSS applicants, MN eligibility is considered the last option for obtaining Medicaid coverage, both because the burden on beneficiaries is the most significant and the opportunities for coordinating and managing care are so limited. There is not a MN option for MACC group adults, unless they are eligible through the pathway for parents/caretakers. Accordingly, for these adults, IHCC eligibility is the only avenue to MN coverage. For LTSS applicants, MN eligibility is also the last option; though the income eligibility limits are higher than through other eligibility pathways, beneficiary liability tends to be as well. In addition, access through this pathway limits access to SSP assistance (i.e., only available if income is at or below 300% of SSI) and the range of LTSS settings in some instances. h. MPPP. Elders and adults with disabilities who are participating in the MPPP are only eligible for the MACC group for parents/caretakers. Otherwise, MPPP participants must access Medicaid financial help through the IHCC groups. In addition, participation in the MPPP has the potential to affect eligibility for Medicaid health coverage through the Community Medicaid MN pathway. As indicated in Subchapter 05 Part 2 of this Chapter, Medicare premiums are health expenses that count toward the amount a person must spend down in order to obtain Medicaid coverage during the six (6) month MN period. MPPP participants are not permitted to use these expenses toward a spenddown as they are paid by the State.
2. Eligibility Across Pathways – Eligibility specialists and application assisters must be available to provide applicants and beneficiaries with information about the impact the limits above have on the choice of eligibility pathways. Such information is also provided with paper applications and built into the self-service portal to assist applicants and beneficiaries in making informed choices about their Medicaid health options. The table below summarizes the major cross pathway eligibility opportunities by major Medicaid populations. Selected Eligibility Cross Pathways By Population (Excludes beneficiaries eligible on basis of other programs) Population MACC Group – MAGI-Based (No Retroactive Coverage) IHCC Group SSI methodology- based (Retroactive Coverage Possible) Both MACC and IHCC Eligibility determined using both Children Up to MACC income limit (261% of FPL + 5% disregard) MN only if income above MACC limit and have high health expenses Family income above MACC limit and meeting institutional level of care – Katie Beckett eligibility based on child’s income only
Not Applicable Pregnant People Up to MACC income limit (253% of FPL + 5% disregard) EAD or MN if disabled, but only until next renewal or birth of baby, Option for MACC and MPPP if have Medicare
Selected Eligibility Cross Pathways By Population (Excludes beneficiaries eligible on basis of other programs) Population MACC Group – MAGI-Based (No Retroactive Coverage) IHCC Group SSI methodology- based (Retroactive Coverage Possible) Both MACC and IHCC Eligibility determined using both whichever comes first; MN if non- disabled and income above MACC limit and have high health expenses LTSS Adults 19-64, no Medicare Up to MACC income limit (133% FPL + 5% disregard), LTSS with no resource limit EAD or MN if have a disability and are seeking retroactive coverage LTSS Not Applicable Adults with disabilities 19- 64 If no Medicare, up to MACC limit for adults, including while awaiting a disability determination by the State or SSA EAD, MPPP and/or MN Ticket to Work Plan if working LTSS Option MACC group for parents/caretak ers and MPPP
Selected Eligibility Cross Pathways By Population (Excludes beneficiaries eligible on basis of other programs) Population MACC Group – MAGI-Based (No Retroactive Coverage) IHCC Group SSI methodology- based (Retroactive Coverage Possible) Both MACC and IHCC Eligibility determined using both Elders Only if a parent/caretaker EAD, MPPP, MN Sherlock Plan if working LTSS Option MACC group for parents/caretak ers and MPPP 3. Continuing Eligibility Reviews Prior to Termination of Coverage – The State must evaluate whether a beneficiary may qualify for Medicaid health coverage through an alternative pathway prior to the termination of eligibility. This requirement only applies when the reason for the termination is a change in an eligibility factor (e.g., age, income, resources or disability, relationship, etc.). The State uses any information known about the beneficiary through their account and electronic data sources to evaluate the options for continuing coverage. A beneficiary is informed in writing about this evaluation, which is referred to as an ex parte review, and of any additional materials that must be submitted to determine whether alternative forms of eligibility exist at least ten (10) days prior to the date the eligibility termination takes effect. Such notification is provided more than thirty (30) days in advance of the date of the agency action whenever feasible. In addition to evaluating beneficiaries for other forms of Medicaid eligibility, anyone under age sixty-five (65) is also considered for commercial coverage with financial help through HSRI. 2.9 Renewal of Eligibility for IHCC Groups 2.9.1 Scope and Purpose A. One of the principal requirements of Medicaid is that continuing eligibility must be re-evaluated at least once per year. For the IHCC groups, this annual review was called a “redetermination” and, accordingly, often required beneficiaries to
reapply for coverage. Federal regulations at 42 C.F.R. § 435.916(b) (2023) governing the IHCC groups now require that these annual reviews consider only those eligibility factors that are subject to change. Accordingly, the continuing eligibility of the IHCC group beneficiaries receiving Community and LTSS Medicaid is now conducted by requiring them to review their account information on key eligibility factors, as updated by internal and external data sources, and report any inaccuracies or changes in the manner described in this Section. B. The factors subject to change include income, resources, household composition (e.g., as a result of births, deaths, divorce, etc.), disability or clinical factors, access to third-party coverage, and changes in family size (e.g., due to death, marital status, birth or adoption of child), and/or immigration status. LTSS beneficiaries may be required to provide additional information related to change in care settings. Note: The provisions in this Section do not apply to beneficiaries who are deemed eligible due to participation in other programs (e.g., SSI recipients), or who are determined eligible by the SSA. Special MPPP renewal provisions also apply. 2.9.2 Agency Responsibilities A. IHCC group renewals are conducted in accordance with the following: 1. Frequency – The Medicaid renewal process occurs at least once every twelve (12) months and no more frequently unless as a result of a change in eligibility factors. 2. Types of Information – The eligibility renewal is based on information already available to the full extent feasible. Such information may be derived from reliable sources including, but not limited to, the beneficiary’s automated eligibility account, current paper records, or databases that may be accessed through the IES. Information about eligibility factors that are not subject to change or matters that are not relevant to continuation of Medicaid eligibility are not requested or used at the time of renewal. Factors that are not subject to change include, but are not limited to, U.S. citizenship, date of birth, and Social Security Number. 3. Notice – Timely notice must be provided of: a. Renewal Date. A notice of the date of the annual renewal is sent at least thirty days (30) days prior to the renewal date. The beneficiary is also provided with a pre-populated form containing information from the Integrated Eligibility System and other sources on each relevant eligibility factor. In instances in which the Medicaid beneficiary is required to take action in addition to completing the pre-populated form, such as providing paper documentation or explaining a discrepancy, a timeline is included for completing the action as well as indication of the consequences for failure to do so.
b. Renewal Action. At least ten (10) days prior to the renewal date, Medicaid beneficiaries are provided with a notice stating the outcome of the renewal process and explaining the basis for any agency action – continuation or termination of eligibility. The notice also contains the right to appeal and obtain an administrative fair hearing. Beneficiaries are also notified that they have the right to have their health coverage continued while awaiting a hearing if an appeal is filed in ten (10) days from the date of the renewal notice is received. The date the notice is received is presumed to be five (5) days from the date on the notice. 4. Consent – At the time of initial application, Medicaid beneficiaries sign or provide an electronic signature giving the State consent to obtain and verify information through external data sources and from certain providers for the purposes determining eligibility and renewing health coverage. 5. Passive Renewal – All IHCC beneficiaries are subject to a passive (ex parte) renewal process that proceeds as follows: a. When possible, all IHCC beneficiaries are passively renewed. Passively renewed individuals are sent a benefit decision notice indicating that their Medicaid coverage has been renewed for twelve (12) months. Beneficiaries who are passively renewed are not required to take any action during the renewal process. b. If an IHCC beneficiary cannot be passively renewed, they will be sent a pre-populated form containing all information related to eligibility on record, typically in their IES accounts, that has been self-reported and/or obtained through electronic data matches at application, post-eligibility verification, and change reports. Beneficiaries are required to review this form, make any necessary changes and required actions, and then attest to the accuracy and completeness of the information provided on any eligibility factor subject to change. Failure to return this form will result in the termination of eligibility. 6. Reconsideration Period a. Under 42 C.F.R. § 435.916, the agency is required to provide a ninety (90) day reconsideration period after a procedural termination; that is, for failure to return information needed to renew eligibility. When a beneficiary takes the actions required to resolve the discrepancy or information gap in the ninety (90) day period after eligibility is terminated, a reinstatement of Medicaid eligibility will be made.
2.10.3 Beneficiary Responsibilities A. Medicaid beneficiaries must meet the requirements associated with making and completing an application as set forth in § 2.7 of this Part and the general Medicaid and other cooperation requirements in Part 10-00-3 of this Title.
210-RICR-40-00-2 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 - MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 00 - INTEGRATED COVERAGE GROUPS PART 2 - APPLICATION AND RENEWAL PROCESS FOR IHCC GROUPS (210-RICR- 40-00-2) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 01/02/2025 December 12, 2024 E-SIGNED by Richard Charest on 2024-12-12 19:53:03 EST December 13, 2024 E-SIGNED by Department of State on 2024-12-13 11:08:07 EST
210-RICR-40-00-3 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 – MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 00 – INTEGRATED COVERAGE GROUPS PART 3 – SSI FINANCIAL ELIGIBILITY DETERMINATIONS 3.1 Incorporated Materials A. These Regulations hereby adopt and incorporate 20 C.F.R. Part 416 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these Regulations. B. These Regulations hereby adopt and incorporate 20 C.F.R. Part 618 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these Regulations. 3.2 Overview of the SSI Methodology 3.2.1 Scope and Purpose A. All Supplemental Security Income (SSI) recipients are automatically eligible for Medicaid. The State has agreed to determine the eligibility of persons who have an SSI characteristic – age sixty-five (65) and older, blind or disabled – but do not qualify for cash benefits using the SSI methodology and in a manner that is no more restrictive than the way it is applied for SSI. B. For the purposes of this Chapter, the SSI methodology applies to adults with an SSI characteristic – often called SSI lookalikes – who have income at or below the SSI eligibility standard of about seventy-five percent (75%) of the Federal Poverty Level (FPL) as well as those in the State’s optional coverage group for low-income elders and adults with disabilities and all populations that qualify for Medically Needy (MN) eligibility under the Medicaid State Plan. The SSI methodology also applies to persons seeking Medicaid Long Term Services and Supports (LTSS). C. The basic tenets of the SSI methodology are established in the Social Security Administration's rules for determining eligibility for SSI which are set forth in federal regulations at 20 C.F.R. § 416.101 et seq. 3.2.2 Authority A. This Part is promulgated pursuant to Federal authorities as follows:
1. Federal Law: Title XIX of the U.S. Social Security Act; 42 U.S.C. §§ 1396a-1396w-7; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148; and the Health Care and Education Reconciliation Act of 2010, Pub. L. 111-115. 2. The Medicaid State Plan and the Section 1115 Waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. B. Applicable State authority is derived from R.I. Gen. Laws Title 40 and R.I. Gen. Laws Chapter 42-7.2. 3.2.3 Organization of SSI Methodology Provisions in this Chapter A. Sections pertaining to the SSI treatment of income and resources and their application are as follows: 1. § 3.2 of this Part – Overview of Methodology 2. § 3.3 of this Part – Treatment of Income 3. § 3.6 of this Part – Treatment of Resources 4. Part 05-1 of this Chapter – Community Medicaid B. Except as otherwise noted, the provisions in this Part apply to the determination of countable income and resources for Medicaid LTSS applicants and beneficiaries in the Integrated Health Care Coverage groups (IHCC). LTSS specific provisions related to the treatment of income and resources for IHCC members are set forth in Part 50-00-6 of this Title. The income of Affordable Care Act (ACA) expansion adults in the Medicaid Affordable Care Coverage (MACC) category is evaluated in accordance with Part 30-00-3 of this Title, except that the person seeking Medicaid LTSS is treated as a family of one (1) irrespective of whether they live at home or a health institution or community-based service setting. All Medicaid LTSS applicants and beneficiaries, without regard for the method of determining financial eligibility, are subject to the transfer of asset provisions in Part 50-00-6 of this Title. 3.2.4 Definitions A. For the purposes of this Section, the following meanings apply: 1. “Child” means someone who is not married, is not the head of a household, and is either under age eighteen (18) or is under age twenty- two (22) and a student for the purposes of IHCC group eligibility only. See definition of a child for MACC group eligibility in Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways, Part 30-00-1 of this Title.
2. “Couple” means a person seeking initial or continuing eligibility for Medicaid and their spouse, regardless of whether the spouse is also an applicant or beneficiary unless otherwise indicated. 3. “Federal benefit rate” or “FBR” means the amount of the monthly cash assistance authorized by the Social Security Administration for the recipients of the SSI program. The FBR is the SSI income eligibility standard, as adjusted for the number of cash recipients, living arrangement and SSP levels. 4. “Financial responsibility unit” or “FRU” means the group of persons living with the person seeking Medicaid benefits whose income and resources are considered available when determining financial eligibility and, as such, may count and/or be attributed to others in the household when the deeming process applies. 5. “Medicaid eligibility group” means the total number of persons counted in a household – that is, the family size involved – when identifying the FPL income level that applies when determining a person’s Medicaid eligibility. 6. “Medicaid health coverage” means the full scope of essential health care services and supports authorized under the State’s Medicaid State Plan and/or Section 1115 Waiver, and provided through an authorized Medicaid delivery system. The term does not apply to partial dual eligible persons who, under the provisions of this Chapter, qualify only for financial assistance through the Medicare Premium Payment Program (MPPP) to help pay Medicare cost-sharing. 7. "Medically necessary service" means a medical, surgical, or other service required for the prevention, diagnosis, cure, or treatment of a health- related condition including any such services that are necessary to slow or prevent a decremental change in medical and/or mental health status. 8. “Medically needy” or “MN” means the IHCC pathway for elders, persons with disabilities, parents/caretakers, and certain pregnant people and children with income above the limits for their applicable Medicaid coverage group who incur enough health expenses during a set period to spenddown to the eligibility threshold for coverage. 9. "Section 1115 Waiver" means the waiver authorized pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. 10. “SSI methodology” means the basis for determining Medicaid eligibility that uses the definitions and calculations for evaluating income and resources established by the U.S. Social Security Administration (SSA) for the SSI program. 3.2.5 Key Elements of the SSI Methodology
A. Though the application of the SSI methodology sometimes varies across coverage groups, there are several key common elements, as follows: 1. Financial Determination – The basis for determining financial eligibility using the SSI methodology is a multi-step process for evaluating income and resources, including the formation of the FRU and Medicaid eligibility groups and the application of exclusions, deductions and disregards, all of which may be applied differently depending on eligibility pathway. 2. Characteristic Requirements – Due to the historical tie to the SSI program, some IHCC Community Medicaid group members must have certain characteristics related to age, blindness or disability, or clinical status to qualify for Medicaid health coverage. General characteristic requirements that drive eligibility for Community Medicaid are in Part 05-1 of this Chapter. 3. LTSS Need and Level of Care – LTSS is a Medicaid State Plan benefit for both IHCC and MACC group beneficiaries who have the need for a level of care typically provided by a health care institution. Federal law defines “institution” narrowly in terms of three (3) specific types of health facilities – nursing facilities (NF), intermediate care facilities for persons with intellectual/developmental disabilities (ICF-ID), and hospitals. To qualify for Medicaid-funded LTSS, individuals must meet the functional/clinical criteria related to level of need for care in one (1) of these health institutions as described in Part 50-00-5 of this Title. 4. General and Group Specific Eligibility Requirements – All persons seeking Medicaid benefits must also meet the general eligibility requirements related to residency, citizenship, third (3rd) party coverage and cooperation. The general eligibility requirements for IHCC Community Medicaid are specified in Part 05-1 of this Chapter as well as in the sections related to specific coverage group requirements. Documentation related to both financial and functional/clinical eligibility factors is specified in these same sections. 5. Clinical Reviews – Clinical reviews may consist of a determination of disability, an assessment of functional need and/or health status, or an evaluation whether an applicant or beneficiary requires the level of care provided in a health institution. The criteria and processes for making these determinations may vary considerably in accordance with the type of Medicaid health coverage a person is seeking and the scope of Medicaid coverage available. a. The provisions governing clinical reviews for the determination of disability for non-LTSS, Community Medicaid are located in Part 05-1 of this Chapter. For Medicaid LTSS, the provisions governing functional/clinical eligibility are set forth in Part 50-00-5 of this Title;
for Katie Beckett eligibility, clinical reviews are conducted in accordance with Part 50-10-3 of this Title. 3.2.6 Income A. The evaluation of income is the process that determines the amount that counts when determining financial eligibility using the SSI methodology. For these purposes, income is defined as follows: 1. Earned Income – Earned income is income from work and may be in cash or in-kind and may include more of a person’s income than they actually receive if amounts are withheld because of a garnishment or to pay a debt or other legal obligation, or to make any other payments. See § 3.4 of this Part for more detailed information. 2. Unearned Income – Unearned income is all income that is not earned through employment whether received in cash or in-kind. The provisions governing the counting of unearned income are also located in § 3.4 of this Part. B. The Rules governing the determination of countable income for IHCC category Community Medicaid members are in Part 05-1 of this Chapter. ACA expansion adult provisions related to income are set forth in Part 30-00-5 of this Title. C. Medically needy (MN) eligibility is an option for applicants and beneficiaries who have income above the limits established in this Part. See Part 05-2 of this Chapter for non-LTSS MN; provisions pertaining to medically needy eligibility for Medicaid LTSS are located in Part 50-00-2 of this Title. 3.2.7 Resources A. A resource is cash or other liquid assets or any real or personal property that a person (or spouse, if any) owns and could convert to cash to be used for support and maintenance. For the purposes of determining financial eligibility using the SSI methodology, the following distinctions apply: 1. Liquid Resources – A liquid resource is any resource in the form of cash, or any other form which can be converted to cash within twenty (20) business days. Examples of resources that are ordinarily liquid are stocks, bonds, mutual fund shares, promissory notes, mortgages, life insurance policies, financial institution accounts (including savings, checking, and time deposits, also known as certificates of deposit) and similar items. Liquid resources, other than cash, are evaluated according to the person’s equity in the resources. 2. Non-liquid Resources – A non-liquid resource is a resource that is not in the form of cash or in any other form which cannot be converted to cash within twenty (20) business days. Examples of resources that are
ordinarily non-liquid include loan agreements, household goods, automobiles, trucks, tractors, boats, machinery, livestock, buildings and land. Non-liquid resources are evaluated according to their equity value except when otherwise indicated. The equity value of an item is the price that it can reasonably be expected to sell for on the open market in the particular geographic area involved, minus any encumbrances. B. § 3.6 of this Part explains the types of resources and applicable exclusions in general when using the SSI method to determine financial eligibility. Part 05-1 of this Chapter focuses on Community Medicaid. Medicaid LTSS-specific provisions are located in Part 50-00-6 of this Title. 3.2.8 Income and Resource Standards A. The following standards are used in the determination of the countable income and resources of an individual or couple when using the SSI method for determining Medicaid financial eligibility: 1. Monthly Federal Benefit Rate (FBR) – The FBR is set by the Federal government and is based on the SSI monthly cash payment for an individual or couple. The FBR is reduced by one-third if the individual or couple lives in the household of another. Accordingly, the FBR serves as the SSI income eligibility standard and in the Medicaid eligibility determination process for calculating allowances and deeming purposes. The FBR is adjusted annually on January 1, as necessary, to reflect changes in the cost of living and published by the Social Security Administration. The FBR is also the basis for the income eligibility cap for LTSS in certain circumstances. 2. Optional State Supplemental Payment (SSP) Limits – The limits for SSP eligibility are tied to SSI and EAD eligibility. SSP amounts are established by statute at R.I. Gen. Laws § 40-6-27. No SSP benefit is available if the beneficiary has income in excess of the amounts established in 218- RICR-20-00-5. 3. Medically Needy (MN) Monthly Income Standards – There are different MN income standards for determining eligibility for Community Medicaid and LTSS. a. Community Medicaid. For persons seeking non-LTSS Medicaid MN coverage, previously known as the flexible test of income, eligibility is reserved for applicants with income above the eligibility standard and high health care expenses who are able to spenddown to the applicable income limit during a specified MN eligibility period of six (6) months. MN beneficiaries are eligible for Medicaid health coverage once they have spent down to this limit, as indicated below.
(1) Part 05-2 of this Chapter covers Community Medicaid MN eligibility in detail. Under the Rhode Island Medicaid State Plan, MN coverage is available to elders and adults with disabilities (EAD), MACC group parents/caretakers, children and pregnant people. There is no MN option for MACC adults, ages nineteen (19) to sixty-four (64); members of this group who have a disability may apply through the EAD pathway and, if found to have a disability, may pursue Community Medicaid MN eligibility if they have income above one hundred percent (100%) of the FPL. All MN beneficiaries are subject to the SSI method for determining eligibility, though income limits vary as indicated in the table below. Accordingly, for the purposes of determining eligibility, all are treated as members of the Community Medicaid group (hereinafter referred to as the Community Medicaid MACC group MN), even though the general population to which they belong is sometimes covered under a MACC group, using the MAGI-standard, such as children and pregnant people. (2) Medically Needy Income Limit (MNIL). The MNIL provides the MN income eligibility threshold and is based on the limit set for the specific coverage group. b. LTSS. Persons seeking Medicaid LTSS who have income above the eligibility limits, but below the cost of care at the average private pay rate established in the institutional cost of care comparison as set forth in Part 50-00-2 of this Title, in an institution or HCBS setting also may seek MN eligibility. The MN eligibility period for LTSS is one (1) month. The provisions governing MN eligibility for Medicaid LTSS are set forth in Part 50-00-2 of this Title. The private pay rates are also used as the divisor to determine the length of a penalty resulting from a disqualifying transfer as indicated in Part 50-00-6 of this Title. 4. Income Guidelines – The IHCC group income limits and, where applicable, companion SSI-related limits are as follows: Income Limits All IHCC Groups Coverage Group Income Limits Elders and Adults with Disabilities (EAD) At or below 100% FPL
Income Limits All IHCC Groups Community Medicaid Elders and adults with Disabilities Medically Needy (MN) Above 100% FPL Spenddown to Medically Needy Income Limit Refugee Medicaid Assistance (RMA) MN At or below 200% FPL Spenddown to Medically Needy Income Limit Community Medicaid MACC Group MN Varies by population as indicated in Part 05-2 of this Chapter QMB 100% FPL SLMB 120% FPL QI 135% FPL Sherlock Plan 250% FPL Ticket to Work Not Applicable LTSS – SSI Pathway SSI Income Limit LTSS – MAGI Pathway Up to 133% of FPL and possible 5% disregard LTSS Special Income/HCBS (217 lookalikes) Up to 300% SSI Level LTSS — MN Pathway Up to cost of care 5. Resource Standards – Federal regulations require States that have expanded IHCC group eligibility to low-income elders and adults with
disabilities up to one hundred percent (100%) of the FPL to use the same resource limits in effect for MN eligibility. Resource Standards for IHCC Groups Coverage Group Limits Community Medicaid – EAD and MN $4,000.00 (I) $6,000.00 (C) Community Medicaid – MACC Group MN Not Applicable SSI – Protected Status Varies by pathway. See Part 05-1 of this Chapter SSP – State Determination (EAD) $4,000.00 (I) $6,000.00 (C) SSP – SSA Determination $2,000.00 (I) $3,000.00 (C) Breast and Cervical Cancer None Refugee Medicaid None Sherlock Plan $10,000.00 (I) $20,000.00 (C) Ticket to Work Not Applicable LTSS – SSI $2,000.00 LTSS – Special Income/HCBS (217 lookalikes) $4,000.00 LTSS – Medically Needy $4,000.00 MPPP Varies by pathway – See Chart in Part 05-1 of this Chapter 6. Student Earned Income Exclusion (SEIE) – For students under age twenty-two (22) and persons who are blind or living with a disability and
regularly attending school, the SSI methodology provides an income exclusion. The income exclusion is adjusted annually to reflect Federal cost of living adjustments (COLAs), when there is one, and is published by the Social Security Administration. 7. LTSS Spousal Impoverishment Standards – All values are published by the Federal Centers for Medicare and Medicaid Services (CMS). a. Minimum Monthly Maintenance of Need Allowance – The minimum amount of income that married individuals receiving services in institutional settings must be permitted to transfer to a spouse who is living in the community for the maintenance needs of the spouse. This value is updated July 1 annually. b. Maximum Monthly Maintenance of Need Allowance – The maximum amount of income that married individuals receiving services in institutional settings may be permitted to transfer to a spouse who is living in the community for the maintenance needs of the spouse. This value is updated January 1 annually. c. Community Spouse Monthly Housing Allowance – The amount that married individuals receiving services in institutional settings are permitted to transfer to a spouse who is living in the community for the housing needs of the spouse. This value is updated July 1 annually. d. Community Spouse Resources (updated January 1 annually) (1) Minimum – The minimum amount of resources that must be available to an individual with a spouse that is receiving services in an institutional setting. (2) Maximum – The maximum amount of resources that may be available to an individual with a spouse that is receiving services in an institutional setting. e. Home Equity Limit (updated January 1 annually) (1) The Home Equity Limit is the maximum value allowable for the State to attribute to an institutionalized individual's home when calculating the value of the individual's resources. Federal law permits states to choose a Home Equity Limit within a range set by CMS and the State uses the minimum Home Equity Limit allowable under CMS guidelines. 8. Medically Needy Income Limit (MNIL) (updated January 1 annually)
Family Size MNIL Annual January 2026 Monthly 2026 1 $14,400 $1,200.00 2 $14,900 $1,242.00 3 $18,300 $1,525.00 4 $21,000 $1,750.00 5 $23,600 $1,967.00 6 $26,300 $2,192.00 7 $28,900 $2,408.00 8 $31,600 $2,633.00 9 $34,200 $2,850.00 10 $36,900 $3,075.00 a. For each family member above ten (10), add two hundred seventeen dollars ($217.00) to the monthly rate or two thousand six hundred dollars ($2,600.00) to the annual rate. 3.3 SSI Methodology: Treatment of Income 3.3.1 Scope and Purpose A. This Section focuses on the treatment of income and, specifically, the way earned and unearned income are defined and evaluated when calculating countable income. For the purposes of this Section, countable income is the total income available to a person seeking Medicaid benefits subsequent to the application of any required exclusions, disregards, and/or deductions and, as appropriate, deeming. 3.3.2 Definitions A. For the purposes of this Section, the following definitions apply:
1. “Available income” means when the person has a legal interest in a liquidated sum and has the legal ability to make that sum available for support and maintenance. 2. “Countable income” means the total amount of earned and unearned income that is used to determine whether an applicant or beneficiary meets the standard for income eligibility for the applicable IHCC group. 3. “Deeming” means the process of attributing income and resources from non-applicant members of the household, a parent or spouse, to the person seeking Medicaid eligibility as a low-income elder or adult with disabilities who is not seeking LTSS coverage. 4. “Infrequent income” means income that is received no more than once in a calendar quarter from a single source. 5. “PASS” means a written employment plan approved by the SSA that protects an SSI recipient’s eligibility for Medicaid as long as the recipient continues to make progress toward work goals in accordance with a set timetable. 6. “Non-applicant person” means a parent, child or spouse of the applicant in the IHCC group who is not applying for or receiving Medicaid health coverage, but whose finances are considered for the purposes of determining income and resources. For the purposes of Medicaid LTSS eligibility, the term “non-LTSS spouse” refers to the member of a couple who is not applying for or receiving Medicaid. 7. “Unavailable income” means the person cannot gain access to the income. 3.3.3 State Responsibilities A. In calculating countable income, all sources of income a person receives or may be eligible to receive is reviewed. Not all sources of income are reviewed when renewing eligibility as indicated in § 3.3.5 of this Part. When determining initial eligibility using the SSI methodology, State responsibilities include, but are not limited to, the following: 1. Evaluation of Income – All income, earned and unearned, must be evaluated including any that is self-reported in the application process or that may become known through authorized state, federal, and commercial electronic data matches. Additional details regarding the application and renewal process are described in Part 40-00-2 of this Title. 2. Exclusions – Certain forms of earned and unearned income are excluded or treated as “not income” under Federal law or Regulations when determining income eligibility. The State also excludes certain types of
income allowed under the Medicaid State Plan and Section 1115 Waiver. All possible exclusions must be applied prior to the determination of eligibility. 3. Application of Disregards and Deductions – There are income disregards and deductions that apply when evaluating income. The State must apply these disregards and deductions in a specific order when calculating countable income. 4. Deemed Income, Non-LTSS only – A portion of the income of a non- applicant (NAPP) included in the FRU must be deemed as attributable if it is available to the applicant or beneficiary. Deeming is permitted from spouse-to-spouse, parent-to-child and sponsor to non-citizen included within the FRU, but never from sibling-to-sibling or child-to-parent. As only an applicant child seeking MN eligibility is subject to a State determination using the SSI methodology, the instances in which deeming will apply are limited. There is no resource limit in the MACC group for children, which is the principal eligibility pathway for person under age nineteen (19). The deeming of income is subject to conditions and limitations. Part 05-1 of this Chapter sets forth the deeming of income provisions that apply to Community Medicaid when eligibility is determined by the State. 5. Availability – In evaluating income, whether it is available affects how it is counted. Specifically, under certain circumstances, the amount of income that is determined to be available may be greater than the amount a person will be able to use. § 3.4 of this Part explains situations in which income may be unavailable. 6. Determination of Income Eligibility – Income evaluations are only one (1) facet of the eligibility determination process that must be completed within the specific timeframes required set forth in Part 2 of this Subchapter. As eligibility is considered across multiple pathways, failure to meet the income standard of one (1) coverage group does not necessarily result in an immediate denial or termination of eligibility as indicated in Part 2 of this Subchapter. 3.3.4 Beneficiary Responsibilities A. All persons seeking initial or continuing Medicaid health coverage are required to provide timely and accurate information on all matters related to eligibility. In addition, although attestations and electronic verifications of income are conducted to the full extent feasible, supporting documentation must be provided in the manner indicated in the application process. Failure to provide timely and accurate information may result in delays in the determination process, reapplication, or denial of eligibility due to non-cooperation. 3.3.5 Types of Income
A. When determining financial eligibility for Medicaid using the SSI methodology, income types are as follows: 1. Not Income – Some items or payment received by a person are not counted as income in the month received, though they may be treated as resources, as indicated in § 3.7 of this Part, if they are retained in the month after receipt. Items that are not income include, but are not limited to: a. Converted resources including cash received from the sale of a resource, money withdrawn from a savings account or other liquid resources, reverse mortgages or home equity loans or lines of credit; b. Distributions from health flexible spending arrangements or a health savings account; c. Federal, State or local tax refunds; d. Interest on excluded resources; e. Health care services if given free of charge or paid for directly to the provider by someone else and room and board received during a medical confinement; f. Assistance provided in cash or in-kind (including food or shelter) through a government program whose purpose is to provide health care services and supports, or social services (including vocational rehabilitation); g. Cash provided by any non-government health care program or under a health insurance policy if the cash is either a reimbursement for service costs incurred and already paid or an advance for future services; h. Direct payment of health insurance premiums by anyone on a person’s behalf; i. Payments from the U.S. Department of Veterans Affairs (VA) resulting from unusual health care expenses, such as Aid and Attendance or Housebound Allowance; j. Payments in cash or in-kind excluded by Federal law, as indicated in §§ 3.4 and 3.5 of this Part. 2. Countable Earned Income – Any earned income received as cash or an in-kind benefit a person receives in exchange for work must be considered in the financial eligibility determination process. Not all earned income is
countable for Community Medicaid and several of the IHCC groups subject to the SSI methodology. In general, countable earned income includes, but is not limited to, the following with the exceptions noted: a. Employee income. When derived from: (1) Commissions (2) Severance pay, based on accrued leave time (3) Tips (4) Vacation donation compensation (5) Wages (6) Any other forms of payment provided in exchange for work performed such as payment for babysitting, housekeeping, shoveling and so forth unless irregular or infrequent. b. Irregular or infrequent income. Earned lump sum, non-gift, or income from an employer, trade or business above the first (1st) thirty dollars ($30.00) received in a calendar quarter. c. Net earnings from self-employment. This includes gross income minus all expenses the Internal Revenue Service (IRS) allows as a self-employment expense calculated on a taxable year basis. d. Net rental income. The gross rental income minus verified rental and repair expenses, when the person spends an average of ten (10) hours or more per week maintaining or managing the property. Rental deposits are not income while subject to return to the tenant. Rental deposits used to pay rental expenses become income at the point of use. Verified expenses for providing a room or food or both to a roomer or boarder are subtracted from rental income. e. In-kind. Earned in-kind income is a non-cash payment a person receives in place of wages or money from self-employment. In-kind earned income can be for food or shelter, such as free rent in exchange for apartment maintenance or items that could be sold or converted to obtain food or shelter. The current market value of earned in-kind income is countable, unless the exclusions in § 3.4.7 of this Part apply. f. Other income. Income received in exchange for work or service, such as jury duty pay, picket duty pay, blood and blood plasma sales and royalties and honoraria.
3. Countable Unearned Income – Unearned income is cash received that does not require performing a work or service. The following types of unearned income are countable to the extent indicated when determining eligibility using the SSI methodology: a. Adoption assistance involving funds granted under Title IV-E of the Social Security Act, 42 U.S.C. §§ 670-679c. This assistance is counted dollar for dollar and is exempt from the twenty dollars ($20.00) general disregard. See § 3.8 of this Part below for types of adoption assistance that are not counted. b. Alimony, spousal and other adult support. These payments are cash or in-kind contributions to meet some or all of a person's needs for food or shelter and are made voluntarily or because of a court order. Alimony payments are unearned income to an adult. c. Annuities, pensions and other periodic payments. Payments counted in this category are usually related to prior work or service and include, for example, private pensions, Social Security benefits, disability benefits, Veterans benefits, Worker's Compensation, railroad retirement annuities and unemployment insurance benefits. d. Child support and arrearage payments. When made for a deceased child, such payments are counted for the person who receives the payment. Otherwise, support payments are countable income for the child, excluding one third (1/3), unless provided for health and/or other such purposes as indicated in § 3.4.4 of this Part. e. Disability payments. If disability payments are part of an employer’s benefit package they are counted. f. Extended income Trade Adjustment Assistance (TAA) support payments under 20 C.F.R. Part 618 (2023). The TAA is a Federal program that provides support payments to individuals as a way of reducing the damaging impact of imports on certain sectors of the economy. Under the current structure, such payments are countable. g. Foster care payments. When foster care payments are made under Title IV-E of the Social Security Act, 42 U.S.C. §§ 671-679b, they are countable income for the person receiving care. Such payments are Federally-funded and thus the income is not subject to the twenty dollars ($20.00) general disregard. See § 3.4.4(A)(8) of this Part for types of foster care payments that are not counted. h. In-kind. Unearned in-kind income is a non-cash payment a person receives that is not in place of wages or self-employment monies. In-kind unearned income can be either food or shelter or any item
that can be sold or converted to buy food or shelter. See § 3.4.7 of this Part for treatment of income. i. Interest, dividends and certain royalties. Dividends and interest are returns on capital investments, such as stocks, bonds, or savings accounts. Royalties are compensation paid to the owner for the use of property, usually copyrighted material or natural resources. Such payments are countable as any income earned on resources unless specifically treated as non-countable under § 3.6 of this Part. j. Irregular or infrequent lump sum. Unearned lump sum income that comes from an individual, organization, or investment if over thirty dollars ($30.00) in a calendar quarter is counted. Treatment of lump sum income more generally is located in § 3.4.5 of this Part. k. Net rental income. Net rental unearned income counts when the person spends an average of less than ten (10) hours per week maintaining or managing the property. l. Regular and frequent gift income. Unearned income from gifts counts when receipt occurs on a continual basis, at expected intervals such as monthly, or periodically on an irregular basis. m. Retirement, Survivor's, and Disability Insurance (RSDI). Monthly RSDI payments are countable as are other pensions and retirement pensions. The amount of any premiums deducted from RSDI for the optional Supplemental Medical Insurance (SMI) under Medicare are also counted. n. Retroactive RSDI. Lump sum payments are counted in the month received. See § 3.4.5 of this Part for information on the treatment of lump sum income more generally. o. Severance pay. Countable as unearned income only when it is not based on accrued leave time. p. Spousal maintenance or allowance. q. Student financial aid, in the following situations: (1) Distributions from a Coverdell Educational Savings Accounts are counted ONLY if not used or set aside for qualified educational expenses. (2) Scholarships, grants, and fellowships. Unless authorized by Title IV of the Higher Education Act (HEA) of 1965, Pub. Law 89-329, or the Bureau of Indian Affairs (BIA), grants,
scholarships, fellowships and other non-loan financial aid not used for or set aside for educational expenses is countable. r. Tribal per capita payments from casinos. s. Unemployment Insurance, including Rhode Island Temporary Disability Insurance (TDI) payments. Payments made through insurance programs that provide protection for lost wages as a result of an illness or injury that prevents work are countable unless explicitly prohibited by Federal law. t. VA benefits. Pensions are counted when not related to a disability. Any amounts allocated for a dependent child are not counted, however. 3.4 Factors Considered in the Treatment of Income 3.4.1 Scope and Purpose A. When calculating countable income using the SSI methodology, certain disregards and exclusions apply: some only to earned income, others only to unearned income, and a few apply to both earned and unearned income. The availability of income also affects whether it is counted. This Section focuses on these and any other factors considered in the treatment of income for Medicaid eligibility purposes across populations. The specific Rules for how they apply when determining income eligibility for Community Medicaid are located in Part 05-1 of this Chapter; for Medicaid LTSS, all special provisions that apply are located in Part 50-00-6 of this Title. 3.4.2 Both Earned and Unearned Income Disregards and Exclusions A. The following disregards and exclusions apply to both earned and unearned income: 1. Infrequent/Irregular Income Disregards – Income is considered to be infrequent if received only once during a calendar quarter from a single source. Income is considered to be received irregularly if a person is not expected to receive such income on a routine basis. Treatment of irregular and infrequent income is as follows: a. Disregarded. Amounts less than thirty dollars ($30.00) per calendar quarter of earned income and sixty dollars ($60.00) per calendar quarter of unearned income is disregarded. b. Countable. If the amount of irregular/infrequent income is above the amount allowed to be disregarded, all of the income is countable. c. A “calendar quarter” is defined in Part 1 of this Subchapter.
2. Twenty dollars ($20.00)/Month General Income Disregard – The first (1st) twenty dollars ($20.00) per month of unearned income is disregarded. For the disregard to apply to unearned income, the income must not be a benefit of a government funded program in which a person’s income was a factor in determining eligibility. The disregard is applied as follows: a. Order. The twenty dollars ($20.00) disregard is applied to earned income only if it cannot be applied to unearned income. b. Limits. The dollar amount of the disregard is not increased when an applicant and NAPP spouse who are living together both have income. A couple, in which both spouses are Medicaid applicants or beneficiaries, receives one (1) twenty dollar ($20.00) exclusion per month. 3. PASS Disregard – Income, whether earned or unearned, of a person who is blind or living with a disabling impairment may be excluded if such income is needed to fulfill a Plan for Achieving Self-Support (PASS). This exclusion does not apply to applicants who are blind or a person with disabilities who is age sixty-five (65) or older, unless the applicant was receiving an SSI or SSP related to blindness before reaching that age. For additional information on the PASS, see the Federal SSI Regulations at 20 C.F.R. §§ 416.1180 through 416.1182 (2023). 4. Federally Mandated Exclusions – Certain Federal laws other than the U.S. Social Security Act exclude various types of earned and/or unearned income from the calculation of countable income in the financial eligibility process. A list of these exclusions is located in § 3.5 of this Part and is updated on a periodic basis. 3.4.3 Earned Income Disregards and Exclusions A. Deductions to earned income as a result of disregards and exclusions are applied in accordance with certain rules. First, earned income is never reduced below zero (0) as a result of applying disregards and exclusions. Second, any unused earned income disregard or exclusion is never applied to unearned income. Last, any unused portion of a monthly exclusion cannot be carried over for use in subsequent months. Within these Rules, disregards and exclusions are applied as follows: 1. Sixty-five dollars ($65.00) and one half (1/2) Earned Income Disregard – If the applicant or non-applicant spouse is employed, earned income of sixty-five dollars ($65.00)/month plus one half (1/2) of the balance is disregarded. When both eligible spouses are employed, income is combined and then the disregard is applied. 2. AmeriCorps – Payments made to participants in AmeriCorps State and National and AmeriCorps National Civilian Community Corps (NCCC) are
disregarded. These payments may be made in cash or in-kind and may be made directly to the AmeriCorps participant or on the AmeriCorps participant's behalf. These payments include, but are not limited to: living allowance payments, stipends, educational awards, and payments in lieu of educational awards. 3. Child Care Tax Credit – The child care tax credit is given to taxpayers at the end of the tax year for each dependent child who is under the age of seventeen (17). The credit is disregarded as earned income as it reduces the taxpayer's liability on a dollar-for-dollar basis. 4. Earned Income Tax Credit/Refund – The Earned Income Tax Credit (EITC) is not counted. The EITC is a special tax credit for certain low income working taxpayers. This tax credit may be provided as refund through the Federal Internal Revenue Service under the Internal Revenue Code (IRC), 26 U.S.C. § 32, or as an advance payment from an employer under 26 U.S.C. § 3507. The EITC may or may not result in a payment to the taxpayer. 5. Impairment-Related Work Expenses – Earned income used by a person with disabilities to pay impairment-related work expenses is disregarded. For the disregard to apply, the person must be disabled but not blind and under age sixty-five (65) or must have received SSI as a disabled individual (or received disability payments under a former State plan) for the month before reaching age sixty-five (65). In addition, the following must be met: a. The severity of the impairment must require the person to purchase or rent items and services in order to work; b. The expense must be reasonable; c. The expense must be paid in cash (including checks, money orders, credit cards and/or charge cards) by the person and must not be reimbursable from another source, such as Medicare or private insurance; and d. The payment for the expense must be made in a month the person receives earned income and both worked and used the services or the item purchased, or the person must be working and pay the expense before earned income is received. e. Impairment-related work expenses that may qualify for this disregard are described in Federal SSI Regulations at 20 C.F.R. § 416.976 (2023). 6. Student Child Earned Income Exclusions (SEIE) – For a student under age twenty-two (22) or a person who is blind or disabled and regularly
attending school, a set amount of earned income per month up to a yearly maximum may be excluded. The Federal government determines the monthly and maximum amounts based on variety of factors and adjusts the figures annually to reflect increases in the cost living. 7. Work-Related Expenses of Blind Persons – Earned income used to meet any expenses reasonably attributable to the earning of the income by a person who is blind and under age sixty-five (65) or received SSI as a blind person for the month before reaching the age sixty-five (65). Further, expenses may be disregarded if the person has an approved plan for self- support (PASS). The amounts must be reasonable and not exceed the earned income of the blind person or a blind spouse. See references on PASS, including types of expenses that qualify for this disregard in § 3.4.2(A)(3) of this Part. 3.4.4 Unearned Income Disregards and Exclusions A. Exclusions on unearned income never reduce unearned income below zero (0). Except for the twenty dollars ($20.00) general unearned income exclusion, no other unused unearned income exclusions may be applied to earned income. SSI methodology uses the following when considering whether an unearned income disregard or exclusion applies: 1. Assistance Based on Need – This is unearned income which is wholly funded by the State or a local subdivision. Assistance based on need is disregarded whether provided in-cash or in-kind as it is provided through programs that use a person’s income as factor when determining eligibility for benefits or assistance. Assistance based on need that is not counted as unearned income includes the optional State Supplemental Payment (SSP). 2. Burial Funds – Interest earned on the value of excluded burial funds is excluded from income (and resources) if left to accumulate in the burial fund. Interest earned on agreements representing the purchase of an excluded burial space is excluded from income (and resources) but only if left to accumulate. If not left to accumulate – that is, paid directly to the person, spouse or parent – the receipt of the interest may result in countable income. 3. Child Support and Arrearage Payments – One third (1/3) of a child support payment made to or for a child by a non-custodial parent is excluded. A parent is considered non-custodial if the parent and the child do not reside in the same household. The other types of these support and arrearage payments that are excluded are: a. Court ordered health care support payments;
b. Payments to reimburse the custodial parent for health care expenses; and/or c. Payments received and retained by the DHS child support enforcement unit on behalf of a child enrolled in Rhode Island Works, foster care, or Medicaid LTSS Home and Community Based Services (HCBS), including through the Katie Beckett eligibility option. 4. Death Benefits – A death benefit is something received as the result of another's death. a. Proceeds of a life insurance policy received due to the death of the insured; b. Lump sum death benefit from SSA; c. Railroad Retirement burial benefits; d. VA burial benefits; e. Inheritances in cash or in-kind; f. Cash or in-kind gifts given by relatives, friends or a community group to "help out" with expenses related to the death. g. Death benefits are excluded for any expenses paid by applicant or beneficiary related to the deceased's last illness and burial. Any benefits above the actual expenses paid are countable. Recurring survivor benefits such as those received under RSDI and private pension programs are not death benefits. 5. Disaster Assistance – At the request of a State Governor, the President may declare a major disaster when the disaster is of such severity and magnitude that effective response is beyond the capabilities of the State and local governments, and Federal assistance is needed. Under such circumstances, the value of disaster assistance provided by a government agency or an organization such as the Red Cross is excluded from countable income if the person resided in permanent or temporary housing in the disaster area prior to the date of the Presidential designation. 6. Federal Housing Assistance – The U.S. Department of Housing and Urban Development (HUD) and State and local governments and housing authorities provide various forms of assistance that help pay shelter costs. This includes subsidized housing, loans for modifications, mortgage supports and guaranteed loans. Housing assistance is excluded income if
payment is made in the form of cash or a voucher and provided under the authority of any of the following, as amended: a. The United States Housing Act of 1937, 42 U.S.C. § 1437; b. The National Housing Act, 12 U.S.C. § 1715; c. § 101 of the Housing and Urban Development Act of 1965, 12 U.S.C. § 1701s; d. Title V of the Housing Act of 1949, 42 U.S.C. § 1471; or e. § 202(h) of the Housing Act of 1959, 12 U.S.C. § 1701q. 7. Food and Nutrition Assistance – Federal and State governments provide food and nutrition assistance via SNAP, national school breakfast and lunch programs, WIC and several other publicly funded programs that serve elders, children and persons with disabilities. Food and nutrition assistance from these program is excluded income. 8. Foster Care Payments – In contrast to countable payments made under Title IV-E of the Social Security Act, 42 U.S.C §§ 670-679c, Foster Care payments provided under Title IV-B of the Social Security Act, 42 U.S.C. §§ 621-628b, or Title XX of the Social Security Act, 42 U.S.C. §§ 1397- 1397n-13, are social services and are excluded from the foster child's income. 9. Gifts – Gifts from an organization which is tax exempt under the IRC to, or for the benefit of, a person under age eighteen (18), who has a life- threatening condition are excluded up to a maximum of two thousand dollars ($2,000.00) in a calendar year. 10. Grants, Scholarships, Fellowship – Grants, scholarships, and fellowships are educational financing instruments funded by private, non-profit agencies, and Federal, State and local governments. Any portion of a grant, scholarship or fellowship used to pay for qualified education expenses (tuition, fees or books, etc.) is not countable income. This exclusion does not apply to any portion set aside or actually used for room and board. 11. Home Energy Assistance Payments – Home energy or support and maintenance assistance is excluded if it is based on need and provided in- kind by a private nonprofit agency or in cash or in-kind by a supplier of home heating oil or gas, a utility company providing home energy, or a municipal utility providing home energy. 12. Refugee Cash Assistance – Refugee cash assistance payments and federally reimbursed general assistance payments to refugees are
disregarded under a PASS, but otherwise it is counted. The twenty dollar ($20.00) general income disregard does not apply to this income. 13. Relocation Assistance – This form of assistance is provided to people who are displaced by government projects which acquire real property whether under eminent domain or a similar action. Assistance provided in these circumstances is excluded as income. 14. Reparation Payments – Reparations associated with the following are excluded from income: a. Reparation payments received from the Federal Republic of Germany; b. Austrian social insurance payments based in whole or in part on wage credits granted under the nationwide class action lawsuit Bondy v. Sullivan (1991) involving the Austrian General Social Insurance Act; c. Restitution payments made by the U.S. Government to Japanese Americans (or if deceased, their survivors) and Aleuts who were interned or relocated during World War II; and d. Agent Orange settlement payments. 15. Rhode Island Works Under a PASS – Rhode Island Works payments under a PASS are excluded. However, Rhode Island Works payments unless excluded under a PASS, are countable income. The twenty dollar ($20.00) general income disregard does not apply to this income. 16. Student Loans – Federal and State funds or insurance are provided for educational programs at middle school, secondary school, undergraduate and graduate levels under Title IV of the Higher Education Act, 20 U.S.C. §§ 1070-1099d, and student assistant programs of the Bureau of Indian Affairs. Any loan to an undergraduate student for qualified education expenses made and/or insured by the Federal government or the State’s higher education financing authority is excluded as both an income and resource. 3.4.5 Lump Sum Income Disregards and Exclusions A. Lump sum income is irregularly or infrequently received income. It can be earned or unearned income. Whether lump sum income is countable when determining financial eligibility depends on what is received, how often it is received, and the health care program for which the person is eligible. Examples of lump sum income include: 1. Winnings (lottery, gambling), Insurance settlements
2. Worker's Compensation Settlements, Inheritances, Retroactive payments of RSDI, VA, and Unemployment Insurance 3. General Treatment of Lump Sum Income – For all IHCC groups subject to the SSI methodology, the following are excluded from lump sum income: a. Costs associated with getting the lump sum, such as attorney's fees. b. Any portion of the lump sum earmarked for and used to pay health expenses not covered by Medicaid or another form of insurance. c. Any portion of the lump sum recovered by the EOHHS or its agents. d. Any portion of the lump sum earmarked for and used to pay funeral and burial costs upon the death of a spouse or child. 4. RSDI and SSI Payments – When eligibility for RSDI and SSI benefits are first approved, beneficiaries often receive a one (1) time payment that includes retroactive payments back to the date of a disability. These RSDI and SSI payments are lump sums, and are treated somewhat differently depending on the person’s Medicaid eligibility pathway: a. SSI/SSP Pathway. Retroactive lump sum payments of SSI and all other lump sum income (including RSDI) of an SSI/SSP recipient are excluded even if the lump sum is a retroactive payment for a period in which the recipient is a Medicaid beneficiary. The only exception is that any portion of a lump sum payment that is designated as a benefit for a dependent of the beneficiary is counted as unearned income to the dependent in the month received. b. Community Medicaid, MPPP, and Medicaid LTSS pathways. (1) Retroactive RSDI lump sum payments are counted as unearned income in the month received. If the beneficiary is not receiving SSI, the RSDI payment is a resource in the following month if retained. RSDI payments are not counted as a resource for nine (9) months once converted from income. (2) Retroactive lump sum payments of SSI are excluded as income and resources in the month received. (3) Any retroactive SSI or RSDI lump sum payment received before March 2, 2004 is excluded as a resource.
5. Medicare Part B Reimbursements – A dual eligible beneficiary’s Medicare Part B premium could be reimbursed in a lump sum if determined retroactively eligible as a Specified Low-Income Medicare Beneficiary (SLMB). In such cases, the beneficiary will receive a reimbursement check from CMS after the State has provided back payment for those retroactive months. A Medicare Part B reimbursement is counted if the beneficiary used Medicare Part B premiums as all or a portion of a spenddown expense. The lump sum reimbursement is excluded if the beneficiary did not use Part B premiums as an expense for spenddown purposes. Such reimbursements may be counted in the month received for Medicaid LTSS beneficiaries receiving RSDI. 3.4.6 Self-Employment Income A. Self-employed beneficiaries are responsible for their own work schedules and are not covered under an employer's liability insurance or Workers' Compensation. Depending on the type of self-employment, a beneficiary may or may not have Social Security tax (FICA) deducted from pay. Examples of self- employment enterprises include but are not limited to: Farming; Product Sales (involving personal goods such as jewelry, household goods, clothing and the like); Personal Training; Professional Consulting; Small businesses; Services (personal care or day care); and Skilled Trades (roofers, painters, home design, etc.). The process for evaluating self-employed income includes: 1. Treatment of self-employment income in general – Self-employment income is reported as earned or unearned on the application and is generally accepted as attested unless conflicts are identified. Net self- reported income – gross self-income minus allowable deductions for business – is countable as earned income. 2. Treatment of property related to self-employment income – Certain types of self-employment involve use of real property. Deductions from gross self-employment income for allowable expenses are made in accordance with Federal Internal Revenue Service (IRS) requirements associated with the business use of the home/vehicle. Special treatment is required with the following: a. Rental income. Income from rental property is counted as earned income only in those months the applicant/beneficiary spends an average of at least ten (10) hours per week maintaining or managing the property. Otherwise, rent is treated as unearned income. Deductible expenses are subtracted from gross rent in the month they are incurred. Any expense over the income are subtracted from the next month’s rent. Rental deposits used to pay rental expenses or repairs become income to the landlord at the point of use. Verified expenses for providing a room or food or both to a roomer or boarder are subtracted from rental income.
b. Room/Board Income. Roomer/boarder situations include the following: (1) A roomer lives with the household and pays for lodging only. (2) A boarder eats with the household and pays for meals only. (3) A roomer and boarder lives and eats with the household and pays for lodging and meals. (4) Net self-employment income derived from room and board is countable. To determine net income in such cases, allowable expenses are deducted from gross receipts. For these purposes, allowable expenses include costs for providing a room, food or both to a roomer/boarder; shelter costs based on percent of total rooms in the house that are for rent; and any costs related strictly to renting a particular room, such as accommodations related to a disability or to a particular boarder, such as a special diet. c. In-home Day Care. When a person provides family child care services in a home in which they have an ownership interest, net self-employment income is countable. In such instances, allowable expenses are itemized as business expenses for tax filing purposes and include food (meal and snacks) and educational and entertainment materials in addition to transportation and shelter costs. If the care is provided in a home in which there is no ownership interest, the applicant/beneficiary is treated as a private contractor and these additional allowable expenses are not deducted from gross employment income. Payments made by the DHS to an in-home child care provider in association with the State’s Child Care Assistance Program (CCAP) are countable. 3.4.7 In-Kind Income A. In-kind income, whether earned or unearned, is generally counted at market value. Special Rules apply when such income takes the form of food or shelter: 1. Earned In-kind – Food and shelter provided in lieu of a cash payment for work is countable and subject to the applicable income disregards. 2. Unearned in-kind – When no work is performed in exchange for room and shelter, its value is determined as follows: a. Assistance Household. If everyone in a household is receiving government assistance for income and maintenance based on need, income in the form of food or shelter is excluded regardless of value and source;
b. Living in household of another. When a person is living in the household of another for an entire month and they do not have an ownership interest or pay an appropriate share of the monthly expenses for maintaining that household, a portion of the value of the food and shelter they receive is excluded. (1) If all meals and shelter are provided in-kind, the countable value is one third (1/3) of the FBR and the general income disregard does not apply. No other in-kind income is counted. (2) If food or shelter is provided, but not both, the presumed maximum value (PMV) Rule applies. The PMV is equal to one third (1/3) of the FBR and the twenty dollars ($20.00) disregard. This amount is counted unless the person can provide documented evidence that the market value of the food or shelter is below the PMV. All other disregards and exclusions apply. c. Living in own household. If the person lives in their own home and receives food and/or shelter in-kind, the PMV rule applies. 3.4.8 Availability A. Under the following circumstances, the availability of income determines whether it is counted: 1. Support Payments – When an individual has been court-ordered to pay child support and/or spousal support to a former spouse, these payments are not deducted from countable income to the applicant. When the child support/spousal support is paid directly to the former spouse or child's guardian by the employer or benefit payer, the income continues to be determined available to the applicant/beneficiary. 2. Income Deductions – Court-ordered income deductions are considered available income to the Medicaid beneficiary. A division of marital property in a divorce settlement is not considered a court-ordered income deduction in the context of this Rule. 3. Loan Deductions – Deductions due to a repayment of an overpayment, loan, or other debt is considered as available income unless the amount being withheld to reduce a previous overpayment was included when determining the amount of unearned income for a previous month. 4. Garnishments and Liens – When either is placed against earned or unearned income of a person, the amount must not be deducted from countable income, regardless of the purpose for the garnishment or lien.
3.5 Federally Mandated Income Exclusions A. Federally Mandated Income Exclusions Federally Mandated Income Exclusions Agent Orange settlement payments Child care assistance under the Child Care and Development Block Grant Act of 1990, Pub. Law 113-186 The first (1st) two thousand dollars ($2,000.00) per calendar year received as compensation for participation in clinical trials that meet the criteria detailed in § 1612(b) of the Social Security Act, 42 U.S.C. 1382a(b) Payments made for supporting services or reimbursement of out-of-pocket expenses to volunteers participating in corporation for national and community service (CNCS, formerly ACTION) programs: AmeriCorps program Special and demonstration volunteer program; University year for ACTION (UYA) Retired senior volunteer program (RSVP) Foster grandparents program Senior companion program Energy employees occupational illness program payments Federal food and nutrition programs: Food assistance (formerly known as food stamps) U.S. department of agriculture food commodities distributed by a program (private or governmental) School breakfast, lunch, and milk programs; Women, infants, and children program (WIC); Nutrition programs for older Americans
Federally Mandated Income Exclusions Student financial assistance received under the Higher Education Act of 1965 (U.S.C. Title 20) or Bureau of Indian Affairs is excluded from income and resources, regardless of use: Pell Grants Student services incentives Home energy assistance provided on the basis of need, in accordance with 20 C.F.R. § 416.1157 (2023) Matching funds that are deposited into individual development accounts (IDAs), either demonstration project or TANF-funded, in accordance with 42 U.S.C. § 604 Japanese-American and Aleutian restitution payments Payments to victims of Nazi persecution Netherlands WUV payments to victims of persecution from 1940-1945 Department of Defense payments to certain persons captured and interned in North Vietnam, in accordance with the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act of 1998, Pub. Law 105-78 Radiation exposure compensation trust fund payments, in accordance with the Radiation Exposure Compensation Act (“the Act” or “RECA”), Pub. Law 101-426 Veterans Affairs payments made to or on behalf of:
Federally Mandated Income Exclusions Certain Vietnam veterans’ natural children regardless of age or marital status, for any disability resulting from spina bifida suffered by such children Certain Korea service veterans’ natural children regardless of their age or marital status, for any disability resulting from spina bifida suffered by such children Women Vietnam veterans’ natural children regardless of their age or marital status, for certain birth defects Austrian social insurance payments received under the provisions of the Austrian General Social Insurance Act, 20 U.S.C. § 1613(a), 20 C.F.R. § 416.1236 (2023). These payments must be documented and identifiable from countable insurance Payments made to Native Americans as listed in Part IV of 20 C.F.R. Part 416 Appendix to Subpart K (2023) Payments from the Ricky Ray hemophilia relief fund or the class settlement in the case of Susan Walker v. Bayer Corporation et al. under the Ricky Ray Hemophilia Relief Fund Act of 1998, Pub. Law 105-369 3.6 SSI Methodology: Treatment of Resources 3.6.1 Scope and Purpose A. For the purposes of Medicaid eligibility, the assessment of resources is not tied, at least directly, to the person's availability to pay for health care. Instead, a resource is defined broadly as cash or other property that a person owns or has access to that is or could be used for personal support and maintenance. This Section describes the general treatment of resources when using the SSI methodology to determine eligibility for the IHCC groups to which it applies. There are differences in the types of resources that count and how they are reviewed for Community and LTSS Medicaid. Key differences in the review process are as follows: 1. Simplified Resource Review for Community Medicaid – States that have expanded eligibility for low-income elders and adults with disabilities up to one hundred percent (100%) of the FPL have the authority under Federal Regulations to utilize a simplified standard when evaluating resources for initial eligibility and at renewal. Although the same resources are
considered when using this simplified standard, they are evaluated in less depth than required for Medicaid LTSS eligibility because the provisions on resource transfers and spousal allocations do not apply. In addition, attestations with respect to certain resources are accepted at the time of initial application and the point of renewal. Depending on the availability of electronic data sources, verification through materials may be required subsequent to the determination of eligibility in the post-eligibility verification process. Note income and resource deeming is included in the simplified standard in Rhode Island. 2. Comprehensive Resource Review for LTSS – There are both MAGI and SSI-related eligibility pathways for LTSS that differ in terms of the treatment of income and resource limits, at least at the point in which an institutional level of care becomes required. Applicants evaluated using the SSI method (IHCC groups) are subject to a resource review and, in some instances, using specialized criteria as indicated in Part 50-00-6 of this Title; the resources of applicants seeking coverage through a MAGI pathway (MACC groups) are not an eligibility factor and therefore are not considered on that basis. However, all LTSS applicants, irrespective of eligibility pathway, are subject to an in-depth review of the transfer of assets – including income and resources – to ensure that the rules are applied equitably and in accordance with the standards set in Federal and State laws and Regulations governing estate recovery. The specific provisions applicable to the evaluation of resources and transfers of assets for Medicaid LTSS are set forth in Part 50-00-6 of this Title. 3.6.2 Definitions A. For the purposes of this Section the following terms apply: 1. “Annuity” means a purchased contract in which one (1) party (annuity issuer) agrees to pay the purchaser, or the person the purchaser designates (the payee or payees), a return on money deposited with the annuity issuer (either in the form of a single lump sum or several payments deposited over several months or years) according to the terms of the annuity contract. 2. “Available resource” means that a person has the legal ability to access and use the resource(s) for support and maintenance. A resource is considered unavailable when there is a legal impediment that prevents the person from utilizing it for such purposes. 3. “Burial expense fund” means any resources set aside for the payment of burial services or expenses. Includes burial fund and burial space funds designated for a person or a person’s spouse related to burial, cremation or other burial-related expenses. May take the form of revocable burial contracts, revocable burial trusts, other revocable burial arrangements
(including the value of certain installment sales contracts for burial spaces); cash accounts and other financial instruments with a definite cash value or irrevocable burial contracts. 4. “Equity value” means the price an item can be reasonably expected to sell for on the local open market minus any encumbrances. 5. “Fair market value” means a certified appraisal or an amount equal to the last or average price of the property or good on the open market in the locality at the time of the transfer transaction or contract for sale, if earlier. 6. “Guardian” means a person or institution appointed by a court in any State to act as a legal representative for another person, such as a minor or a person with disabilities. 7. “Home” means a residential property in which the person and/or person's spouse possess an ownership interest providing it also serves as the principal place of residence of the applicant and/or the applicant's spouse or dependent child. 8. “Intent to return” means an expression by a person indicating that they plan to live in the home used as the principal place of residence after a temporary absence. The intent to return home is subjective rather than objective and, as such, must be expressed by the applicant or beneficiary, or an authorized representative, and take the form of a signed, written statement. 9. “Life estate” means a legal arrangement entitling the owners to possess, rent, and otherwise profit from real or personal property during their lifetime. 10. “Liquid resources” means cash or other personal property that can be converted to cash within twenty (20) working days. 11. “Non-liquid resources” means property that is not cash, including real and personal property that cannot be converted to cash within twenty (20) working days. 12. “Ownership interest” means the person seeking Medicaid holds sole or joint legal title to the residential property or is a party to a legal covenant establishing property ownership, such as a life estate. 13. “Principal place of residence” means the residential property where the beneficiary, and/or in the instances specified the spouse or a dependent child of such a person lives the majority of the time during the year – one hundred eighty-three (183) days in the previous twelve (12) months.
14. “Real property” means land and generally whatever is erected, growing on, or affixed to land. 15. “Representative payee” means an individual, agency, or institution selected by a court or the Social Security Administration to receive and manage benefits on behalf of another person. 16. “Resource transfer” means the conveyance of right, title, or interest in either real or personal property from one (1) person to another. The conveyance may be by sale, gift, or other process. 17. “Temporary absence” means a limited period in which an applicant/beneficiary is not residing in the home in which they have an ownership interest due to a hospitalization or convalescence with a relative. Temporary absences do not affect the determination of a person’s principal place of residence. 18. “Trust” means property that is legally held or managed by a person or organization other than by its owners. 3.6.3 State Responsibilities A. In calculating countable resources, the State’s responsibilities include, but are not limited to: 1. Scope of Resource Evaluation – The resources of the person seeking Medicaid and each member of the FRU when deeming applies are evaluated at the time of initial application, when a beneficiary reports, or the State receives, information about a change in an eligibility factor, including in conjunction with the annual renewal of Medicaid eligibility and when applying for Medicaid LTSS or moving across eligibility pathways. 2. Factors Affecting the Evaluation of Resources – The following factors must be considered when evaluating resources: a. Availability. The extent to which a resource can be legally accessed, and used for income support and maintenance, affects how resources are evaluated and counted. Availability is often affected when more than one (1) person has an ownership interest in the same resource. b. Liquidity. The ease of converting a resource into cash – sometimes referred to as a liquid asset – is considered when determining how it is treated for financial eligibility purposes. c. Equity value. Equity value of a resource is considered when determining the amount of a resource that counts. In general,
equity value means the price an item is expected reasonably to sell for on the local open market minus any encumbrances. d. Countable vs. Excluded Resources. A resource may be counted or excluded when determining financial eligibility. The State must consider whether a resource is counted or subject to a general or coverage group-specific exclusion and then assure any applicable exclusions are considered as follows: (1) Countable Resource: A resource, whether real or personal property, that is available to the applicant or beneficiary and thus counts toward a resource limit. Resource deeming applies unless otherwise specific when determining eligibility for IHCC groups providing Community Medicaid; (2) Excluded Resource: A resource that is not counted toward the resource limit because of a specific provision in Federal or State laws or Regulations. Some resources are excluded categorically under Federal law or Regulations; other resources are excluded regardless of value for some IHCC coverage groups but at a set amount for other groups – there is no limit on the value of a home for Community Medicaid but a cap based on equity value for LTSS; and still other resources are excluded only to the extent they do not exceed a specific threshold amount, such as life insurance face value limit. 3. Deemed Resources – non-LTSS only – The resources of members of the FRU must also be evaluated and any that are countable attributed to the applicant(s) in the deeming process in accordance with Part 05-1 of this Chapter. For Medicaid LTSS, there is no deeming and the evaluation of resources is always based on the applicant or individual – that is, an FRU and Medicaid eligibility unit size of one (1) – unless both spouses are seeking coverage subsequent to the initial determination of eligibility. 4. Determination of Resource Eligibility – Resource eligibility is determined by comparing the countable resources of the FRU to the resource limits for the applicable IHCC group adjusted for the Medicaid eligibility group size. 3.6.4 Beneficiary’s Responsibilities A. Applicants and beneficiaries are responsible for: providing accurate information about their resources in the application process and submitting any necessary documentation and/or signed authorizations that may be necessary for verification purposes. 3.6.5 Types of Resources and Related Exclusions
A. The SSI-methodology generally divides resources into non-liquid and liquid resources. Except for cash, any kind of property may be either liquid or non- liquid. A third (3rd) distinction has been added below for resources of both kinds managed by a third (3rd) party, such as trusts. 1. Non-Liquid Resources – A non-liquid resource is property that is not cash, including real and personal property that cannot be converted to cash within twenty (20) business days. Real property, life estates, life insurance and burial funds, described below, are some of the more common kinds of non-liquid resources. Certain other non-cash resources, though they may occasionally be liquid, are nearly always non-liquid including, but not limited to, household goods and personal effects, vehicles, livestock, and machinery. Types of non-liquid resources evaluated when determining eligibility for IHCC groups are as follows: a. Home and Adjoining Land (real property). A home is a residential property which includes the shelter where a person lives, the land on which the shelter is located, related outbuildings, and surrounding property not separated from the home by intervening property owned by others. Public rights of way, such as roads that run through the surrounding property and separate it from the home, do not affect the exemption of the property. A home in which the applicant or the spouse of an applicant has an ownership interest is excluded as a resource, regardless of its value, for EAD or MN Community Medicaid. A home is also excluded for LTSS, but only up to the equity value limits established in § 3.2.8(A)(7)(e) of this Part and the provisions set forth in Part 50-00-6 of this Title with respect to the intent to remain are met. Factors affecting application of the exclusion include: (1) Principal Place of Residence. The excluded home must serve as the owner’s principal place of residence. A home serves as the principal place of residence if the person or spouse with an ownership interest, sibling with an equity interest and/or dependent (minor child or relative with a disability) resides in the home for at least six (6) months and one (1) day (one hundred eighty-three (183) days) in any given year. (2) Multiple Residences. Although an applicant may own residential properties either alone or in conjunction with others, only one (1) is considered a home and may be treated as an excluded resource at any given point in time. Even in situations in which both spouses in the household are applicants, the value of only one (1) home may be excluded. When the person and their spouse/dependent child make conflicting claims over which residential property
is subject to the home exclusion the following decision Rules apply: (AA) If the applicant and applicant's spouse live in separate residential properties in Rhode Island in which they share ownership, the home exclusion applies to the residential property where the person lived at the time the application for Medicaid health coverage was received by the State. (BB) If each spouse lives in a separate residential property in Rhode Island in which they share ownership, and both spouses apply for Medicaid, the home exclusion applies to the property where the spouse who applied first resides. (CC) If both spouses apply on the same day, the spouses must agree in writing which home is to be excluded. If no agreement can be reached, the home exclusion is applied to the residential property with the greatest value. (3) Out-of-State Residences. To be eligible for Medicaid, a person must be a Rhode Island resident and, as such, have intent to stay in the State permanently or for an indefinite period. Accordingly, an applicant who declares an out-of- State residential property as a home to return to is not considered a Rhode Island resident for the purposes of determining Medicaid eligibility. The out-of-State residence is considered a countable resource. (4) Multi-State Residences – When a person owns residential properties both in and out-of-State, the home exclusion is applied to the residential property located in Rhode Island. The value of any out-of-State residential property is a countable resource, even if it is the principal place of residence of the applicant's spouse/dependent child, as long as the applicant maintains an ownership interest in any Rhode Island residential property. (5) Out-of-State property owner – If the person does not own residential property in Rhode Island but lives and intends to remain in the State, the home exclusion may be applied to an out-of-State residential property if, and only if, it is the principal place of residence of the person's spouse or dependent child.
(6) Sale of the Home – The home exclusion remains in effect if the Medicaid beneficiary or spouse with an ownership interest is making an effort to sell the home. For Medicaid LTSS purposes, the provisions in Part 50-00-6 of this Title apply if the home serves as the principal place of residence for an applicant or beneficiary. If efforts to sell a home that is not or no longer meets the criteria to be excluded under this Section are unsuccessful, the value of the home is treated as a countable resource unless documentation of such efforts is provided by a competent authority such as an attorney or real estate broker. Even when such documentation is provided, there is a limit on the length of time the resource is treated as unavailable as indicated in Part 50-00-6 of this Title. (7) Proceeds from the Sale – Once a home has been sold, the proceeds are excluded for six (6) months from the date they are received for Community Medicaid eligibility in accordance with Part 05-1 of this Chapter. Unless obligated or used for the purchase, repair or construction of another domicile or another excluded resource, the proceeds become countable on the first (1st) of the month (FOM) in the month after the sale Medicaid LTSS eligibility. (8) Temporary Absences – A home exclusion is unaffected by temporary absences due to placement in a health facility or institutional setting, including a correctional facility, provided that the owner has not placed the home in a revocable trust and the owner and: (AA) Intends to return to the home even if the likelihood of return is apparently nil; (BB) Has a spouse or dependent residing in the home; or (CC) Has a health condition that prevented the owner from living there before. b. Business/Trade Property (real property). Real estate used in business or a trade is excluded regardless of its equity value and whether it produces income. c. Income Producing Real Estate (real property). Up to six thousand dollars ($6,000.00) of the equity value in non-business real estate (excluding the home), mortgages, deeds of trust or other promissory notes may be excluded. For the exclusion to apply, the
property must produce an annual income of six percent (6%) of the net market value or current face value of the property. d. Vehicle (personal property). Any motorized mode of transportation that moves persons or articles from place to place. This includes automobiles, trucks, motorcycles, tractors, snowmobiles, recreational vehicles, campers, and motorized boats. One (1) vehicle that is used as the primary source of transportation for the applicant or beneficiary is excluded, regardless of its value. The equity value above four thousand five hundred dollars ($4,500.00) of any other vehicles owned by members of the FRU is counted. e. Life estate (real property). Life estate means a legal arrangement entitling the owner of the life estate (sometimes referred to as the “life tenant”) to possess, rent, and otherwise profit from real or personal property during their lifetime. The amount of a life estate that is countable depends on when it was established, whether the applicant(s) have the legal right to sell the home, and the portion of the proceeds of the sale, if allowed, is available. The owner of a life estate sometimes may have the right to sell the life estate but does not normally have future rights to the property. Life estates are only excluded in full when the owner retains the power to sell or mortgage the home. If the owner does not retain this right, the provisions in Part 50-00-6 of this Title apply. f. Burial Funds (personal property). Any funds clearly designated for burial expenses including burial spaces and related items and services. May take the form of contracts, revocable or irrevocable trusts, or other agreements, accounts, or instruments with a cash value. The following applying when determining the amount of burial expenses that may be excluded under one (1) of the following: (1) Burial Fund Exclusion (BFE). The BFE allows an individual to exclude up to one thousand five hundred dollars ($1,500.00) of resources for services including preparing the body for burial and services that are not performed at the burial site. The exclusion for a couple is three thousand dollars ($3,000.00) and for a person seeking MN eligibility is four thousand dollars ($4,000.00). These resources must be clearly designated for the person or their spouse’s burial, cremation, or other burial-related services; they cannot be commingled with other resources intended for burial. This exclusion applies only if the funds set aside for burial expenses are kept separate from all other resources not intended for burial. The BFE is reduced by the face value of any whole life insurance policy excluded under this Section
as well as any amounts for such services covered in a revocable burial contract. (2) Burial Space Exclusion (BSE). The BSE allows burial space items to be excluded without limiting their value. Burial space items include the burial site, a repository for bodily remains, services performed at the burial site, and items related to the burial site. Only burial space items may be excluded under the BSE. Burial services are never excluded under the BSE. (3) Irrevocable burial contracts. If a burial contract is irrevocable, the funds deposited into the agreement are unavailable and cannot be withdrawn by the person or the funeral provider until the time of need. Irrevocable burial contracts include those funded by life insurance, those funded by annuities, and those in which the person directly pays the funeral provider. Interest earned on these contracts may be separately designated as revocable or irrevocable. If the interest is designated as irrevocable, it is unavailable. If the interest is designated as revocable, it is a counted resource. The maximum amount of an exclusion for an irrevocable contract is fifteen thousand dollars ($15,000.00). Any amounts above this limit are treated as a resource for the purposes of determining financial eligibility. (4) Revocable burial contracts. If an agreement is revocable, the funds deposited into the agreement are available and can be withdrawn at any time. A revocable burial contract may be an excludable resource depending on what burial costs it is intended to cover and whether any portion of the allocated funds can be excluded due to the BSE or BFE. When a revocable burial contract is a countable resource, either the amount the owner would receive if the contract was revoked, or the current market value if it is a saleable contract, is counted less the BFE amount if not otherwise applied – that is, one thousand five hundred dollars ($1,500.00) for an individual, three thousand dollars ($3,000.00) for a couple, or four thousand dollars ($4,000.00) for a person seeking MN eligibility. g. Personal Effects and Household Goods (personal property). Personal effects are items goods such as clothing, heirlooms, jewelry and accessories. Household goods include home furnishings, such as furniture, rugs, and decorations and recreational items, such as televisions, table or digital games, musical instruments and equipment. Such items are excluded.
h. Life Insurance Policy. A contract between the policy holder and an insurer in which the insurer agrees to pay a designated beneficiary a sum of money in exchange for a premium, upon the death of the insured person – in this case the applicant/beneficiary (often the policy holder). Whole life insurance is permanent and builds cash value over the insured person’s lifetime because it has an added investment component along with its death benefit. The value of a whole life insurance policy is only counted if the person, or the person’s spouse (couple) is the owner. Policies on the life of a person or applicant’s spouse owned by another member of the FRU are not considered even when deeming applies (non-LTSS). Whether a policy is counted as a resource depends on two (2) factors: (1) Cash surrender value. Cash surrender value is the amount which the insurer will pay (usually to the owner) upon cancellation of the policy before death of the insured or before maturity of the policy. (2) Face value. Face value is the basic death benefit of the policy exclusive of dividend additions or additional amounts payable because of accidental death or under other special provision. (3) Counting rule. If the total face value of all life insurance policies on any person is at or below four thousand dollars ($4,000.00), no part of the cash surrender value of the life insurance is included when determining countable resources. If the face value is above four thousand dollars ($4,000.00) only the cash surrender value above four thousand dollars ($4,000.00) is a countable resource. The total amount of the cash surrender value above four thousand dollars ($4,000.00) is added to all other countable resources when determining whether an applicant or beneficiary is at or below the resource limit for Medicaid financial eligibility. The cash surrender value below four thousand dollars ($4,000.00) is treated as an unavailable resource unless or until the policy is cashed out. Term insurance and burial insurance are not taken into account. 2. Liquid Resources – A liquid resource is cash or other property that can be converted to cash within twenty (20) business days. Accounts in financial institutions; retirement funds; stocks, bonds, mutual funds, and money market funds; annuities; mortgages and promissory notes; and home equity conversion plans, described below, are some of the more common kinds of liquid resources.
a. Annuities. A contract reflecting payment to an insurance company, bank, charitable organization, or other registered or licensed entity; it may also be a private contract between two (2) parties. The purchase of an annuity may constitute a disqualifying transfer that results in a period of ineligibility for seeking initial or continuing Medicaid LTSS. The applicable provisions related to asset transfers are set forth in Part 50-00-6 of this Title. In addition, there are two (2) phases to an annuity, each of which also affects how it is treated as resource: an accumulation phase and a payout phase. Annuities also vary significantly by type, how beneficiaries are treated, and how they accumulate and pay out money, such as lump sum v. scheduled, usually on a monthly basis. All these factors influence whether the value of the annuity is counted or excluded. In addition, the State considers whether the annuity is a liquid resource, and ownership. Since annuities are trust-like instruments, terminology similar to trusts is used when it describes the availability of cash from annuities. The amount of any penalties paid when cashing-in an annuity is deducted from the amount of the payout. In general, exclusions are as follows: (1) Annuity that can be surrendered, cashed in or assigned. An annuity that can be surrendered, cashed in or assigned by the owner is presumed to be a revocable annuity. A revocable annuity is considered a countable resource when the person seeking Medicaid is the owner. An annuity is presumed to be revocable when the annuity contract is silent on revocability. (2) Annuity owned by someone other than the applicant or spouse. An annuity is an unavailable resource when the owner of the annuity is not the person or the person’s spouse or either spouse has abandoned all rights of ownership. However, if payments from the annuity are being made to the person seeking Medicaid (or spouse), those payments may be counted as income and considered for both income eligibility and deeming purposes. (3) Treatment by Phase. An annuity owned by a person seeking Medicaid is a countable resource in its accumulation phase because it can be liquidated for a lump sum or sold. An annuity in its pay-out phase is considered an excluded resource if the person only has the right to liquidate the annuity for the present value of all future payments and this commuted value is less than its equity value. b. Cash and Accounts in Financial Institutions. Cash on hand is a countable resource. In addition, accounts held in financial
institutions – checking and draft accounts, savings and share accounts, money market account, and certificates of deposit – are all countable resources for both the person seeking Medicaid and members of the FRU for deeming purposes. In instances in which an account is jointly held, the value is apportioned equally among owners unless there is a title or deed to the contrary. In cases in which there is ownership in common or in entirety, the provisions in § 3.7.2(A)(4) of this Part apply. For the purposes of calculating Medicaid LTSS eligibility, an applicant who is a joint owner of an account is presumed to be legally able to withdraw and obtain unrestricted access to funds in the account. An applicant may rebut this presumption by providing documentation such as a deed or title. Absent such documentation, the full value of the account is treated as a countable resource when determining financial eligibility including allocation of resources for Medicaid LTSS eligibility in accordance with Part 50-00-6 of this Title. c. Investments. Stocks, bonds, mutual funds and other investment instruments are evaluated in terms of sole or joint ownership as follows: (1) Savings Bonds. For U.S. Savings Bonds, the value of the bond is the amount that is paid out if the bond is cashed. The value of the bond is a countable resource, unless the bond cannot be cashed for a legal reason other than the standard twelve (12) month waiting period. (2) Bonds and Securities. The cash value of bonds/securities is the bid price. The bid price is a countable resource unless it was not paid for in full at the time of purchase – that is, bought on the margin. Any debt owed is deducted from the value when calculating the amount of the resource that is countable. (3) Stocks. The value of a stock is the closing price if it is publicly traded. The value of stocks is a countable resource. (4) Availability. The value of a jointly owned investment, account or holding is considered unavailable and does not count toward the resource limit, if it cannot be redeemed or sold because the co-owner cannot be located or refuses to cooperate by providing a necessary signature/authorization or, in the case of a bond, the paper bond or access to electronic transaction authority. d. Loans. A loan is an oral or written contract or statement clearly indicating a borrower’s indebtedness, the personal or real property
used to secure the borrowed amount (collateral), if any, and the terms of repayment. Loans may be made through commercial entities including financial institutions and informally between persons and entities. The treatment of loans depends on whether it is “bona fide” – that is, the terms of the loan agreement are made in good faith and are enforceable under applicable State law (the borrower can be sued if the loan is not paid back), the agreement is in effect at the time the lender transfers funds, the loan is secured, and the borrower agrees to the terms of repayment. Any loan that is not bona fide may be treated as a gift, unless it qualifies as a promissory note under § 3.6.5(A)(2)(f) of this Part below; in such instances, the full value of the loan may be counted as income and/or a resource depending on whether the applicant is the lender or borrower and the manner in which it is paid. In addition, such loans may be considered a disqualifying transfer for Medicaid LTSS purposes if their fair market value cannot be discerned in accordance with Part 50-00-6 of this Title. In general, unless explicitly excluded as a resource under § 3.7.4 of this Part, bona fide loans are treated as follows for the lender or borrower: (1) Borrower. The amount of the loan that the borrower must repay, along with any interest, is excluded as a countable resource in the month the loan is executed. Any portions of the loan remaining on the FOM after the month it is executed is a countable resource. (2) Lender. The amount the lender loans and the loan repayments may be treated as countable resources depending on the circumstances of its execution. If a loan is negotiable and can be sold or discounted on the open market it is considered a countable resource. Interest is always treated as unearned income; principal payments are the conversion of a resource and are not treated as income. e. Mortgages. A debt instrument, secured by the collateral of specific piece of real estate property, that a borrower is obliged to pay back without paying the entire purchase price upfront by making a pre- determined set of payments. A borrower is considered an owner of a mortgaged property for the purposes of determining Medicaid eligibility. The purchase of a mortgage may be treated as a disqualifying transfer for Medicaid LTSS purposes if made for less than fair market value in accordance with Part 50-00-6 of this Title. f. Promissory notes. A promissory note is a written, unconditional agreement, usually given in return for goods, money loaned, or services rendered, whereby one (1) party promises to pay a certain sum of money at a specified time (or on demand) to another party.
It may be given in return for goods, money loaned, or services rendered to the owner of the agreement (the seller). A promissory note is a liquid resource. The property itself is not a resource because the seller cannot legally convert it to cash while it is encumbered by the agreement. If payments received by the seller consist of both principal and interest, only the interest portion is income. The principal portion the promissory note is the conversion of a resource and is not income but is an available resource unless it is non-negotiable and the person provides evidence of a legal bar to the sale of the promissory note. Treatment of a promissory note for Medicaid LTSS eligibility related to the transfer of assets is located in Part 50-00-6 of this Title. g. Retirement funds. Any resource set aside by a person to be used for self-support upon their withdrawal from active life, service, or business. Retirement funds include, but are not limited to, certain IRAs, Keogh plans, 401K plans, pensions, mutual funds, stocks, bonds, securities, money market accounts, whole life insurance, and retirement annuities. The value of a retirement fund is the amount of money that can currently be withdrawn from the fund, less any penalties for withdrawal. An applicant or beneficiary who owns a retirement fund must apply for such funds or liquidate the fund. Retirement funds are excluded when owned by the person seeking Medicaid and termination of employment is required to obtain a payout from the fund; the owner is not eligible for periodic payments and does not have the option of withdrawing a lump sum; or the owner is eligible for periodic payments and is drawing down on the fund at a rate consistent with their life expectancy. When funds are being drawn down, the payout is treated as countable income for financial eligibility purposes and there is no deeming under Part 05-1 of this Chapter or attribution under Part 50-00-6 of this Title to a non-applicant spouse or child. The retirement fund of a non-applicant spouse is a non-deemable resource. In instances in which the retirement accounts are countable as a resource, the amount counted is the amount that can be withdrawn from the account, less any penalties. Any taxes owed as a result of the withdrawal are not deducted when determining the countable value of the retirement fund. Medicaid LTSS-specific provisions related to the treatment of retirement funds for the purposes of the community spouse resource allocation and the transfer of assets are located in Part 50-00-6 of this Title. h. Education funds. Resources set aside to pay for qualified education expenses such as 529 accounts and Coverdell Educational Savings Accounts. The full amount of such funds is excluded as a resource and are unavailable for deeming in the determination of financial eligibility when the monies deposited into the account are
for the qualified educational expenses of the applicant or beneficiary, or their non-LTSS spouse, or dependent(s). Distributions are excluded as income when made for qualified educational expenses, even if the applicant or beneficiary as co- owner must consent to the release of funds and/or receives the distribution and provides the payment or receives reimbursement for the qualified education expenses of the spouse or dependent(s). Third (3rd) party contributions to an education fund made by an applicant or beneficiary in which they are not the named co-owner are considered gifts. For the purposes of Medicaid eligibility in Rhode Island, such contributions are excluded providing the amount does not exceed the limit for the special deduction permitted under Rhode Island law (R.I. Gen. Laws § 44-30- 12(c)(4)) of five hundred dollars ($500.00) for an individual and one thousand dollars ($1,000.00) for a couple even if the beneficiary is a member of the FRU. i. Health Savings Accounts (HSAs). Accounts used to set aside funds to meet medical expenses. Unless the individual can demonstrate that the funds in their HSA are not available to them, the HSA is a countable resource. B. Resources, liquid and non-liquid, managed by a third (3rd) party include, but are not limited to, trusts, guardianship accounts, and retirement funds. Resources of a person managed by a third (3rd) party, such as a trustee, guardian, conservator, or agent under a power of attorney are considered available to that person as long as they can direct the third (3rd) party to dispose of the resource, or the third (3rd) party has the legal authority to dispose of the resource on the person’s behalf without the person’s direction. 1. Guardianship/Conservator funds – A person or institution appointed by a court in any State to act as a legal representative for another person, such as a minor or a person with disabilities. Cash or funds held by a guardian or conservator in bank or similar financial institution are presumed to be available for the support and maintenance of the protected person and are countable resources. Other resources of the person subject to a guardianship or conservatorship, such as real estate, brokerage accounts, stocks, bonds, life insurance policies, and automobiles, are presumed to be unavailable due to a legal impediment and are not countable resources for the purposes of determining Medicaid eligibility. Such other resources may become available when the guardian or conservator is required as a condition of obtaining or maintaining the person’s Medicaid eligibility to seek court approval to liquidate and convert assets into cash or funds in a bank or similar accessible account available for the person’s support and maintenance.
2. Power of attorney – Funds managed by an agent under a power of attorney are not property of the agent and cannot be counted as resources of the agent. 3. Representative payee – A person, agency, or institution selected by a court or the SSA to receive and manage benefits on behalf of another person. A representative payee has responsibilities to use these payments only for the benefit of that person, to notify the payer of any event that will affect the amount of benefits the person receives or circumstances that would affect the performance of the representative payee’s responsibilities, and account periodically for the benefits received. Funds managed by a representative payee are not property of the representative payee and cannot be counted as resources of the representative payee. 4. Trust – A property interest that usually takes the form of fund comprised of a variety of liquid and non-liquid resources, including but not limited to, cash, stocks, bonds, personal effects, life insurance, business interests, and real estate – that is held by a person or entity (called a “trustee”) who is legally responsible for ensuring the property owned by trust is used to benefit another person (the “trust beneficiary). The person who transfers the resources to the trust is known as the “grantor.” In some instances, the grantor is also named as a trust beneficiary or “grantee.” The treatment of a trust for Medicaid eligibility purposes depends on its type, whether the property it holds is accessible, and who is the grantor, grantee and/or trustee. In general, the treatment of trusts is determined in accordance with Part 50-00-6 of this Title. 3.7 Factors Considered in the Treatment of Resources 3.7.1 Scope and Purpose A. There are several common features in the process for evaluating resources when using the SSI methodology that apply across IHCC groups, whether using a full or simplified review. The purpose of this Section is to set forth these features and identify any exceptions where appropriate. 3.7.2 Process Rules A. The following process Rules apply generally in the evaluation of resources across IHCC groups. 1. First of the Month Rule – Countable resources are determined as of the first (1st) of the month. This determination is based on the resources the person owns, their value, and whether or not they are excluded as of the first (1st) of the month.
2. Resource Changes – What a person owns in countable resources can change during a month, but the change is always effective with the following month's resource determination. The kinds of changes that may occur include: a. Changes in value of existing resources. The value of an existing resource may increase or decrease. b. Disposition or acquisition of resources. A person may dispose of an existing resource, such as close a savings account and purchase an item, or may acquire a new resource, such as an inheritance which is subject to the income-counting Rules in the month of receipt. c. Change in exclusion status of existing resources. A person may replace an excluded resource with one (1) that is not excluded, such as sell an excluded vehicle for non-excluded cash, or vice versa (use non-excluded cash to purchase an excluded automobile). Similarly, a time-limited exclusion (such as the period for exclusion of retroactive Title II – RSDI – benefits) may expire. d. Change in resource form. The sale or transfer of a resource is treated as a change in the form of the resource rather than in countable income. 3. Resource Reduction – If countable resources exceed the limit as of the first (1st) moment of a month, the applicant is not eligible for that month, unless the resources are reduced by expenditures on certain allowable expenses. In general, allowable expenses for resource reduction include: a. Health care services that are not covered under the Medicaid State Plan and the State’s Section 1115 Waiver and are not reimbursable by a third (3rd) party such as Medicare, or some form of insurance. Such expenses must occur in a month of eligibility, including periods of retroactive eligibility when applicable. Certain LTSS home health care services are allowable expenses for Community Medicaid applicants when delivered by certified providers but only up to the amount Medicaid pays for the same or similar services on a fee-for-service basis. Additional Rules apply for Medicaid LTSS and are available at Part 50-00-6 of this Title. b. Tax payments based on assessments by the Federal Internal Revenue Service, the Rhode Island Department of Revenue or, other State or municipal taxing authority. c. Fees for court-appointed guardians or conservators including, but not limited to, court filing fees, the cost of a Probate Bond, court-
approved guardianship/conservatorship fees, and court-approved legal fees. d. Legal fees associated with disposing or gaining access to resources. 4. Evaluation Factors – The methods for evaluating resources vary depending on the standard of review, as indicated above, as well the type of resources. In general, each type of resource has its own unique deductions, exclusions, and methods for determining its countable value. Unless a resource is excluded, the ownership interest in a resource is evaluated in accordance with the following: a. Countable value. The countable value of a resource is the equity value. The equity value is the current fair market value minus any legal debt or encumbrances on the item. To be considered a debt against the resource, the debt must be legally recognized as binding on the resource’s owner. The current fair market value is the amount an item can be sold for on the open market. b. Jointly Owned Resources. When two (2) or more parties share rights to sell, transfer, or dispose of part or all of personal or real property, the ownership share held by each person must be evaluated. This rule applies to resources such as joint checking or savings accounts and real estate held in common. In instances in which the document creating the joint interests, such as a deed to real estate or a bank account signature card, specifies the shares of the parties, the fair market value of the entire resource is divided between the joint owners according to the shares specified. The factors related to the availability and salability of jointly owned resources are taken into account in this review process. In instances in which a co-owner who must consent to the sale or redemption of a jointly owned resource is unavailable or refuses to take the actions necessary for the sale or redemption of the resource, then the resource is considered unavailable and is not included in the calculation of countable resources. Attribution of jointly owned resources is otherwise determined as indicated below: (1) Tenancy in common. Applies to all jointly owned resources involving two (2) or more persons which do not specify the ownership portion of each party – as in cases of joint tenancy or tenancy in its entirety. When the person seeking Medicaid and/or spouse has a tenancy in common with someone outside the household, the total value of non-liquid resources is divided among the total number of owners in direct proportion to the ownership interest held by each. By
contrast, when a liquid resource such as an account in a financial institution is held in common, the entire equity value of funds in the account is considered available to its owner. (2) Joint tenancy. Occurs when each of two (2) or more persons has one (1) and the same undivided ownership interest and possession of the whole property for the duration of the tenancy. In effect, each owner owns all of the property. One (1) owner may sell, transfer or otherwise dispose of their share of the property without permission of the other owner(s) but cannot take these actions with respect to the entire property. Upon death of the joint tenant, title automatically vests in the surviving joint tenant. While alive any joint tenant may convey the interest held to a third (3rd) party. After such a conveyance, the new parties own the property as tenants in common. (3) Tenancy in its entirety. The value of any resource owned in its entirety by a person is considered available to its owner and is included as such for deeming in Community Medicaid and the allocation of resources for Medicaid LTSS. (4) Proportional joint ownership. The value of shared property in which each person only owns their fractional interest in the property is determined by dividing the total value of the property among all the owners in direct proportion to the ownership share held by each. c. Counting Order. If excluded funds are combined with countable resources, it is assumed the countable resources are spent first. d. Prudent-person standard. The prudent-person standard is used when determining whether a lower fair market value for a resource is reasonable. For example, for property sold at an auction, the current fair market value is considered to be the highest bid unless there is evidence that the transaction constitutes a resource transfer rather than a sale. 5. Legal Factors Affecting Availability – A court restriction may make all or part of the resource unavailable. Other legal restrictions on resources may be included in: liens, domestic orders, divorce decrees, child support orders, probate matters, tax intercepts and garnishments, and/or bankruptcy proceedings. Other factors affecting the availability of a resource are specified below in § 3.7.2(A)(6) of this Part below and for LTSS eligibility purposes in Part 50-00-6 of this Title.
6. Identifiability – Some resources must be identifiable to be excluded and, as such must be distinguishable from other resources. A resource is identifiable if: a. The funds are kept physically apart from other funds, such as in a separate bank account. b. The funds are not kept physically apart from other funds but can be identified using a complete history of account transactions dating back to the initial date of deposit based on the records of the account holder. c. When a withdrawal is made from a commingled account, the non- excluded funds are assumed to be withdrawn first, leaving as much of the excluded funds in the account as possible. d. The excluded funds remaining in the account can only be increased by deposits of subsequently received excluded funds and excluded interest. If interest on the excluded funds is excluded, the percent of an interest payment to be excluded is the same as the percent of funds in the account that is excluded at the time the interest is posted. The excluded interest is then added to the excluded funds in the account. 3.7.3 Mandatory Resource Exclusions A. Resource exclusions may be mandated under the SSI methodology or by Federal laws other than the Social Security Act, 42 U.S.C. Chapter 7, as well as by the State and various other program requirements. 1. Exclusions Required by Federal Law – Federal law establishes that certain resources are excluded when determining Medicaid eligibility using the SSI methodology across all IHCC coverage groups. A list of mandated Federal exclusions based on how they are treated if identifiable is located in § 3.8 of this Part. 2. Required by State law or Regulation – Rhode Islanders are permitted a State tax deduction for funds committed to the State-administered 529 education account. Funds contributed to such an account are excluded, except for the amount of the Rhode Island tax deduction, as long as they are set aside for qualified educational expenses. 3.7.4 Special and Limited Time Exclusions A. There are a number of special and time-limited exclusions that apply across the IHCC groups as well. Applicable general time-limited exclusions are as follows:
1. Retroactive Social Security and SSI/SSP – Retroactive payments of Federal SSI, SSP (the State only supplement to SSI), or RSDI benefits are excluded for nine (9) months beginning on the FOM after the month of receipt. These payments are also excluded as resources during the month of receipt. 2. Funds for Replacing Excluded Resources – Cash and interest earned on that cash are excluded when received from any source, including casualty insurance, when it is for the purpose of repairing or replacing an excluded resource that is lost, stolen, or damaged. The exclusion is allowed for nine (9) months from the month of receipt of such funds and may be extended for an additional nine (9) months for good cause. 3. Earned Income Tax Credit – State and Federal earned income tax credit refunds and advance payments are excluded as resources for one (1) year beginning the month after receipt. 4. Health and Human Services Payments – Cash received for Health and Human Services is excluded for the calendar month following the month of receipt. The month following the month of receipt, the cash counts as a resource if it has been retained. 5. Victim’s Compensation Payments – State-administered victims’ compensation payments are excluded for twelve (12) months after the month of receipt. 6. Relocation Payments – State and local government relocation payments are excluded for twelve (12) months after the month of receipt. 7. Expenses from Last Illness and Burial – Payments, gifts, and inheritances occasioned by the death of another person are excluded provided that they are used for expenses resulting from the last illness and burial of the deceased and by the end of the calendar month following the month of receipt. 8. Long-term Care Insurance Partnership – Amounts equal to the amount paid monthly in benefits from the time of application for long-term care insurance are disregarded as a resource when determining Medicaid eligibility under the Federal Deficit Reduction Act of 2005, Pub. Law 109- 171. For purposes of LTSS eligibility, the same amount is excluded when determining the amount to be recovered from a beneficiary’s estate. 9. Dedicated home repair and modification funds – Up to an additional four thousand dollars ($4,000.00) may be set aside for a limited period – not to exceed one (1) year – in a separate dedicated account for the purposes of home repairs/modifications that enable a Medicaid LTSS beneficiary to continue to receive home-based care. Funds may only be used for such expenses when they are not covered by a third (3rd) party, including
Medicare, Medicaid and any Federally or State-funded housing or assistance authority, and must be spent on repairs and modifications necessary to ensure a beneficiary is able to safely continue to obtain care in their own home. The set-aside must be approved by a Medicaid LTSS specialist based on documentation that the repairs/modifications are required for the person’s health and safety and the cost estimates are deemed reasonable – estimates from a properly qualified contractor. Documentation that repairs are needed may be provided by a health practitioner or contractor. Any funds remaining in the account at the eligibility renewal after the account was established or used for purposes other than qualified home repairs or modifications are counted as a resource on the first (1st) day of the month following the renewal date. 10. ABLE accounts – The federal Achieving a Better Life Experience Act (ABLE) of 2014, 26 U.S.C. § 529A, amended § 529 of the IRS code to permit States to create tax-advantaged savings accounts for persons who have proof of a documented disability or blindness, the onset of which occurred before age twenty-six (26). In accordance with R.I. Gen. Laws § 42-7.2-20.1 et seq., balances held in an ABLE account are excluded when determining financial eligibility for non-LTSS Medicaid under this Part and Medicaid LTSS pursuant to Part 50-00-6 of this Title. For persons eligible for Medicaid based on receipt of Supplemental Security Income (SSI), as described in Part 05-1 of this Chapter, balances of up to one hundred thousand dollars ($100,000.00) are excluded in the determination of financial eligibility. An SSI recipient with an ABLE account in excess of this balance loses SSI cash benefits until the balance is below this limit but is deemed eligible for the purposes of maintaining Medicaid eligibility. The resource exclusion for Medicaid eligibility continues to apply unless or until the contributions for the person benefiting from the ABLE account exceeds the annual limit of fifteen thousand dollars ($15,000.00) or the maximum life-time limit of three hundred ninety-five thousand dollars ($395,000.00). ABLE accounts are managed by the State and funds must be used only for the Qualified Disability Expenses established in Federal and State laws. Additional information on ABLE accounts is located at the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) website at: https://bhddh.ri.gov/developmental- disabilities-services/services-adults/able-saving-plan. 3.7.5 Determination of Resource Eligibility A. Once the appropriate exclusions have been applied and the value of each type of resource is determined, the value of all countable resources (including deemed resources) are added together to determine the total countable resources for the Medicaid eligibility group for the family size involved. If the resources of the Medicaid eligibility unit fall below or are equal to the applicable eligibility resource standard, the resource test is passed. If an excess resource amount remains after all exclusions have been applied, the applicant/beneficiary has not passed
the resource test and must either reduce resources in accordance with the applicable provisions in § 3.7.2(A)(3) of this Part or give away excess resources subject to the transfer of resources Rule for Medicaid LTSS set forth in Part 50- 00-6 of this Title. 3.8 Federally Mandated Exclusions A. The following is a list of federally mandated exclusions based on whether or not they are identifiable: Federally Mandated Resource Exclusions Identifiable and Excluded Indefinitely (unless otherwise indicated) Agent Orange Settlement Fund payments Blood Product Settlement payments Corporation for National and Community Service (CNCS) payments. Payments to volunteers, including the following payments authorized under the Domestic Volunteer Services Act, Pub. Law 93-113, are excluded: AmeriCorps Urban Crime Prevention Program Special Volunteer Programs under Title I Demonstration Programs under Title II Senior Corp: Retired Senior Volunteer Program (RSVP) Foster Grandparent Program Senior Companions Individual Development Accounts (IDA) Japanese and Aleutian Restitution payments Jensen Settlement Agreement payments. Payments received by class members are excluded. Funds received under this agreement from countable resources at the time of application and at each renewal are deducted.
Federally Mandated Resource Exclusions Low Income Home Energy Assistance Program (LIHEAP) payments Nazi Persecution payments Radiation Exposure Compensation Trust Fund (RECTF) payments Real estate taxes, homeowner’s insurance and funds set aside for upkeep expenses of the property. Up to one (1) year’s expenses are excluded. Funds must be kept in a separate account. Relocation Assistance payments, Federal Ricky Ray Hemophilia Relief Fund payments Student financial aid received under Title IV of the Higher Education Act (HEA) Pub. Law 89-329, or Student financial aid received from the Bureau of Indian Affairs (BIA) Non-Title IV and non-BIA grants, scholarships, fellowships and other non-loan financial aid, if used or set aside to pay educational expenses until the month following the last month the student is enrolled in classes Distributions from a Coverdell Educational Savings Accounts (ESA) if the funds are used for educational expenses Excluded for the designated beneficiary of the account for nine (9) months following the month of receipt of a distribution Excluded for anyone who is not a beneficiary who contributes money to the account beginning the month after the month the funds are transferred into the account Excluded, due to being a conversion of a resource, for a contributor who is the designated beneficiary beginning with the month after the month the cash is transferred into the account Veteran’s Affairs (VA) benefits designated as educational assistance both undergraduate and graduate students until the month following the last month the student is enrolled in classes Plan to Achieve Self Support (PASS) student financial aid
Federally Mandated Resource Exclusions Training expenses paid by the Trade Act of 1974, Pub. Law 93-618 Qualified Tuition Programs (QTP), also known as a 529 Plans, for the designated beneficiary (the student or future student) who is not the owner of the account and does not have any rights to the funds in the account Tribal payments and interests. The following tribal resources are excluded: Tribal trust or restricted lands, individual interest Tribal per capita payments from a tribal trust Tribal land settlements and judgments Uniform Gift to Minors Act/Uniform Transfers to Minors Act, Pub. Law 107-210, (UGMA/UTMA) The full value of resources established under the UGMA/UTMA is excluded. An adult designated to receive, maintain and manage custodial property on behalf of a minor beneficiary is not the owner of UGMA/UTMA resources because the adult cannot legally use any of the funds for their support and maintenance. When the UGMA/UTMA property is transferred to a beneficiary at the end of the custodianship (usually at the age of eighteen (18) or twenty-one (21) depending on State law) the property becomes available to the beneficiary. It is counted as income in the month of transfer and as a resource in the following month. Veterans’ Children with Certain Birth Defects payments Vietnamese Commando Compensation Act, Pub. Law 104-210, payments Excluded Resources Regardless of Identifiability (unless otherwise noted) Adoption Assistance payments are excluded in the month of receipt and thereafter. Accrued Interest on resources is excluded if any excess is properly reduced at eligibility redetermination.
Federally Mandated Resource Exclusions Alaska Native Claims Settlement Act (43 U.S.C. §§ 1601 – 1624) (ANCSA) payments Appeal Payments are excluded as resources in the month received and for three (3) months after the month of receipt. Clinical trial participation payments excluded by SSI. The first two thousand dollars ($2,000.00) a person receives during a calendar year is excluded. Cobell Settlement for American Indians for a period of twelve (12) months beginning with the month of receipt. This exclusion applies to all household members. Crime victim payments Disaster assistance, Federal payments Disaster assistance, State payments Filipino Veterans Equity Compensation (FVEC) payments Foster Care payments Gifts to Children with Life Threatening Conditions from 501(c)(3) tax-exempt corporation. These are not considered resources of a parent and apply only to children who are under age eighteen (18). Cash gifts up to two thousand dollars ($2,000.00) in any calendar year are excluded. The amount of total cash payments that exceed two thousand dollars ($2,000.00) each year are counted as a resource. Multiple cash gifts in the same calendar year are added together and up to two thousand dollars ($2,000.00) of the total is excluded, even if none of the cash gifts exceeds two thousand dollars ($2,000.00) individually. Homestead real property Household goods and personal effects
Federally Mandated Resource Exclusions James Zadroga 9/11 Health and Compensation Act of 2010, Pub. Law 111-347 Kinship payments Proceeds from the sale of a homestead are excluded if a person: Plans to use the proceeds to buy another homestead, and Does so within three (3) full calendar months of receiving the funds Reimbursements for replacement of lost, damaged or stolen excluded resources are excluded for the month of receipt and nine (9) months thereafter. The funds are excluded for up to nine (9) more months if the person tries to replace the resources during that time but cannot do so for good reason. Representative Payee Misuse payments. If a person’s Supplemental Security Income (SSI), Retirement, Survivors and Disability Insurance (RSDI) benefits, or Veterans Benefits for the Elderly are reissued because an individual representative payee misuses benefits, the reissuance is excluded as a resource for nine (9) months if retained after the month of receipt. Retroactive RSDI and SSI benefits are excluded for the nine (9) calendar months following the month in which the person receives the benefits. Any accrued interest on that account is counted as income in the month received and as a resource in the following months. State Annuities for Certain Veterans Relocation payments, State and local Tax credits, rebates, and refunds are excluded for twelve (12) months after the month of receipt Term life insurance
210-RICR-40-00-3 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 - MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 00 - INTEGRATED COVERAGE GROUPS PART 3 - MEDICAID INTEGRATED HEALTH CARE COVERAGE, SSI FINANCIAL ELIGIBILITY DETERMINATIONS (210-RICR-40-00-3) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 03/19/2026 February 27, 2026 E-SIGNED by Richard Charest on 2026-02-27 13:01:56 EST February 27, 2026 E-SIGNED by Department of State on 2026-02-27 13:04:07 EST
210-RICR-40-05-1 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 – MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 05 – COMMUNITY MEDICAID PART 1 – MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES: COMMUNITY MEDICAID 1.1 Overview A. The IHCC groups established in this Section provide the principal Medicaid non- Long-Term Services and Supports (LTSS) eligibility pathways for elders and adults with disabilities who have Supplemental Security Income (SSI), an SSI characteristic, and/or meet special program specific requirements. The medically needy (MN) eligibility pathway for all populations seeking non-LTSS Medicaid coverage is also included in this Section as well as Part 2 of this Subchapter. The State uses the term “Community Medicaid” to distinguish Integrated Health Care Coverage (IHCC) group members from Medicaid LTSS beneficiaries eligible using SSI financial eligibility requirements. 1.2 Authority A. This Part is promulgated pursuant to Federal authorities as follows: 1. Federal Law: Title XIX of the U.S. Social Security Act; 42 U.S.C. §§ 1396a-1396w-7; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148; and the Health Care and Education Reconciliation Act of 2010, Pub. L. 111-115. 2. The Medicaid State Plan and the Section 1115 Waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. B. Applicable State authority is derived from R.I. Gen. Laws Title 40 and R.I. Gen. Laws Chapter 42-7.2.
1.3 Incorporated Materials A. These Regulations hereby adopt and incorporate 8 C.F.R. Part 204 (2023) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. B. These Regulations hereby adopt and incorporate 8 C.F.R. Part 213A (2023) by reference, not including any further editions or amendments
thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. C. These Regulations hereby adopt and incorporate 8 C.F.R. Part 236 (2023) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. D. These Regulations hereby adopt and incorporate 20 C.F.R. Part 404 (2023) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. E. These Regulations hereby adopt and incorporate 20 C.F.R. Part 416 (2023) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. F. These Regulations hereby adopt and incorporate 42 C.F.R. § 435.404 (2023) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. G. These Regulations hereby adopt and incorporate 42 C.F.R. § 435.541 (2023) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. H. These Regulations hereby adopt and incorporate 42 C.F.R. § 447.56 (2023) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. 1.4 Scope and Purpose A. The purpose of this Rule is to establish and describe the Community Medicaid IHCC groups and the requirements for determining Medicaid eligibility. The summary table below shows each of these groups and the agency authorized to determine eligibility or the basis for eligibility: Community Medicaid Eligibility Pathways IHCC Group Agency Responsible for Determining Eligibility Low-income Elders and Adults with Disabilities (EAD) EOHHS
Community Medicaid Eligibility Pathways IHCC Group Agency Responsible for Determining Eligibility SSI Recipients Social Security Administration (SSA) SSP Recipients SSA and EOHHS Pickle Amendment EOHHS Employed Adults with Disabilities under § 1619(a), 42 U.S.C. § 1382h(a) SSA Medicaid While Working under § 1619(b), 42 U.S.C. § 1382h(b) SSA Protected Surviving Spouses EOHHS Adult Children with Disabilities EOHHS Divorced/Surviving Spouses with Disabilities SSA SSP Recipients, 12/73 EOHHS Divorced/Surviving Spouses with Disabilities – Actuarial Changes SSA Breast and Cervical Cancer Screening and Treatment Department of Health (DOH) Refugee Medicaid Assistance (RMA) EOHHS Sherlock Plan EOHHS Ticket to Work Plan EOHHS 1.5 Definitions A. For the purposes of this Section, the following definitions apply:
1. “Adult dependent child” means an unmarried person eighteen (18) years of age or older who has a disabling impairment that began before age twenty-two (22) that is collecting disability related benefits from the U.S. Social Security Administration (SSA). 2. “Applicant” means the person seeking initial or continuing eligibility for Medicaid. 3. “Community Medicaid eligibility standards” means the income and resource standards used as the basis for determining initial and continuing Medicaid eligibility for each coverage group included in this Section. 4. "Deemed income" means income attributed to another person whether or not the income is actually available to the person to whom it is deemed. 5. "Deemor" means a person whose income and/or resources are subject to deeming. Such individuals include non-applicant parents and spouses and sponsors of non-citizens. 6. “Non-applicant” or “NAPP” means a person whose finances are considered for deeming purposes although is not seeking or is unqualified for Medicaid. 7. "Parent" means a natural or adoptive father or mother living in the same household as the eligible child. 1.6 Eligibility for Elders and Adults with Disabilities 1.6.1 Scope and Purpose A. This Section identifies the primary eligibility pathways for persons sixty-five (65) and older and nineteen (19) to sixty-four (64) with disabilities. 1.6.2 EAD Eligibility Pathway – Low-income Elders and Adults with Disabilities A. Under § 1902 the Social Security Act, 42 U.S.C. § 1396a, States have the option under the Medicaid State Plan of expanding eligibility to elders and adults with disabilities (EAD) up to and inclusive of one hundred percent (100%) of the federal poverty level (FPL). R.I. Gen. Laws § 40-8.5-1 establishes the categorically needy EAD coverage group. The EAD coverage group has higher income and resource limits than the SSI program and serves, therefore, as the State’s primary general eligibility pathway for anyone with an SSI characteristic who does not qualify for SSI benefits. Coverage group features are as follows: 1. Eligibility Criteria – To qualify for Medicaid coverage through the EAD eligibility pathway, a person must meet the general eligibility requirements related to residency, citizenship and cooperation set forth in § 1.10 of this Part and the following:
a. Characteristic Requirements. A person must be without SSI and meet the characteristic requirements with respect to: (1) Age. Sixty-five (65) and older; or (2) Disability. Determined by the State’s Medicaid Assessment and Review Team (MART) to meet the applicable SSI disability standards; or (3) Blindness. Federal Regulations preclude States that have expanded SSI-based eligibility to income above the SSI standard (approximately seventy-five percent (75%) FPL) to treat blindness as a distinct eligibility characteristic. Accordingly, applicants who are blind and are ineligible for SSI or an SSI Protected Status are subject to a MART disability determination. b. Financial Requirements. The person must meet income and resource standards for EAD eligibility based on the SSI methodology as follows: (1) Income. Total countable income must be at or below one hundred percent (100%) of the FPL for the family size involved; and (2) Resources. Total countable resources must not exceed four thousand dollars ($4,000.00) for an individual and six thousand dollars ($6,000.00) for a couple. 2. Determination Process – The application review process evaluates all persons seeking Medicaid for eligibility through a MACC group using the MAGI standard. Anyone who self-reports a disabling impairment or who is sixty-five (65) or older is then evaluated for Community Medicaid eligibility through the pathways set forth in this Section. Federal Regulations at 42 C.F.R. § 435.404 (2023) require EOHHS to provide anyone determined eligible through multiple pathways to choose the coverage group that best suits their needs. 3. Continuing Eligibility – With implementation of the State’s integrated eligibility system (IES), EOHHS utilizes a modified passive renewal process. Beneficiaries are required to review and update a pre-populated form containing information obtained in their accounts and updated monthly or quarterly through electronic data matches about eligibility factors subject to change. Detailed provisions pertaining to the passive renewal process are set forth in Subchapter 00 Part 2 of this Chapter. 4. Agency Responsibilities – The EOHHS is responsible for overseeing the evaluation of applications for EAD eligibility, enrollment, and processing
renewals, with the Department of Human Services (DHS) as its designated agent pursuant to the terms of an interagency agreement. In addition, prior to ending Medicaid health coverage, the EOHHS must ensure that a review is conducted to determine whether eligibility exists through any other eligibility pathway. Other responsibilities are set forth in greater detail, as indicated, in other sections of this Rule. 1.6.3 Medically Needy (MN) Eligibility Pathway A. Medically needy eligibility is available to certain IHCC group members who do not need LTSS. Different rules apply for LTSS MN eligibility as indicated in Part 50-00-2 of this Title. Under the Rhode Island Medicaid State Plan, MN coverage is an option for elders and adults with disabilities, parents/caretakers, children and pregnant people. Adults age nineteen (19) to sixty-four (64) in the MACC group do not qualify for MN coverage, and must therefore reapply through the Community Medicaid MN pathway. There is also a MN pathway for Refugee Medicaid Assistance as indicated in § 1.8.3 of this Part. See Part 2 of this Subchapter for provisions related to the Community Medicaid MN pathway. 1.6.4 SSI and SSP Recipients and SSI Protected Status A. Federal law requires the States to provide Medicaid health coverage to SSI and SSP recipients. There are certain circumstances in which SSI recipients who lose or otherwise no longer qualify for full cash assistance benefits are afforded “protected status” which allows them to retain their Medicaid eligibility. In such instances, the person is treated as if they are an SSI recipient for Medicaid eligibility purposes. The Medicaid SSI, SSP and protected status coverage groups are described below: 1. SSI Recipients – There is no distinct State-based eligibility pathway for SSI recipients. Medicaid eligibility is automatic upon approval of SSI. The SSA determines eligibility for SSI and notifies the State of the SSI recipient’s eligibility through an electronic data exchange. The State is responsible for enrollment and the provision of Medicaid health coverage until SSI eligibility ceases unless protected status is available. The EOHHS is responsible for determining whether EAD coverage is available through an alternative Medicaid eligibility pathway for SSI recipients without protected status who have or are about to lose SSI. 2. State Supplement Payment (SSP) Recipients – Persons who are eligible to receive the optional State-funded supplemental payment are automatically eligible for Medicaid health coverage under the Medicaid State Plan. a. Eligibility criteria. To qualify, a person must be an SSI recipient, a former SSI recipient with Medicaid protected status, or a person who meets the criteria for EAD or LTSS and resides in one (1) of
several pre-approved SSP living arrangements as specified in R.I. Gen. Laws § 40-6-27 et seq. b. Determination process. The SSA determines eligibility for SSP for SSI recipients. As the State agency that shares responsibility with the SSA for administering the SSI program in Rhode Island, the Rhode Island Department of Human Services (DHS) requires non- SSI recipients to qualify for SSP on the basis of the EAD or applicable LTSS eligibility criteria. Eligibility criteria for all other SSP categories are located in 218-RICR-20-00-5, Supplemental Security Income and State Supplemental Payment Rules and Regulations. c. Continuing eligibility. Renewal of Medicaid for SSP recipients is conducted in accordance with the requirements for SSI or EAD, depending on the basis of eligibility, and the applicable requirements related to living arrangement. The amount of the payment, which depends on a characteristic, living arrangement and certain other factors, is not considered in determining countable income for continuing Medicaid eligibility purposes. Medicaid eligibility based solely on SSP ceases when a recipient no longer qualifies for the payment unless there is another basis for coverage. d. Agency responsibilities. The SSA determines initial eligibility for SSP using the SSI methodology and any additional criteria required by the State. DHS determines eligibility for non-SSI recipients through the State’s IES. The EOHHS and DHS share responsibility for certifying that a beneficiary qualifies for SSP cash assistance in Category D (assisted living) based on living arrangement. e. Applicant/beneficiary responsibilities. SSP beneficiaries must meet all specified application and general eligibility requirements and provide the evidence required to certify payment based on living arrangement. 3. Pickle Amendment Eligibility Pathway – Since enacted in 1977, § 503 of Pub. Law No. 94-566, known as the “Pickle Amendment,” protected Medicaid eligibility for certain persons who receive Social Security or Retirement, Survivor, or Disability Insurance (RSDI) benefits. The Pickle Amendment requires the State to apply certain income disregards using a specific federal formula, which essentially deems the person an SSI recipient for Medicaid eligibility purposes. a. Eligibility Criteria. Pickle Amendment coverage is available for a person who meets all other SSI eligibility criteria and:
(1) Was simultaneously entitled to receive both Social Security RSDI and SSI in some month after April 1977; (2) Receives income that would qualify them for SSI after deducting all RSDI cost-of-living adjustments (COLA) received since the last month in which the person was eligible for both RSDI and SSI; and (3) Is currently ineligible for SSI and eligible for and receiving RSDI. b. Determination process. When determining Pickle eligibility, the current SSI Federal benefit rate plus any SSP payment is compared to the person’s other countable income plus the amount of the RSDI benefit at the time SSI/SSP eligibility was lost. The COLA at the time Pickle eligibility is determined is disregarded in this calculation as are any COLAs for years prior up to and including the year SSI payments ceased, as long as the date the increase occurred is after April 1977. The result of this calculation is the “Protected Benefit Amount” (PBA) and is used as the basis for determining continuing Pickle Amendment eligibility. Income of any financially responsible family members is factored into the PBA calculation. All other general eligibility criteria apply; however, a MART determination of disability is not required. c. Continuing eligibility. Persons eligible under the Pickle Amendment are subject to EAD passive renewal requirements. The COLA disregards continue to apply as long as income permits. As the SSI benefit rises from year to year, it may increase to an amount that exceeds the RSDI and the countable income amount at the time SSI eligibility ceased. At this point, the State discontinues Pickle Amendment eligibility and determines whether eligibility through an alternative pathway is available. d. Agency responsibilities. SSA informs the State annually about potential “Pickles” at cost-of-living adjustment (COLA) time. The EOHHS is responsible for applying the COLA disregards when determining EAD eligibility of anyone who may qualify for Medicaid in this group. If found ineligible on this basis, the State also evaluates whether Medicaid is available through any other pathway. e. Applicant/beneficiary responsibilities. Potential members of this coverage group must provide any additional information that may be required to determine eligibility and comply with the applicable general requirements for SSI-based eligibility set forth in § 1.10 of this Part.
f. Table of RSDI Cost-of-Living Adjustments. For a history of automatic cost-of-living adjustments, see: https://www.ssa.gov/cola/#:~:text=Beginning%20in%201975%2C% 20Social%20Security,value%20from%20Social%20Security%20be nefits. 4. Employed Persons with Disabilities, § 1619(a) of the Social Security Act, 42 U.S.C. § 1382h(a) a. Working persons with disabilities who have gross earnings at or above the SSI income standard may qualify for continuing payments, and thus Medicaid health coverage, providing they meet all SSI non-disability requirements. The following must be met for coverage under § 1619(a) of the Social Security Act, 42 U.S.C. § 1382h(a): (1) Eligibility Criteria. To qualify, the person receiving SSI based on disability must have gross earnings at or above the SSI income standard and: (AA) Maintain disability status while working; (BB) Meet all other SSI eligibility criteria; (CC) Have been eligible for and received a regular SSI payment based on disability for a previous month within the current SSI eligibility period. (2) Determination process. As long as the beneficiary meets the criteria for coverage, no income or resource standards apply e.g., income can be above the EAD limits set forth in § 1.6.2 of this Part. (3) Continuing Eligibility. Medicaid health care coverage for members of this group is automatic and continues until ended by the SSA for any reason for which it may be granted. (4) Agency responsibilities. The SSA determines initial and continuing eligibility and notifies the EOHHS on a monthly basis of beneficiaries who qualify for coverage under § 1619(a) of the Social Security Act, 42 U.S.C. § 1382h(a). The EOHHS is responsible for determining whether beneficiaries who no longer qualify are eligible through an alternative eligibility pathway. 5. Medicaid While Working, § 1619(b) of the Social Security Act, 42 U.S.C. § 1382h(b), provides Medicaid to employed persons with disabilities who no
longer qualify for coverage under the above provision (§ 1.6.4(A)(4) of this Part) but need coverage to continue working. This pathway preserves Medicaid eligibility when a working person’s total countable income, both earned and unearned, including deemed income, is too high for an SSI cash payment. This pathway provides “Medicaid While Working” protection when SSI cash benefits are no longer available. Medicaid health coverage is preserved for both members of a couple if each is working, and their total combined income would result in the loss of SSI cash benefits, even if the income of one (1) would not alone trigger non- payment status. However, a non-working spouse has no protection and loses Medicaid when the earned income of their spouse exceeds the limits for SSI cash benefits. For Community Medicaid health coverage through this pathway, the following apply: a. Eligibility Criteria. A person must have received an SSI cash payment based on disability, including under 42 U.S.C. § 1382h(a), for at least one (1) month in the most recent SSI benefit period, and (1) Continue to meet the disability criteria for SSI payments except for earnings; (2) Have insufficient earnings to replace the SSI/SSP cash benefit, Medicaid health coverage, and/or personal care or attendant services that would be available if they did not have such earnings; and (3) Need Medicaid health coverage to continue to work or obtain employment. b. Determination process. As long as the beneficiary meets the eligibility criteria for Medicaid While Working, and income remains below the 42 U.S.C. § 1382h(b) threshold for Rhode Island, which changes annually and can be obtained on the Social Security Administration’s website, no income or resource standards apply. c. Continuing Eligibility. Medicaid coverage for members of this group is automatic and continues until ended by the SSA for any reason for which it may be granted or income exceeds the threshold for Rhode Island. d. Agency responsibilities. The SSA determines initial and continuing eligibility and notifies the EOHHS on a monthly basis of beneficiaries who qualify in this coverage group. The EOHHS is responsible for determining whether beneficiaries who no longer qualify, are eligible for Medicaid through an alternative eligibility pathway.
6. Protected Surviving Spouses – In the Omnibus Budget Reconciliation Act of 1990, Pub. Law No. 101-508, Congress permanently revised eligibility standards set in § 1634(b) of the Social Security Act, 42 U.S.C. § 1383c(b), to protect access to Medicaid health coverage for divorced and surviving spouses who lose SSI eligibility as a result of RSDI benefits. a. Eligibility criteria. To qualify, a person must be between the ages of fifty (50) and sixty-five (65) and meet all other eligibility criteria for SSI except for income and the following: (1) Were it not for RSDI benefits, the person would continue to be eligible for SSI and/or SSP; (2) Received an SSI payment the month before RSDI payments began; and (3) Must not eligible for Medicare Part A (hospital coverage insurance). b. Determination process. For the purposes of Medicaid eligibility, the State must disregard the RSDI benefit and consider a person who meets these criteria a deemed SSI recipient until they become eligible for Medicare Part A. c. Continuing eligibility. Medicaid eligibility in this coverage group ends on the first (1st) day of the month the beneficiary becomes eligible for Medicare Part A. d. Agency responsibilities. The SSA notifies the EOHHS that an SSI recipient losing eligibility may qualify for Medicaid through this pathway. Notification is also provided to the State of the date in which Medicare Part A becomes available. The State then determines whether coverage is available through EAD or another alternative eligibility pathway. The RSDI disregard, the basis for protected status, is no longer included in the determination of countable income when the person is being evaluated for these other forms of Medicaid health coverage. 7. Adult Dependent Child with Disabilities – § 1634 of the Social Security Act, 42 U.S.C. § 1383c, provides protection of Medicaid eligibility status for certain adult children with disabilities who lose SSI due to income from a parent’s RSDI benefits or Social Security Disability Insurance (SSDI) benefits from the adult child’s own work record. For the purposes of this coverage, “adult child” includes an adopted child, or, in some cases, a stepchild, grandchild, or step grandchild who is unmarried and is age eighteen (18) or older. When determining EAD eligibility for members of this group, the parent’s RSDI or child’s SSDI benefit is disregarded to preserve continuing Medicaid eligibility.
a. Eligibility criteria. To qualify for this eligibility pathway, a person must be: (1) At least eighteen (18) years of age; (2) Living with a disabling impairment that began prior to the age of twenty-two (22); (3) An SSI recipient based on blindness or a disabling impairment; and (4) No longer be qualified for SSI due to income resulting only from either the RSDI benefits associated with the retirement, death or disability of a parent or an SSDI benefit paid to an adult child with disabilities. b. Determination process. RSDI or SSDI benefits paid to the beneficiary are disregarded when calculating countable income. SSI rules for the treatment of income otherwise apply. Protected eligibility is granted if the RSDI or the SSDI benefit is the ONLY source of additional income. c. Continuing eligibility. Protected status as a result of the RSDI or SSDI disregard continues to apply as long as the beneficiary meets the disability/blindness criteria, there are no additional sources of increased countable income, and resources remain within the applicable limits. d. Agency responsibilities. SSA notifies the State when a recipient loses SSI on this basis and qualifies for the disregards for eligibility through this pathway. The EOHHS is responsible for determining whether other relevant criteria for continuation of protected status and application of the disregard is warranted. Beneficiaries who lose protected status must be evaluated for alternate forms of Medicaid eligibility before their coverage is terminated. 8. Divorced or Surviving Spouses with Disabilities – This coverage group consists of surviving and divorced spouses who have been determined disabled and lose SSI and/or SSP due to receipt of the RSDI Disabled Widow Benefits (DWB). For Medicaid purposes, these persons are deemed to be SSI recipients until they are entitled to receive Medicare. The SSA is responsible for informing the State of persons who are eligible for continuing eligibility on this basis. 9. State Supplemental Recipients, 12/73 – This coverage group consists of Medicaid beneficiaries eligible under the Medicaid State Plan on the basis of SSI in December 1973 and their spouses who continue to live with them and are essential to their well-being. Medicaid eligibility of the spouse
continues as long as the SSI recipient remains eligible under the 1973 eligibility requirements. The SSA notifies the State of persons who are deemed eligible in this group. 10. Surviving Spouses with Disabilities Affected by Actuarial Changes – The Social Security Amendments of 1983, Pub. Law No. 98-21, eliminated an actuarial reduction formula applied to the RSDI benefits of surviving spouses with disabilities who became entitled to RSDI benefits before age sixty (60). To offset the loss of Medicaid eligibility that occurred as a result, the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, Pub. Law No. 99-272, restored Medicaid eligibility for any surviving spouses with disabilities who lost coverage and filed an application for Medicaid before July 1, 1988. SSA notifies the State of any SSI recipients who may qualify for Medicaid coverage via this eligibility pathway. Eligibility continues until such time as coverage through another Medicaid eligibility pathway becomes available or the beneficiary’s countable income exceeds the total of the SSI benefit rate and the RSDI payment at the time protected status was initially conferred. 1.7 The Medicare Premium Payment Program (MPPP) 1.7.1 Scope and Purpose A. The Medicare Premium Payment Program (MPPP) helps low-income elders age sixty-five (65) and older and adults with disabilities pay all or some of the costs of Medicare Part A and Part B premiums, deductibles and co-payments. 1. Basis of Eligibility – A person’s income and resources, as calculated using the SSI methodology, determine which type of Medicare premium assistance is available. Members of this coverage group are known as “dual eligible,” as they qualify for both Medicare and Medicaid, as defined below: a. Dual eligible beneficiaries who qualify for the MPPP, but not full Medicaid health coverage are referred to as “partial dual eligible” beneficiaries. b. Dual eligible beneficiaries who meet the all the eligibility requirements for an IHCC or MACC group and are enrolled in Medicare Part A and Part B are known as “full dual eligible beneficiaries.” c. Dual eligible beneficiaries who receive Medicaid health coverage through the MN pathway, and meet the income requirements for the MPPP, are referred to as “partial dual eligible plus beneficiaries.”
2. Medicare Coverage and the MPPP – Medicare provides the following types of coverage: a. Medicare Part A. Pays for hospital services and limited skilled nursing services. Medicare Part A is provided at no-cost to a person who: is insured under Social Security or Railroad Retirement Systems (e.g., paid into the system for forty (40) quarters of work) and sixty-five (65) years of age; has reached the twenty-fifth (25th) month of a permanent and total disability; or received continuing kidney dialysis or had a kidney transplant. Under an agreement with the SSA, the State is authorized to purchase Part A through the MPPP for persons who are elderly or living with a disability who do not qualify for no-cost Part A coverage. b. Medicare Part B. Pays for physician services, durable medical equipment and other outpatient services. Medicare Part B is available to persons who pay a monthly premium and are sixty-five (65) years of age or older without regard to whether they are insured in the Social Security or Railroad Retirement Systems as well as anyone who has reached the twenty-fifth (25th) month of a permanent and total disability. Initial enrollment is a seven (7) month period that starts three (3) months before a person first qualifies for Medicare and extends three months past the sixty-fifth (65th) birthday or, if failing to enroll during this period, through an open enrollment period held each year from January through the end of March. The State pays the Part B premium for Medicare beneficiaries eligible through all of the MPPP eligibility pathways listed below. c. Medicare Part C. Medicare managed care (“Advantage”) plans provide Medicare Part A, Part B and Part D (prescription drug coverage) for beneficiaries who qualify. d. Medicare Part D. Pays for prescription drug coverage for enrolled Medicare beneficiaries. Costs for beneficiaries vary. Low-income Medicare beneficiaries who qualify for the Federal government’s Extra Help program, which provides assistance in paying the costs for Part D, are automatically eligible for the MPPP. The SSA provides electronic notification to the States of Medicare beneficiaries who are eligible for the MPPP on this basis. e. Medicaid wraps around Medicare’s coverage by providing financial assistance to beneficiaries in the form of payment of Medicare premiums and cost-sharing, as well as coverage of some benefits not included in the Medicare program. Not all dual eligible
beneficiaries receive the same level of Medicaid benefits, as indicated below. 1.7.2 MPPP Eligibility Pathways A. The specific eligibility requirements and benefits coverage groups included in the MPPP pathway are as follows: 1. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) – Financial assistance in this group is provided to beneficiaries who are eligible for or enrolled in Medicare Part A, have countable income of one hundred percent (100%) of FPL or less and resources that do not exceed the amounts set annually by the Federal government. For partial dual eligible QMBs: a. Medicaid makes a direct payment to the Federal government for the Part A premium (if any), the Part B premium, and provides payments for Medicare co-insurance and deductibles as long as the total amount paid by Medicare does not exceed the amount Medicaid allows for the service. b. Eligibility begins on the first (1st) day of the month after the application is filed and all eligibility requirements are met. c. Eligibility is renewable in twelve (12) month periods. d. Deeming rules do not apply. e. There is no retroactive coverage. 2. QMBs with Medicaid health coverage (QMB Plus) – Persons who qualify through this pathway must be entitled to Medicare Part A, have countable income at or below one hundred percent (100%) of the FPL, and resources at four thousand dollars ($4,000.00) for an individual or six thousand dollars ($6,000.00) for a couple. Beneficiaries eligible through this pathway are full dual eligible beneficiaries and receive premium assistance and Medicaid health coverage. Includes MN Medicaid beneficiaries. Access to Medicaid retroactive coverage, continuing eligibility, and the full scope of Medicaid essential benefits is available. 3. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) – These individuals are entitled to Medicare Part A, have countable income of greater than one hundred percent (100%) FPL, but less than one hundred twenty percent (120%) FPL, resources within the federally defined limits, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only. a. Medicaid pays the Medicare Part B premium to SSA.
b. Eligibility begins on the first (1st) day of the month in which the application is filed and all eligibility requirements are met. c. Eligibility is authorized for a twelve (12) month period and is renewable on that basis. d. Deeming rules do not apply. e. Retroactive coverage may be available. 4. SLMBs with Medicaid health coverage (SLMB Plus) – To be eligible through this pathway, a person must be entitled to Medicare Part A, have countable income of greater than one hundred percent (100%) FPL but less than one hundred twenty percent (120%) FPL, and resources of no more than four thousand dollars ($4,000.00) for an individual or six thousand dollars ($6,000.00) a couple. A person qualifies for Medicaid through this pathway only if MN requirements are met. In addition to full Medicaid essential benefits, the MPPP also pays the beneficiary’s Medicare Part B premiums, coinsurance, deductibles and copayments. 5. Medicaid pays the SSA. Community Medicaid EAD general eligibility requirements govern access to Medicaid retroactive coverage, continuing eligibility, and scope of coverage. 6. Qualified Disabled and Working Individuals (QDWIs) – This pathway covers beneficiaries who lost their Medicare Part A benefits due to their return to work. They must be eligible to purchase Medicare Part A benefits, have countable income of two hundred percent (200%) FPL or less and resources that do not exceed twice the limit for SSI eligibility EAD limits of four thousand dollars ($4,000.00) for an individual or six thousand dollars ($6,000.00) for a couple), and must not be otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only. a. Medicaid makes a direct payment to the SSA for the Part A premium; b. Eligibility begins the month in which all requirements are met, including enrollment in Part A, and continues for a year unless or until changes in employment result in resumption of Medicare without MPPP assistance. 7. Qualifying Individuals-1 (QI-1) – To qualify for eligibility through this pathway, beneficiaries must be entitled to Medicare Part A, have countable income of at least one hundred twenty percent (120%) FPL, but less than one hundred thirty-five percent (135%) FPL, resources that do not exceed the amounts set by the Federal government, and be otherwise ineligible for Medicaid. Medicaid pays Medicare Part B premiums only. Federal matching funds for members of this group is one hundred percent
(100%) and, as such, the availability of financial assistance through QI-1 eligibility is contingent on Federal appropriations. For members of this group: a. Medicaid makes a direct payment to the SSA for the Part B premium. b. Eligibility begins the month in which the application is filed and all requirements are met and ends on December thirty-first (31st) of the year in which the application is filed. c. Cost-of-living increases in Title II benefits (COLAs), effective in January each year, are disregarded in determining income eligibility through the month following the month in which the annual Federal Poverty Guideline update is published. d. Deeming applies. e. Retroactive coverage may be available. Retroactive eligibility (of up to three (3) calendar months prior to application) applies if the individual met all QI eligibility criteria in the retroactive period, and the retroactive period is no earlier than January 1st of that calendar year. 8. MN and QMB (+) and SLMB (+) – Participation in the MPPP may adversely affect the income eligibility of a person seeking initial or continuing Medicaid health coverage through the MN pathway. As the State pays some or all Medicare costs for MPPP participants, these allowable health expenses cannot be counted toward a MN spenddown. This, in turn, may make it difficult to obtain Medicaid health coverage for high costs services that are covered only in part or not at all by Medicare. MPPP enrollment may also affect other forms of Medicaid eligibility if it changes the way income or resources are counted. An agency eligibility specialist should be consulted by an applicant or beneficiary who is concerned that enrolling in the MPPP will affect access to Medicaid health coverage. 1.7.3 MPPP Application Process A. There are multiple application pathways for pursuing MPPP eligibility. 1. MPPP – Persons seeking MPPP coverage may apply through the State or the SSA. If applying through the State’s IES, a person has the option of applying for the MPPP only or Medicaid health coverage and the MPPP. 2. LIS and Social Security Administration (SSA) – An application for the LIS program is available online at: https://secure.ssa.gov/i1020/start or by calling 1-800-772-1213 or TTY 1-800-325-0778, Monday-Friday, 7 a.m. –
7 p.m. The State uses information provided by the SSA for determining LIS eligibility to initiate an application for the MPPP, when appropriate. 1.7.4 MPPP Eligibility and Continuing Eligibility A. Persons seeking MPPP assistance are subject to the SSI methodology for determining financial eligibility, though the income and resource standards specific to the MPPP coverage group, as indicated in § 1.7 of this Part, are applied. A disability determination is not required for MPPP financial help only. Continuing eligibility is determined using a modified passive renewal process (See Subchapter 00 Part 2 of this Chapter). 1.7.5 MPPP Summary A. The following provides a summary of the MPPP eligibility pathways by coverage group that shows financial eligibility limits and the benefits provided: MPPP Eligibility Pathways Coverage Group Full or Partial Eligible Income and Resource Limits Individual/Couple Benefits QMB Partial Dual 100% FPL All MPPP applicants receive a $20.00 income disregard. Resources may not exceed the maximum resource standard for the QMB group permitted by the federal Centers for Medicare and Medicaid Services (CMS) Entitled to Medicare Part A and qualify for Medicaid payment of: Medicare Part A premiums (if needed) Medicare Part B premiums Certain premiums charged by Medicare Advantage plans Medicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D, QMB+ Full Dual 100% FPL $4,000.00 / $6,000.00 All of the above AND Medicaid health coverage
MPPP Eligibility Pathways Coverage Group Full or Partial Eligible Income and Resource Limits Individual/Couple Benefits SLMB Partial Dual 101% – 120% FPL Resources may not exceed the maximum standard for the SLMB group published by Entitled to Medicare Part A and qualify for Medicaid payment of: Medicare Part B premiums SLMB + Full Dual 101% – 120 % FPL $4,000.00 / $6,000.00 Same as above AND: Certain premiums charged by Medicare Advantage plans Medicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D, the Medicare drug program) Full Medicaid QI Partial Dual 121% – 135% FPL Resources may not exceed the maximum standard for the QI group published by CMS Entitled to Medicare Part A and qualify for Medicaid payment of: Medicare Part B premiums
MPPP Eligibility Pathways Coverage Group Full or Partial Eligible Income and Resource Limits Individual/Couple Benefits QWDI Partial Dual 200% FPL $4,000.00 – Individual $6,000.00 – Couple Lost Medicare Part A benefits because of return to work but eligible to purchase Medicare Part A and qualify for Medicaid payment of: Medicare Part A premiums 1.8 Special Coverage Groups 1.8.1 Overview A. There are certain IHCC groups that are exempt from various income and/or resource requirements because they provide coverage to people with unique characteristics and/or health needs. 1.8.2 Breast and Cervical Cancer A. The Breast and Cervical Cancer Prevention and Treatment Act of 2000, Pub. L. No. 106-354, amended Title XIX of the Social Security Act, 42 U.S.C. §§ 1396- 1396w-7, to include an optional Medicaid coverage group for uninsured people who are screened and need treatment for breast or cervical cancer or for precancerous conditions of the breast or cervix. The Rhode Island Department of Health (DOH), Women’s Cancer Screening Program, is responsible for administering the screening required for Medicaid eligibility through this pathway. 1. Eligibility Criteria – To qualify, an applicant must be under age sixty-five (65) and receive screening for breast or cervical cancer under the CDC Breast and Cervical Cancer Early Detection Program administered by DOH and found to need treatment for either breast or cervical cancer, or a precancerous condition of the breast or cervix. In addition, an applicant must not be Medicaid eligible in another coverage group or have access to or be enrolled in a health insurance plan that provides essential benefits, as defined in Federal Regulations at 42 C.F.R. § 447.56 (2023). All general requirements for Medicaid must also be met. There is no resource
limit. Retroactive eligibility is available for eligible members of this coverage group and no disability determination is required. 2. Determination process – Members of this coverage group are not required to meet EAD income and resource limits or those established for other Medicaid eligibility pathways. Under the State’s Section 1115 Waiver, income eligibility for members of this coverage group is set at two hundred fifty percent (250%) of the FPL. In addition, presumptive eligibility is also available to people who meet the screening requirements, prior to a full determination of Medicaid eligibility, if the person is a resident of the State. 3. Continuing eligibility – A redetermination of Medicaid eligibility must be made periodically to determine whether the beneficiary continues to meet all eligibility requirements. Eligibility ends when the beneficiary: a. Attains age sixty-five (65); b. Acquires qualified health insurance/creditable coverage; c. No longer requires treatment for breast or cervical cancer; d. Fails to complete a scheduled redetermination; e. Is no longer a Rhode Island resident; OR f. Otherwise does not meet the eligibility requirements for the program. 4. Agency responsibilities – The DOH administers the screening and application segments of the program. EOHHS conducts redeterminations and renewals and is responsible for providing timely notice and the right to appeal when any change in eligibility occurs. 5. Applicant/beneficiary responsibilities – Beneficiaries are responsible for providing timely and accurate information about the status of their condition/treatment prior to the date of redetermination or at intervals specified. 1.8.3 Refugee Medical Assistance (RMA) – MN Option A. Refugee Medical Assistance (RMA) is a one hundred percent (100%) Federally- funded program for individuals and families operating under the auspices of the U.S. Department of Health and Human Services, Office of Refugee Resettlement (ORR). RMA is an eligibility pathway for individuals and families who are otherwise ineligible for Medicaid. Until enactment of the ACA, all persons seeking RMA were evaluated using the SSI methodology through the MN eligibility pathway. The ORR has waived these requirements and directed that, prior to a determination for RMA, States should evaluate all participants in its programs for
Medicaid and commercial coverage, using the MAGI methodology (MACC groups under Part 30-00-1 of this Title) and SSI-related coverage (§ 1.6 of this Part) before pursuing RMA through the MN pathway. 1. Eligibility Criteria – Any member of the Federal resettlement program for refugees who has income at or below two hundred percent (200%) of the FPL and is otherwise ineligible for Medicaid or an HSRI plan providing financial help, may apply for RMA using the MN process. This includes adults age nineteen (19) to age sixty-four (64) who have no other Medicaid MN eligibility option and certain persons in need of LTSS. The criteria set forth in Subchapter 05 Part 2 of this Chapter for Community Medicaid apply for establishing the spenddown period and allowable expenses except there are no resource requirements and deeming is not permitted. 2. Determination Process – All persons seeking Medicaid coverage who have refugee status are evaluated for MACC group eligibility first using the MAGI before being evaluated for IHCC group coverage using the SSI methodology or special eligibility requirements in this Section. This includes the MN pathways identified in Part 2 of this Subchapter for elders, adults with disabilities, children, parents/caretakers, and pregnant people. If determined ineligible through these pathways, the person is evaluated for coverage through HSRI and then the MN eligibility pathway through RMA. The RMA MN eligibility pathway requires a beneficiary to spenddown to the MNIL for elders and adults with disabilities, adjusted for family size. 3. Continuing Eligibility – Receipt of RMA under the characteristic of "refugee" is limited to the first eight (8) months residing in the United States, beginning with the month the refugee initially entered the United States, or the entrant was issued documentation of eligible status by the Federal government. a. Coverage Limit. Coverage and one hundred percent (100%) Federal matching funds continue until the end of the eighth (8th) month or the date in which the person no longer meets the immigration status requirement, whichever comes first. Prior to ending eligibility for Medicaid through this pathway, a review of other possible forms of Medicaid eligibility is conducted by the State. b. No Five Year Bar. Federal law exempts refugees from the five (5) year bar for qualified non-citizens established under § 402 of the U.S. Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, Pub. L. No. 104-193. Once the (8) eight month RMA period ends, States are required to continue Medicaid eligibility under any other coverage group for which a refugee may
qualify providing all other requirements are met. (See Part 30-00-1 of this Title for more immigration information.) Renewals for continuing coverage are conducted in accordance with the applicable coverage group requirements including six (6) month budget periods through the MN pathway. 4. Agency responsibilities – Beneficiaries eligible under this Section are required to meet the spenddown requirements set forth in Part 2 of this Subchapter. The agency is responsible for ensuring that the spenddown period coincides with the eligibility period. In addition, the EOHHS must evaluate each applicant/beneficiary in this group for MAGI-based Medicaid and HSRI eligibility prior to granting MN eligibility. Federal payment for eight (8) months is provided regardless of pathway. 5. Applicant/beneficiary responsibilities – Beneficiaries are responsible for meeting the spenddown requirements set forth in Part 2 of this Subchapter. 1.8.4 Sherlock Plan and Ticket to Work Plan A. The Sherlock Plan Medicaid for Working People with Disabilities Program is an SSI-related IHCC group comprised of working adults with disabilities age sixty- five (65) and older pursuant to 42 U.S.C. § 1396a(a)(10)(ii)(XIII). The Ticket to Work Plan is an SSI-related IHCC group comprised of working adults with disabilities ages sixteen (16) to sixty-four (64) pursuant to 42 U.S.C. § 1396a(a)(10)(ii)(XV). Eligibility for the Sherlock and Ticket to Work Plans is included in Subchapter 15 Part 1 of this Chapter, which focuses on Medicaid eligibility for adults with disabilities who are working. 1.8.5 Emergency Medicaid A. Medicaid health coverage is available to non-citizens in emergency situations without regard to immigration status. 1. Eligibility Criteria – To qualify for emergency Medicaid, a non-citizen must meet all of the eligibility requirements for a MACC or an IHCC group, except for immigration status. Persons seeking emergency Medicaid are evaluated as follows: a. Persons under age sixty-five (65). All persons in this group are evaluated for the MACC groups identified in Part 30-00-1 of this Title using the MAGI standard, at the income limit applicable for the population to which they belong – e.g., child, adult or parent/caretaker, pregnant person. There is no resource limit and no determination of disability. b. Elder age sixty-five (65) and older. Non-citizens in this category are evaluated using the IHCC Community Medicaid EAD eligibility
requirements and income standard. Resource limits apply, but there is no determination of disability. c. Medically Needy. Persons who are ineligible under §§ 1.8.5(A)(1)(a) or (b) of this Part because their income is too high, may seek coverage through the IHCC pathway as MN in accordance with § 1.6.3 of this Part and Part 2 of this Subchapter in detail. d. In addition, the person must require treatment for an emergency health condition in accordance with the prudent layperson standard – as defined in the Balanced Budget Act of 1997, Pub. Law No. 105-33 – as specified below and obtain such services from a certified Medicaid provider. Such an emergency health condition is: (1) A health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant person, the health of the person or their unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. 2. Determination Process – Emergency service providers – typically an acute care facility such as a hospital – provides assistance with completing any required forms upon determining, in conjunction with the presumptive eligibility process specified in Part 30-00-4 of this Title, that emergency Medicaid coverage may be required. In situations in which eligibility for emergency Medicaid cannot be determined or ascertained in this process, an agency eligibility specialist is contacted to provide the non-citizen with assistance in applying for coverage and assuring payment is made for any of the Medicaid-covered emergency services rendered. MN eligibility is available, as a last resort, for non-citizens who have income above the applicable eligibility limits for other coverage groups if the costs incurred for emergency services are sufficient for a spenddown. Payments to providers are typically made post-treatment. 3. Continuing Eligibility – Emergency Medicaid coverage is limited to the period in which the emergency health condition is treated. Under applicable Federal Regulations, such coverage does not include any follow-up services deemed medically necessary to prevent the need in the future for emergency services for the same illness, disease or condition in an acute care facility.
4. Agency responsibilities – The EOHHS is responsible for assisting in the application process and making timely payment for services provided under this Subsection, including for any services billed separately by licensed providers and professionals as long as the costs were incurred during the emergency health period for the condition specified. 5. Applicant/beneficiary responsibilities – Applicants must provide timely and accurate information on all eligibility factors unrelated to immigration status required for making a determination for Medicaid health coverage. 1.9 Community Medicaid – LTSS Preventive Services 1.9.1 Authority A. Under the terms of the State’s Section 1115 Waiver, Community Medicaid beneficiaries who do not yet need Medicaid LTSS but are at risk for the nursing facility institutional level of care have access to LTSS preventive services. Beneficiaries who meet the needs-based criteria for these LTSS preventive services are eligible for a limited range of home and community-based services and supports along with the full range of primary care essential benefits they are entitled to receive. The goal of preventive services is to delay or avert LTSS institutionalization or more extensive and intensive home and community-based care. 1.9.2 Scope of Services A. Depending on a beneficiary’s needs, the following LTSS preventive services may be available to Community Medicaid beneficiaries: 1. Limited Certified Nursing Assistant/Homemaker Services – These services include general household tasks (e.g., meal preparation and routine household care) and are available when a beneficiary can no longer perform them on their own and there is no other person available to provide assistance. Limited personal care may also be available. a. Maximum hours available: Six (6) hours per week for a single beneficiary or ten (10) hours per week for a household with two (2) or more beneficiaries. 2. Minor Environmental Modifications – Minor modifications may be available to a beneficiary to facilitate independence and the ability to live at home or in the community safely. Such modifications may include: grab bars, versa frame (toilet safety frame), handheld shower and/or diverter valve, raised toilet seats, and simple devices, such as: eating utensils, a transfer bath bench, shower chair, aids for personal care (e.g. reachers) and standing poles. 1.9.3 Prior Authorization
A. To qualify, the beneficiary’s Health Care provider must provide documentation that that one (1) or more LTSS preventive services will improve or maintain the ability of a beneficiary to perform Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs) and/or delay or mitigate the need for intensive home and community-based or institutionally based care. 1.9.4 Limits A. To qualify for preventive level services, there must be no other form of coverage for the services provided and no other person or agency responsible or capable for doing so. 1.9.5 Continuing Need A. The need for LTSS preventive services is reassessed annually in conjunction with the renewal process. Preventive services continue until the beneficiary reports that the risk for LTSS has been mitigated or a follow-up functional assessment conducted by the State or State designee finds that such services need to be changed or terminated. 1.10 Community Medicaid General Eligibility Requirements 1.10.1 Scope and Purpose A. All applicants for Medicaid in the IHCC groups must meet general eligibility requirements in addition to those related to income, resources, and clinical need. 1.10.2 Characteristic Requirements A. Unless specifically exempt, a person applying for Community Medicaid when eligibility is determined by the State must establish their categorical relationship to SSI by qualifying on the basis of one (1) of the following characteristics: 1. Age – A person qualifying on the basis of age must be at least sixty-five (65) years of age in or before the month in which eligibility begins. a. Verification: An applicant’s age is verified electronically with information about date of birth from the SSA and/or the Rhode Island Department of Health, Division of Vital Statistics. If data matches are unsuccessful, an applicant is required to provide paper documentation of date of birth to support a self-attestation of age. 2. Disability – Determined to meet the SSI disability criteria applied by the MART, or the SSA for SSI cash benefits or RSDI or SSDI. Note: An applicant must be determined disabled due to blindness by the MART or by an entity of the SSA. If income is at or below SSI income standard, a disability determination for blindness is not required.
1.10.3 Non-Financial Criteria A. Applicants must also meet all of the following non-financial eligibility criteria for Medicaid: 1. Social Security Number – Each person applying for Medicaid must have a Social Security Number (SSN) as a condition of eligibility for the program. a. Condition of Eligibility. Applicants must be notified prior to or while completing the application that furnishing an SSN is a condition of eligibility. Only members of a household who are applying for Medicaid are required to provide an SSN, however. An SSN of a non-applicant may be requested to verify income. Refusal of a non- applicant to provide an SSN cannot be used as a basis for denying eligibility to an applicant who has provided an SSN. If an SSN is unavailable, other proof of income must be accepted. b. Limits on Use. Applicants must also be informed that their SSN will be utilized only in the administration of the Medicaid program, including in verifying income and eligibility. c. Verification. SSN is verified through an electronic data-match with the SSA. Applicants must provide documentation of SSN if the data match fails. Paper documentation indicating that an application for an SSN has been made is required for applicants who do not have an SSN at the time of application. 2. Residency – A person must be a resident of Rhode Island to be eligible for Medicaid. The State of residence of a person is determined according to the following: a. SSP. For persons receiving an SSP payment, the State of residence is the State paying the supplement. Exception: Persons involved in work of a transient nature or who have moved to the State to seek employment may claim Rhode Island as their State of residence and be granted Medicaid in Rhode Island if they meet all other eligibility criteria. These persons may be granted Rhode Island Medicaid even though they continue to receive a State supplemental payment from another State. b. Persons under twenty-one (21). Residency is determined as follows for minors: (1) A person who is blind or living with a disabling impairment under the age of twenty-one (21) who is not residing in an institution, the State of residence is the State in which the person is living.
(2) Any person residing in a health care or treatment facility who is under the age of twenty-one (21), or who is twenty-one (21) or older and became incapable of indicating intent prior to the age of twenty-one (21), the State of residence is that of: (AA) The parents or legal guardian, if one (1) has been appointed, or (BB) The parent applying for Medicaid on behalf of the person if the parents live in different States, or (CC) The person or party who has filed the application on behalf of the applicant if the applicant has been abandoned by their parents and does not have a legal guardian. c. Persons twenty-one (21) and older. For adults age twenty-one (21) or older, residence is determined as follows: (1) If not living in an institution, the State of residence is the one in which the person is living: (AA) With intent to remain permanently or for an indefinite period of time; (BB) While incapable of stating intent; or (CC) After entering with a job commitment or in pursuit of employment whether or not currently employed. (2) A person age twenty-one (21) or older who is residing in a health institution and became incapable of stating intent at or after age twenty-one (21), residing is in the State in which the person is physically present, unless another State arranged for placement in a Rhode Island institution. (3) For any other person age twenty-one (21) or older living in an institutional setting, residence is in the State where the person is living with the intention to remain permanently or for an indefinite period, unless another State has made a placement. A person living in a health care institution cannot be considered a Rhode Island resident if they own a home in another State and has an intent to return there even if the likelihood of return is apparently nil. d. Absence Due to Military Assignment. A blind or impaired child who travels out of the State for an indefinite period with a parent in the
armed forces is no longer eligible for Medicaid or SSP even if SSI benefits continue. e. Temporary Absence. Temporary absences from Rhode Island for any of the following purposes do not interrupt or end Rhode Island residence: (1) Obtaining necessary health care; (2) Visiting; (3) Obtaining education or training under a program of the Rhode Island Office of Rehabilitation Services (ORS), work incentive or higher education program, or (4) Residing in an LTSS facility in another State, if arranged by an agent of the State of Rhode Island, unless the person or their parents or guardian, as applicable, stated an intent to abandon Rhode Island residence and to reside outside Rhode Island upon discharge from LTSS. f. Placement in Rhode Island Institutions. When an agent of another State arranges for a person’s placement in a Rhode Island institution, the person remains a resident of the State which made the placement, irrespective of the person’s intent. g. Incapable of Stating Intent. Persons are incapable of stating intent regarding residence if they are judged to be legally incapable of doing so or there is medical documentation or other documentation acceptable for such purposes that supports a finding that they are incapable of stating intent. h. Residence as Payment Requirement. A person must be a resident of Rhode Island at the time a medical service is rendered in order for Rhode Island Medicaid to pay for that service. The service does not, however, have to be rendered in Rhode Island. i. Specific Prohibitions. Under Federal law, the State may not deny Medicaid eligibility to an applicant for any of the following reasons: (1) Failure to reside in the State for a specified period; or (2) Failure of a person receiving care in an institutional setting to establish residence in the State before entering the institution if otherwise satisfying the residency rules set forth in this Section; or
(3) Temporary absence from the State if the person intends to return when the purpose of the absence has been accomplished, unless another State has determined that the person is a resident there for purposes of Medicaid; or (4) Failure to have a permanent or fixed address. Homeless persons may designate a mailing address. j. Verification – At the time of initial application for Medicaid, self- attestation of Rhode Island residency is accepted and/or verified electronically and the intent to remain is accepted unless required for the evaluation of resources or income that has been earned by the applicant in another State. 3. Living Arrangements – A person’s living arrangement is a factor when determining eligibility for programs and payment amounts that may directly or indirectly affect access to Medicaid for certain Medicaid services. In addition, incarceration is also a factor that affects eligibility status and access to Medicaid coverage. a. Financial eligibility. The financial responsibility of relatives varies depending upon the type of living arrangement. Thus, when determining financial eligibility, the living arrangements of individuals and couples matter as follows: (1) Living in own home such as a house, apartment, or mobile home or someone else’s household affects Medicaid MACC household composition and RIte Share participation and thus is a factor considered in the process noted in § 1.10.3(A)(2) of this Part. (2) Residing in a community-based group care or board and care facility such as assisted living or supportive home for persons with developmental disabilities or behavioral health needs. Determines Medicaid eligibility group size and cap on room and board charges and allowances and contributions to cost of care; (3) Residing in a health care or treatment institution such as a hospital, nursing facility, intermediate care facility for persons with intellectual disabilities, residential care facility for adults or children requiring treatment or rehabilitation services. An institution is, for these purposes, an establishment that furnishes food, shelter and some health treatment, services, and/or supports to four (4) or more persons unrelated to the proprietor. Determines Medicaid eligibility group size and countable income;
(4) Persons who are homeless are considered to be living in their own homes if they reside in a shelter or move from one temporary living arrangement to another for more than six (6) months during a calendar year. b. SSP. Eligibility for and the amount of the optional State supplemental payment is affected by the following living arrangements which, in turn, may determine a Medicaid beneficiary’s choice of care settings: (1) Residence in a hospital or nursing facility for the whole month and Medicaid pays for over one half (1/2) of the cost of care; (2) Medicaid LTSS beneficiary living in a Medicaid certified assisted living residence authorized in accordance with R.I. Gen. Laws § 40-6-27; (3) Medicaid beneficiary who is SSI or EAD eligible (non-LTSS) and is residing in an assisted living residence; (4) Medicaid beneficiary under twenty-one (21) residing in a hospital or nursing facility for the entire month and private insurance and/or Medicaid together pay over one half (1/2) of the cost of care; or (5) Medicaid beneficiary of an age or IHCC group residing in a public or private health care treatment facility and Medicaid is paying for more than one half (1/2) of the cost of care. If residing in the facility for the whole month, the SSP payment is limited to forty-five dollars ($45.00). c. Verification – For both Medicaid eligibility (a) and SSP (b), self- attestation of living arrangement is accepted during initial application for persons living in their own homes or in someone else’s household. Documentation certifying that a person is or will be residing in a community-based residence that qualifies for one (1) of the special SSP payments is required. Proof of living in a health care or treatment institution must be provided when no other source of verification is available. Notification to EOHHS and DHS of change in living arrangement from a community-based to an institutional setting or the reverse is mandatory and must be made within ten (10) days of the date the change occurs for all applicants and beneficiaries. d. Correctional Facility. While living in a correctional facility, including a juvenile facility, Medicaid health coverage for otherwise IHCC eligible persons is suspended except for inpatient and emergency
services provided outside of the facility. Residence in a correctional facility begins on the date of incarceration and continues until the date the person is released from the correctional facility. A person transferred from a correctional facility to a hospital for part or all of the sentencing period is considered to be still living in the correctional facility for general eligibility purposes, unless the exemption for Medicaid coverage of inpatient and emergency care applies. e. Verification. Self-attestation of incarceration is accepted initially and then verified through information exchanges with the Rhode Island Department of Corrections (DOC). In addition, electronic data matches with DOC records are conducted on a regular basis in conjunction with the post-eligibility verification process. 4. Citizenship and Immigration Status – Immigration and citizenship status affect Community Medicaid eligibility as follows: a. Citizen or Qualified Non-citizen. An applicant for coverage in one (1) of the IHCC groups must be a United States citizen or a lawfully present “qualified” non-citizen immigrant who has been in the U.S. for five (5) years or more. Lawfully present qualified non-citizens include persons in the U.S. as legal permanent residents (LPR), with humanitarian statuses or as a result of such circumstances (e.g., refugees, asylum applicants, temporary protected status), valid non-immigrant visas, and legal status conferred by other Federal laws (temporary resident, LIFE Act, Pub. Law No. 106-553 and 106-554, Family Unity Act, 8 C.F.R. Part 236 Subpart B (2023), etc.). There are exceptions in Federal law and, more generally, under the Rhode Island Medicaid Program which permit qualified non-citizens who might otherwise be subject to the bar to obtain Medicaid health coverage. These exceptions are located in Part 30- 00-1 of this Title. General exceptions specific to Rhode Island are as follows: (1) Pregnant people are eligible if they meet all other requirements regardless of immigration status. (2) Children under age nineteen (19) are not subject to any of the eligibility requirements related to citizenship and immigration status. b. Non-qualified Non-citizen. With the exception of pregnant people, adult “non-qualified” non-citizens are not eligible for Medicaid. Non- qualified non-citizens are persons from other nations who are not considered to be immigrants under current Federal law, including those in the United States on a time-limited visa (such as visitors or
persons in the U.S. on official business) and those who are present in the country without proper documentation (includes people with no or expired status). Non-qualified non-citizens may obtain Medicaid health coverage in emergency situations only, as indicated in § 1.8.5 of this Part. Non-emergency services may be obtained through Federally Qualified Community Health Centers. (1) Lawfully present adult non-citizens may be eligible for commercial coverage with financial assistance, through HSRI. Further information is available at: www.healthsourceri.org. c. Verification: Individuals who are applying for coverage must provide their immigration and citizenship status. Non-applicants in the FRU are exempt from the requirement. Any information provided by an applicant on paper or electronically must be used only for verifying status. Acceptable documentation, when required, is set forth in Part 10-00-3 of this Title. 5. Other Forms of Cooperation – Rhode Island’s Medicaid State Plan states that as a condition of eligibility for Medicaid, applicants must at the time of application: a. Agree to cooperate in identifying and providing information to assist the State in pursuing any third (3rd) party who may be liable to pay for care and services; b. Agree to cooperate with the State in obtaining medical support and payments (e.g., signing papers necessary to pursue payments from absent parents); c. Agree to apply for eligibility for any other forms of public assistance which may be available upon receiving notification from the EOHHS in accordance with Part 10-00-3 of this Title; d. Enroll in a RIte Share-approved employer-sponsored health insurance plan if cost-effective to do so, in accordance with Part 30- 05-3 of this Title; and e. Agree to cooperate in establishing the paternity of a child born out of wedlock for whom the applicant can legally assign rights. 1.10.4 Good Cause for Failing to Cooperate A. A Medicaid applicant or beneficiary must have the opportunity to claim good cause for refusing to cooperate. Good cause may be claimed by contacting an agency representative. To claim good cause, a person must state the basis of the claim in writing and present corroborative evidence within twenty (20) days of
the claim; provide sufficient information to enable the investigation of the existence of the circumstance that is alleged as the cause for non-cooperation; or, provide sworn statements from other persons supporting the claim. 1. A determination of good cause is based on the evidence establishing or supporting the claim and/or an investigation by EOHHS agency staff of the circumstances used as justification for the claim of good cause for non- cooperation. 2. The determination as to whether good cause exists must be made within thirty (30) days of the date the claim was made unless the agency needs additional time because the information required to verify the claim cannot be obtained within the time standard. The person making the claim must be notified accordingly. B. Upon making a final determination, notice must be sent to the person making the claim. The notice must include the right to appeal through the EOHHS Administrative Fair Hearing Process set forth in Part 10-05-2 of this Title, or its successor Regulation. 1.11 State-Administered Community Medicaid Disability Determinations 1.11.1 Scope and Purpose A. Disability determinations are made by the State’s Medicaid Assessment and Review Team (MART) in accordance with the applicable requirements of the SSA based on information supplied by the applicant and by reports obtained from treating physicians and other health care professionals. Anyone who is blind and is seeking IHCC group Community Medicaid who does not qualify for SSI or has never received a determination of disability on that basis by a government agency, is subject to an evaluation by the MART. 1.11.2 Disability Standards for Community Medicaid A. For the purposes of IHCC groups providing Community Medicaid, the standards for determining whether a person has a disability centers on: 1. Duration – The disabling impairment or chronic condition is expected to result in death or has lasted or can be expected to last for at least twelve (12) consecutive months; 2. Substantial Gainful Activity – The impairment or condition adversely affects the person’s ability to engage in substantial gainful activity or SGA. For these purposes, SGA is work activity that involves doing significant physical or mental activities. Work may be substantial even if it is done on a part-time basis or if a person does less, gets paid less or has less
responsibility than during prior employment. Gainful work activity is the kind of work done for pay or profit whether or not a profit is realized. 3. Application of Standards – The disability determination standards that apply for Community Medicaid vary by age: a. Persons age eighteen (18) or older. Disability determinations for applicants in this age group are made by the MART using the SSI criteria and standards. The determination is based on an assessment of whether the person seeking coverage is unable to engage in any substantial gainful activity due to any medically determinable physical or mental impairment, or combination of impairments, expected to result in death, or last or could be expected to last for a continuous period of not fewer than twelve (12) months. To meet this definition, there must be a severe impairment, which makes the person unable to do their previous work or any other substantial gainful activity existing in the national economy. To determine whether a person is able to do any other work, the MART considers residual functional capacity, age, education, and work experience. b. Children under age nineteen (19) – MN Only. The MART is not usually responsible for making disability determinations for persons under nineteen (19). In general, these disability determinations are made formally by the SSA in conjunction with SSI eligibility, evaluations conducted by professionals for educational or child welfare services or through a qualified Medicaid provider. The SGA standard does not apply; however. The child must have a physical, mental, or behavioral health impairment, or combination of impairments, resulting in marked and severe functional limitations, expected to result in death or that have lasted or are expected to last for at least twelve (12) consecutive months. The MART may make such disability determinations for MN applicants under age nineteen (19) using the applicable SSI standards. c. Disability based on Blindness. Applicants seeking eligibility for a disability based on blindness who do not qualify for SSI because their income is too high must meet the duration and SGA standard and have central visual acuity of 20/200 or less, even with glasses, or a limited visual field of twenty degrees (20°) or less in the better eye with the use of a correcting lens. d. Working Persons with Disabilities. Applicants who have disabilities but who are working are exempt from the SGA step of the sequential evaluation of the disability determination. This exemption applies if the person otherwise meets the requirements set forth for
coverage under Subchapter 15 Part 1 of this Chapter, or other related provisions for adults with disabilities. 1.11.3 MART Five Step Determination Process A. This Subsection explains the five (5) step sequential review process the MART uses when determining whether an applicant who is age nineteen (19) or older meets the SSI disability criteria. When using the review process, the MART considers all the evidence in an applicant’s case record in a series of sequential steps. Upon making a determination of disability at any step in the sequence, the review process stops and the MART does not proceed to the next step. If no determination is made, the MART proceeds from one (1) step to the next in order until a decision is made. The steps are as follows: 1. Step One (1) – At the first (1st) step, the MART must consider the work activity of the person applying, if any. If the applicant is engaging in substantial gainful activity, they will be determined ineligible except in instances in which the provisions in Subchapter 15 Part 1 of this Chapter, or related provisions apply, pertaining to Medicaid eligibility for working persons with disabilities. 2. Step Two (2) – A determination is made whether the individual has a medically determinable impairment that is severe, or a combination of impairments that is severe (20 C.F.R. § 416.920(c) (2023)) and whether the impairment has lasted or is expected to last for a continuous period of at least twelve (12) months (20 C.F.R. § 416.909 (2023)). If the durational standard is not met, the MART will find that the individual is not disabled. A. An impairment or combination of impairments is not severe within the meaning of the federal Regulations if it does not significantly limit an individual’s physical or mental ability to perform basic work activities (20 C.F.R. § 416.921 (2023)). Examples of basic work activities are listed at 20 C.F.R. § 416.921(b) (2023). b. In determining severity, the MART considers the combined effect of all of an individual's impairments without regard to whether any such impairment, if considered separately, would be sufficient severity (20 C.F.R. § 416.923 (2023)). (1) If the MART finds a medically severe combination of impairments, then the combined impact of the impairments will be considered throughout the disability determination process. (2) If the individual does not have a severe medically determinable impairment or combination of impairments, the MART will find that they are not disabled
c. The MART will not consider the individual's age, education, or work experience at Step (2). d. Step (2) is a de minimis standard. In any case where an impairment (or multiple impairments considered in combination) has more than a minimal effect on the individual's ability to perform one (1) or more basic work activities, adjudication must continue beyond Step (2) in the sequential evaluation process. 3. Step Three (3) – At the third (3rd) step, the MART must also consider the medical severity of the person’s impairment(s). If the person has at least one (1) impairment that meets or equals one (1) of the listings in the SSI rules at 20 C.F.R. Part 404, Appendix 1 to Subpart P (2023) and meets the duration requirement, the MART determines the person to be disabled for Medicaid eligibility purposes. 4. Step Four (4) – The fourth (4th) step entails MART consideration of the required assessment of the person’s residual functional capacity and past relevant work. If the person continues to perform past relevant work, the MART will the find the person not disabled. 5. Step Five (5) – At the fifth (5th) and last step, the MART considers the assessment of the person’s residual functional capacity, age, education, and work experience to determine if the person is able to make an adjustment to other work. If a person is found to be able to make an adjustment to other work, the MART determines the person is not disabled. If the person is not able to make such an adjustment to other work, the MART will find the person to be disabled. 1.11.4 Referral to the MART A. All adults over age nineteen (19) applying for Medicaid are evaluated by the Integrated Eligibility System using the MAGI standard before consideration using the SSI-methodology. The application includes questions about a person’s need for care, previous or pending disability determinations and the need for retroactive Medicaid, which provides coverage for certain health expenses incurred in the three (3) months prior to making application. 1. Referral to the MART – Applicants who indicate on the Medicaid application that they have been determined to have a disabling condition by a government agency and/or are seeking retroactive eligibility are referred to the MART for a disability review if they: a. Are not currently an SSI or RSDI recipient and do not qualify for MAGI-based coverage due to Medicare eligibility or enrollment and/or are seeking retroactive eligibility; or
b. Qualify for such MAGI coverage but would prefer to be evaluated for IHCC through a pathway for Community Medicaid. 2. Limits on Referral – In accordance with Federal Regulations at 42 C.F.R. § 435.541 (2023), when a person is seeking Medicaid on the basis of a disability, the following limitations apply: a. The MART may not make a determination of disability when the only application for benefits has been filed with the SSA. b. The MART may not make an independent determination of disability if the SSA has made such a determination on the same issues presented in the Medicaid application within the ninety (90) day time limit allowed by Federal Regulations. c. A determination of disability made by the SSA is binding. Accordingly, the MART must refer to the SSA all applicants alleging new information or evidence affecting previous determinations of ineligibility based on disability for reconsideration or reopening of the determination except in cases specified in 42 C.F.R. § 435.541(c)(4) (2023). 3. These limits on referrals to the MART do not apply if the person is seeking Medicaid as a non-cash recipient with income above the SSI standard through the EAD pathway and the person has not applied for SSI cash benefits; has applied and has been found ineligible for SSI for a reason other than disability; or the SSA has not made a determination on a disability related application within ninety (90) days from the date the application for Medicaid was filed with the SSA. 1.11.5 Continuing Eligibility for EAD Adults with Disabilities A. Continuing eligibility for beneficiaries eligible due to a disability is multifaceted. 1. Medicaid Renewal – Beneficiaries eligible through the EAD pathway on the basis of a disabling impairment are renewed on an annual basis in accordance with the provisions of Subchapter 00 Part 2 of this Chapter, subject to periodic reviews by the MART. 2. MART Periodic Reviews – These reviews must focus on whether there has been any medical improvement in a beneficiary’s impairment since the comparison point decision and, if so, whether the improvement is related to the beneficiary’s ability to work. For these purposes: a. Comparison Point Decision (CPD). The most recent favorable decision which is the latest final determination or decision involving a consideration of the medical evidence and whether a person is disabled or continues to be disabled.
b. Medical Improvement. Any decrease in the medical severity of the impairment that was presented at the CPD as measured by changes in symptoms, signs and/or laboratory findings associated with the impairment. 3. The MART must conduct these reviews in accordance with Federal SSI Regulations at 20 C.F.R. § 404.1594 (2023) and the schedule for conducting reviews identified at 20 C.F.R. § 416.990 (2023). This schedule indicates the reviews must generally be conducted as follows: a. Impairment expected to improve – six (6) to eighteen (18) months from date of CPD; b. Impairment not considered permanent, but medical improvement cannot be accurately predicted – once every three (3) years from CPD; c. Impairment is considered permanent – at least once every seven (7) years, but not more often than once every five (5) years from CDP; d. Immediately, for the reasons set forth in subsection (b) of the Federal Rule including, but not limited to: the beneficiary returns to work or is reported by government agency or other source to be able to begin working or no longer disabled, electronic data sources indicating earnings increased substantially, or a self-reported recovery from the impairment. 4. Limitations – A periodic review is not required for any beneficiary with a disability determined by the SSA and/or authorized to work under the Sherlock Plan, Ticket to Work Plan, or any other eligibility pathway for adults with disabilities who are working as identified in this Chapter. 5. The eligibility of Medicaid beneficiaries who are sixty-five (65) and older are renewed on an annual basis in accordance with the provisions located in Subchapter 00 Part 2 of this Chapter. 1.11.6 Agency and Applicant Responsibilities A. The applicant must provide the health care authorizations and information necessary to make a timely and accurate determination of disability. The MART is responsible for assuring that determinations are made in accordance with 20 C.F.R. §§ 416.920-985 (2023) and may be obtained in hard copy by contacting the Social Security Administration, One Empire Plaza, 6th Floor, Providence, RI 02903 or 1-877-402-0808 (TYY 1-800-325-0778).
1.12 Financial Eligibility Determination 1.12.1 Scope and Purpose A. To determine a person’s eligibility using the SSI methodology, a comparison is made between the countable income and resources of the applicant’s FRU and the income limits applicable to the Medicaid eligibility IHCC group. Once these groups have been established, financial eligibility is determined in accordance with the provisions for the SSI treatment of income and resources set forth in Subchapter 00 Part 3 of this Chapter, and/or the special eligibility requirements in § 1.8 of this Part. This Section focuses on the financial eligibility determination process for the Community Medicaid pathways in which the State is responsible for initial and continuing eligibility. 1.12.2 The Medicaid Eligibility Group A. The Medicaid eligibility group for Community Medicaid when determined by the State is as follows: 1. Single Adults – A single adult requesting Community Medicaid, including Medicaid LTSS, is treated as an “individual” – that is – Medicaid eligibility group of one (1). 2. Groups for Adults with Spouses – When two (2) spouses are living together, both the person requesting Medicaid and the applicant’s spouse are considered members of the applicant’s Medicaid eligibility group – a “couple” or group of two (2) – unless one (1) of the exceptions specified below applies. This is true whether or not the spouse is also requesting Medicaid. a. Living together. A couple is considered living together in any of the following circumstances: (1) Until the first (1st) day of the month following the calendar month of death or marriage separation, that is, when one (1) spouse dies or the couple separates; (2) When the number of days one (1) spouse is expected to receive LTSS in an institution or home and community- based setting is fewer than thirty (30) days; and (3) When the resources of the couple are reassessed and allocated at the point in which the need for continuous LTSS is determined and an application for Medicaid coverage of LTSS is made as indicated in Part 50-00-6 of this Title. b. Exceptions. Adult applicants with spouses are treated as an “individual” for eligibility purposes in the following circumstances:
(1) When one (1) spouse in a couple is receiving long-term care and applying for Medicaid LTSS, the applicant for Community Medicaid is treated as an “individual” – group of one (1) – for the determination of initial and ongoing income eligibility and resource reviews. The couple, whether or not still married, is treated as no longer living together as of the first (1st) day of the calendar month that the spouse receiving LTSS became eligible for Medicaid. This remains true even if the other spouse receiving Community Medicaid begins receiving Medicaid LTSS in a subsequent month. (2) When both spouses receive Community Medicaid and are residing in a residential care setting serving four (4) persons or more, each spouse is treated as an individual without regard to whether they live together. This applies to Community Medicaid beneficiaries who do not qualify for LTSS while residing in licensed assisted living residences, behavioral health community residences, adult supportive care homes, and supportive living arrangements for adults with developmental disabilities. c. Dependent child in the household. The Medicaid eligibility group increases in size for any dependent child under age nineteen (19) who is not receiving SSI. 3. Child (Applicable for MN Eligibility Only) – The Medicaid eligibility group for a dependent child up to age nineteen (19) applying for MN coverage using the SSI methodology is a group of one (1). Once reaching age nineteen (19), the Rules related to a single adult apply. 4. Parent-Child – When a parent and dependent child living together are both seeking Medicaid in IHCC groups in which the SSI methodology applies, they are treated as two (2) Medicaid groups of one (1), if the parent is not living with a spouse. If the parent is living with a spouse, the parents are treated as a Medicaid group of two (2) and the child as a Medicaid group of one (1). When a parent/caretaker is seeking MN eligibility, any MAGI- eligible members of the household are excluded from the eligibility group. 1.12.3 Formation of the FRU A. The financial responsibility unit (FRU) consists of the persons whose income and resources are considered available to the applicant or beneficiary in the eligibility determination. The FRU is relevant for deeming purposes for non-LTSS Medicaid and in determining eligibility for certain IHCC Community Medicaid coverage groups. The following subsections set forth the Rules for determining membership in the FRU and the portion of income considered available to the person seeking Medicaid:
1. FRU Composition for Citizens – The FRU for citizens and sponsored non- citizens differs due to deeming requirements. For citizens, the FRU consists of the person seeking Medicaid and, as appropriate, a spouse, parent, and/or dependent child. Other members of the household are not included in the FRU even if they make financial contributions. a. FRU Single Adults. The FRU for an adult requesting SSI-related Medicaid, including Medicaid LTSS, is the same as the adult’s Medicaid eligibility group. b. FRU Child. The financial responsibility group for a dependent child includes the child and any parents living with the child, until the child reaches the age of nineteen (19) or twenty-one (21) if the child has a disabling impairment. A child’s income is never deemed to a parent. If the child is under age nineteen (19) and seeking Medicaid LTSS through the Katie Beckett eligibility pathway under Part 50- 10-3 of this Title, the income and resources of the child’s parents are deemed unavailable and the FRU is composed of the child only. c. FRU Couples. Except in instances in which a member of a couple is a Medicaid LTSS applicant or beneficiary, spouses are considered financially responsible for one another during the financial eligibility determination process. The FRU includes the applicant and spouse, even when the spouse is not applying for Medicaid (NAPP spouse). The child’s income is never deemed to a parent or a sibling. 2. FRU for Sponsored Non-citizens – The FRU for a non-citizen admitted to the United States on or after August 22, 1996, based on a sponsorship under the Immigration and Nationality Act (INA), 8 C.F.R. Part 204 (2023), includes the income and resources of the sponsor and the sponsor’s spouse, if the spouse is living with the sponsor, when all four (4) of the following conditions are met: A. The sponsor has signed an affidavit of support on a form developed by the United States Attorney General as required by the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, Pub. Law No. 104-193, to conform to the requirements of 8 C.F.R. § 213A (2023); b. The non-citizen is lawfully admitted for permanent residence, and a five (5) year period of ineligibility for Medicaid following entry to the United States has ended; c. The non-citizen is not battered; and
d. The non-citizen is not indigent, defined as unable to obtain food and shelter without assistance, because their sponsor is not providing adequate support. e. The financial responsibility of a sponsor continues until the noncitizen is naturalized or credited with forty (40) qualifying quarters of coverage by the SSA. 1.12.4 General Rules for Counting Income – Community Medicaid A. For Community Medicaid, the determination of income eligibility using the SSI methodology follows a set sequence of calculations related to the application of exclusions and disregards as set forth in Subchapter 00 Part 3 of this Chapter. Unearned income exclusions and disregards are applied first. 1. Order of Unearned Income Exclusions and Disregards – Unearned income is countable as income in the earliest month it is received by the person; credited to a person’s account; or set aside for the person’s use. The order for applying exclusions and disregards is as follows: a. Federal law. Exclusions mandated in Federal law or Regulations as set forth in Subchapter 00 Part 3 of this Chapter are applied first unless indicated otherwise. b. Medicaid. The following types of unearned income are excluded or disregarded in the order indicated: (1) Any refund of taxes; (2) Assistance based on need which is provided under a program which uses income as a factor of eligibility and is wholly funded by the State or a local government. General Public Assistance (GPA) and the optional State Supplemental Payment (SSP) for SSI beneficiaries and SSI- lookalikes are examples of excluded payments in this category. (3) Grants, scholarships, fellowships, or gifts used for paying educational expenses are excluded or countable depending upon their use: (AA) Any portion of a grant, scholarship, fellowship, or gift used for paying tuition, fees, or other necessary educational expenses at any educational institution, including vocational or technical education institutions, is excluded from income.
(BB) Any portion of such educational assistance that is not used to pay current tuition, fees or other necessary educational expenses but is set aside to be used for paying this type of educational expense at a future date is excluded from income in the month of receipt. If these funds are not spent after nine (9) months, they become a countable resource the first (1st) day of the tenth (10th) month following receipt. (CC) Any portion of a grant, scholarship, fellowship, or gift that is not used or set aside for paying tuition, fees, or other necessary educational expenses is income in the month received and a resource the month after the month of receipt if retained. (4) Food which a person or their spouse raises if it is consumed by the household; (5) Assistance received under the FEMA Disaster Assistance Reform Act of 2015, H.R. 1471, and assistance provided under any Federal statute because of a presidentially declared disaster; (6) The first sixty dollars ($60.00) of infrequent or irregular unearned income received in a calendar quarter; (7) Alaska longevity bonus payments; (8) Foster care payments that are not funded through Title IV-E of the Social Security Act, 42 U.S.C. §§ 670-679c; (9) Any interest earned on excluded burial funds and any appreciation in the value of an excluded burial arrangement which are left to accumulate and become a part of that burial fund; (10) Support and maintenance assistance based on need: (AA) Provided in-kind by a private nonprofit agency; or (BB) Provided in cash or in-kind by a supplier of home heating oil or gas, or by a private or municipal utility company. (11) One-third (1/3) of child support payments made by a non- custodial absent parent, unless exempt in accordance with Subchapter 00 Part 3 of this Chapter;
(12) Twenty dollar ($20.00) general income disregard. The disregard does not apply to program payments when income is used as an eligibility factor and the payment is wholly or partially funded by the Federal government or by a non- governmental agency such as Catholic Charities or the Salvation Army. (13) Unearned income used to fulfill an approved plan to achieve self-support (PASS); (14) Federal housing assistance provided by: (AA) An office or program of the U.S. Department of Housing and Urban Development (HUD); or (BB) The U.S. Department of Agriculture's Rural Housing Service (RHS), formally known as the Farmers Home Administration (FHA); (15) Any interest on excluded burial space purchase agreement if left to accumulate as part of the value of the agreement; (16) The value of any commercial transportation ticket which is received as a gift and is not converted to cash; (17) Payments from a State compensation fund for victims of crime; (18) Relocation assistance provided under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, Pub. Law No. 91-646, provided to individuals displaced by any Federal or Federally-assisted project or State or local government or through a State- assisted or locally-assisted project involving the acquisition of real property; (19) Combat fire pay received from the uniformed services; (20) Interest on a dedicated account in a financial institution, the sole purpose of which is to receive and maintain past-due SSI benefits which are required or allowed to be paid into such an account, and the use of which is restricted by 42 U.S.C. § 1383(a)(2)(F); (21) Gifts to children with life-threatening conditions from an organization described in § 501(c)(3) of the Internal Revenue Code of 1986, Pub. Law No. 99-514, within the following limitations:
(AA) In-kind gifts are not converted to cash; (BB) No more than the first two thousand dollars ($2,000.00) of any cash gifts within a calendar year may be excluded; (CC) Interest and dividend income from a countable resource or from a resource excluded under a Federal statute other than 42 U.S.C. § 1382b(a); (DD) An annuity paid by a State, to a person and/or the person’s spouse, on the basis of the State's determination that the person is a veteran and is blind, sixty-five (65) or older and/or living with a disabling impairment. 2. Order of Earned Income Exclusions – In general, earned income disregards and exclusions are applied in the following order: a. Federal law. Exclusions mandated in Federal law or Regulations as set forth in Subchapter 00 Part 3 of this Chapter are applied first, unless indicated otherwise. b. SSI Methodology. The following types of earned income are excluded or disregarded in order: (1) Earned income tax credit payments and child care tax credit payments; (2) The first (1st) thirty dollars ($30.00) of infrequent or irregular earned income received in a calendar quarter; (3) Student earned income exclusion (SEIE) up to the monthly limit, and not more than the yearly limit as indicated in Subchapter 00 Part 3 of this Chapter; (4) Any portion of the twenty dollars ($20.00) monthly general income disregard which has not been excluded from unearned income in that same month; (5) The first (1st) sixty-five dollars ($65.00) of earned income in a month; (6) Earned income of a person with disabilities used to pay impairment-related work expenses (IRWEs), as described in 20 C.F.R. § 404.1576 (2023); (7) One half (1/2) of remaining earned income in a month;
(8) Work expenses of a person who is blind; and (9) Earned income used to fulfill an approved Plan to Achieve Self-Support (PASS). 3. Unused exclusions and disregards – When calculating countable income, the limitations below apply: a. Exclusions never reduce earned or unearned income below zero (0). b. Unused portions of a monthly disregard or exclusion cannot be carried over for use in subsequent months. c. Unused earned income disregards and exclusions are never applied to unearned income. d. Other than the twenty dollars ($20.00) general income disregard, no unused unearned income exclusion may be applied to earned income. e. The twenty dollars ($20.00) general and sixty-five dollars ($65.00) earned income exclusions are applied only once to a couple, even when both members have income, since the couple's earned income is combined in determining Medicaid eligibility. 1.12.5 Income Deeming A. To deem income is to attribute one (1) person’s countable income in the calculation of another person’s countable income. Income deeming requirements are based on the FRU rather than the Medicaid eligibility group rule. A person may be included in the Medicaid eligibility group without being included in the FRU (e.g., the sibling of a child seeking MN eligibility) and having their income deemed to an applicant or non-applicant in the household. The general rules for determining countable income related to the application of earned and unearned income exclusions identified above in § 1.12.4 of this Part are applied. In addition: 1. The person seeking initial or continuing Medicaid eligibility is referred to as the “applicant;” members of the household who are not covered by or applying for Medicaid are referred to in this Subsection as “non-applicants” or NAPPs. 2. Whose income is deemed to an applicant is determined separately for each member of the FRU. 3. Income based on need, in which income is a factor in determining eligibility, provided by any local, State or Federal agency and any income
which was taken into account in determining eligibility and which affected the amount of such assistance or payment is excluded in the income deeming process, unless specifically indicated otherwise. Includes: SSI; SSP; RI Works and GPA cash assistance; Veteran’s Administration (VA) pensions; or in-kind support and maintenance. B. Spouse-to-Spouse – Except as indicated in the situations noted below, the income of a NAPP spouse is deemed to an applicant if the spouses live together. If an applicant is not divorced but is legally separated from their spouse, and continues to live in the same household, the NAPP spouse’s income is deemed. In the following situations, spouse-to-spouse income deeming does not apply: 1. The spouses do not live together. 2. The applicant is seeking coverage under the Sherlock Plan as a working adult with a disability in accordance with Subchapter 15 Part 1 of this Chapter. a. Deeming. The amount of income that is deemed to the applicant spouse is calculated by subtracting from the NAPP spouse's gross income: (1) An amount equal to the deeming standard for each dependent child in the household. The "deeming standard" is the difference between the Federal Benefit Rate (FBR) for a couple and the limit for a single person, as defined in Subchapter 00 Part 3 of this Chapter, less any countable income from the child. The difference between the two (2) is the living allowance for the NAPP child, as indicated herein. (2) Any portion of the NAPP spouse’s income paid in court- ordered child support for a child living in another household. (3) Exclusions and disregards that apply when calculating countable income for the applicant spouse. (4) If the NAPP spouse's remaining income after exclusions and disregards are applied is greater than the deeming standard, then the couple's income is calculated according to the general Rules for determining countable income using SSI methodology. That income is then compared against the Medicaid eligibility group income limit for the family size involved – i.e., household size. b. Treatment of deemed income. The deemed amount is counted as unearned income in determining the applicant’s income eligibility for Medicaid.
C. Parent-to-Child – Except in the situations noted below for MN eligibility, the income of a biological or adoptive parent is deemed to a child who is under age eighteen (18) and living with a parent as long as the child has not been legally emancipated. When the father is not married to the child’s mother, the father’s income is only deemed to the child if they reside together and paternity has been established. 1. In the following situations, the income of a parent is NOT deemed to a child: a. The child is not eligible for SSI, but is participating in a foster care or adoption subsidy program administered by the State. b. The child is seeking LTSS through the Katie Beckett eligibility option in accordance with Part 50-10-3 of this Title. 2. Deeming Rules: The amount of income deemed from parent to child requires a multi-step calculation of income that must be followed in the sequence below: a. The earned and unearned income of the parents of the applicant child is calculated allowing the standard exclusions EXCEPT for the standard twenty dollar ($20.00) and sixty-five dollar ($65.00) plus one half (1/2) disregards. b. The living allowance allocated to NAPP children is determined by multiplying their number by the deeming standard. Any children receiving SSI or RI Works cash assistance are not included in this calculation. The income of each NAPP child is deducted from this sum, if any. c. The total of the unearned income of the parents is calculated and then any remaining allowance for NAPP children in the household not met by their own income is subtracted. d. The earned income of the parents is totaled and any remaining living allowance for NAPP children is subtracted. If there is no remainder, there is no income to deem. If there is income remaining, deeming is applicable. e. Deemed income from parent to child is then calculated by: deducting the twenty dollar ($20.00) income disregard from any remaining parental unearned income; subtracting sixty-five dollars ($65.00), plus any of the remainder of the twenty dollar ($20.00) disregard and one half (1/2) of the still remaining parental earned income. The remaining unearned and earned income is added and, from this total, so too is the individual FBR (for a one (1) parent household) or the couple FBR (for a two (2) parent household).
f. The remaining income is deemed to be unearned income to the child. Note: If more than one (1) child is applying, deemed income is divided equally. D. Other Household Members – When determining a person’s initial or continuing eligibility, income is NOT deemed from a: 1. Child to a parent; 2. Sibling to another sibling, or other children under twenty-one (21) living in the household; 3. Stepparent to a stepchild; 4. Grandparent to a grandchild; or 5. Relative caretaker to a child. E. Sponsor Deeming – Sponsor deeming rules apply to non-citizens who are sponsored by one (1) or more individuals under a signed Affidavit of Support (USCIS I-864), unless one (1) of the following exceptions applies: 1. Exceptions to Sponsor Deeming. Sponsor deeming does not apply to sponsored non-citizens when: a. The non-citizen is under age twenty-one (21). b. The non-citizen is pregnant. This exception ends when the sponsored pregnant person's twelve (12) month postpartum period ends. Sponsor deeming applies the month following the end of the postpartum period. c. The non-citizen has sponsorship deferred by USCIS when their immigration status is changed to “Battered Non-citizen.” d. If the non-citizen needs placement in a facility and placement is jeopardized by the sponsor’s failure or inability to provide support, or inability of the non-citizen to locate the sponsor. 2. General rules of sponsor deeming. Income of a sponsor and the sponsor’s spouse is deemed to each non-citizen covered by the affidavit regardless of whether the sponsor actually contributes to the non-citizen’s support and maintenance needs. Income is deemed even if the sponsor or the sponsor’s spouse is receiving public assistance in Rhode Island or another State. The following types of income of the sponsoring individual/couple are deemed:
a. Gross income, including any cash assistance received by the sponsor or the sponsor’s spouse; b. Net self-employment income, minus self-employment expenses; c. If the sponsor is a member of the FRU, the sponsor’s income is already deemed to the sponsored non-citizen spouse and family members in accordance with income deeming rules contained in § 1.12.5(E) of this Part. 3. If the sponsor is not a member of the FRU or is a member of the Medicaid eligibility group whose income is not deemed under income deeming rules in § 1.12.5(E) of this Part, the following apply: a. The total gross income of the sponsor and the sponsor’s spouse is deemed to each sponsored non-citizen. b. The sponsor or the sponsor’s spouse’s income are considered available and are not excluded. 1.12.6 General Rules for Counting Resources – Community Medicaid A. The State uses a more simplified process for counting resources for Community Medicaid, as explained in Subchapter 00 Part 3 of this Chapter, which permits attestations about the value of certain resources during the application process when determining financial eligibility. For Medicaid LTSS eligibility, full verification of resources and a transfer of asset review are required for IHCC group members prior to the determination of eligibility and authorization of services. There is no review of the transfer of assets for Community Medicaid. 1. Process – The process rules identified in Subchapter 00 Part 3 of this Chapter are used in evaluating resources to determine which are included in the calculation. 2. Application of Exclusions – Both federally mandated and program specific exclusions are applied for resources of a Community Medicaid applicant or beneficiary, the following items are excluded in the following order in the amounts indicated: a. The home and adjoining land; b. Household goods and personal effects; c. One (1) automobile and the equity value of a second (2nd) vehicle above four thousand five hundred dollars ($4,500.00); d. Property of a trade or business which is essential to the means of self-support;
e. Non-business property which is essential to the means of self- support; f. Resources of person who is blind or living with a disabling impairment which are necessary to fulfill an approved PASS; g. Stock in regional or village corporations held by natives of Alaska during the twenty (20) year period in which the stock is inalienable pursuant to the Alaska Native Claims Settlement Act, 43 U.S.C. §§ 1601-1629h, h. Whole life insurance owned by a person and/or spouse but only when the combined face value of all policies per person is at or below one thousand five hundred dollars ($1,500.00) for EAD or four thousand dollars ($4,000.00) for medically needy; i. Restricted allotted Indian lands; j. Payments or benefits provided under a Federal statute other than Title XVI (OASDI, including RSDI and SSD) of the Social Security Act, 42 U.S.C. §§ 1381-1385, where an exclusion is required by such statute as indicated in Subchapter 00 Part 3 of this Chapter; k. Disaster relief assistance; l. Burial expense funds and set asides to the extent allowed up to one thousand five hundred dollars ($1,500.00) for EAD and four thousand dollars ($4,000.00) for persons who are MN; m. Title XVI (OASDI) of the Social Security Act, 42 U.S.C. §§ 1381- 1385, or Title II (SSI) of the Social Security Act, 42 U.S.C. §§ 401- 434, retroactive payments; n. Housing assistance; o. Refunds of Federal income taxes and advances made by an employer relating to an earned income tax credit; p. Payments received as compensation for expenses incurred or losses suffered as a result of a crime; q. Relocation assistance from the State or a local government; r. Dedicated financial institution accounts; s. Gifts to children under age eighteen (18) with life-threatening conditions;
t. Restitution of SSI, Title VIII of the Social Security Act, 42 U.S.C. §§ 1001-1013, or RSDI benefits because of misuse by certain representative payees; u. Any portion of a grant, scholarship, fellowship, or gift used or set aside for paying tuition, fees, or other necessary educational expenses; v. Payment of a refundable child tax credit, as provided; and w. Any annuity paid by a State to a person (or their spouse) based on the State's determination that the person is a veteran (as defined in 38 U.S.C. § 101) and blind, living with a disabling impairment, or aged. 1.12.7 Resource Deeming A. To deem resources is to count one (1) person’s resources in the calculation of another person’s countable resources. As with income deeming, resource deeming requirements apply to members of the FRU, which is not always the same as the Medicaid eligibility group. Only the resources of the applicant's spouse or the parent(s) of a child are considered for the purposes of deeming resources. The deeming process proceeds as follows: 1. Spouse-to-Spouse – In deeming resources from one (1) spouse to the other, only the resources of the couple are considered. a. Living together. When an applicant and NAPP spouse live together, all resources are combined and the couple is permitted resources up to the amount allowed for the Medicaid eligibility group of two (2). The couple's resource limitation is not affected by whether the spouse of the applicant is applying for or receiving Medicaid or is a non-applicant. b. Living apart. When an applicant and spouse are no longer living together, each person is considered as an individual living alone beginning the month after separation and the individual resource limit applies. For the month of separation, the spouses are treated as a couple, as long as they were living together at some point during the month. 2. Single individual – When an applicant is not living in a home with a spouse or parent(s), only the resources of the applicant are considered. The resource limits for an “individual” or Medicaid eligibility group of one (1) apply. 3. Parent-to-child – In deeming resources from a parent to a child, the resources of a child consist of whatever resources the child has in their
own right plus whatever resources are deemed to the child from their parent(s). a. In determining the amount of resources to be deemed to an applicant child, the resources of the child and of the parents are computed separately and both the child and the parents are each allowed all of the resource exclusions they would normally be eligible to receive in their own right. Only one (1) home and one (1) vehicle are completely excluded, however. The equity value of a second (2nd) vehicle is counted in accordance with Subchapter 00 Part 3 of this Chapter. b. It does not matter whether a parent(s) is or is not eligible for Medicaid. c. After the exclusions are applied, only the countable resources over the resource exclusion of the parent(s) living in the home are deemed to the child when there is only one (1) child. d. When there is more than one (1) applicant/eligible child, the resources available for deeming are shared equally among the eligible children. e. None of the parents’ resources are deemed to any other non- applicant/ineligible children. f. A child is not eligible for Medicaid as MN if their own countable resources plus the value of the parents' resources deemed to the child exceed the resource limit for an individual – Medicaid Eligibility group of one (1) – of four thousand dollars ($4,000.00).
210-RICR-40-05-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 - MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 05 - COMMUNITY MEDICAID PART 1 - MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES: COMMUNITY MEDICAID (210-RICR-40-05-1) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 01/02/2025 December 12, 2024 E-SIGNED by Richard Charest on 2024-12-12 19:51:56 EST December 13, 2024 E-SIGNED by Department of State on 2024-12-13 11:05:13 EST
210-RICR-40-05-2 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 – MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 05 – COMMUNITY MEDICAID PART 2 – Community Medicaid: Medically Needy Eligibility 2.1 Scope and Purposes A. A medically needy (MN) spenddown, previously referred to as the “Flexible Test of Income”, is a cost-sharing approach that provides a Medicaid eligibility pathway for certain people who have income above the limit for their applicable coverage group if they have high health expenses. Under the State’s Medicaid State Plan, members of these populations become eligible for Medicaid by “spending down” their income to a limit established by the State – known as the medically needy income limit or “MNIL” by deducting certain health care expenses. The following populations may be medically needy eligible under this section: 1. Elders and adults with disabilities with income above one hundred percent (100%) of the FPL; 2. Children with income above the MACC limit of two hundred sixty-six percent (266%) of the FPL (includes the five percent (5%) disregard); 3. Pregnant women with income above the MACC limit of two hundred fifty- eight percent (258%) of the FPL (includes the five percent (5%) disregard); 4. Parents/caretakers with income above the MACC limit of one hundred thirty-eight percent (138%) of the FPL (includes the five percent (5%) disregard); 5. Non-qualified non-citizens seeking coverage for emergency Medicaid if ineligible under all other pathways. (See § 1.7.5 of this Subchapter); and 6. Certain refugees, as defined in § 1.7.3 of this Subchapter, who do not otherwise qualify for Medicaid health coverage or commercial insurance with financial help through HSRI. B. This section describes the Community Medicaid (non-LTSS) MN eligibility pathway in general and establishes the provisions governing initial and continuing eligibility for persons in these populations seeking Medicaid health coverage through this option.
2.2 General Provisions Eligibility Criteria A. For the IHCC groups in this section, MN coverage is available to elders and persons with disabilities with high medical expenses who have income above the EAD income limit, but otherwise meet all of the general eligibility requirements for Medicaid set forth in § 1.9 of this Subchapter. 1. Determination process – Applicants who do not meet the income limits for Medicaid in the IHCC groups are automatically evaluated for MN coverage. Members of the MACC groups must contact an agency eligibility specialist if seeking MN coverage. The MN cases are determined for a six (6) month period beginning with the first (1st) day of the month in which the application is received. NOTE: To ensure EOHHS’ continuation of eligibility for enhanced Federal funding, during the novel Coronavirus Disease (COVID-19) Federal declaration of emergency, the State will temporarily extend the six (6) month eligibility period. This extension will last at least until the end of the Federal emergency period. This extension only applies to individuals that are not also enrolled in another Minimum Essential Coverage group (MEC), as defined in 42 C.F.R. § 433.400. This extension supersedes all references to the six (6) month eligibility period for the duration of the COVID-19 Federal declaration of emergency. Effective the last day of the month following the month in which the Federal declaration of the COVID-19 public health emergency is terminated, the six (6) month eligibility period will no longer be automatically extended. 2. Eligibility for Medicaid health coverage as MN is not established, however, until the applicant has presented proof of health expenses incurred and paid or that remain outstanding for the eligibility period. Any health expenses for which a beneficiary continues to be liable dating back to the retroactive period are also considered. 3. Continuing eligibility – The date of eligibility is the actual day of the month the applicant incurs a health expense – not the billing date – which reduces income to the MNIL. Eligibility may be renewed on a continuing basis if the beneficiary is liable for health care expenses that exceed current income. Otherwise, a re-evaluation of eligibility, based on the cost of health costs currently being incurred is required. 4. Agency responsibilities – The EOHHS must inform applicants who have income above the applicable limit for the appropriate IHCC group that MN coverage is an option and provide information about allowable health expenses for spenddown purposes and the scope and limits of obtaining coverage through this eligibility pathway. In addition, applicants must be informed of the impact of obtaining MN Medicaid health coverage for other programs, including the Supplemental Nutrition Assistance Program (SNAP) and the MPPP.
5. Applicant/beneficiary responsibilities – Eligibility and renewal is contingent upon the applicant/beneficiary providing bills and receipts related to allowable health care expenses that are not paid through a third (3rd) party. Therefore, the chief responsibility of the applicant/beneficiary is to maintain and present this information, unless submitted directly by a provider, to the State agency. 2.3 Spenddown Calculation A. For a person who has income above the income standard across applicable eligibility pathways, the spenddown standard for their eligibility coverage group is applied. For example, the appropriate spenddown standard for parents/caretakers is one hundred thirty-eight percent (138%) of the FPL (ceiling for MACC eligibility when five percent (5%) disregard is applied) and two hundred sixty-six percent (266%) of the FPL for children (MACC ceiling including disregard). The appropriate spenddown standard for elders and adults with disabilities is the medically needy income limit adjusted for household size. 1. Spenddown Amount – The spenddown amount is calculated as follows: a. The beneficiary’s anticipated monthly net income for each month of the eligibility period based on the criteria appropriate for the specific coverage group using the SSI methodology. b. Net income for all six (6) months. 2. FPL Comparison – The applicable six (6) month FPL standard is subtracted from the beneficiary’s six (6) month net income. If the result is: a. Equal to or less than the FPL standard, the applicant is eligible for Medicaid without a spenddown, even if they exceed the monthly FPL standard in one (1) or more months of the six (1) month period. No further calculation is necessary. b. Greater than the FPL standard continue, further calculations are required. 3. Six-month Spenddown Amount – The six (6) month spenddown amount is determined by subtracting the applicable six (6) month FPL spenddown standard from the total six (6) month net income. The result is the six (6) month spenddown amount. 4. Application of Allowable Expenses – Allowed health care expenses are applied to the six (6) month spenddown amount. If the applicant will incur bills to satisfy the spenddown after the date the application is processed, the final processing will be delayed until after the applicant has received the health care services. Pre-approval of certain remedial and Medicaid
LTSS services is required if the MN beneficiary does not qualify for an LTSS preventive level of care. 2.4 Six-Month Spenddown Renewal Upon renewal, a six (6) month spenddown is calculated in the same manner. 2.5 Allowable Expenses A. Allowable health care expenses are those that are incurred by the beneficiary or other allowable family member(s) that are not subject to payment by a third (3rd) party and may be: 1. Paid or unpaid health care bills incurred in the current eligibility period; and 2. Unpaid bills incurred prior to the current eligibility period. B. The portion of a bill used to meet a previous spenddown cannot be used again in future spenddown calculations, unless the entire eligibility period was denied. 1. Allowable health care expenses – Such expenses include, but are not limited to: physician /health care provider visits; health insurance premiums, co-pays, co-insurance, and deductibles; dental and vision care; chiropractic and podiatric visits; prescription medications; tests and X- rays; acute hospital and nursing care; home nursing care, such as personal care attendants, private duty nursing and home health aides; audiologists and hearing aids; dentures; durable medical equipment such as wheelchairs and protective shields; therapy, such as speech, physical, or occupational therapy; transportation for medical care, such as car, taxi, bus or ambulance; and LTSS expenses at home or in a health institution at the State Medicaid reimbursement rate. 2. Conditions on application – An expense is allowable for the Medicaid spenddown if it is for health insurance costs or specific types of Medicaid non-covered and covered services. The scope, amount and duration of the service determines whether it qualifies as an allowable expense as a Medicaid covered or non-covered service and, therefore, the order in which it is deducted from excess income. The sequences of deductions for allowable expenses is as follows: a. Health insurance expenses. The costs for maintaining insurance coverage for health care services and supports for both the person seeking coverage and any dependents. Includes, premiums, co- pays, co-insurance and deductibles including for Medicare and commercial plans. Premiums for optional supplemental plans are not allowable expenses.
b. Non-Medicaid expenses. These are expenses incurred for health care and remedial services that are recognized under State law but are not covered under the Medicaid State Plan or the State's Section 1115 demonstration waiver such as home stabilization services and non-medical transportation. c. Excess Medicaid expenses. Includes expenses incurred for Medicaid covered services that exceed limitations on amount, duration, or scope established in the State Plan or Section 1115 demonstration waiver. Expenses allowed in this category must be medically necessary and include both the costs incurred for an expanded service (such as dentures, in-patient behavioral health care for an extended period, contact lenses or a second pair of prescription reading glasses) and associated ancillary health costs (x-rays, needs assessments, lab tests, office visits and the like). d. Covered Medicaid expenses. These are incurred expenses that do not exceed limitations on amount, duration, or scope allowed under current Federal authorities. They are deducted in chronological order based on the date of service beginning with the oldest expense. (1) An expense incurred in a month for which MN eligibility is approved is presumed to be a Medicaid covered expense unless documentation is provided to the State that it is not a covered service. (2) When a person is receiving a service or set of services Medicaid pays for in a daily or bundled rate, the items and services included in that rate are not separate allowable expenses. e. Health institution expenses. Under the existing Medicaid State Plan, Rhode Island has taken the option under 42 C.F.R. § 435.831(3)(g)(1) to allow LTSS expenses incurred for both HCBS and health institutional care to be deducted from excess income. In accordance with the applicable Federal requirements therein, the maximum amount allowed is the State Medicaid reimbursement rate projected to the end of the budget period. f. Costs related to LTSS level or remedial care, such as home nursing care/homemaker services, adult day and home stabilization may be applied to a spenddown when a beneficiary meets the LTSS preventive level of need. In all other instances, Community Medicaid MN beneficiaries must obtain per-authorization from an agency eligibility specialist to count these costs toward a spenddown.
2.6 Expense Exceptions A. Certain health care expenses are not allowed to be deducted from income. Such expenses include, but are not limited to: 1. Premiums paid by Medicaid or paid by the MPPP as a health care expense. Applicants and beneficiaries should consider whether participation in the MPPP will adversely affect their ability to maintain MN eligibility and vice versa with the assistance of an eligibility specialist. 2. Health care expenses incurred before the first (1st) day of the six (6) month certification period are not eligible for Medicaid payment; the beneficiary remains responsible for those bills.
210-RICR-40-05-2 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 - MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 05 - COMMUNITY MEDICAID PART 2 - COMMUNITY MEDICAID: MEDICALLY NEEDY ELIGIBILITY (210-RICR-40- 05-2) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 03/30/2022 March 10, 2022 E-SIGNED by Womazetta Jones on 2022-03-10 12:24:18 EST March 10, 2022 E-SIGNED by Department of State on 2022-03-10 12:26:54 EST
210-RICR-40-05-3 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 - MEDICAID INTEGRATED HEALTH CARE COVERAGE SUBCHAPTER 05 – COMMUNITY MEDICAID Part 3 – Retroactive Coverage 3.1 Scope and Purpose
Medicaid coverage may start retroactively for up to three (3) months prior to the month of application for IHCC groups, unless explicitly excluded. To qualify, a person must have met the criteria for Medicaid eligibility during the retroactive period. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility. The provisions in this section do not apply to the MAGI-eligible individuals and families in the Medicaid Affordable Care Coverage (MACC) groups identified in the Medicaid Code of Administrative Rules, Affordable Care Coverage Groups, except when a person who is ineligible for coverage in one of these groups applies for MN IHCC in accordance with the provisions in Part 2 of this Subchapter. 3.2 General Provisions A. Medicaid beneficiaries in the IHCC groups may request retroactive eligibility for up to three months prior to the month of application. 1. Eligibility criteria – To obtain retroactive coverage, applicants must meet all eligibility criteria related to the applicable IHCC group during the retroactive period. Retroactive coverage is also available to IV-E and non IV-E foster children and adoption subsidy family-related coverage groups. a. The applicant must meet Medicaid eligibility requirements for each month in which an unpaid medical bill was incurred. Thus, retroactive eligibility may be determined for one, two, or three months of the retroactive period. b. Only the income and resources available to the applicant in the retroactive period are used to determine eligibility. No deeming is required. c. The following chart details beneficiaries’ eligible retroactive benefits:
Persons Eligible Eligible for Retro IV-E and non IV-E Foster Children Y Adoption Subsidy Children Coverage Groups Y IHCC group members, excluding partial dual Qualified Medicare Beneficiaries (QMBs) Y Non-citizens who are eligible for emergency Medicaid Y LTSS beneficiaries Y d. At the time of application for Medicaid, if the applicant in one of these categories indicates that an unpaid health medical bill was incurred in the three-month period preceding the application, eligibility for retroactive coverage must be determined. 2. Limits – Current eligibility for Medicaid does NOT affect retroactive eligibility. A person denied Medicaid in the month of application may be eligible for retroactive coverage. a. An applicant need not be alive when an application for retroactive coverage is made. A family member or authorized representative may sign and submit an application on the deceased person’s behalf. b. Retroactive eligibility is not available to persons who were not residents of Rhode Island in the retroactive period at the time the service was provided. Retroactive coverage applies only to unpaid medical bills for services provided within the scope of the Medicaid program. The bills must have been incurred during the three month retroactive period. c. Note: All services provided in the retroactive period and the costs incurred are subject to the same Title XIX utilization review standards as all other medical services of the Medicaid Program.
210-RICR-40-05-3 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 - MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 05 - COMMUNITY MEDICAID PART 3 - RETROACTIVE COVERAGE (210-RICR-40-05-3) Type of Filing: Refile Capabilities Department of State _________________________________________________________________ Regulation Effective Date Original Signing Date _________________________________________________________________ Department of State Initials Department of State Date 01/04/2022 N/A December 15, 2021 E-SIGNED by Department of State on 2021-12-15 16:19:15 EST
210-RICR-40-10-1 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 – MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 10 – MANAGED CARE Part 1 – Managed Care Service Delivery Arrangements 1.1 Overview of this Rule A. The purpose of this Rule is describe the managed care service delivery options for Elders and Adults with Disabilities and long-term care beneficiaries. The purpose is also to set forth in clear language the respective roles and responsibilities of the Executive Office of Health and Human Services (EOHHS), beneficiaries, health plans, and other contractual entities related to managed care enrollment and service delivery for Elders and Adults with Disabilities and long-term care beneficiaries. Program Rhody Health Partners Medicare-Medicaid Plan PACE Population Elders and Adults with Disabilities who do not have Medicare or other third-party coverage; Persons without Medicare who are receiving LTSS in the home or community- based service setting, are enrolled in RHP for essential primary care services only. Elderly and non-elderly adults who have full Medicare (Parts A, B, and D) coverage and Medicaid Health Coverage Medicaid beneficiaries age 55 and older who qualify for a nursing home level of care Mandatory/ Voluntary Enrollment Mandatory Voluntary Voluntary Covered Services Medicaid Medicaid and Medicare Parts A, B, and D Medicaid and Medicare Parts A, B, and D (if eligible)
Program Rhody Health Partners Medicare-Medicaid Plan PACE Participation Criteria Age 21 and older; and Eligible for Medicaid Health Coverage on the basis of the SSI income standard (IHCC group) Age 21 and older; Eligible for Medicaid Health Coverage on the basis of the SSI income standard (IHCC group) or the MAGI income standard (MACC group); and Enrolled in Medicare Part A, enrolled in Medicare Part B, and eligible to enroll in Medicare Part D Age 55 years and older; Meet criteria for high or highest need for a nursing facility level of care; and Meet all other requirements for LTSS 1.2 Definitions A. For the purpose of this Rule, the following terms are defined as follows: 1. “Appeal” means a request to review an “adverse benefit determination” based on medical necessity, appropriateness, health care setting, and effectiveness. 2. “Categorical eligibility” means an applicant/beneficiary included in an IHCC group who is eligible for Medicaid health coverage on the basis of income, resources, a characteristic, and/or a level of need in a mandatory or optional coverage group under the Medicaid State Plan, or who is treated as such, under the State’s Section 1115 demonstration waiver, in accordance with Title XIX. It excludes persons who must spenddown to become eligible for Medicaid health coverage as medically needy. 3. “Elders and adults with disabilities" or "EAD” means the Medicaid IHCC group established by R.I. Gen. Laws Chapter 40-8.5 for adults with an SSI characteristic related to age (elders sixty-five (65) years of age or older) or disability. 4. “Executive Office of Health and Human Services" or "EOHHS” means the State agency that is designated under the Medicaid State Plan as the Single State Agency responsible for the administration of the Title XIX Medicaid Program. 5. “Full dual eligible” means a beneficiary who is enrolled in Medicare Parts A and B and is eligible for Medicaid Health Coverage through an IHCC or MACC group for elders and adults with disabilities on the basis of income, resources and, when applicable, a characteristic or need for LTSS.
6. “Grievance” means an expression of dissatisfaction about any matter other than an action associated with an adverse benefit determination and includes complaints about the quality of care or services provided, and aspects of interpersonal relations such as rudeness of a provider or an employee or a failure to respect an enrollee’s rights. 7. “Integrated Health Care Coverage Group” or "IHCC" means any Medicaid coverage group consisting of adults who are eligible on the basis of receipt of Supplemental Security Income (SSI), SSI protected status, the SSI income methodology and a related characteristic (age or disability), or as a result of participation in another federal or State program (e.g., Breast and Cervical Cancer). Includes beneficiaries eligible for community Medicaid (non-long-term care), Medicaid-funded LTSS, and the Medicare Premium Payment Program (MPP). 8. “Integrated Care Initiative" or "ICI” means a Medicaid initiative that delivers integrated and coordinated services to certain Medicaid and Medicare enrolled (MME) beneficiaries through a managed care arrangement. The ICI includes services from across the care continuum including primary, subacute, and long-term care. The Medicare-Medicaid Plan (MMP) was established through ICI. 9. “Long-term services and supports" or "LTSS” means a spectrum of services covered by the Rhode Island Medicaid program that are required by individuals with functional impairments and/or chronic illness, and includes skilled or custodial nursing facility care, as well as various home and community-based services. 10. “Managed care arrangement" or "MCA” means a system that may use capitated financing to deliver high quality services and promote and optimize health outcomes through a medical home. Such an arrangement also includes services and supports that optimize the health and independence of beneficiaries who are determined to need or be at risk for Medicaid funded LTSS. An MCA includes any arrangement under which an MCO or contracted entity is granted some or all of the responsibility for providing and/or paying for long-term care services and supports through a contractual agreement with the Medicaid program. 11. “Managed care organization" or "MCO” means an entity that provides health plan(s) that integrate an efficient financing mechanism with quality service delivery, provides a "medical home" to assure appropriate care and deter unnecessary services, and emphasizes preventive and primary care. 12. “Medicaid Affordable Care Coverage Groups” or "MACC" means a classification of persons eligible to receive Medicaid based on similar
characteristics who are subject to the MAGI standard for determining income eligibility as outlined in Part 30-00-1 of this Title. 13. “Medicaid and Medicare enrolled" or "MME” means full dual eligible or partial dual eligible plus beneficiaries who are receiving Medicaid health coverage, are enrolled in Medicare Part A, enrolled in Medicare Part B, and eligible to enroll in Medicare Part D. 14. “Medicaid health coverage” means the full scope of health care services and supports authorized under the State’s Medicaid State Plan and/or Section 1115 demonstration waiver provided through an authorized Medicaid delivery system. The term encompasses the scope of health coverage available to categorically and medically needy eligible beneficiaries as well as those who are treated as such under the State’s Section 1115 demonstration waiver. However, the term does not apply to partial dual eligible persons who, under the provisions of this section, qualify only for financial assistance through the MPPP to help pay Medicare cost-sharing. 15. "Medically necessary service" means a medical, surgical, or other service required for the prevention, diagnosis, cure, or treatment of a health- related condition including any such services that are necessary to prevent or slow a decremental change in either medical or mental health status. 16. “Medically needy” means an IHCC group for elders and persons with disabilities who have high medical expenses and income that exceeds the maximum eligibility threshold for Medicaid. For non-LTSS beneficiaries in this coverage group, Medicaid eligibility and coverage occur when the amount they spend on medical expenses meets the medically needy income limit established by the State. For LTSS beneficiaries, excess income must be contributed toward the cost of care. Non-LTSS medically needy beneficiaries are covered on a fee-for-service basis. 17. “Medicare-Medicaid Plan" or "MMP” is an integrated managed care plan under contract with the Federal Centers for Medicare and Medicaid Services (CMS) and EOHHS to provide fully integrated Medicare and Medicaid benefits to eligible MME beneficiaries. 18. “Member" or "Enrollee” means a Medicaid-eligible person receiving benefits through Rhody Health Partners, a Medicare-Medicaid Plan, or the Program for All-Inclusive Care for the Elderly. 19. “Partial dual eligible” means a Medicare beneficiary who does not meet the requirements for Medicaid Health Coverage, but who is eligible for the State’s Medicare Premium Payment Program (MPP).
20. “Partial dual eligible plus” means a Medicare beneficiary who is eligible for Medicaid health coverage as medically needy and the MPP. 21. “Person-centered planning” means an individualized approach to planning that supports an individual to share his or her desires and goals, to consider different options for support, and to learn about the benefits and risks of each option. Person-centered planning places the individual at the center of decision-making. It is designed to enable people to direct their own services and supports to live a meaningful life that maximizes independence and community participation. Person-centered planning is a process that is directed by the individual, with impartial assistance and supported decision-making when helpful. Person-centered planning teams may include people who are close to the individual, as well as people who can help to bring about needed change for the person and access to appropriate services. However, at all times, the individual is empowered to decide who is part of the planning team. Person-centered planning must meet the requirements of 42 C.F.R. § 441.301(c)(1) including, but not limited to, ensuring that a person has sufficient and necessary information in a form he/she can understand to make informed choices, enabling the person to direct the process to the maximum extent possible, and conducting planning meetings at times and in locations that are convenient to the individual. 22. “Primary care” means an array of primary, acute, and specialty services provided by licensed health professionals that includes, but is not limited to: health promotion, disease prevention, health maintenance, counseling, patient education, various specialty services and diagnosis and treatment of acute and chronic medical and behavioral health illnesses and conditions in a variety of health care settings (e.g., office, inpatient, care, home care, day care). 23. “Program of All Inclusive Care for the Elderly" or "PACE” means a risk- based managed care service delivery option for beneficiaries who have Medicare and/or Medicaid coverage and meet the financial and clinical criteria for a nursing facility level of long-term services and supports. Beneficiaries must be fifty-five (55) years or older to participate in this option. 24. “Rhody Health Options” or “RHO” means the capitated managed care delivery system operating under contract with EOHHS to manage and coordinate Medicaid covered services and supports, including LTSS, for eligible MNM and MME beneficiaries and to coordinate Medicaid covered services with Medicare covered services for eligible MME beneficiaries. RHO terminates as service delivery option on September 30, 2018. 25. “Rhody Health Partners" or "RHP” means the Medicaid managed care service delivery option for adults in the IHCC groups that provides
primary/acute and specialty care through a medical home that focuses on prevention and promoting healthy outcomes. The Rules for RHP for adults ages nineteen to sixty-four (19 – 64) in the MACC groups are located in Part 30-05-2 of this Title. 26. “SSI income standard” means the basis for determining Medicaid eligibility that uses the definitions and calculations for evaluating income and resources established by the U.S. Social Security Administration for the Supplemental Security Income (SSI) program. 27. “SSI protected status” means the class of beneficiaries who retain categorical eligibility for Medicaid even though they are no longer eligible for SSI due to certain changes in income or resources. 1.3 Rhody Health Partners (RHP) 1.3.1 Authority and Scope A. In 2005, R.I. Gen. Laws § 40-8.5-1.1 authorized the Medicaid agency to establish mandatory managed care delivery systems for adults nineteen (19) years of age or older who are eligible on the basis of participation in the Supplemental Security Income (SSI) program (see § 00-1.5 of this Chapter) or an SSI-related characteristic associated with age or a disability and income. In Rhode Island, persons with SSI-related characteristics are eligible under the Medicaid State Plan option for low-income elders and adults living with disabilities (EAD) in accordance with R.I. Gen. Laws Chapter 40-8.5. The requirements for adults in associated special eligibility groups that have unique financial (e.g., SSI Protected Status) or clinical criteria (e.g., breast and cervical cancer coverage group) or limited benefits (e.g., partial dual eligible group and the Medicare Premium Payment Program) are also located in § 05-1.6 of this Chapter. B. Beneficiaries eligible in these coverage groups who do not require LTSS are sometimes referred to as “Community Medicaid” and are members of the State’s Integrated Health Care Coverage (IHCC) groups. The provisions governing eligibility set forth in Subchapter 05 Part 1 of this Chapter and § 00-3.1.2 of this Chapter and enrollment as established herein will remain in effect unless or until replaced. C. IHCC group beneficiaries who are eligible on the basis of SSI income standard, do not require LTSS, and do not have third (3rd) party coverage are subject to mandatory enrollment in a Rhody Health Partners (RHP) Medicaid managed care plan. Eligible beneficiaries have the choice of two (2) RHP-participating health plans. 1.3.2 EOHHS Responsibilities
A. EOHHS, or its designee, is responsible for determining the eligibility of members in the IHCC groups in accordance with requirements established in the applicable sections of Federal and State laws, Rules and Regulations unless deemed eligible by virtue of receipt of SSI. In general, persons will be informed of their enrollment options at the time a determination of eligibility is made. B. IHCC group beneficiaries who are eligible on the basis of SSI income standard, do not require LTSS, and do not have third (3rd) party coverage are subject to mandatory enrollment in an RHP Medicaid managed care plan. EOHHS enters into contractual arrangements with the MCOs offering RHP plans that assure access to high quality Medicaid covered services and supports. EOHHS is also responsible for informing beneficiaries of their service delivery options and initiating enrollment in a participating RHP plan. 1.3.3 RHP Enrollees A. Enrollment in an RHP plan typically occurs no more than thirty (30) days from the date of the determination of eligibility unless excluded from enrollment. B. Excluded from RHP enrollment. Beneficiaries in the following categories are excluded from enrollment in an RHP plan and may be enrolled in an alternative Medicaid managed care arrangement: 1. Third-Party Coverage – SSI and EAD eligible beneficiaries who are enrolled in Medicare Parts A and/or B or have other third (3rd) party coverage are not subject to mandatory enrollment in an RHP plan. 2. Exempt Due to Age – SSI and EAD beneficiaries who are between the ages of nineteen (19) and twenty-one (21) are exempt from mandatory enrollment in RHP and receive all Medicaid health coverage on a fee-for- service basis. 3. Medically Needy Eligible, Non-LTSS – Beneficiaries who are determined eligible as medically needy due to excess income and resources are also exempt from enrollment in managed care. Medicaid health coverage for beneficiaries in this category is provided in accordance with the provisions of Subchapter 05 Part 2 of this Chapter. 4. The excluded populations receive all Medicaid covered services on a fee- for-service basis, unless they are otherwise eligible for another Medicaid delivery system. In addition, during the period while awaiting plan enrollment, beneficiaries eligible for RHP receive health coverage on a fee-for-service basis. 1.3.4 RHP Enrollment Process A. RHP-eligible beneficiaries have the choice of two (2) participating plans. EOHHS employs a formula, or algorithm, to assign prospective enrollees to a health plan.
Eligible beneficiaries are sent a letter from EOHHS at least forty-five (45) days prior to the enrollment effective date notifying them of their health plan assignment and the enrollment effective date. The letter also includes information on their health plan choices. Beneficiaries are given at least thirty (30) days to review the health plan enrollment assignment and request a change. At the end of this timeframe, EOHHS enrolls the beneficiary, effective the first (1st) day of the following month, as follows: 1. Beneficiary Action – If the beneficiary makes a choice to change health plan assignment, EOHHS initiates enrollment, as appropriate, into the selected RHP plan. 2. No Beneficiary Action – If a beneficiary does not respond within the allotted timeframe, the beneficiary is enrolled in the assigned RHP plan. 3. Delivery System Changes –Enrollment into RHP is always prospective in nature. Medicaid beneficiaries are required to remain enrolled in this service delivery option, but they can request reassignment to another plan within the first (1st) ninety (90) days of enrollment. They are also authorized to transfer from one MCO to another once a year during an open enrollment period. Medicaid enrollees who challenge an auto- assignment decision or seek to change plans more than ninety (90) days after enrollment in the health plan must submit a written request to the Medicaid agency and show good cause, as provided in Subchapter 00 Part 2 of this Chapter for reassignment to another plan. A written decision must be rendered by the Medicaid agency within ten (10) days of receiving the written request and is subject to appeal, as described in Part 10-05-2 of this Title. If a beneficiary becomes eligible for LTSS and: a. Does not have Medicare, essential primary care services through RHP are continued if the LTSS is provided in a home or community-based setting; in such cases, all LTSS is provided on a fee-for-service basis. If LTSS is provided in a health institution such as a nursing facility, EOHHS initiates RHP disenrollment and all Medicaid covered services, including essential primary care services and LTSS are provided fee-for-service; b. Is eligible for or enrolled in Medicare, EOHHS initiates RHP disenrollment and, if eligible, offers the alternative option of enrolling in Medicaid LTSS managed care arrangements such as the Program for All-Inclusive Care for the Elderly (PACE), a Medicare-Medicaid Plan, or a fee-for-service (FFS) alternative. 4. Auto Re-Assignment after Resumption of Eligibility – Medicaid beneficiaries who are disenrolled from RHP due to a loss of eligibility and who regain eligibility within sixty (60) calendar days are automatically re- enrolled, or assigned, back into the managed care service delivery option
they were in previously if they do not make a plan selection. If more than sixty (60) calendar days have elapsed, the enrollment process will follow the process established in this section. 1.3.5 RHP Member Disenrollment A. Disenrollment from an RHP plan may be initiated by EOHHS or the plan in a limited number of circumstances as follows: 1. EOHHS Initiated Disenrollment – Reasons for EOHHS-initiated disenrollment from an RHP plan include but are not limited to: a. Death; b. No longer Medicaid eligible; c. Eligibility error; d. Enrolled in Medicare or other third (3rd) party coverage; e. Placement in a long-term care institution – such as a nursing facility – for more than thirty (30) consecutive days; f. Placement in Eleanor Slater, Tavares, or an out-of-State hospital; g. Incarceration; or h. Eligibility for Medicaid LTSS in a facility. 2. Member Disenrollment Requested by RHP plan – An RHP plan may request in writing the disenrollment of a member whose continued enrollment seriously impairs the plan’s ability to furnish services to either the particular member or to other members. An RHP plan is not permitted to request disenrollment of a member due to: a. An adverse change in the member's health status; b. The member's utilization of medical services; or c. Uncooperative behavior resulting from the member's special needs. 3. All plan-initiated disenrollments are subject to approval by EOHHS, after an administrative review of the facts of the case has taken place. Beneficiaries have the right to appeal EOHHS’ disenrollment decision (see Part 10-05-2 this Title). EOHHS will determine the disenrollment date as appropriate, based on the results of this review. 1.3.6 Grievances, Appeals and Hearings
A. Federal law requires that Medicaid MCOs have a system in place for enrollees that includes a grievance process, an appeal process, and access to an administrative fair hearing through the State Administrative Fair Hearing Process. For in-plan services, RHP members must exhaust the internal MCO Level I and Level II appeals process before requesting an EOHHS hearing. Regulations governing the appeals process for out-of-plan services are found in Part 10-05-2 of this Title. 1. Types of Internal Appeals – The plan must maintain internal policies and procedures to conform to state reporting policies and implement a process for logging appeals. Appeals filed with a managed care plan fall into three (3) categories: a. Medical Emergency. An MCO must decide the appeal within seventy-two (72) hours when a treating provider, such as a doctor who takes care of the member, determines the care to be an emergency and all necessary information has been received by the MCO. b. Non-Emergency Medical Care. The two (2) levels of a non- emergency medical care appeal are as follows: (1) For the initial level of appeal, the MCO must decide the appeal within fifteen (15) days from the date that all necessary information is dated as received by the MCO. If the initial decision is adverse to the member, then the MCO must offer the second (2nd) level of appeal. (2) For the second (2nd) level of appeal, the MCO must make a decision within fifteen (15) days of the date that all necessary information is dated as received by the MCO. c. Non-Medical Care. If the appeal involves a problem other than medical care, the MCO must resolve the appeal within thirty (30) days of the date that all necessary information is dated as received by the MCO. 2. External Appeal. RHP members who exhaust the health plan’s internal appeal processes may choose to initiate an “external appeal,” in accordance with Part 10-05-5 of this Title. A member does not have to exhaust the third (3rd) level appeal before accessing an EOHHS hearing. 3. Regulations governing the appeals process are found in Part 10-05-2 of this Title.
1.4 RHP Benefit Package A. The IHCC groups participating in RHP under this section receive the full scope of services covered under the Medicaid State Plan and the State’s Section 1115 waiver. Covered services may be provided through the managed care plan or through the fee-for-service delivery system if the service is “out-of-plan” – that is, not included in the managed care plan but covered under Medicaid. Fee-for- service benefits may be furnished either by the managed care provider or by any participating provider. 1. Access to Benefits – Each RHP member selects a primary care provider (PCP) who performs necessary medical care and coordinates referrals to specialty care. The PCP orders treatment determined to be medically necessary in accordance with the health plan’s policies. Prior authorization rules may apply, as required by the Medicaid agency. 2. Delivery of Benefits – In-plan services are paid for on a capitated basis. 3. Medical Necessity – The standard of "medical necessity" is used as the basis for determining whether access to a Medicaid covered service is required and appropriate. Medically necessary services must be provided in the most cost-efficient and appropriate setting and must not be provided solely for the convenience of the member or service provider. 4. Medicaid Benefits – The coverage provided through RHP is categorized as follows: RHP Benefits (a) In-Plan (b) Out-of-Plan Inpatient Hospital Care Dental Services Outpatient Hospital Services Court-ordered Mental Health and Substance Abuse Services Ordered to a Non-Network Facility or Provider Physician Services Non-Emergency Transportation Services (The health plan is required to coordinate with EOHHS’ non-emergency transportation broker.) Family Planning Services Nursing home Services in Excess of 30 Consecutive Days
RHP Benefits (a) In-Plan (b) Out-of-Plan Prescription Drugs Residential Services for Beneficiaries with Intellectual and Developmental Disabilities Non-Prescription Drugs
Laboratory Services Center of Excellence for Opioids Radiology Services Peer Recovery Specialist Diagnostic Services Recovery Navigation Program (RNP) Long-term care services and supports after 30 days Outpatient & Inpatient Mental Health and Substance Use Services
Court-ordered Mental Health and Substance Abuse Services – Criminal Court
Court-ordered Mental Health and Substance Abuse Treatment – Civil Court
Home Health Services
Emergency Room Service and Emergency Transportation Services
Nursing Home Care and Skilled Nursing Facility Care for the first 30 days
RHP Benefits (a) In-Plan (b) Out-of-Plan Services of Other Practitioners
Podiatry Services
Optometry Services
Oral Health
Hospice Services
Durable Medical Equipment Group/Education Programs
Interpreter Services
Transplant Services
Adult Day Services
HIV/AIDS Non-Medical Targeted Case Management for People Living with HIV/AIDS and those at High Risk for Acquiring HIV
AIDS Medical Case Management
Opioid Treatment Provider Health Home
Preventive services, including:
RHP Benefits (a) In-Plan (b) Out-of-Plan Homemaker Minor Environmental Modifications Physical Therapy Evaluation and Services 1.5 Integrated Care Initiative (ICI) 1.5.1 Authority and Overview A. In accordance with R.I. Gen. Laws Chapter 40-8.13, the State’s Section 1115 Waiver Demonstration, and other Federal waivers and authorities, EOHHS has developed and implemented the ICI to expand access to comprehensive care management and services through a managed care delivery system known as the Medicare-Medicaid Plan (MMP). B. Under the authority of a special Federal Financial Alignment Demonstration, the MMP integrates and coordinates Medicare and Medicaid covered services through a managed care arrangement for MME beneficiaries. Enrollment is voluntary for eligible beneficiaries. The operations of the MMP are bound by a three (3) way agreement between EOHHS, the Federal Centers for Medicare and Medicaid Services (CMS), and the participating MCO. 1.5.2 EOHHS Responsibilities A. As the single State agency for Medicaid, EOHHS oversees administration of the program and is responsible for ensuring that eligibility determinations and enrollment procedures are conducted in accordance with applicable Federal and State laws and Regulations. To enroll in the MMP, applicants must qualify as an MME in accordance with the applicable provisions set forth herein. Enrollment in PACE is a standing option for eligible beneficiaries. Applicants are processed as summarized below: 1. Eligibility Determinations – EOHHS or its designee is responsible for determining the eligibility of applicants for Medicaid and Medicaid-funded LTSS, including those who have third (3rd) party coverage through Medicare. All LTSS applicants must meet financial and clinical criteria related to the need for an institutional level of care set forth in Part 50-00-5 of this Title and Part 50-00-6 of this Title. The eligibility duties of EOHHS also include:
a. Level of Need. EOHHS applies clinical criteria to determine whether and to what extent the needs of an applicant/beneficiary require the level of care provided in an institutional setting – nursing facility, hospital, intermediate care facility for intellectual disabilities. EOHHS is also responsible for identifying beneficiaries for whom there is unlikely to be an improvement in functional/medical status. b. Beneficiary Liability. EOHHS determines the amount LTSS beneficiaries must pay toward the cost of the care – beneficiary liability – through a process referred to as the post-eligibility treatment of income (PETI). All beneficiaries of Medicaid-funded LTSS are required under the Medicaid State Plan and the State’s Section 1115 Waiver to contribute to the cost of the services they receive to the full extent their income and resources allow, irrespective of care setting or service delivery option. Failure to make such payments may result in termination of eligibility for non- cooperation (See Part 50-00-8 of this Title). c. Person Centered Planning and Service Arrangements. In addition to determining eligibility and beneficiary liability for Medicaid LTSS, EOHHS is responsible for engaging beneficiaries in person- centered care planning in which the beneficiary leads an assessment and discussion of his or her needs and goals and information about various care options. This process includes the development of a service plan that corresponds to the beneficiary’s needs and goals and assists beneficiaries and their families in selecting the appropriate service delivery option and making care arrangements. In response to the novel Coronavirus Disease (COVID-19), EOHHS will postpone in-person, person centered planning. 2. Service Delivery Options and Enrollment – EOHHS assures that every beneficiary has access to health coverage through the service delivery options provided for in Federal and State law that most appropriately meet his/her needs. Once a determination of eligibility has been made, beneficiaries are evaluated for enrollment in managed care versus fee-for service. 1.5.3 Service Delivery Options A. EOHHS provides the following delivery options to Medicaid beneficiaries who meet program participation criteria: 1. Medicare-Medicaid Plan (MMP) – The MMP is a managed care service delivery system designed to manage and coordinate the full spectrum of both Medicaid and Medicare services for Medicare and Medicaid (MME) adults. See § 1.7 of this Part for more information on the MMP.
2. PACE – PACE is a service delivery option for beneficiaries who have Medicare and/or Medicaid coverage and meet a “high” or “highest” level of need for LTSS in accordance with Part 50-00-5 of this Title. Beneficiaries must be fifty-five (55) years old or older to participate in this option. See § 1.13 of this Part for more information on PACE. 3. Fee-for-service – Beneficiaries participating in the MMP receive at least some of their Medicaid health coverage on a fee-for-service basis. Beneficiaries eligible for the MMP, and PACE also have the option to obtain all of their Medicaid covered services on a fee-for-service basis. 4. Care Management Entity provide care coordination and assistance to beneficiaries in Medicaid fee-for-service who are not eligible for enrollment in managed care. The Care Management Entity provides beneficiaries assistance with: a. Navigating the health care system b. Care management, client advocacy, and health education c. Working with a person’s primary care provider and d. Provides links to community resources. 5. Participation in Care Management is voluntary. The State targets eligible beneficiaries for care management based upon clinical need and functional status. 1.6 Rhody Health Options (RHO) A. In accordance with § 7 of Pub. Laws 18-047 enacted on June 22, 2018, Medicaid beneficiaries enrolled in RHO on and before October 1, 2018 will be placed in fee-for-service arrangements effective that date for all Medicaid covered long- term services and supports. The RHO program termination date is September 30, 2018. B. Medicaid beneficiaries who were enrolled in RHO on and before October 1, 2018 will continue to receive all medically necessary services as contained in § 1.4(A)(4) of this Part. The standard of "medical necessity" is used as the basis for determining whether access to a Medicaid covered service is required and appropriate. Prior to the termination date of RHO for existing beneficiaries and after for all new beneficiaries, any member who is dually eligible for Medicaid and Medicare may be enrolled in a MMP while retaining the choice to opt out and receive LTSS on a fee-for service basis. For Medicaid beneficiaries who do not have Medicare, the transition is as follows: 1. Medicaid-only LTSS in a home and community-based setting -- Beneficiaries who are seeking or receiving LTSS in a home and
community-based setting as defined in Part 50-10-1 of this Title will receive all essential primary care benefits through a Rhody Health Partners managed care plan. Medicaid LTSS will be provided out-of-plan and paid for on a fee-for-service basis after the first 30 days. 2. Medicaid-only LTSS in a health institution --Persons seeking or receiving Medicaid in an institutional setting such as a nursing facility or hospital in accordance with Part 50-05-1 of this Title will be receive all Medicaid- covered services (primary care, subacute care, long-term services and supports) on a fee-for-service basis. 1.6.1 RHO Appeals
The class of Medicaid beneficiaries who were enrolled in RHO on and before October 1, 2018 do not have the right to appeal the termination of their RHO coverage in accordance with 42 C.F.R. § 431.220 (b) and § 10-05-2.2.1(A)(7)(a) of this Title. The right to appeal agency actions unrelated to this change in law and policy that affect eligibility, or the scope, amount, and or duration of Medicaid benefits is preserved. 1.7 Medicare-Medicaid Plan (MMP) 1.7.1 Overview
Under the authority of a special Federal Financial Alignment Demonstration, the MMP is designed to manage and coordinate the full spectrum of both Medicaid and Medicare services for Medicare and Medicaid (MME) adults. Enrollment is voluntary for eligible beneficiaries. A three (3) way agreement between EOHHS, the MCO operating the MMP, and the Federal Centers for Medicare and Medicaid Services (CMS) governs the organization, financing, and delivery of Medicaid and Medicare services to MME beneficiaries who choose to participate. 1.7.2 MMP Participation Criteria A. MME beneficiaries are eligible for participation in the MMP if they are age twenty- one (21) and older as follows: 1. MME Enrollees – Medicare-Medicaid beneficiaries who are receiving Medicaid health coverage, enrolled in Medicare Part A, enrolled in Medicare Part B, and eligible to enroll in Medicare Part D. This cohort includes MME and other Community Medicaid IHCC group beneficiaries as well as those who need LTSS. Eligible MME beneficiaries include: a. Members of the IHCC groups receiving Community Medicaid, including persons with serious and persistent mental illness, who do not need LTSS; b. MAGI-eligible adults in the MACC group for parents/caretakers;
c. LTSS recipients residing in institutional or home and community- based settings including those qualifying for the level of care provided in a nursing facility and intermediate care facility for persons with intellectual disabilities (ICF-ID) – such as nursing facility, assisted living and ID group home residents as well as those residing in their own homes; and d. Persons with End Stage Renal Disease (ESRD) at the time of enrollment. 2. MME beneficiaries are entitled to Medicaid State Plan and Section 1115 waiver services that are not covered by Medicare. 3. Excluded Beneficiaries – Certain Medicaid beneficiaries are excluded from participating in the MMP as indicated below: a. Beneficiaries excluded from the MMP. b. Medicare beneficiaries who are not eligible for Medicaid health coverage, including partial dual eligible beneficiaries who participate in the Medicaid Premium Payment Program (MPP) as Qualified Medicare Beneficiaries (QMBs), Specified Low-Income Beneficiaries (SLMBs), and Qualifying Individuals (QIs). c. Dual Eligible beneficiaries who are not qualified to enroll in all segments of Medicare. d. Medicaid beneficiaries residing in Tavares, Eleanor Slater, or out- of-State hospitals. e. Beneficiaries who are in hospice on the effective enrollment date. Enrollees who elect hospice care after they are enrolled in the MMP can remain in the MMP. f. Beneficiaries who reside out-of-State for six (6) consecutive months or longer. g. Beneficiaries who are eligible for the Medicaid Buy-In Program for Working People with Disabilities (known as the “The Sherlock Plan” in Rhode Island). h. Dual eligible beneficiaries who are between the ages of nineteen (19) and twenty (20) are exempt from enrollment in managed care and receive all Medicaid health coverage on a fee-for-service basis. i. Beneficiaries who are determined eligible as medically needy for Community Medicaid due to excess income and resources are exempt from enrollment in managed care.
1.7.3 MMP Service Delivery Option
MMP participating beneficiaries receive services through a managed care arrangement operating under contract with EOHHS and CMS. MMP enrollees receive services through a health plan offered by an MCO. The operations of the MMP are bound by a three (3) way agreement with EOHHS and CMS to integrate the full range of Medicare and Medicaid services (primary care, acute care, specialty care, behavioral health care, and LTSS) in accordance with a rate structure that includes Federal and State funding streams for all MME adults. Accordingly, the MMP must provide accessible, high-quality services and supports focused on optimizing the health and independence of one of the most fragile Medicaid populations. Enrollment in the MMP is voluntary. 1.7.4 MMP Enrollment A. The MMP offers MME beneficiaries the opportunity to obtain comprehensive integrated services through a single health plan. 1. Passive or Auto-Enrollment – Eligible beneficiaries may be passively enrolled by EOHHS, or auto-enrolled, in the MMP unless they are excluded from passive enrollment on the basis of one (1) of the following criteria: a. The MME beneficiary is enrolled in a Medicare Advantage plan that is not operated by the same MCO as the MMP; b. The beneficiary has been auto-enrolled by CMS into a Medicare Part D plan in the same calendar year that the MME would qualify for the MMP; c. The MME is currently enrolled in comprehensive health insurance coverage through a private commercial plan or group health plan provided through an employer, union, or TRICARE; or d. The beneficiary has affirmatively opted-out of passive enrollment into an MMP or a Medicare Part D plan. 2. Opt-in Enrollment – Eligible beneficiaries may be offered the option to opt into the MMP. MME beneficiaries who are not eligible for passive enrollment will be offered the opportunity to opt-in to an MMP by completing an application in writing or via phone. Individuals enrolled in PACE may elect to enroll and participate in the MMP if they choose to disenroll from PACE. 1.7.5 Enrollment Information A. EOHHS is responsible for ensuring that all MME beneficiaries who meet the criteria to participate in the MMP have access to the information necessary to
make a reasoned choice about their coverage options. As indicated in § 1.2(A)(25) of this Part, the person-centered planning process plays a critical role in ensuring that beneficiaries are aware of the full range of service delivery options available to them based on their level of need and personal goals. Accordingly, prospective participants are sent a written communication informing them of the option to enroll in an MMP, as well as information on the availability of independent enrollment options counseling and other supports to help beneficiaries make informed enrollment decisions. Eligible individuals who opt- out of or do not enroll in an MMP have the option to enroll in PACE if eligible, or receive all Medicaid covered services – including LTSS – on a fee-for-service basis, unless they are otherwise eligible for another Medicaid delivery system. B. Communications with MME beneficiaries who qualify to participate in the MMP includes information about each of the following: 1. Enrollment Opt-In and Opt-Out Process – Participation in an MMP is voluntary. MME beneficiaries eligible for passive enrollment are informed that they may choose to opt out of enrollment in the MMP and are provided with instructions on how to proceed. MME beneficiaries eligible for passive enrollment who opt-out may choose any of the alternative service delivery options for which they may qualify. Eligible beneficiaries who are not passively enrolled are provided with instructions on how to enroll in an MMP. 2. Decision Timeframe – Eligible beneficiaries may enroll in an operational MMP at any time up until six (6) months prior to the end of the Federal demonstration under which the MMP was implemented. The Federal demonstration is scheduled to end on December 31, 2020. Information is provided about enrollment decision time-frames as follows: a. Passive Enrollment. Beneficiaries eligible for passive enrollment into the MMP are sent a first (1st) notification that they will be passively enrolled between sixty (60) and ninety (90) days prior to the effective date of enrollment; a second (2nd) reminder notification is sent to the beneficiary at least thirty (30) days prior to the effective date of enrollment. If the beneficiary makes an enrollment choice within the specified timeframe, EOHHS initiates enrollment accordingly. If a beneficiary does not respond within the specified timeframe, enrollment in the MMP proceeds in accordance with the terms specified in the initial communication from EOHHS. b. Opt-in Enrollment. MME beneficiaries who are eligible for the MMP but are not passively enrolled may be sent a notification that they have the option to enroll in an MMP. Opt-in enrollment requests received through the tenth (10th) day of the month will take effect on the first (1st) day of the following calendar month. Opt-in enrollment requests received on the eleventh (11th) day of the month or later
will take effect on the first (1st) day of the second (2nd) month after the request was submitted. Beneficiaries do not need to make an enrollment decision to opt into the MMP within a specified timeframe after receiving notice from EOHHS informing them that they are eligible to enroll in the MMP. However, no new enrollments will be accepted during the six (6) months prior to the end date for the Federal demonstration under which the MMP was implemented. The Federal demonstration is scheduled to end on December 31, 2020. 3. Opportunity to Change – Beneficiaries who are being passively enrolled or who opt-in to an MMP may cancel their enrollment any time prior to their effective enrollment date. Once enrolled, beneficiaries may change service delivery options on a monthly basis at any time, but enrollment in the MMP will continue through the end of the month. The requested change will be effective on the first (1st) day of the following month. Beneficiaries who cancel enrollment into or voluntarily disenroll from an MMP will be enrolled in fee-for-service (FFS), effective the first (1st) day of the following month. Beneficiaries who voluntarily disenroll from the MMP plan can choose to re-enroll in the plan on a monthly basis if they continue to be eligible for enrollment in the MMP, but they will not be passively enrolled in the MMP. Beneficiaries may also be eligible for enrollment in PACE (see § 1.13 of this Part). 4. Auto Re-Assignment after Resumption of Eligibility – MME beneficiaries who are disenrolled from an MMP due to a loss of eligibility are eligible for re-enrollment in the plan if eligibility is reinstated and they otherwise meet the requirements for enrollment. Beneficiaries eligible for re-enrollment will be passively enrolled if they meet the requirements for passive enrollment. Otherwise, they will be offered opt-in enrollment. 1.7.6 MMP Member Disenrollment A. EOHHS Initiated Disenrollment – Reasons for EOHHS disenrollment from an MMP include but are not limited to: 1. Death; 2. No longer eligible for Medicaid; 3. Loss of Medicare Part A and/or Part B; 4. Enrollment into a Medicare Advantage (Part C) plan or Medicare Part D prescription drug plan; 5. Eligibility error;
6. Placement in Eleanor Slater Hospital, Tavares, or out-of-State residential hospital; 7. Incarceration; 8. Changed State of residence; 9. Enrollment in PACE; and 10. Opt-out to fee-for-service. B. Beneficiaries who are involuntarily disenrolled because of incarceration are provided Medicaid coverage on a fee-for-service basis. Beneficiaries who are involuntarily disenrolled for any other reason and remain eligible for Medicaid coverage are enrolled in FFS. C. Medicare-Medicaid Plan Disenrollment Request – The Medicare-Medicaid plan may make a written request to EOHHS and CMS asking that a particular member be disenrolled. Any such request is only considered by EOHHS and CMS when made on the grounds that the member’s continued enrollment seriously impairs the entity’s capacity to furnish services to either the particular member or other members, the member knowingly provided fraudulent information on the MMP enrollment form that materially affected his/her eligibility to enroll in the MMP, or the member intentionally permitted others to use his/her member identification card to obtain services under the MMP. EOHHS and CMS do not permit disenrollment requests based on: 1. An adverse change in the member's health status; 2. The member's utilization of medical services; 3. Uncooperative or disruptive behavior resulting from the member's special needs; 4. The member exercising treatment decisions with which the MCO or the MCO’s provider(s) disagree; or 5. Diminished or diminishing mental capacity of the member. D. Beneficiaries who are involuntarily disenrolled based on a written request by the MMP receive their Medicaid benefits on a fee-for-service basis. E. Disenrollment Review – All disenrollments are subject to approval by EOHHS and CMS. Beneficiaries have the right to appeal EOHHS’ and CMS’ disenrollment decision (see Part 10-05-2 of this Title). EOHHS and CMS determine jointly the disenrollment date as appropriate. 1.7.7 Grievances, Appeals and Hearings
A. MMP members have multiple avenues for contesting decisions that affect their health coverage, including EOHHS and CMS administrative fair hearings. The process is as follows: 1. MMP Grievances – Grievances directed toward the MMP may be internal or external. a. Internal or plan level grievances. MMP members, or their authorized representatives, can file a grievance with the MCO or a participating provider at any time by calling or writing the MCO or the provider. The MCO must require providers to forward grievances to the MCO. If the MMP member is requesting remedial action related to a Medicare issue, the member must file the grievance with the MCO or the provider no later than sixty (60) days after the event or incident triggering the incident (see Part 10-05-2 of this Title). The MCO must respond, orally or in writing, to an internal grievance within thirty (30) days after the MCO receives the grievance. The MCO must respond, orally or in writing, within twenty-four (24) hours whenever the MCO extends the timeframe for a decision or refuses to grant a request for an expedited grievance. b. External. MMP members, or their authorized representatives, can file a grievance by contacting 1-800-MEDICARE or EOHHS. Any grievance filed with EOHHS will be reviewed by a joint EOHHS- CMS contract oversight team and be made available to the MCO. 2. MMP Appeals – The process for handling appeals varies depending on whether the beneficiary is disputing an action related to Medicaid or Medicare coverage. For services covered under Medicare Part D, MMP members must follow the appeals process established by CMS in Subparts M and U of 42 C.F.R. Part 423. For services covered by Medicare Part A, Medicare Part B, and/or Medicaid in-plan services, MMP members must complete one (1) level of internal appeal before requesting an external review. Regulations governing the appeals process for Medicaid out-of-plan services are found in Part 10-05-2 of this Title. The process for filing subsequent appeals after the first level internal appeal is as follows: a. Services covered by Medicare Part A and/or B. Subsequent appeals after the first (1st) level internal appeal for traditional Medicare A and B services that are not fully in favor of the enrollee will be automatically forwarded to the Medicare Independent Review Entity (IRE) by the MMP. b. Services covered by Medicaid only. Subsequent appeals for services covered by Medicaid only (including, but not limited to,
LTSS and behavioral health) may be made to the EOHHS Hearing Office and/or to the Rhode Island External Review Entity per State Regulations (Part 10-05-2 of this Title) after the first (1st) plan-level Appeal has been completed. If an appeal is filed with both the Rhode Island External Review Entity and the EOHHS Hearing Office, the MCO will be bound by any determination in favor of the member that is closest to the relief requested by the member. Appeals related to drugs excluded from Medicare Part D that are covered by Medicaid must be filed with the MMP in accordance with Part 10-05-2 of this Title, and Subchapter 00 Part 2 of this Chapter, and the requirements contained herein. c. Services covered by both Medicare and Medicaid. After the first (1st) level internal appeal, appeals for services for which Medicare and Medicaid overlap (including, but not limited to, home health, durable medical equipment, and skilled therapies, but excluding Part D) will be auto-forwarded to the IRE by the MMP. d. After the first (1st) plan-level appeal for Medicare and Medicaid overlapping services, a member may file a request for a hearing with the EOHHS State Fair Hearing Office. After the first (1st) plan- level appeal for Medicare and Medicaid overlap services, a member may also file a request for a hearing with the Rhode Island External Review Entity per State Regulations (Part 10-05-2 of this Title). If an appeal is filed with both the IRE and either the Rhode Island External Review Entity or the EOHHS Hearing Office, the MCO will be bound by any determination in favor of the member that is closest to the relief requested by the member. 3. Internal appeals timeframes a. First (1st) Level. An MMP member must file a first (1st) level internal appeal with the plan within sixty (60) calendar days following the date of the notice of adverse action that generates the appeal. b. Standard appeals. For first (1st) level internal appeals, the MMP must render a decision within thirty (30) calendar days of the date that the appeal request has been received by the managed care entity. The MMP can extend the deadline for a decision by up to fourteen (14) days if requested by the beneficiary or if the delay is in the beneficiary’s best interest. c. Expedited appeals. For first (1st) level internal appeals, the MMP must render a decision within seventy-two (72) hours of the date that the appeal request has been received by the managed care entity when either the MMP or the member’s provider determines that standard appeal resolution could seriously jeopardize the
member’s life or health or ability to attain, maintain, or regain maximum function. The MMP can extend the deadline for a decision by up to fourteen (14) days if requested by the beneficiary or if the delay is in the beneficiary’s best interest. 1.7.8 MMP Benefit Package A. The MMP provides a comprehensive benefit package to members that includes a full continuum of Medicare and Medicaid services as follows: 1. Medicare – Medicare Parts A, B, and D-funded medically necessary services. 2. Medicaid Services – The standard of "medical necessity" is used as the basis for determining whether access to a Medicaid covered service is required and appropriate. Medically necessary services must be provided in the most cost-efficient and appropriate setting and must not be provided solely for the convenience of the member or service provider. Medicaid services may be in-plan or out-of-plan. In-plan services are paid for on a capitated basis. Certain Medicaid-covered services are considered “out-of- plan” and are provided on a fee-for service basis. The MMP is not responsible for delivering or reimbursing out-of-plan services but is expected to coordinate in-plan services with out-of-plan services. Out-of- plan services are provided by existing Medicaid-approved providers who are reimbursed directly by Medicaid on a fee-for-service basis. The Medicaid coverage provided through the MMP is categorized as follows: MMP Medicaid Benefits (a) In-Plan (b) Out-of-Plan (01) Inpatient Hospital Care (01) Dental Services (02) Outpatient Hospital Services (02) Non-Emergency Transportation Services (The health plan is required to coordinate with EOHHS’ non- emergency transportation broker) (03) Physical Therapy Evaluation and Services (03) Residential Services for Clients with Intellectual and
MMP Medicaid Benefits (a) In-Plan (b) Out-of-Plan Developmental Disabilities (04) Physician Services (04)
(05) Care Management Services
(06) Family Planning Services
(07) Prescription Drugs
(08) Non-Prescription Drugs
(09) Laboratory Services
(10) Radiology Services
(11) Diagnostic Services
(12) Mental Health and Substance Use Disorder Treatment- Outpatient/Inpatient
(13) Home Health Services
(14) Emergency Room Service and Emergency Transportation Services
(15) Nursing Home Care and Skilled Nursing Facility Care
(16) Services of Other Practitioners
MMP Medicaid Benefits (a) In-Plan (b) Out-of-Plan (17) Podiatry Services
(18) Optometry Services
(19) Oral Health
(20) Hospice Services
(21) Durable Medical Equipment
(22) Environmental Modifications (Home Accessibility Adaptations)
(23) Special Medical Equipment (Minor Assistive Devices)
(24) Adult Day Health
(25) Nutrition Services
(26) Group/Individual Education Programs
(27) Interpreter Services
(28) Transplant Services
(29) HIV/AIDS Non-Medical Targeted Case Management for People Living with HIV/AIDS and those that are at High Risk for Acquiring HIV
MMP Medicaid Benefits (a) In-Plan (b) Out-of-Plan (30) AIDS Medical Case Management
(31) Court-ordered Mental Health and Substance Abuse Services – Criminal Court
(32) Court-ordered Mental Health and Substance Abuse Treatment – Civil Court
(33) Telemedicine
(34) Preventive Services, including: Homemaker Personal Care Services Minor Environmental Modifications Physical Therapy Evaluation and Services Respite
(35) Long Term Services and Supports, including: Homemaker Meals on Wheels (Home Delivered Meals) Personal Emergency Response (PERS)
MMP Medicaid Benefits (a) In-Plan (b) Out-of-Plan Skilled Nursing Services (LPN Services) Community Transition Services Residential Supports Day Supports Supported Employment RIte @ Home (Supported Living Arrangements- Shared Living)* Private Duty Nursing Supports for Consumer Direction (Supports Facilitation) Self- Directed Goods and Services Financial Management Services (Fiscal Intermediary) Senior Companion (Adult Companion Services) Assisted Living Personal Care Assistance Services Respite Rehabilitation Services
MMP Medicaid Benefits (a) In-Plan (b) Out-of-Plan (36) Opioid Treatment Provider Health Home
1.8 Prescriptions: Generic Policy A. For RHP and MMP enrolled members, Medicaid prescription benefits must be for generic drugs. Exceptions for limited brand coverage for certain therapeutic classes may be granted if approved by the Medicaid agency, or the MCO acting in compliance with their contractual agreements with EOHHS, and in accordance with the criteria described below: 1. Availability of suitable within-class generic substitutes or out-of-class alternatives. 2. Drugs with a narrow therapeutic range that are regarded as the standard of care for treating specific conditions. 3. Relative disruptions in care that may be brought on by changing treatment from one drug to another. 4. Relative medical management concerns for drugs that can only be used to treat patients with specific co-morbidities. 5. Relative clinical advantages and disadvantages of drugs within a therapeutic class. 6. Cost differentials between brand and generic alternatives. 7. Drugs that are required under federal and State regulations. 8. Demonstrated medical necessity and lack of efficacy on a case by case basis. B. For the MMP, the generic policy applies only to Medicaid covered drugs that are not part of the Medicare Part D formulary covered by the MMP. The MMP may cover brand name drugs as part of its Medicare Part D formulary, in accordance with Medicare Part D guidelines. 1.9 Non-Emergency Transportation Policy
Responsibility for transportation services rests first with the member. If the member's condition, place of residence, or the location of the medical provider
does not permit the use of bus transportation, non-emergency transportation for the Medicaid enrollee may be arranged for by EOHHS, or its agent, in accordance with the provisions established in Part 20-00-2 of this Title. 1.10 Interpretation Services Policy
EOHHS will notify the health plan when it knows of members who do not speak English as a primary language who have either selected or been assigned to the plan. If more than fifty (50) members speak a single language, the RHP health plan must make available general written materials, such as its member handbook, in that language. If more than five percent (5%) or fifty (50) members, whichever is less, speak a single language, the MMP must make available general written materials, such as its member handbook, in that language. Interpreter services, including sign language interpreters, are covered for any RHP or MMP member who speaks a non-English language as a primary language or who is deaf or hard of hearing. 1.11 Tracking, Follow-up, Outreach
Tracking, follow-up, and outreach services are provided by the health plan in association with an initial visit with the member's PCP, preventive visits and prenatal visits, referrals that result from preventive visits, and preventive dental visits. Outreach includes mail, phone, and home outreach, if necessary, for members who miss preventive and follow-up visits, and to resolve language, transportation, and other barriers to care. 1.12 Mainstreaming/Selective Contracting
The mainstreaming of Medicaid beneficiaries into the broader health delivery system is an important objective of RHP and MMP. The MCO therefore must ensure that all of its network providers accept its members for treatment. The MCO also shall accept responsibility for ensuring that network providers do not intentionally segregate RHP and MMP members in any way from other persons receiving services. MCOs may develop selective contracting arrangements with certain providers for the purpose of cost containment but shall adhere to the access standards as defined in the MCO contracts. 1.13 Program of All-Inclusive Care for the Elderly (PACE) 1.13.1 Overview
PACE provides a managed plan of coordinated Medicare and Medicaid covered services from across the care continuum to certain beneficiaries age fifty-five (55) and older. The operations of PACE are bound by a three (3) way agreement between EOHHS, CMS, and the PACE provider to integrate the full range of Medicare (if eligible) and Medicaid services (primary care, acute care, specialty care, behavioral health care, and LTSS) for PACE participants.
1.13.2 EOHHS Responsibilities
EOHHS is responsible for the eligibility and enrollment functions set forth in § 1.13.4 of this Part, establishing PACE provider standards, and oversight and monitoring of all aspects of the PACE program. 1.13.3 PACE Provider Responsibilities A. The PACE provider is responsible for: 1. Point of entry identification; 2. Submitting all necessary documentation for initial determinations and reevaluations of a level of need and referral to EOHHS for a determination of financial eligibility; 3. Verifying PACE enrollment prior to service delivery; 4. Verifying and collecting required beneficiary liability (cost-share amount); 5. Providing and coordinating all integrated services; 6. Reporting changes to the PACE-eligibility status of participants; and 7. Adhering to all PACE provider requirements as outlined in the PACE Program Agreement between EOHHS and CMS, and to all credentialing standards required by EOHHS including data submission. 1.13.4 PACE Participation Criteria A. To qualify as a Medicaid-eligible PACE participant, an individual must: 1. Be fifty-five (55) years of age or older; 2. Meet the criteria for a high or the highest need for a nursing facility level of care in accordance with Part 50-00-5 of this Title; and 3. Meet all other financial and non-financial requirements for Medicaid LTSS such as, but not limited to, citizenship, residency, resources, income, and transfer of assets. B. Medicaid-eligible PACE participants may be, but are not required to be, enrolled in Medicare. 1.13.5 PACE Disenrollment A. Reasons for PACE Disenrollment – Reasons for disenrollment from PACE include but are not limited to:
1. Death; 2. Loss of Medicaid eligibility; 3. Eligibility error; 4. Placement in an out-of-State residential hospital; 5. Incarceration; 6. Change of State residence; 7. Loss of functional level of care; and 8. Voluntary opt-out to Medicaid FFS. B. The PACE provider may also request in writing that a member be disenrolled on the grounds that the member’s continued enrollment seriously impairs the entity’s capacity to furnish services to either the particular member or other members. In such instances, EOHHS will notify the PACE provider about its decision to approve or disapprove the disenrollment request within fifteen (15) days from the date EOHHS has received all information needed for a decision. Upon EOHHS approval of the disenrollment request, the PACE provider must, within three (3) business days, forward copies of a completed Disenrollment Request Form to EOHHS and to the Medicare enrollment agency (when appropriate). The PACE provider must also send written notification to the member that includes: 1. A statement that the PACE provider intends to disenroll the member; 2. The reason(s) for the intended disenrollment; and 3. A statement about the member's right to challenge the decision to disenroll and how to grieve or appeal such decision. C. Disenrollment Requests Not Allowed. EOHHS does not permit disenrollment requests based on: 1. An adverse change in the member's health status; 2. The member's utilization of medical services; or 3. Uncooperative behavior resulting from the member's special needs. D. Voluntary Disenrollment – PACE participants may voluntarily disenroll from PACE at any time. A voluntary disenrollment from PACE will become effective at midnight of the last day of the month in which the disenrollment is requested. E. Disenrollment Process. Regardless of the reason for disenrollment, EOHHS is responsible for completing all disenrollment actions. Disenrollments requested by
the PACE provider on the grounds that the member’s continued enrollment seriously impairs the entity’s capacity to furnish services to either the particular member or other members are subject to EOHHS approval. Beneficiaries who are disenrolled from PACE but retain Medicaid eligibility will be enrolled in Medicaid fee-for-service and may subsequently choose or be enrolled in an alternative service delivery if they qualify. Beneficiaries have the right to appeal EOHHS’s disenrollment action (see Part 10-05-2 of this Title). F. Disenrollment Effective Date. Regardless of the reason for disenrollment, all disenrollments from PACE will become effective at midnight of the last day of the month in which the disenrollment is requested. 1.13.6 Disenrollment Appeal
If the member files a written appeal of the disenrollment within ten (10) days of the decision to disenroll, the disenrollment shall be delayed until the appeal is resolved. 1.13.7 Re-enrollment and Transition Out of PACE
All re-enrollments will be treated as new enrollments except when a participant re-enrolls within two (2) months after losing Medicaid eligibility. In this situation, the participant's re-enrollment will not be treated as a new enrollment. The PACE provider shall assist participants whose enrollment ceased for any reason in obtaining necessary transitional care through appropriate referrals, by making medical records available to the participant's new service providers, and (if applicable), by working with EOHHS to reinstate the participant's benefits. 1.14 PACE Benefit Package A. CMS and EOHHS approve PACE providers who are responsible for providing the full scope of Medicare (if eligible) and Medicaid State Plan and waiver services, including but not limited to: 1. Multidisciplinary assessment and treatment planning; 2. Case Management services; 3. Personal Care; 4. Homemaking; 5. Rehabilitation; 6. Social Work; 7. Transportation;
8. Nutritional Counseling; 9. Recreational Therapy; 10. Minor Home Modifications; and 11. Specialized Medical Equipment and Supplies. B. The PACE program is voluntary for any eligible person, but if an individual selects this program, he/she must get all medical and support services through PACE. There are no benefits outside of the PACE program.
1.15 Federal Poverty Limits (FPLs) 2019
210-RICR-40-10-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 - MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 10 - MANAGED CARE PART 1 - MEDICAID MANAGED CARE SERVICE DELIVERY ARRANGEMENTS (210- RICR-40-10-1) Type of Filing: Refile Capabilities Department of State _________________________________________________________________ Regulation Effective Date Original Signing Date _________________________________________________________________ Department of State Initials Department of State Date 01/04/2022 09/15/2021 December 15, 2021 E-SIGNED by Department of State on 2021-12-15 16:19:56 EST
210-RICR-40-15-1 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 – MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 15 – WORKING ADULTS WITH DISABILITIES PART 1 – WORKING ADULTS WITH DISABILITIES 1.1 Scope and Applicability A. One of the principal objectives of health and human services policymakers is to support Medicaid-eligible adults with disabilities who work by enabling them to obtain or maintain the coverage they need to retain their independence and optimize their health. Toward this end, an array of State and Federal laws and Regulations have been adopted that establish special provisions for disregarding all or a portion of the earned income of adults with disabilities who work. The State also provides Medicaid coverage for an array of employment services and supports to assist beneficiaries with disabilities who are employed. This Part describes the eligibility pathways that are available to adults with disabilities who are working. B. In addition, the State has taken the options under Federal law to create two (2) eligibility pathways – known as the Sherlock Plan and the Ticket to Work Program – which enable working adults with disabilities who are otherwise Medicaid ineligible or unable to obtain needed employment supports to buy into the program at a low monthly cost. To qualify for the Medicaid special income provisions afforded by the Sherlock Plan or the Ticket to Work Program, a person must be determined to have a disability by a Federal or State government entity or appropriately designated contractual agent of the State in accordance with the standards set forth in Subchapter 05 Part 1 of this Chapter. Such entities include the U.S. Social Security Administration and the Medicaid Assessment and Review Team (MART) described in Subchapter 05 Part 1 of this Chapter. Adults with disabilities who work and are seeking initial or continuing eligibility for Medicaid long-term services and supports (LTSS) may be subject to distinct “clinical/functional disability” criteria, as set forth in § 1.8.1 of this Part. A beneficiary who meets these disability criteria and qualifies for these special income provisions is eligible for the full range of Medicaid covered employment services and supports. C. Employment services and supports may also be available to adults with disabilities over age nineteen (19) who are eligible for Medicaid in accordance with the provisions of Part 30-00-1 of this Title in one (1) of the Medicaid Affordable Care Coverage (MACC) groups based on the modified adjusted gross income (MAGI) standard. Although a disability determination is not required, the
scope of employment services and supports available may not be as extensive as through the other eligibility pathways for working adults with disabilities. Accordingly, seeking eligibility based on a formal determination of disability is an option, as set forth in herein in the following sections. 1.2 Legal Authority A. This Part is promulgated pursuant to Federal authorities as follows: 1. Federal Law: Title XIX of the U.S. Social Security Act; 42 U.S.C. §§ 1396- 1396w-7; 2. The Rhode Island Medicaid State Plan and Title XIX, Section 1115 (a) Demonstration Waiver B. Applicable State authority is derived from R.I. Gen. Laws Chapters 40-6; 40-8; and 40-8.7. 1.3 Incorporated Materials A. These regulations hereby adopt and incorporate 20 C.F.R. § 416.976 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. B. These regulations hereby adopt and incorporate 20 C.F.R. §§ 416.1180- 416.1182 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. C. These regulations hereby adopt and incorporate 42 C.F.R. § 435.120 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. D. These regulations hereby adopt and incorporate 42 C.F.R. § 435.121 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. E. These regulations hereby adopt and incorporate 42 C.F.R. § 441.301 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. F. These regulations hereby adopt and incorporate 42 CFR § 447.55 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. 1.4 Definitions A. As used herein, the following terms are defined as follows:
1. “Couple” means a person seeking initial or continuing eligibility for Medicaid and their spouse, regardless of whether the spouse is also an applicant or beneficiary unless otherwise indicated. 2. “Executive Office of Health and Human Services" or "EOHHS” means the State agency established under the provisions of R.I. Gen. Laws Chapter 42-7.2 designated as the single State agency for the Medicaid program. 3. “Long-Term Services and Supports” or “LTSS" means a spectrum of services covered by the Rhode Island Medicaid Program for persons with clinical and functional impairments and/or chronic illness that require the level of care typically provided in a health care institution. Medicaid LTSS includes skilled or custodial nursing facility care, therapeutic day services, and personal care as well as various home and community-based services. Medicaid beneficiaries eligible for LTSS are also provided with primary care essential benefits. 4. “Medicaid Affordable Care Coverage” or “MACC” means the eligibility categories for individuals and families subject to the Modified Adjusted Gross Income (MAGI) standard identified in Part 30-00-1 of this Title. 5. “Medicaid health coverage” means the full scope of essential health care services and supports authorized under the State’s Medicaid State Plan and/or Section 1115 Waiver provided through an authorized Medicaid delivery system. 6. “Primary care essential benefits” means non-LTSS Medicaid health coverage and includes an array of acute, subacute, and specialty essential benefits, as identified under the Medicaid State Plan, provided by licensed health professionals and providers. These essential benefits include, but are not limited to: health promotion, disease prevention, health maintenance, counseling, patient education, various specialty services, and diagnosis and treatment of acute and chronic medical and behavioral health illnesses and conditions in a variety of health care settings (such as office visits, inpatient, home care, and day care). 7. "Section 1115 Waiver" means the waiver authorized pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. 8. “Section 1619(a)” or “§ 1619(a)” means § 1619(a) of the Social Security Act, 42 U.S.C. § 1382h(a). 9. “Section 1619(b)” or “§ 1619(b)” means § 1619(b) of the Social Security Act, 42 U.S.C. § 1382h(b). 10. “Work supports” means the array of Medicaid services available to beneficiaries who have disabilities who need support to obtain or maintain employment. Depending on whether an LTSS level of care is required,
these supports may include: pre-vocational services, education and training opportunities that build on strengths and interests, individually tailored and preference-based career planning, job development, job training, and job support that recognizes each person's employability and potential contributions to the labor market. 1.5 SSI-Eligible Beneficiaries A. Rhode Island provides Medicaid coverage to anyone who is eligible for and receiving Supplemental Security Income (SSI) based on a determination by the Federal Social Security Administration (SSA). The SSI program provides basic income to aged, blind, and disabled individuals who have little to no income and resources and who are unable to engage in substantial gainful activity. The State automatically enrolls SSI beneficiaries in Medicaid upon receipt of electronic notification from the SSA and must continue to provide coverage unless or until SSI status changes. B. The SSA also determines whether working adults with disabilities receiving SSI qualify for continuing Medicaid eligibility after an SSI status change under the special provisions in § 1619(a) or § 1619(b). Under § 1619(a) and § 1619(b), SSI beneficiaries who have increased earned income from work are able to retain their Medicaid coverage. The amount of the additional earned income affects whether these provisions apply and, respectively, whether SSI cash assistance is reduced or eliminated. However, Medicaid primary care essential benefit coverage and, as applicable, LTSS continue without regard to changes in SSI status until the State is notified otherwise by the SSA. 1. § 1619(a) – “Special cash assistance” is available when an SSI beneficiary with a disability has gross earned income for the month that exceeds the amount ordinarily allowed to obtain or retain SSI eligibility. Both the special cash payments and Medicaid coverage are authorized in this instance under § 1619(a). Any beneficiary may qualify for § 1619(a) as early as their second month on the SSI rolls. To qualify, a person must: a. Continue to have a disabling impairment and meet all other non- disability requirements; and b. Have been eligible for and received a regular SSI cash payment based on disability for a previous month within the current period of eligibility. The prerequisite month does not necessarily have to be the immediate prior month. 2. § 1619(b) – SSI beneficiaries who have earnings too high for an SSI cash payment may be eligible for Medicaid if they meet certain requirements. To qualify for continuing Medicaid coverage under § 1619(b), a person must:
a. Have been eligible for an SSI cash payment for at least one (1) month before the month when § 1619(b) is established; b. Continue to have a disabling impairment and, except for earnings, meet all other non-disability requirements; c. Need Medicaid benefits to continue to work; and d. Have gross earnings after excluding all work-related impairment expenses, blind work expenses, and earnings used to achieve an approved plan for self-support that are insufficient to replace SSI, Medicaid, and publicly funded attendant care services. (1) SSA uses a threshold amount to measure whether a person’s earnings are high enough to replace their SSI and Medicaid benefits. This threshold is based on the amount of earnings which would cause SSI cash payments to stop in the person’s State and average Medicaid expenses for persons who are blind or living with a disability in the State. The amount is recalculated annually and is published by the SSA. (2) If an SSI beneficiary has gross earnings higher than the threshold amount, SSA calculates an individual threshold amount, taking into account: (AA) Impairment-related work expenses; (BB) Blind work expenses; (CC) A plan to achieve self-support; or (DD) The value of any personal attendant services that are publicly funded through the DHS Office of Rehabilitative Services; and (EE) Medical expenses above the average State amount or, if higher, the person’s actual medical expenses. C. The respective roles and responsibilities of the State and beneficiaries eligible for continuing Medicaid coverage through § 1619(a) or § 1619(b) are as follows: 1. State a. Benefits. The State must ensure that all required primary care essential benefits and any necessary work supports covered under the Medicaid State Plan or Section 1115 Waiver are available to members of these coverage groups on a timely basis.
b. Continuing eligibility. All SSI Medicaid-eligible beneficiaries are auto-renewed unless or until the State receives notification of termination of SSI. The State must evaluate whether Medicaid eligibility is available in all other coverage categories before initiating the termination process in accordance with Part 40-00-2 of this Title. 2. Applicants/Beneficiaries a. Applicants and beneficiaries must provide timely, accurate and complete information about any eligibility factors subject to change, including any changes in work circumstances or earnings that may affect continuing access to coverage through the pathways identified in this Part. In addition: (1) Consent – At the time a Medicaid beneficiary eligible on the basis of SSI no longer qualifies for continuing coverage under § 1619(a) or § 1619(b), the State may request that they provide the State with consent to retrieve and review any information not currently on record pertaining to the eligibility factors subject to change through electronic data matches conducted through the State’s eligibility system. Once such consent is provided, the Medicaid agency may retrieve and review such information when conducting all subsequent eligibility determinations and annual renewals. (2) Duty to Report – Medicaid beneficiaries are required to report changes in eligibility factors to the Medicaid agency within ten (10) days from the date the change takes effect. Self-reports are permitted through the eligibility system consumer self-service portal as well as in person, via fax, or mail. Flexibility in reporting is allowed when a beneficiary changes work status and employers do not provide timely documentation of such changes. 1.6 Community Medicaid Eligibility for Low-income Elders and Adults with Disabilities (EAD) A. Working adults with disabilities who do not qualify for SSI due to excess income may be eligible for initial or continuing Medicaid coverage through the EAD pathway pursuant to Subchapter 05 Part 1 of this Chapter or as medically needy under Part Subchapter 05 Part 2 of this Chapter. All EAD beneficiaries are entitled to primary care essential benefits and any necessary work supports covered under the Medicaid State Plan or Section 1115 Waiver. B. Working adults with disabilities may obtain initial or continuing eligibility through the following:
1. Work-related protections – Some applicants/beneficiaries may qualify for several of the same special provisions available to applicants and beneficiaries that reduce or protect earned income set forth in Subchapter 00 Part 3 of this Chapter, including but not limited to: a. PASS Disregard – Income, whether earned or unearned, of a person who is blind or living with a disabling impairment may be excluded if such income is needed to fulfill a Plan for Achieving Self-Support (PASS). This exclusion does not apply to applicants who are age sixty-five (65) or older, unless the applicant was receiving SSI or State Supplemental Payment (SSP) before reaching that age. For additional information on the PASS, see the Federal SSI Regulations at 20 C.F.R. §§ 416.1180 through 416.1182. b. Impairment-Related Work Expenses – Earned income used by a person with disabilities to pay impairment-related work expenses is disregarded. For the disregard to apply, the person must have a disability and be under age sixty-five (65) or have been eligible for and received SSI based on disability for the month before reaching age sixty-five (65). In addition, the following must be met: (1) The severity of the impairment must require the person to purchase or rent items and services in order to work; (2) The expense must be reasonable given the nature of the disability or impairment and the type of employment, as determined by the agency; (3) The expense must be paid in cash (including checks, money orders, credit cards and/or charge cards) by the person and must not be reimbursable from another source, such as Medicare or private insurance; and (4) The payment for the expense must be made in a month the person receives earned income and anticipated work or worked and used the services or the item purchased, or the person must be working and pay the expense before earned income is received. (5) Impairment-related work expenses that may qualify for this disregard are described in Federal SSI Regulations at 20 C.F.R. § 416.976. b. Student Child Earned Income Exclusions (SEIE) – For a student under age twenty-two (22) or a person who is blind or disabled and regularly attending school, a set amount of earned income per month up to a yearly maximum may be excluded. The Federal
government determines the monthly and maximum amounts based on variety of factors and adjusts the figures annually to reflect increases in the cost of living. The amount of the exclusion is set by the Federal government and updated on an annual basis, as described in Part 40-00-3 of this Title. c. Work-Related Expenses of Blind Persons – Earned income used to meet any expenses reasonably attributable to the earning of income by a person who is blind and under age sixty-five (65) or received SSI as a blind person for the month before reaching the age of sixty-five (65). Further, expenses may be disregarded if the person has a PASS. The amounts must be reasonable and not exceed the earned income of the blind person or a blind spouse. See references on PASS, including types of expenses that qualify for this disregard in Part 40-00-3 of this Title. d. RI Works Under a PASS. RI Works payments administered by the RI Department of Human Services under a PASS are excluded. However, RI Works payments not excluded under a PASS are countable income. 2. Community Medicaid Medically Needy – Coverage is available to elders and adults with disabilities with high medical expenses who have income above the EAD countable income limit of one hundred percent (100%) of the FPL, but otherwise meet all of the general eligibility requirements for Medicaid as set forth in Part 40-05-1 of this Title. Work related disregards identified in § 1.6(B) of this Part are taken into account when determining financial eligibility for the Community Medicaid medically needy pathway. Beneficiaries have the option of consulting with an agency eligibility specialist when considering whether the Medically needy pathway provides them with the level Medicaid benefits and coverage they need while continuing to work. The Sherlock or Ticket to Work pathway may be a more appropriate option in some instances due to the following: a. Scope of coverage. Until excess income over the eligibility limit has been exhausted during the six (6) month spenddown period, beneficiaries who choose the medically needy pathway are responsible for paying out-of-pocket for all health care expenses that are not covered by a third party such as Medicare or a commercial plan, including for any necessary work supports. Expenses associated with third party coverage, such as premiums, co-pays and deductibles do count toward the spenddown. See Subchapter 05 Part 2 of this Chapter on the Medically needy eligibility pathway for additional information. b. Continuing eligibility. Renewal of Medically needy eligibility and the initiation of another spenddown period may require a
redetermination of countable income through the integrated eligibility system (IES). 3. Sherlock Plan for Working People with Disabilities and the Ticket to Work Program – Applicants who qualify for Medicaid coverage under more than one (1) eligibility pathway may choose the pathway most suited to their unique needs. Accordingly, the Sherlock or Ticket to Work eligibility pathways are also available for applicants and beneficiaries who qualify through the medically needy pathway but are unable to obtain the supports they need through a spenddown. C. The respective roles and responsibilities of the State and applicants/beneficiaries with disabilities who are working and seeking initial or continuing Medicaid coverage through the EAD pathway are set forth in Part 40-05-1 of this Title. 1.7 Medicaid Affordable Care Coverage (MACC) MAGI-Eligible Adults A. Working adults with disabilities who are eligible through the Medicaid Affordable Care Coverage (MACC) groups in: the ACA adult expansion pathway for persons ages nineteen (19) through sixty-four (64); the parent/caretaker pathway; or pregnant people pathway may obtain the work-related services and supports they need through their Medicaid managed care plan or, if enrolled in fee-for- service or a RIte Share approved employer-sponsored insurance plan, through certified Medicaid providers. Pre-authorization of services by the plan or Medicaid provider is required unless a disability determination has been made by the Medicaid Assessment and Review Team (MART) or another government entity such as the Federal Social Security Administration (SSA). B. There are no special disregards for working adults with disabilities available through the MAGI methodology for determining income eligibility. However, MACC eligible beneficiaries, including those who qualify for Medicaid LTSS, are not liable under Federal law to pay a share of the costs of their care. C. If earnings from work increase income above the applicable MACC group eligibility limit, applicants and beneficiaries must seek coverage through an alternative Medicaid eligibility pathway that uses the SSI methodology and requires a formal disability determination by the MART, unless such a determination has already been made by another government authority including the SSA. The IES automatically evaluates persons for these alternative forms of eligibility if they do not qualify for MACC group coverage due to excess income. Depending on a person’s income and resources and level of need, the available pathways are as follows: 1. Community Medicaid (Non-LTSS) – The three (3) alternative eligibility pathways for MACC eligible working adults with disabilities who are not seeking or do not meet the level of care criteria for the full scope of
Medicaid long-term services and supports are: Community Medicaid EAD, including the Medically needy pathway as specified in Parts 40-05-1 and 40-05-2 of this Title and above, the Sherlock pathway, as set forth in § 1.9 of this Part, and the Ticket to Work Program as set forth in § 1.10 of this Part. The SSI work-related income disregards indicated in § 1.5(B)(1) of this Part are applied and a disability determination by the MART or SSA is required. 2. Medicaid LTSS – MAGI-eligible working adults with disabilities who meet the level of care requirements for Medicaid long-term services must be determined disabled to obtain work-related services and supports. If income exceeds the MACC group limit due to earnings from work, eligibility may continue to be available through the LTSS/SSI-related pathways including LTSS Medically needy (§ 1.8 of this Part), the Sherlock pathway (§ 1.9 of this Part), or the Ticket to Work Program (§ 1.10 of this Part). The SSI work-related income disregards indicated in § 1.5(B)(1) of this Part are applied and a disability determination by the MART or SSA is required. 1.8 Medicaid Long-term Services and Supports (LTSS) 1.8.1 Eligibility Determination Process A. Adults with disabilities who are seeking LTSS – both current Medicaid beneficiaries and new applicants – who do not qualify for MACC group LTSS are evaluated for eligibility across the pathways set forth in Part 50-00-1 of this Title using the SSI methodology. Accordingly, they may qualify for the work-related income disregards identified in § 1.5(B)(1) of this Part in the eligibility determination process. If a beneficiary is eligible for multiple LTSS options, the beneficiary may choose their eligibility group. B. In accordance with Part 50-00-5 of this Title, all applicants/beneficiaries seeking LTSS must meet clinical/functional level of care criteria. A separate disability determination by the SSA or MART is not required for applicants/beneficiaries who meet the clinical/functional level of care criteria for Medicaid LTSS unless the person is seeking LTSS through the Sherlock Plan or Ticket to Work Program. 1.8.2 Service Plan A. All Medicaid LTSS beneficiaries must have a service plan that ties benefits to their functional and clinical needs. If employment supports are needed, the role of work, if any, and any associated employment supports must be a component of this plan. For LTSS beneficiaries choosing home and community-based services, the service plan must reflect the decisions they make about their health goals established in the person-centered planning process set forth in 42 C.F.R. § 441.301 and in Part 50-10-1 of this Title. The development of a service plan is
guided by agency representatives as the components may vary depending on the type of a person’s disability, program requirements, and associated provisions under the Section 1115 Waiver and Medicaid State Plan. Accordingly, specific guidance is provided on this process. 1.8.3 Cost of Care A. In accordance with Federal requirements, under the State’s Medicaid State Plan and Section 1115 Waiver, all LTSS Medicaid beneficiaries eligible based on the SSI methodology who can afford to do so must pay a portion of income toward the cost of their care. A beneficiary’s liability for the cost of care is calculated in the post-eligibility treatment of income process in accordance with Part 50-00-8 of this Title and is based on gross monthly income – earned and unearned – less certain deductions or “allowances.” To encourage LTSS beneficiaries who have disabilities to work, there are special allowances which require the State to exclude some or all of the beneficiary’s earned income when determining the amount available to be applied toward the cost of care. In addition, under the Sherlock Plan and Ticket to Work Program, a beneficiary may opt to pay a monthly premium instead of a cost of care. B. A beneficiary’s LTSS cost of care may increase or decline when there are changes in income. The State provides timely notice of any changes in LTSS cost of care that may result at least ten (10) days before the start of the month when the change takes effect. 1.9 The Sherlock Plan A. The Sherlock Plan for Working People with Disabilities is an SSI-related eligibility pathway for working adults with disabilities age sixty-five (65) and older established pursuant 42 U.S.C. § 1396a(a)(10)(ii)(XIII) and R.I. Gen. Laws § 40- 8.7-1 et seq. B. Adults with disabilities eligible through the Sherlock pathway are entitled to the full scope of Medicaid benefits and home and community-based services and supports necessary to facilitate and/or maintain employment. This is the same scope of coverage available to all Medicaid-eligible adults with disabilities who work, without regard to eligibility pathway. Financial eligibility for the Sherlock pathway is determined in accordance with the SSI methodology as described in Subchapter 00 Part 3 of this Chapter y. Changes in employment follow the provisions in § 1.9.4. C. The Sherlock eligibility pathway is open to adults with disabilities who are working and seeking Medicaid coverage, either with or without LTSS HCBS benefits:
D. To qualify through the Sherlock pathway, a person must be determined disabled by a State or Federal government authority using the criteria established for the SSI program except for the provisions related to substantial gainful activity. 1. General eligibility requirements –To be Sherlock-eligible, a person must: a. Meet the non-financial eligibility requirements set forth in Part 10- 00-3 of this Title; b. Be age sixty-five (65) or older; and c. Have proof of active, paid employment such as a pay stub or current quarterly U.S. Internal Revenue Service (IRS) tax statement (for those who are self-employed). 2. Financial eligibility – Applicants for Sherlock eligibility are subject to the SSI methodology for counting income and resources set forth in Subchapter 00 Part 3 of this Chapter. The following income and resource standards apply: a. Income. Countable earned net income must be no greater than two hundred fifty percent (250%) of the FPL. Countable earned net income is defined as the total of earned income remaining after all SSI-related disregards are applied; and b. Resources. Total countable resources must be no greater than ten thousand dollars ($10,000.00) (individual) or twenty thousand dollars ($20,000.00) (couple). Medical savings accounts, retirement accounts, or accounts determined to be for the purposes of maintaining independence are not counted as a resource; approved items that are necessary for a person to remain employed are also not counted as a resource (such as a wheelchair accessible van). 3. Retroactive coverage – As an SSI-related coverage group, applicants may be eligible for up to ninety (90) days of retroactive coverage. Eligibility for retroactive coverage is determined in accordance with Subchapter 05 Part 2 of this Chapter once the premium or cost of care requirements set forth below in § 1.8.2 of this Part have been met. 1.9.1 Types of Cost Sharing A. Depending on their countable income from all sources, both LTSS and non-LTSS Sherlock beneficiaries may be required to pay a share of the cost of coverage. Non-LTSS Sherlock beneficiaries subject to a cost share are required to pay a premium; LTSS Sherlock beneficiaries who have a cost share have the choice of paying a cost of care or a premium.
1. Sherlock Premium – To calculate a premium, the earned income of the Sherlock beneficiary and their spouse, if applicable, are added together and then all SSI-related disregards are applied. The remaining earned income is added to the unearned income of the beneficiary or couple (after unearned income disregards are applied) and are assigned a premium as follows: a.
Income Monthly Premium Less than 150% FPL No premium At least 150% and less than 185% FPL $ 61.00 At least 185% and less than 200% FPL $ 77.00 At least 200% and up to 250% FPL $ 92.00 b. Premiums must be paid in full before retroactive coverage for allowable health care expenses is made available by the State. 2. LTSS Sherlock Cost of Care – The State bases its calculation of a LTSS Sherlock beneficiary’s cost of care in accordance with the post-eligibility treatment of income rules set forth in Part 50-00-8 of this Title. A LTSS Sherlock beneficiary is entitled to all the allowances set forth therein when determining the amount of income available to pay toward the cost of care. 3. Sherlock LTSS beneficiary choice – The State calculates both the monthly premium and the LTSS cost of care for Sherlock LTSS beneficiaries. An LTSS eligibility specialist is responsible for informing the beneficiary of the premium versus the LTSS cost of care and assisting the beneficiary in making an appropriate choice. The State does not impose or collect a cost share until a Sherlock LTSS beneficiary has been so informed and made a choice. Coverage may not be delayed or denied pending the beneficiary’s decision. 1.9.2 Non-Payment Sherlock Cost Share A. Absent a hardship exemption, EOHHS will terminate eligibility after a beneficiary fails to pay their premium for ninety (90) days.
B. The provisions governing non-payment of LTSS cost of care are set forth in the LTSS post-eligibility treatment of income rule contained in Part 50-00-8 of this Title. 1.9.3 Hardship Exemption A. If circumstances arise that prevent a beneficiary eligible through the Sherlock pathway from paying their premium in a given month, the beneficiary may apply for a hardship exemption.
1. An individual is eligible for a hardship exemption if they meet any of the following criteria in the month for which they are applying: a. They were unhoused b. They were evicted in the past six (6) months or were facing eviction or foreclosure c. They received a shut-off notice from a utility company d. They recently experienced domestic violence e. They recently experienced the death of a close family member f. They experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to their property g. They filed for bankruptcy in the last six (6) months h. They had medical expenses they could not pay in the last 24 months that resulted in substantial debt i. They experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member j. They expect to claim a child as a tax dependent who has been denied coverage in Medicaid and Children’s Health Insurance Program (CHIP), and another person is required by court order to provide medical support to the child and that person does not do so k. They experienced other extenuating circumstances that inhibited their ability to pay their premium
2. If the hardship exemption request is approved the beneficiary will not be required to pay the premium amount that was due on the invoice to which the individual responded with the hardship request. Invoices will reflect the amount due for the current month as well as any past-due amounts for the previous unpaid premiums.
3. If the hardship exemption request is denied, the beneficiary will be required to pay the premium.
4. Beneficiaries have the right to appeal an adverse hardship decision. Additional information regarding appeals can be found in Part 10-05-2 of this Title. 1.9.4 Loss of Employment or Eligibility A. A Sherlock beneficiary who loses employment may retain eligibility for up to four (4) months by continuing to pay the applicable cost share, whether a premium or LTSS cost of care payment. If the person is still unemployed at the end of the four (4) month period, Sherlock eligibility is terminated. Prior to taking this action, the State evaluates the Sherlock beneficiary for all other forms of Medicaid eligibility as well as for coverage for a commercial plan through HSRI, the State’s health insurance marketplace. 1.9.5 Available Services A. Services include the full scope of categorical Medicaid benefits, including home and community-based services if eligible for LTSS, including personal care services provided through an agency or through a self-directed program and services needed to facilitate and/or maintain employment, as described in Chapter 50 of this Title. Services are coordinated through the appropriate unit in EOHHS, DHS or BHDDH or a contractual designee of the agency. B. Services to maintain and support employment are determined when developing a service plan, or through an assessment of need utilizing a state approved assessment instrument or an EOHHS approved prior authorization plan. Authorized personal care services may be provided in the home, workplace or other necessary setting (such as a physician office). 1.10 The Ticket to Work Program A. The Ticket to Work Program is an SSI-related eligibility pathway for working adults with disabilities established pursuant to 42 U.S.C. § 1396a(a)(10)(A)(ii)(XV) and R.I. Gen. Laws § 40-8.7-1 et seq. B. Adults with disabilities eligible through the Ticket to Work Program are entitled to the full scope of Medicaid benefits and home and community-based services and supports necessary to facilitate and/or maintain employment. This is the same scope of coverage available to all Medicaid-eligible adults with disabilities who work, without regard to eligibility pathway. Financial eligibility for the Ticket to Work pathway is determined in accordance with the SSI methodology as described in Subchapter 00 Part 3 of this Chapter.
C. The Ticket to Work eligibility pathway is open to adults with disabilities who are working and seeking Medicaid coverage, either with or without LTSS HCBS benefits: D. To qualify through the Ticket to Work pathway, a person must be determined disabled by a State or Federal government authority using the criteria established for the SSI program except for the provisions related to substantial gainful activity. 1. General eligibility requirements –To be Ticket to Work-eligible, a person must: a. Meet the non-financial eligibility requirements set forth in Part 10- 00-3 of this Title; b. Be age between the ages of sixteen (16) and sixty-four (64); and c. Have proof of active, paid employment such as a pay stub or current quarterly U.S. Internal Revenue Service (IRS) tax statement (for those who are self-employed). 2. Financial eligibility – Applicants for Ticket to Work eligibility are subject to the SSI methodology for counting income and resources set forth in Subchapter 00 Part 3 of this Chapter. However, there are no income or resource limits for the program. Nonetheless, income and resources must be reported for the purposes of calculating cost sharing amounts and, if applicable, determining if disqualifying transfers of assets have been made according to Part 50-00-6 of this Title. 3. Retroactive coverage – As an SSI-related coverage group, applicants may be eligible for up to ninety (90) days of retroactive coverage. Eligibility for retroactive coverage is determined in accordance with Subchapter 05 Part 2 of this Title once the premium or cost of care requirements set forth below in § 1.10.1 of this Part have been met. 1.10.1 Types of Cost Sharing A. Depending on their countable income from all sources, both LTSS and non-LTSS Ticket to Work beneficiaries may be required to pay a share of the cost of coverage. Non-LTSS Ticket to Work beneficiaries subject to a cost share are required to pay a premium; LTSS Ticket to Work beneficiaries who have a cost share generally have the choice of paying a portion of income or premium. 1. Ticket to Work Premium –To calculate a premium, the earned income of the Ticket to Work beneficiary and their spouse, if applicable, are added together and then all SSI-related disregards are applied. The remaining earned income is added to the unearned income of the beneficiary or
couple (after unearned income disregards are applied) and are assigned a premium as follows: a.
Income Monthly Premium Less than 150% FPL No premium At least 150% and less than 185% FPL $ 61.00 At least 185% and less than 200% FPL $ 77.00 At least 200% and less than 250% FPL $ 92.00 At least 250% and less than 300% FPL $ 110.00 At least 300% and less than 350% FPL $ 130.00 At least 350% and less than 400% FPL $ 150.00 At least 400% and less than 450% FPL $ 170.00 At least 450% and less than 500% FPL $ 190.00 At least 500% and less than 550% FPL $ 210.00 At least 550% and less than 600% FPL $ 230.00 At least 600% and less than 650% FPL $ 250.00 At least 650% and less than 700% FPL $ 270.00 At least 700% and less than 750% FPL $ 290.00
At least 750% and less than 800% FPL $ 310.00 At least 800% FPL and less than 850% FPL $ 330.00 At least 850% FPL and less than 900% FPL $ 350.00 Greater than 900% FPL $ 370.00 b. Premiums must be paid in full before retroactive coverage for allowable health care expenses is made available by the State. 2. LTSS Ticket to Work Cost of Care – The State bases its calculation of a LTSS Ticket to Work beneficiary’s liability for the cost of care in accordance with the post-eligibility treatment of income rules set forth in Part 50-00-8 of this Title. A LTSS Ticket to Work beneficiary is entitled to all the allowances set forth therein when determining the amount of income available to pay toward the cost of care. The LTSS cost of care option is available only if the beneficiary’s countable income is less than or equal to the private pay rates established in Part 50-00-2 of this Title. 3. Ticket to Work LTSS beneficiary choice – The State calculates both the monthly premium and the LTSS cost of care, if applicable, for Ticket to Work LTSS beneficiaries. An LTSS eligibility specialist is responsible for informing the beneficiary of the premium versus the LTSS cost of care costs and assisting the beneficiary in making an appropriate choice if they qualify for both options. The State does not impose or collect a cost share until a Ticket to Work LTSS beneficiary has been so informed and made a choice. Coverage may not be delayed or denied pending the beneficiary’s decision. 1.10.2 Non-Payment Ticket to Work Cost Share A. Absent a hardship exemption, EOHHS will terminate eligibility after a beneficiary fails to pay their premium for ninety (90) days. B. The provisions governing non-payment of LTSS cost of care are set forth in the LTSS post-eligibility treatment of income rule contained in Part 50-00-8 of this Title. 1.10.3 Hardship Exemption A. If circumstances arise that prevent a beneficiary eligible through the Ticket to Work pathway from paying their premium in a given month, the beneficiary may apply for a hardship exemption as described at 1.9.3(A)(1) of this Part.
1. If the hardship exemption request is approved for a given month, that month’s premium invoice will be cleared.
2. If the hardship exemption request is denied, the beneficiary will be required to pay the premium. 1.10.4 Loss of Employment or Eligibility A. A Ticket to Work beneficiary who loses employment may retain eligibility for up to four (4) months by continuing to pay the applicable cost share, whether a premium or LTSS cost of care payment. If the person is still unemployed at the end of the four (4) month period, Ticket to Work eligibility is terminated. Prior to taking this action, the State evaluates the Ticket to Work beneficiary for all other forms of Medicaid eligibility as well as for coverage for a commercial plan through HSRI, the State’s health insurance marketplace. 1.10.5 Available Services A. Services include the full scope of categorical Medicaid benefits, including home and community-based services if eligible for LTSS, including personal care services provided through an agency or through a self-directed program and services needed to facilitate and/or maintain employment, as described in Chapter 50 of this Title. Services are coordinated through the appropriate unit in EOHHS, DHS or BHDDH or a contractual designee of the agency. B. Services to maintain and support employment are determined when developing a service plan, or through an assessment of need utilizing a state approved assessment instrument or an EOHHS approved prior authorization plan. Authorized personal care services may be provided in the home, workplace or other necessary setting (such as a physician office).
210-RICR-40-15-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 40 - MEDICAID FOR ELDERS AND ADULTS WITH DISABILITIES SUBCHAPTER 15 - DISABLED WORKING ADULTS PART 1 - “MEDICAID CODE OF ADMINISTRATIVE RULES, SECTION 1373: MEDICAID FOR WORKING PEOPLE WITH DISABILITIES PROGRAM” (210-RICR-40- 15-1) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 01/02/2025 December 13, 2024 E-SIGNED by Richard Charest on 2024-12-13 11:56:43 EST December 13, 2024 E-SIGNED by Department of State on 2024-12-13 12:46:37 EST
210-RICR-50-00-1 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 – MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 – LONG-TERM SERVICES PART 1 – Medicaid Long-Term Services and Supports Overview and Eligibility Pathways 1.1 Overview
The provisions set forth herein pertain to the scope of Medicaid long-term services and supports (LTSS) and the various pathways for initial and continuing eligibility. 1.2 Legal Authority A. This Chapter of Rules related to Medicaid LTSS is promulgated pursuant to Federal authorities as follows: 1. Federal Law: Title XIX of the U.S. Social Security Act 42 U.S.C. §§ 1396a, 1115, 1902, 1903, 1905, 1915; 1396k; and 1413(b)(1)(A) of the Affordable Care Act. 2. Federal Regulations: 42 C.F.R. Parts 431,435, 440, and 441. 3. The Medicaid State Plan and the Title XIX, Section 1115(a) Demonstration Waiver (11-W-00242/1), effective through December 31, 2018. B. Additionally, legal authority related to LTSS is derived from R.I. Gen. Laws Chapter 40-8 and Chapters 40-8.6 to 40-8.13. 1.3 Definitions A. For the purposes of LTSS Medicaid, the following definitions apply: 1. “Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals" or "BHDDH” means the State agency established under the provisions of R.I. Gen. Laws Chapter 40.1-1 whose duty it is to serve as the State’s mental health authority and establish and promulgate the overall plans, policies, objectives, and priorities for State programs for adults with intellectual and developmental disabilities as well mental illness and substance abuse education, prevention and treatment.
2. “Department of Human Services" or "DHS” means the State agency established under the provisions of R.I. Gen. Laws Chapter 40-1 that is empowered to administer certain human services. The DHS has been delegated the authority through an interagency service agreement with the Executive Office of Health and Human Services (EOHHS), the Medicaid Single State Agency, to determine Medicaid eligibility in accordance with applicable State and Federal laws, Rules and Regulations. 3. “Developmental disability” means, for the purposes of the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, a condition that affects a person, eighteen (18) years or older, who is either an intellectually developmentally disabled adult or a person with a severe, chronic disability that: a. Is attributable to a mental or physical impairment or combination of mental and physical impairments; b. Manifests before the person attains age twenty-two (22); c. Is likely to continue indefinitely; d. Results in substantial functional limitations in three (3) or more of the following areas of major life activity: (1) Personal care (2) Communication (3) Mobility (4) Learning (5) Self-direction (6) Capacity for independent living (7) Economic self-sufficiency; and (8) Reflects the person's need for a combination and sequence of special, interdisciplinary, or generic care, treatment or other services which are life-long or of extended duration and are individually planned and coordinated. 4. "Eligibility date" means the first (1st) day of the month in which a person is eligible for Medicaid LTSS. It is based on the month the application or, for existing beneficiaries, the request for LTSS is made and is otherwise unrelated to the date a person entered an institution or began receiving
LTSS, regardless of payer. The eligibility date does not include periods of retroactive eligibility. 5. “Executive Office of Health and Human Services" or "EOHHS” means the State agency established in 2006 under the provisions of R.I. Gen. Laws Chapter 42-7.2 within the executive branch of State government which serves as the principal agency for managing the Departments of Children, Youth, and Families (DCYF); Health (RIDOH); Human Services (DHS); and Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH). 6. “Financial eligibility” means the set of factors used to determine whether a person is entitled to receive services based upon income and/or resource requirements, as well as limitations related to the transfer of assets, which includes both liquid resources and real property, prior to the application for Medicaid LTSS. 7. “Functional disability” means any long-term limitation resulting from an illness, health condition, or impairment that affects a person’s ability to perform certain activities of daily living without substantial assistance or supervision. 8. “Home and Community-Based Services" or "HCBS” means any Medicaid LTSS State Plan or Section 1115 waiver-authorized services available to beneficiaries at home or in a community-based setting. 9. “Institution” or "Health institution" means a State-licensed health facility that provides health and/or social services and supports on an in-patient basis. For the purposes of this Rule, the term means long-term care hospitals and treatment facilities (LTH), intermediate care facilities for persons with intellectual disabilities (ICF/ID), and nursing facilities (NF). 10. “Integrated Health Care Coverage Groups” or "IHCC" means any Medicaid coverage group consisting of adults who are eligible based on receipt of Supplemental Security Income (SSI), SSI protected status, the SSI income methodology and a related characteristic (age or disability), or as a result of participation in another Federal or State program, such as the Breast and Cervical Cancer Program. This group includes beneficiaries eligible for community Medicaid (non-long-term care), Medicaid-funded LTSS and the Medicare Premium Payment Program (MPPP). 11. “Integrated Health and Human Services Eligibility System" or "IES” means the State's eligibility system that enables applicants, through a single application, to be considered for multiple health and human service programs simultaneously.
12. “Intermediate Care Facility for Persons with Intellectual/Developmental Disabilities" or "ICF/ID” means a State-licensed health care facility that provides long-term services and supports to persons with intellectual/developmental disabilities. 13. “Katie Beckett eligibility” means an eligibility category that allows certain children under age nineteen (19) who have long-term disabilities or complex medical needs who require an institutional level of care to obtain the Medicaid long-term services they need at home. With Katie Beckett eligibility, only the child’s income and resources are considered when determining eligibility. 14. “Long-term services and supports" or "LTSS" means a spectrum of services covered by the Medicaid program for persons with clinical and functional impairments and/or chronic illness or diseases that require the level of care typically provided in a health care institution. Medicaid LTSS includes skilled or custodial nursing facility care, therapeutic day services, and personal care as well as various home and community-based services. Medicaid beneficiaries eligible for LTSS are also provided with primary care essential benefits. The scope of these services and supports and the choice of settings is determined by a comprehensive assessment of each person's unique care needs. 15. “LTSS living arrangement” means the institutional or home or community- based setting where a Medicaid LTSS beneficiary resides while receiving Medicaid LTSS. 16. “LTSS specialist” means a State agency representative responsible for conducting assessments, determining eligibility for LTSS, authorizing services, and/or providing assistance to people in navigating the Medicaid LTSS system. 17. “Medicaid Affordable Care Coverage Groups” or "MACC" means a classification of persons eligible to receive Medicaid who are subject to the Modified Adjusted Gross Income or "MAGI" standard for determining income eligibility as outlined in the Medicaid Code of Administrative Rules, Medicaid MAGI Financial Eligibility Determinations and Verification (See Part 30-00-5 of this Title). 18. “MAGI standard” means the method for evaluating Medicaid income eligibility using the modified adjusted gross income (MAGI) standard established under the ACA. Persons who are or would be income-eligible for the ACA expansion for adults may obtain Medicaid LTSS if they meet the applicable clinical/functional eligibility criteria, are under age sixty-five (65), and are not eligible for or enrolled in Medicare.
19. "Medicaid single state agency" means the State agency authorized under State law, Title XIX of the U.S. Social Security Act (42 U.S.C. § 1396a et seq.) and the Medicaid State Plan as the entity legally responsible for the program/fiscal management and administration of the Medicaid program. The EOHHS is the designated single State agency in Rhode Island. 20. “Needs-based criteria” means the basis for determining clinical/functional eligibility for Medicaid LTSS. The LTSS needs-based criteria encompass medical, social, functional, and behavioral factors, and the availability of family support and financial resources. 21. “Preadmission Screening and Resident Review" or "PASRR” means the process required by Federal law that evaluates and ensures individuals who have a serious mental illness (SMI) and/or intellectual disability are not inappropriately placed in nursing facilities for long-term care. PASRR requires that those applicants for a Medicaid-certified nursing facility are evaluated for appropriateness. 22. “Primary care essential benefits” means non-LTSS Medicaid health coverage, and includes an array of acute, subacute, and specialty essential benefits, as identified under the Medicaid State Plan, provided by licensed health professionals. These essential benefits include, but are not limited to: health promotion, disease prevention, health maintenance, counseling, patient education, various specialty services and diagnosis and treatment of acute and chronic medical and behavioral health illnesses and conditions in a variety of health care settings such as office visits, inpatient, home care, and day care. 1.4 Types of LTSS A. Under the terms of Title XIX of the U.S. Social Security Act of 1964, Medicaid LTSS in an institutional-setting is a State Plan service available to all otherwise eligible Medicaid beneficiaries and new applicants, providing they meet certain eligibility factors. B. “Institution” is the term used in Title XIX to refer to a hospital (H), an intermediate care facility for persons with intellectual/developmental disabilities (ICF/ID), and a nursing facility (NF). These institutions are licensed in Rhode Island by the Department of Health (RIDOH) as health care facilities under Chapter 23-17 of the R.I. Gen. Laws. Although the term "institution" is not accurate in a licensure sense, under Federal Regulations at 42 C.F.R. § 440.40, the eligibility criteria for Medicaid LTSS remain tied to these institutional settings and vary in accordance with types of services each typically provides and the needs of the population(s) they serve. As these services are now also available to beneficiaries in a home and community-based setting, the Medicaid LTSS Rules apply across settings, as follows:
1. Medicaid LTSS in Health Care Institutions – Persons who meet the applicable eligibility requirements may access LTSS in the following State- licensed health care institutions/facilities a. Nursing Facilities (NF). A person is eligible to access Medicaid LTSS in a NF when it is determined, based on a comprehensive assessment, that he or she has the highest need for a NF level of care. b. Intermediate Care Facility for persons with Intellectual/Developmental Disabilities (ICF/ID). To qualify, a person must meet the applicable statutory standards set forth in R.I. Gen. Laws § 40.1-22-6 pertaining to developmental disabilities and: (1) Have the level of need for LTSS typically provided in an ICF- ID; or (2) Would require an ICF/ID level of care if were not for LTSS provided in a home or community based setting. As the State's Section 1115 waiver provides the authority for the home and community-based LTSS provided to members of this population with developmental disabilities, the BHDDH is required to provide services in the least restrictive setting appropriate to a person's level of care needs. c. Long-term Hospital (LTH) – A person must meet the needs-based criteria for long-term services in a hospital setting established by BHDDH and/or the EOHHS. Medicaid LTSS may also be available to children in State custody or with special health care needs receiving services in residential treatment facilities and hospitals if they meet the applicable level of care requirements. 2. Medicaid Home and Community-based (HCBS) LTSS – The State’s Section 1115 demonstration waiver authorizes Medicaid LTSS when provided in a home and offers an array of community-based settings as an alternative to care in one (1) of the three (3) principal covered health care institutions (NF, ICF/ID, or LTH). Access to these services enables beneficiaries to optimize their health and retain their independence while delaying or diverting the need for care in a more restrictive health care institutional setting. a. Scope of HCBS Coverage. Medicaid HCBS includes both core and specialized services and supports authorized under the State Plan or Section 1115 demonstration that address each individual beneficiary's unique long-term functional and clinical needs. The array of HCBS may vary depending on the beneficiary’s needs and the institutional level of care required.
b. Limitations. Room and board are NOT covered for HCBS by Medicaid. 1.5 Applicability
The provisions set forth herein apply to any person seeking Medicaid LTSS coverage, including those who are uninsured, receiving non-LTSS Medicaid under Part 40-00-3 of this Title or “Medicaid Integrated Health Care Coverage, SSI Financial Eligibility Determinations”, or have third (3rd) party forms of coverage through Medicare or a commercial insurer. 1.6 Scope of LTSS Coverage A. Upon being determined eligible for Medicaid LTSS, a beneficiary is entitled to Medicaid State Plan and Section 1115 waiver services across the care continuum. Subchapters 05 and 10 of this Chapter identify the LTSS covered services and the various Medicaid LTSS programs that serve beneficiaries with specific types of health needs, including the following: 1. Primary care essential benefits. All LTSS Medicaid beneficiaries are entitled to receive the primary care essential health benefits available to beneficiaries in the MACC and IHCC groups, covered under the Medicaid State Plan and Section 1115 demonstration waiver, including primary and preventive care as well as acute and subacute services. If a beneficiary has third (3rd) party insurance, such as Medicare or commercial insurance that does not provide the full scope of Medicaid benefits, Medicaid provides wrap-around coverage for any Medicaid services that are unavailable. 2. Institutional and home and community-based care. Medicaid LTSS beneficiaries are eligible for the full scope of LTSS covered by the Medicaid State Plan and Section 1115 waiver. As the State uses needs- based criteria to determine the scope of services a beneficiary is authorized to receive, Medicaid LTSS coverage varies along with a beneficiary’s functional capacity and acuity needs, social environment, access to family and other third (3rd) party supports, and personal choices. The range of Medicaid LTSS extends from 24/7 comprehensive care in a health institution to a limited package of services in a community-based setting, to one (1), a few, or a bundle of home and community core and ancillary services in the home. B. Medicaid beneficiaries who are receiving primary care essential benefits through a managed care plan or fee-for-service through a MACC group MAGI pathway pursuant to Part 30-00-1 of this Title (ACA Expansion Adults) or a IHCC group SSI (Supplemental Security Income or SSI eligible and SSI-protected status and Elders and Adults with Disabilities or EAD) pathway in accordance with Part 40- 00-1 of this Title may be eligible for Medicaid LTSS preventive (see § 40-05-1.8
of this Title) or full benefits if they meet certain clinical/functional and financial eligibility criteria. The State uses information known about the beneficiary when determining eligibility for LTSS for current Medicaid beneficiaries to the full extent feasible. The additional information required, as out-lined below, may be provided by completing the applicable sections of the DHS-2 form, or designated supplemental form, or by updating an on-line account as appropriate: Basis of Eligibility Supplemental Information Required from Existing Beneficiaries Seeking LTSS
Preventive LTSS Clinical/function (See Part 40-05-1 of this Title) Functional/clinical Level of Need (See Part 5 of this Subchapter) Financial Eligibility – Allocation of resources and transfer of assets – Part 40-00-3 of this Title and Part 6 of this Subchapter) Post-eligibility Treatment of Income (See Part 8 of this Subchapter) 1.SSI Documentation from health provider Documentation from health provider Limited to current information on spouse and dependents as related to spousal impoverishment and transfer of assets Applies – information related to allowances including income and expenses of spouse and dependents 2. EAD Documentation from health provider Documentation from health provider Limited to sixty (60) months pre-application of information on spouse and dependents as related to spousal impoverishment and transfer of assets Applies – information related to allowances income and expenses of spouse and dependents 3. ACA Expansion Adults Not applicable Documentation from health provider Limited sixty (60) months of pre- application information on resources of self, spouse and dependents as related to transfer of assets only Not applicable
1.7 Qualifying for Medicaid LTSS A. Under Title XIX, the federal Medicaid law, an applicant for LTSS must be either a current beneficiary or possess an income, clinical/functional, or age-related characteristic related to a MAGI eligible or SSI population AND have an established need to qualify to apply. With the enactment of the Federal Affordable Care Act of 2010, Federal law requires that Medicare, commercial health insurers, and group health plans provide as part of the primary care essential benefit package up to thirty (30) days of subacute and rehabilitative care for persons who have had an acute care incident requiring services in a health institution. Medicaid is also required to provide this benefit. Both existing beneficiaries and new applicants must have established a continuing need for LTSS – that is, for an institutional level of care – to qualify for Medicaid LTSS once the thirty (30) days of essential benefit coverage is exhausted. This need in previous Rhode Island Medicaid Rules was referred to as “considered institutionalized” for the purposes of determining Medicaid LTSS eligibility as indicated below: 1. Existing beneficiaries – Under the Medicaid State Plan, all Medicaid beneficiaries are eligible for up to thirty (30) days of LTSS coverage in addition to the required thirty (30) day essential benefit period of acute and subacute care in a health care institution as part of their non-LTSS primary essential benefit coverage. A separate determination of eligibility or change in service delivery is not required for this period of coverage. Therefore, an existing beneficiary may qualify to apply for Medicaid LTSS without a change in eligibility or service delivery options if they have received the required period of continuous coverage is provided in this manner or, if seeking LTSS in the home and community-based setting, they require or are receiving at least one (1) Medicaid covered LTSS benefit to address a functional need that otherwise would require care in an institutional setting. The Medicaid MCOs and DHS eligibility specialists are available to provide assistance to existing beneficiaries during this period. 2. New applicants – New Applicants are considered to have such a need if they have met one (1) of the following: a. Received the level of services typically provided in a NF, ICF-ID, or LTH setting for at least thirty (30) consecutive days and are expected to have a continued need for such services or have: (1) Obtained acute care services in a hospital or similar health facility for at least thirty (30) consecutive days and are seeking LTSS;
(2) Received Medicaid preventive level services while residing at home or in a community-based care setting for at least thirty (30) consecutive days; (3) Been determined to have needs that require the level of services typically provided in a health care institution for at least thirty (30) consecutive days or would require such services were those in the home and community-based setting not provided. b. Received or required at least one (1) Medicaid covered LTSS benefit at home or in a community-based setting to address a functional/clinical need that would otherwise necessitate the type of LTSS typically provided in a health institution. 1.8 Eligibility Determination Process A. There is a multiphase process for determining eligibility and authorization for Medicaid LTSS that includes the following steps: 1. Information, Referral, Options Counseling – Prior to initiating the application process and/or at any step during the eligibility determination sequence, applicants and/or their family members or authorized representatives may seek information, referral and/or options counseling to assist them in navigating the LTSS system. Part 4 of this Subchapter sets forth role of this service. 2. Person-centered Planning – Upon making application for LTSS, the person-centered planning process must begin for anyone seeking HCBS. The process is available, at the applicant's option, for LTSS in a health care institution as well. Person-centered planning is an individualized approach to planning that places the applicant at the center of decision- making thereby enabling him/her to direct his/her own services and supports in accordance with his/her own desires, goals and preferences, with impartial assistance and supported decision-making when helpful. Accordingly, the person-centered planning is an on-going process that continues through the eligibility determination process through to the authorization of services and thereafter. In accordance with 45 C.F.R. § 441.301(c)(1), the State must ensure that throughout this process, the applicant has sufficient and necessary information in a form he/she can understand to make informed choices and direct the planning process to the maximum extent possible. See Part 4 of this Subchapter for specific provisions. 3. Eligibility Determination Factors – To gain access to LTSS, the information provided by applicants is evaluated across the eligibility factors identified below, though not necessarily in a specific order:
a. General eligibility factors. All persons seeking initial or continuing Medicaid LTSS must meet the general requirements for the program related to residency, citizenship and immigration status, and Social Security Numbers and the like. The application form must be completed and signed along with the authorizations necessary to conduct electronic data matches to verify income and resources; and to request personal health information to assess and review clinical/functional level of need. General eligibility factors for MACC MAGI-based LTSS eligibility are located in § 30- 00-1.5(C) of this Title and for SSI-based LTSS eligibility in Part 5 of this Subchapter. Existing beneficiaries seeking LTSS must only update general eligibility information if there have been changes since the point of their last renewal. b. Clinical/functional eligibility factors. An assessment of clinical and functional needs serves as the basis for a level of care determination and is conducted for all persons seeking Medicaid LTSS, without regard to eligibility pathway. This assessment is based on needs-based criteria that evaluate clinical, functional, social and behavioral needs as well as environmental factors. A Medicaid Assessment and Review Team (MART) determination of disability status is not required unless the applicant is seeking LTSS coverage while working through the Sherlock Plan or unless the applicant has been deemed to have a disability by the Social Security Administration. In response to the novel Coronavirus Disease (COVID-19), until the end of the Federal declaration of the COVID-19 public health emergency, EOHHS will temporarily conduct level of care determinations/redeterminations for all LTSS eligibility pathways via phone and physician records. The responsibilities for assessing need vary for each institutional level of care as follows: (1) Nursing Facility. The State established clinical and functional disability criteria under the Section 1115 waiver which assess the scope of a beneficiary’s need for a NF level of care. The EOHHS is responsible for assessing the level of need of persons seeking Medicaid coverage of LTSS typically provided in a NF and long-term hospital care, including home and community-based alternatives. As indicated in Part 5 of this Subchapter, the scope of a person's clinical/functional need for a NF level of care (high or highest) affects the type of LTSS available to the person and thus the choice of setting (institutional and/or HCBS). (2) Intermediate care facilities for persons with intellectual disabilities. The BHDDH uses needs-based criteria to evaluate clinical/functional eligibility for the ICF/ID level of
care that incorporate the requirements set forth in State law (R.I. Gen. Laws § 40.1-22-6), the scope of services and supports required, and the impact of familial, social, and environmental factors that affect the choice of setting. (3) Long-term Hospital Care. Each agency serving beneficiaries who may require Medicaid LTSS in a hospital setting is authorized under the State’s 1115 waiver to tailor the clinical/functional criteria to meet their population’s general and unique needs within the parameters of applicable Federal Regulations and laws. This applies to persons seeking services through the EOHHS Habilitation Program that were authorized prior to establishment of the Section 1115 demonstration in 2009 under the State’s Section 1915(c) Habilitation Waiver and the various programs administered by the BHDDH. EOHHS determines clinical/functional eligibility for applicants seeking an LTH level of care through the Medicaid Habilitation program and certain persons referred by the BHDDH for admission to the State's Eleanor Slater Hospital. (4) Children with Special Health Care Needs. Children with disabilities and/or serious chronic and disabling conditions may require a NF, ICF/ID or LTH level of care at home or in an institutional-setting. The process for assessing level of need for children who are eligible based on the MAGI, SSI or custody of the State's Department of Children, Youth and Families (DCYF) is conducted by multiple entities under the auspices of the early, periodic, screening, detection and treatment (EPSDT) in Part 30-00-1 of this Title. The designated unit of EOHHS determines clinical/functional eligibility for children who do not qualify for coverage through one (1) of these pathways and are seeking coverage of LTSS in a home setting in accordance with the provisions located in Subchapter 10 Part 3 of this Chapter. Continuing eligibility for current beneficiaries is based on the method used to determine initial eligibility and, if no basis for coverage is found, across the remaining pathways. c. Financial Eligibility Factors. LTSS eligibility specialists in the Department of Human Services (DHS) are responsible for determining financial eligibility through the IES and related systems. The financial requirements pertain to an array of factors including the calculation of countable income and resources using the MAGI or SSI method and the allocation of resources and transfer of asset requirements that are unique to the determination of LTSS eligibility. Both of the following apply to new and existing
beneficiaries seeking LTSS without regard to basis of eligibility and are explained in greater detail in Part 6 of this Subchapter. (1) Allocation of resources with spouses/dependents. The evaluation and allocation of resources at the point the need for LTSS is established and/or at the time of application is required for LTSS applicants who have spouses. This process, referred to as the Community (Non-LTSS) Spouse Resource Allowance (SRA), allocates the joint resources of couples in accordance with Federal standards to ensure a sufficient amount is protected for the non-LTSS spouse's needs – that is, unavailable to pay for the costs of care for the LTSS applicant/beneficiary. The allocation of resources at this state of the eligibility process is distinct from that which occurs when determining the amount of income a beneficiary must pay toward the cost of care in the “post- eligibility” treatment of income. LTSS MAGI beneficiaries are subject to allocation of resource requirements but are exempt from the post-eligibility treatment process. (2) Transfer of assets. The determination of financial eligibility for Medicaid LTSS requires that the State review whether an applicant made a "disqualifying" transfer of assets – liquid resources and real property – in the sixty (60) month period before the need for LTSS was established. A transfer is deemed to be disqualifying if the asset was conveyed for less than fair market value. Under Federal law, such a transfer is presumed to have been made to reduce assets for the expressed purpose of gaining Medicaid LTSS eligibility. The State is required to impose a penalty period, during which Medicaid coverage for LTSS is unavailable, that is equal to the amount of the disqualifying transfer divided by the average cost of care at the private pay rate. B. Once eligibility has been determined, payment for Medicaid LTSS becomes available only after the following inter-related steps are completed: 1. Service Plan – Development of a service plan ensures that a beneficiary is or will be able to attain the full scope of services required to meet his/her needs in the choice of LTSS living arrangement. Towards this end, LTSS specialists from across the EOHHS agencies and their community partners and contractual agents consider the results of the clinical/functional needs-based assessment, more intensive evaluations, as appropriate, and/or the consensus decisions made in the person- centered planning process for HCBS or the results of the PASRR for nursing facility care to help ensure that every beneficiary receives the right services, at the right time, and in the most appropriate setting.
2. Post-Eligibility Treatment of Income (PETI) – Under the State’s Section 1115 waiver, all non-MAGI eligible LTSS beneficiaries are subject to the PETI process. PETI is the basis for calculating a beneficiary's liability to pay toward the cost of care. During this process, income is evaluated a second (2nd) time, Federal spousal impoverishment requirements are applied, if appropriate, and additional deductions from income are taken for personal needs, non-covered health care costs like insurance premiums, and other allowable expenses. PETI varies somewhat depending on the type of Medicaid LTSS – in a health institution or HCBS – selected by a beneficiary and the requirements of his/her service plan. Accordingly, the development of the service plan and the beneficiary's health care priorities and preferences established in the person-centered planning process are important factors that must be considered when calculating beneficiary liability. The PETI process is set forth in detail in Part 8 of this Subchapter. 3. Authorization of Payment for LTSS – Authorization of Medicaid LTSS is required before a payment is made for coverage provided to a beneficiary. This process entails a complex set of transactions in which information about the scope of services approved and/or utilized and the beneficiary's liability are transmitted from the IES to the State's Medicaid claims system (Medicaid Management Information System or “MMIS”). Once these transactions are completed, payment is authorized to an LTSS provider dating back to the eligibility date – the first (1st) day of the month in which the application was filed – and prospectively unless retroactive eligibility has been approved. 1.9 Eligibility Pathways A. The eligibility pathways available to persons seeking Medicaid LTSS have different requirements all of which are automatically taken into account when application information is processed. As indicated below, the process for determining eligibility and the sequence may vary for members of a particular population depending on the pathways available. 1. SSI and SSI-related Groups – SSI recipients and members of certain SSI- related groups are automatically eligibility for Medicaid based on a determination by SSA as indicated in Part 40-00-3 of this Title. Federal Regulations at 42 C.F.R. § 435.603(j) specifically exclude Medicaid determinations of eligibility for members of this group, including for LTSS, using the MAGI standard except in instances in which an SSI recipient no longer meets disability criteria and loses cash assistance on this basis. Special provisions also apply to Medicaid LTSS beneficiaries who are receiving SSI and are expected to need LTSS coverage for ninety (90) days or less. Accordingly, access to LTSS proceeds as follows:
a. Eligibility Criteria. Medicaid beneficiaries who are SSI-eligible and need LTSS are subject to the clinical/functional eligibility factors required for an institutional level of care set forth in Subchapter 05 Part 1 of this Chapter as well as the financial eligibility requirements related to the transfer of assets. The resource limit is set at two thousand dollars ($2,000.00). b. Special Conditions. Re-evaluation of income and resources is not required unless current eligibility is based on different Medicaid group size (couple v. individual) or there is a change in income or resources resulting from need for or use of LTSS. In addition: (1) SSI recipients who have § 1619(b) status, as indicated in § 40-05-1.5.4 of this Title, remain eligible for two (2) months of continuing SSI cash assistance if admitted to an LTH, such as Eleanor Slater Hospital or an equivalent HCBS setting; and (2) SSI recipients who obtain Medicaid LTSS for a period not expected to exceed ninety (90) days may continue to receive SSI cash assistance during this time to maintain a community residence. Such income is excluded in the financial eligibility determination sequence, including the post-eligibility treatment of income. c. Determination Process. SSI recipients are not subject to a MAGI determination and a re-evaluation of income/resource eligibility using the SSI method is not required when applying for LTSS. Although a review of functional/clinical eligibility is conducted, a full assessment of level of care needs may be waived for certain populations based on their type of disability as indicated in Part 5 of this Subchapter. All other steps in the eligibility determination process apply to the extent that the special Rules applicable to the treatment of SSI income allow, as indicated in Part 40-00-3 of this Title. d. Retroactive Coverage. Retroactive coverage is available for any allowable non-Medicaid covered LTSS expenses in the ninety (90) day period prior to the eligibility date in circumstances in which the applicant for LTSS was not enrolled in Medicaid at that time. 2. Adults 19 to 64 – All persons seeking initial or continuing eligibility for Medicaid LTSS in this age group are evaluated across several pathways unless they are currently eligible for Medicaid. a. Eligibility Criteria. Applicants are subject to the general and functional/clinical eligibility requirements. Not all financial eligibility
factors such as resource limits apply, as indicated. The financial eligibility requirements vary across pathways; if a beneficiary is determined ineligible in the current category (existing beneficiaries) or a pathway of choice (new applicants), the IES automatically evaluates whether eligibility through another pathway exists up to and including the medically needy pathway. The process generally proceeds as follows: (1) MACC Group for MAGI-eligible Adults: Income limit – one hundred thirty-three percent (133%) of the FPL; No resource limit. (2) IHCC non-SSI eligible Adults with Disabilities in Community Medicaid: Income limit – one hundred percent (100%) of the FPL; Resource Limit – four thousand dollars ($4,000.00). Applies to new applicants and existing beneficiaries. (3) Special Income/HCBS: Income limit – three hundred percent (300%) of the SSI standard; Resource Limit – four thousand dollars ($4,000.00). New applicants only. (4) Medically Needy: Income limit – Cost of Care; Resource Limit – four thousand dollars ($4,000.00). New applicants only b. Special Conditions. Several eligibility pathways have special conditions that target or exclude certain populations: (1) MACC Group for MAGI-eligible Adults: Pathway is closed to persons who are sixty-five (65) and older or who are eligible for or enrolled in Medicare. In addition to the exemption from a resource limit, PETI rules do not apply and, as a result, beneficiaries in this group do not have to pay a portion of income toward the cost of care. Spousal impoverishment protections, guaranteed through the SSI method, are also unavailable through this pathway. (2) IHCC non-SSI adults with disabilities in Community Medicaid: Current beneficiaries may request to be assessed for an LTSS level of care and provide only the information related to financial eligibility factors to evaluate the transfer of assets, the allocation of resources between spouses/dependents, and beneficiary liability in accordance with Part 8 of this Subchapter. Existing beneficiaries seeking Medicaid LTSS under the Sherlock Plan must apply pursuant to the requirements set forth in Part 40-15-1 of this Title.
(3) Special Income: Pathway for new applicants with income above the Community Medicaid limit (up to three hundred percent (300%) of the SSI benefit rate) and adults with disabilities in the IHCC medically needy group who are seeking care in a health institution such as a hospital or nursing facility. (4) HCBS: Reserved for persons seeking Medicaid LTSS in the HCBS setting who would, absent these services, have the "high" or "highest" need for an institutional level of care. Generally, these are new applicants for Medicaid. (5) Medically Needy: Countable income must be below the average cost of care in the applicable institutional setting, as set forth in Part 40-05-2 of this Title. Special income deductions also apply. c. Determination Process. The principal distinction in the determination process aside from the difference in eligibility criteria is the method for evaluating income – MAGI v. SSI – as indicated below: (1) New Applicants for Medicaid – When applying for Medicaid LTSS, all new applicants who are under age sixty-five (65) and are neither enrolled in or eligible for Medicare are evaluated first to determine whether eligibility using the MAGI method for the MACC group for adults exists. Transfer of asset requirements are applied and an applicant must provide any information about liquid resources and real property necessary to complete that step in the eligibility process. If a new applicant under age sixty-five (65) is found ineligible for the MAGI-based MACC group coverage, or is requesting retroactive coverage, the SSI method is used to determine financial eligibility and all steps in the LTSS determination process, including PETI apply. (2) Current Medicaid Beneficiaries – Current Medicaid beneficiaries who are seeking LTSS remain within the eligibility category that serves as the basis for their existing eligibility and are only referred as appropriate if LTSS eligibility in this category would be denied due to the supplemental information provided when seeking LTSS. Adults with disabilities who are receiving non-LTSS Community Medicaid under Chapter 40 of this Title are referred for a determination of clinical/functional eligibility, in the same manner as those who are SSI-eligible, while the required financial eligibility factors unique to LTSS are
reviewed. All beneficiaries can initiate the LTSS eligibility determination by contacting a DHS LTSS eligibility specialist and completing the applicable sections of the integrated health and human services application form, or an alternative form designated for this purpose, or updating their accounts in the IES Consumer Portal. d. Retroactive Coverage. Retroactive coverage for up to ninety (90) days is available for LTSS applicants in this population who are determined eligible using the SSI method. Under the terms of the State's Section 1115 demonstration waiver, all MAGI-eligible MACC groups, including the ACA expansion adults, do not have access to retroactive coverage unless eligible as a pregnant woman under the terms and conditions of the State’s Section 1115 waiver. 3. Elders 65 and older – The eligibility pathways for persons sixty-five (65) years of age and older vary somewhat when compared to those available for persons between nineteen (19) and sixty-four (64) as specified above. The chief distinction is that members of this population are not evaluated for MAGI-based eligibility even if they are the parents/caretakers of a Medicaid eligible child. Differences in criteria by pathway are as follows: a. Eligibility Criteria. All persons seeking Medicaid LTSS are evaluated using the SSI method through to the authorization of services; MAGI-based eligibility is not permitted under applicable Federal law. Although the income requirements vary, the resource limit is four thousand dollars ($4,000.00) for an individual applicant across pathways: (1) IHCC non-SSI eligible elders in Community Medicaid: Income limit – one hundred percent (100%) of the FPL; Resource Limit – four thousand dollars ($4,000.00). (2) Special Income/HCBS: Income limit – three hundred percent (300%) of the SSI standard; Resource Limit – four thousand dollars ($4,000.00). (3) Medically Needy: Income limit – Cost of Care; Resource Limit – four thousand dollars ($4,000.00). b. Special Conditions. The special conditions for adults with disabilities whose eligibility is determined using the SSI method also apply to elders. c. Determination Process. The principal distinction in the determination process for members of this population is also a function of whether a person is a new applicant or current Medicaid beneficiary.
(1) New Applicants for Medicaid – When applying for Medicaid LTSS, all new applicants who are sixty-five (65) year of age and older are subject to a full financial eligibility review using the SSI method as well a determination of clinical/functional eligibility and all the steps in the LTSS determination process, including PETI apply. (2) Current Medicaid Beneficiaries – Current Medicaid beneficiaries who are sixty-five (65) and older and eligible and receiving non-LTSS MACC Medicaid as a parent/caretaker under Chapter 30 of this Title are referred for both a full financial eligibility review using the SSI method, which requires that they provide additional information related to their own and joint spousal resources, and functional/clinical eligibility review. Current beneficiaries eligible for non-LTSS Community Medicaid under Chapter 40 of this Title are referred for a determination of clinical/functional eligibility, in the same manner as those who are SSI-eligible, while the required financial eligibility factors unique to LTSS are reviewed. All beneficiaries can initiate the LTSS eligibility determination by contacting a DHS LTSS eligibility specialist and completing the applicable sections of the integrated health and human services application form, or an alternative form designated for this purpose, or updating their accounts in the IES Consumer Portal. d. Retroactive Coverage. Retroactive coverage is available for a period of up to ninety (90) day for LTSS applicants evaluated on the basis of the SSI method. Accordingly, all elders are eligible for retroactive coverage. 4. Children up to Age Nineteen (19) – Children requiring LTSS are generally evaluated for MACC group eligibility and provided the services and supports they need under the authorities included in the Medicaid State Plan without requiring a separate determination of eligibility. As indicated in Subchapter 10 Part 3 of this Chapter, there is also a separate eligibility pathway known as Katie Beckett (KB), which was established by Congress for children with serious illnesses and/or disabilities who are receiving care at home and, as a result, would otherwise be ineligible for Medicaid. These children would most likely be eligible if they were receiving care in an institution. The KB pathway, which is named after the young woman who inspired its creation by Congress, applies the SSI institutional Rules to provide Medicaid coverage available to these otherwise ineligible children by deeming their parents’ income as unavailable to them. Accordingly, children eligible through the KB pathway receive the full scope of Medicaid State Plan and Section 1115 waiver
services, including Early, Periodic, Screening, Detection and Treatment (EPSDT), provided to children with severe chronic diseases and/or disabling impairments who qualify in the MACC group pathway based on MAGI pursuant to Subchapter 10 Part 3 of this Chapter. The eligibility pathways differ as follows: a. Eligibility Criteria. All children seeking initial or continuing eligibility for Medicaid LTSS coverage shall meet the general requirements for eligibility, however, notwithstanding any language to the contrary contained in the Rhode Island Code of Regulations, children under the age of nineteen (19) are not required to meet citizenship and immigration status eligibility requirements or to have been assigned a SSN. Financial and clinical requirements vary depending on pathway. Eligibility standards by pathway are set at: (1) MACC group for children: Family income limit – two hundred sixty-one percent (261%) FPL; no resource limit. (2) Katie Beckett: Child income limit – Special income limit for LTSS – Federal benefit rate; resource limit – four thousand dollars ($4,000.00); no income or resource deeming. b. Special Conditions. The special conditions apply only to the KB eligibility pathway. To be eligible, the child must have a disabling impairment and needs requiring the level of care typically provided in a health institution (NF, ICF-ID, LTH) and live at home. A cost- effectiveness test applies; that is, the cost of care at home must be at or below cost of care provided in a health care institution. The child must be otherwise ineligible for Medicaid based on family income, c. Determination Process. The eligibility system considers all children seeking Medicaid eligibility in the MACC group for children first, in accordance with the income limits set in Part 30-00-1 of this Title and the MAGI eligibility process in Part 30-00-5 of this Title. d. Retroactive Coverage. Retroactive coverage is available for KB eligible beneficiaries, but is unavailable for MACC group eligible beneficiaries, including children with special needs. 1.10 Expedited Eligibility A. Expedited eligibility is a special process authorized under the State's Section 1115 demonstration for adults age nineteen (19) and over seeking LTSS in a home and community-based setting. The purpose of this special process is to provide a limited package of HCBS for no more than ninety (90) days to applicants who meet the need for LTSS in a home or community-based setting
as specified in § 1.7(A)(2)(b) of this Part and prefer to remain in or transition to a home or community-based setting for a health institution while a full determination of eligibility is being made. 1. Eligibility criteria – To be considered for expedited eligibility, new applicants must submit a full and completed application for Medicaid LTSS and self-attest to meeting the Medicaid LTSS general and financial eligibility requirements for their appropriate coverage group – that is, elder, adult with disability, MACC group adult and so forth. Existing beneficiaries must notify an LTSS eligibility specialist and provide any supplemental information required to initiate an expedited eligibility review. The need for LTSS must be established in accordance with applicable functional/clinical criteria established by EOHHS by a licensed treating physician or appropriately qualified health practitioner or provider. 2. Applicable circumstances – Expedited eligibility is the default eligibility for new applicants and existing non-LTSS Medicaid beneficiaries who meet the requirements set forth in this Part in the following circumstances: a. Discharge from a hospital. Discharge must be to a home or community-based setting from a hospital or ancillary health institution after an acute care admission. b. Discharge from a from a short-term health institution stay Discharge or transition to a home and community-based setting from a nursing facility or subacute care facility for a short-term stay or skilled rehabilitation if the services provided are not covered as a Medicaid LTSS benefit and, as such, Medicaid reimbursement for the stay is not required. c. Expanded need. A person seeking LTSS eligibility who is receiving preventive level services authorized by EOHHS in accordance with Part 40-05-1 of this Title and has expanded needs or is determined by a treating health practitioner to have the need for in-home assistance to supplement skilled homecare or hospice services currently in place; or to extend to the period after skilled services have ended. B. Expedited eligibility benefits are limited to maximum of: twenty (20) hours weekly of personal care/homemaker services; three (3) days weekly of adult day services; and/or limited skilled nursing services based upon level of need. Upon approval of Medicaid LTSS, the beneficiary qualifies to receive full coverage. The following also apply: 1. Limited duration – The expedited eligibility benefit package is available for up to ninety (90) days or until the eligibility decision is rendered, whichever comes first.
2. Exemptions – There is no PETI conducted in conjunction with expedited eligibility and, as a consequence, no required contribution toward the cost of care during the ninety (90) coverage period. Retroactive eligibility is not available, though costs incurred and unpaid for Medicaid covered services prior to the LTSS application filing date are considered when determining eligibility for full coverage. 3. Restrictions – Under the terms of the State's Section 1115 demonstration waiver, expedited eligibility is not available for LTSS in a health institution setting. 1.11 Roles and Responsibilities A. Persons seeking LTSS Medicaid eligibility must meet the general requirements that apply program-wide related to residency, citizenship, and cooperation, among others. 1. Agency responsibilities – The EOHHS is responsible for determining Medicaid LTSS eligibility, authorizing services, the appropriate level of care planning and service coordination, as dictated by setting, and enrollment in service delivery option of choice. Under the terms of interagency agreements, the DHS and BHDDH have been authorized to determine all or some aspects of LTSS eligibility as an agent of the EOHHS. 2. Applicant Responsibilities – Beneficiaries determined eligible through this pathway must provide accurate and timely information and the consent necessary for EOHHS, or its agent(s), to obtain the health care information required for the clinical eligibility determination. 1.12 Severability
If any provision in any section of this Rule or the application thereof to any person or circumstances is held invalid, its invalidity does not affect other provisions or applications of the Rule which can be given effect without the invalid provision or application, and to this end the provisions of this Rule are declared to be severable.
210-RICR-50-00-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 - MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 - LONG-TERM SERVICES PART 1 - MEDICAID LONG-TERM SERVICES AND SUPPORTS OVERVIEW AND ELIGIBILITY PATHWAYS (210-RICR-50-00-1) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 12/29/2022 February 27, 2023 E-SIGNED by Ana Novais on 2023-02-27 17:19:13 EST February 28, 2023 E-SIGNED by Department of State on 2023-02-28 07:55:06 EST
210-RICR-50-00-2 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 – MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 – LONG-TERM SERVICES PART 2 – Long-term Services and Supports (LTSS) Medically Needy Eligibility Pathway 2.1 Scope and Purpose A. Medically Needy (MN) eligibility for Medicaid long-term services and supports (LTSS), previously referred to as the “Flexible Test of Income”, enables people with income above the Federal benefit cap to obtain Medicaid LTSS coverage in certain circumstances. The Federal benefit cap rate is three hundred percent (300%) of the Supplemental Security Income (SSI) benefit rate and is the income eligibility ceiling for both the “special income” and home and community-based services (HCBS) LTSS pathways identified in Part 1 of this Subchapter. B. Under the Federal law, the LTSS MN pathway is for LTSS beneficiaries only without regard to type of care – institutional or HCBS settings. The provisions related to MN Non-LTSS Community Medicaid are set forth in Part 40-05-2 of this Title. LTSS MN is distinguished from MN Community Medicaid in that the spenddown is based on monthly projected expenses rather than the costs that must be incurred over a six (6) month budget period. 2.2 Incorporated Materials A. These Regulations hereby adopt and incorporate 42 C.F.R. § 435.301 et seq. (2016) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these Regulations. B. These Regulations hereby adopt and incorporate 42 C.F.R. § 435.831(3)(g)(1) (2016) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these Regulations. 2.3 Legal Authority A. Federal Authorities 1. Federal Law: Title XIX, of the Federal Social Security Act at: 42 U.S.C. §§ 1396a, 1396b, and 1396k; 2. Federal Regulations: 42 C.F.R. § 435.301 et seq. (2016).
3. The Rhode Island Medicaid State Plan and the Title XIX, Section 1115(a) Demonstration Waiver (11-W-00242/1), effective through December 31, 2023. B. State Authorities: Among other statutes, R.I. Gen. Laws Chapters 40-6 and 40-8. 2.4 Definitions A. As used in this Part, the following terms are defined as follows: 1. "Beneficiary liability" means the LTSS beneficiary’s financial obligation toward the Medicaid LTSS cost of care, as determined monthly. 2. “Budget period” means the period of time in which an applicant’s income is measured for the purpose of determining eligibility. 3. “Federal cap” means three hundred percent (300%) of the Federal Supplemental Security Income (SSI) Program monthly payment rate. 4. “LTSS beneficiary” means a person who meets all the general, clinical/functional, and financial eligibility requirements for LTSS, or a person receiving Medicaid LTSS of any type regardless of living arrangement. The LTSS beneficiary has been previously referred to as an “institutionalized” individual. 2.5 Medically Needy Eligibility Determination Process A. To be considered for the medically needy pathway, an otherwise Medicaid eligible person must have income above the Federal cap of three hundred percent (300%) of the SSI rate. The LTSS eligibility requirements for Medicaid LTSS are outlined in § 1.9 of this Subchapter and are set forth in greater detail throughout this Part. All LTSS applicants with countable income above the Federal cap are automatically evaluated for the MN eligibility pathway. Total countable income must be at or below the projected cost for the type of LTSS the person is seeking or receiving, at the private pay rate, adjusted annually as set forth in § 2.6 of this Part. B. Eligibility is determined in accordance with the following: 1. Excess income amount – The person's countable income for the month is determined based on the provisions set forth in Part 40-00-3 of this Title, pertaining to the SSI methodology. If income is above the Federal cap after all required disregards and exclusions have been applied, the medically needy income limit (MNIL) is deducted from remaining income. This is the total amount of excess income that must be absorbed to obtain MN eligibility for LTSS.
2. Income and Institutional Cost Comparison – The projected cost of LTSS at the private pay rate in the applicable health institution – nursing facility (NF), intermediate care facility for intellectually/developmentally disabled individuals (ICF/I-DD), or long-term hospital (LTH) – is deducted from the excess income. a. If excess income is absorbed by the cost of LTSS, the person is MN eligible and the provisions related to the post-eligibility treatment of income (PETI), set forth in Part 8 of this Subchapter, are applied to determine the amount of the person's gross income that is available to be applied toward the cost of care each month. b. If excess income is not absorbed, the remaining income provides the basis for determining the LTSS MN spenddown for the projected budget period once the PETI Rules are applied. Allowable expenses are deducted in accordance with § 2.6.1(B) of this Part below. 3. Spenddown – A MN LTSS spenddown is based on the amount of excess income remaining after all required reductions are taken in the PETI process. Income protected in the PETI process is unavailable and therefore is excluded in the calculation of the spenddown. Once protected income is subtracted, the total spenddown is the amount of allowable expenses a person must incur to meet the MNIL. a. Otherwise Medicaid eligible due to a penalty. PETI does not apply when a person who is subject to penalty period for LTSS coverage is otherwise eligible for Medicaid. Therefore, during such a penalty period, in which Medicaid LTSS coverage is not available, all countable income is available for spenddown purposes. b. Verification. The State determines whether the applicant/beneficiary has sufficient allowable expenses each month – both incurred and projected – to meet this spenddown. Proof that incurred allowable expenses meet the monthly spenddown may be required as indicated in § 2.6.1 of this Part below. 4. Monthly projected spenddown period – The State uses a one (1) month budget period to determine beneficiary liability and therefore the amount of the spenddown required to maintain eligibility. a. Start date. A one (1) month budget period begins with the first (1st) calendar month during which the person receives LTSS for any part of the month, applies for Medicaid coverage for that month, and meets all other requirements for Medicaid eligibility.
b. End date. A one (1) month budget period ends with the last calendar month during which the person received LTSS for any part of the month and meets all other eligibility requirements. C. LTSS MN coverage begins on the first (1st) day of the budget period in which allowable expenses meet or exceed the spenddown requirement when using health insurance cost and noncovered health expenses to meet the MNIL. Eligibility becomes effective later than the first (1st) day of the month when a spenddown requirement is met using covered medical expenses. Medicaid LTSS coverage continues to the end of the budget period unless there is a change in income. 1. Penalty period and MN eligibility – The penalty start date for a person seeking LTSS MN eligibility is the date the spenddown is met. If the spenddown is not met in the month of application or the next month, the person is ineligible for LTSS MN coverage and the State must determine whether Community Medicaid MN eligibility is available based on a six (6) month spenddown period. 2. Overlapping providers – Applicants and beneficiaries are responsible for health expenses incurred before the date of eligibility. If receiving LTSS for more than one (1) provider on the date that coverage begins, the applicant/beneficiary must decide which services he or she will be responsible for paying and which providers Medicaid will cover. 2.6 LTSS Medically Needy Allowable Expenses A. The health expenses of the LTSS beneficiary and spouse and dependents, if applicable, may be used to obtain or retain MN eligibility if they qualify as allowable under this Part. The expenses may be paid or incurred and not paid depending on the deduction sequence, the age of the health bills, and whether the expenses are predictable and/or used for other eligibility purposes such as reducing resources or beneficiary liability for the cost of care. B. For an incurred health expense to qualify as allowable for a LTSS MN spenddown, the following apply: 1. No third-party liability – An allowable expense must not be eligible for payment by a third (3rd) party. For these purposes, a third (3rd) party could be individuals, entities or policies that are, or may be, liable to pay the expense including, but not limited to: other health care coverage, such as coverage through Medicare, private or group health insurance, long- term care insurance or through the Veterans Administration (VA) health system; automobile insurance; court judgments or settlements; or Workers’ Compensation. Expenses incurred by the spouse or a financially responsible relative are NOT treated as a third (3rd) party liability if such
expenses are allowable and the services are provided to the applicant or beneficiary. 2. Medically necessary – The expense must be medically necessary. A necessary medical expense is an expense rendered for any of these situations: a. In response to a life-threatening condition or pain; b. Treat an injury, illness or infection; c. Achieve a level of physical or mental function consistent with prevailing community standards for the diagnosis or condition; d. Provide care for a mother and child through the maternity period; e. Prevent the onset of a serious disease or illness; f. To treat a condition that could result in physical or behavioral health impairment; or g. When such services are provided or ordered by a licensed health care professional or provider they are presumed to be medically necessary. In instances when such services are provided by some other person or entity, documentation of medical necessity may be required. 3. Single use – The total amount of a health expense may not be used more than once to meet an eligibility or spenddown requirement. However, if only a portion of a health expense is used to meet the spenddown requirement in a budget period, the portion of the allowable expense that remains is a current liability and may be applied toward a spenddown requirement in a future budget period. 4. Retroactive coverage – Allowable expenses incurred in the three (3) months prior to the date of application may be used to grant Medicaid MN coverage if all other eligibility criteria were met during the retroactive period. If not used to seek eligibility for this period, expenses incurred that are not used for this purpose may be applied in accordance with § 2.6.1(B) of this Part below. 5. Deduction timeframes – Health costs may qualify as allowable expenses when incurred: a. During the current budget period, whether paid or unpaid; b. Before the current budget period and paid in the current period;
c. Before the current period, remain unpaid, and continuing has been established; or d. Paid during the current budget period by a government entity or program that does not receive Medicaid funding. 6. Loans – Health expenses incurred before or during the budget period and paid for by a bona fide loan may be deducted if the expense has not been previously used to meet a spenddown requirement and the applicant or beneficiary or a financially responsible person establishes continuing liability for the loan. To be an allowable expense, all or part of the principal amount of the loan must remain outstanding at some point during the budget period. For these purposes, a bona fide loan means an obligation, documented from its outset by a written contract and a specified repayment schedule. Only the amount of the principal outstanding during the budget period, including payments made on the principal during that period, may be deducted. 2.6.1 Types of Allowable Expenses and Sequence of Deductions A. The types of health and remedial expenses that qualify as "allowable" for the purposes of a MN spenddown are the same for both community Medicaid and LTSS. Such expenses include, but are not limited to: physician/health care provider visits; health insurance premiums, co-pays, co-insurance, and deductibles; dental and vision care; chiropractic and podiatric visits; prescription medications; tests and X-rays; skilled nursing and subacute care if not otherwise covered; home nursing care, such as personal care attendants, private duty nursing and home health aides; audiologists and hearing aids; dentures; durable medical equipment such as wheelchairs and protective shields; therapy, such as speech, physical, or occupational therapy; transportation for medical care, such as car, taxi, bus or ambulance; and LTSS expenses at home or in a health institution at the State Medicaid reimbursement rate. B. An expense is allowable for the Medicaid LTSS spenddown if it is for health insurance costs or specific types of Medicaid non-covered and covered services. The scope, amount and duration of the service determines whether it qualifies as an allowable expense as a Medicaid covered or non-covered service and, therefore, the order in which it is deducted from excess income. The sequence of deductions for allowable expenses is as follows: 1. Health insurance expenses – The costs for maintaining insurance coverage for health care services and supports for both the person seeking coverage and any dependents. This category includes, premiums, co-pays, co-insurance and deductibles including for Medicare and commercial plans. Premiums for optional supplemental plans are not allowable expenses.
2. Non-Medicaid expenses – These are expenses incurred for health care and remedial services that are recognized under State law but are not covered under the Medicaid State Plan or the State's Section 1115 demonstration waiver, such as home stabilization services and non- medical transportation. 3. Excess Medicaid expenses – Includes expenses incurred for Medicaid covered services that exceed limitations on amount, duration, or scope established in the State Plan or Section 1115 demonstration waiver. Expenses allowed in this category must be medically necessary and may include both the costs incurred for an expanded service (such as dentures, in-patient behavioral health care for an extended period, contact lenses or a second pair of prescription reading glasses) and associated ancillary health costs (x-rays, needs assessments, lab tests, office visits and the like). 4. Covered Medicaid expenses – These are incurred expenses that do not exceed limitations on amount, duration, or scope allowed under current Federal authorities. They are deducted in chronological order based on the date of service beginning with the oldest expense. a. An expense incurred in a month for which MN eligibility is approved is presumed to be a Medicaid covered expense unless documentation is provided to the State that it is not a covered service. b. When an applicant for LTSS is receiving a service, or set of services Medicaid pays for in a daily or bundled rate, the items and services included in that rate are not separate allowable expenses whether provided in an institution, such as an NF or hospital, or home and community-based setting, such as a DD group home, assisted living residence, etc. 5. Health institution expenses – Under the existing Medicaid State Plan, Rhode Island took the option under 42 C.F.R. § 435.831(3)(g)(1) to allow LTSS expenses incurred for both HCBS and health institutional care to be deducted from excess income. In accordance with the applicable Federal requirements therein, the maximum amount allowed is the State monthly Medicaid reimbursement rate projected to the end of the budget period when paid or incurred. 2.7 Health Institution and Income Cost Comparison A. The following table sets forth the projected monthly private pay rates associated with each institutional level of care that are used to determine whether a LTSS applicant or beneficiary with excess countable income qualifies for LTSS MN eligibility with or without a spenddown.
Rhode Island: Projected Monthly Private Pay Costs by Institutional Level of Care – updated August 2023 Type of LTSS Monthly/Daily Rate Nursing facility (average skilled) $10,190.00 / $335.00 Intermediate Care Facility for I- DD $22,350.00 / $735.00 Long-term hospital $55,500.00 / $1,825.00 B. The following table shows the State reimbursement for LTSS only. Incurred and paid non-LTSS health care costs are excluded from the rates except in health institutions (NF, ICF/I-DD, and LTH) and may be added toward the required spenddown if allowable. Rhode Island: State Medicaid LTSS-only Monthly Reimbursement Rates by Service – updated May 2023 (Medical Services not included) Service Monthly Rate Nursing facility (average custodial) $7,500.00 Assisted Living $2,500.00 Shared Living $2,100.00 Home-Based Personal Care $3,000.00 Adult Day Services Only $1,600.00 Eleanor Slater – Hospital $55,500.00 Tavares $22,350.00 Other Long-Term Care Hospital $25,850.00 DD at Home $3,300.00
DD Shared living $3,300.00 DD Group Home (Private) $9,200.00
210-RICR-50-00-2 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 - MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 - LONG-TERM SERVICES PART 2 - MEDICAID LONG-TERM SERVICES AND SUPPORTS: MEDICALLY NEEDY ELIGIBILITY PATHWAY (210-RICR-50-00-2) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 12/28/2023 December 08, 2023 E-SIGNED by Richard Charest on 2023-12-08 15:23:12 EST December 08, 2023 E-SIGNED by Department of State on 2023-12-08 15:56:52 EST
210-RICR-50-00-4 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 - MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 - LONG-TERM SERVICES PART 4 - Long-Term Services and Supports Application and Renewal Process 4.1 Overview
The purpose of this regulation is to set forth the Long-Term Services and Supports (LTSS) application review and renewal process in accordance with current State and federal laws and regulations. 4.2 Legal Authority A. Title XIX of the U.S. Social Security Act provides the legal authority for the RI Medicaid program. Additionally, legal authority related to long-term services and supports is derived from the following sources: 1. State Law: R.I. Gen. Laws § 40-8-6.1 2. Federal Law: 42 U.S.C. § 1396a; 42 U.S.C. § 1396k; Section 1413(b)(1)(A) of the Affordable Care Act 3. Federal Regulations: 42 C.F.R. §§ 435.905 THROUGH 910; 42 C.F.R. § 435.912(c) (timelines). 4.3 Definitions A. For the purposes of this rule, the following definitions apply: 1. “ACA adults” means persons between the ages of 19 and 64 who are eligible for Medicaid authorized by the federal Affordable Care Act (ACA) of 2010. 2. “Additional documentation request” or “ADR” means the notice sent to applicants subsequent to an initial review of the application’s completeness that identifies any additional information/forms that must be submitted, and any related deadlines, for a determination of eligibility to proceed. 3. “Application completeness” means the point in time when all information requested by the State, including the application and any ancillary
required forms and authorizations necessary to determine eligibility, are date-stamped as received by the State. 4. “Application timeliness” means the specific time frame for making determinations of Medicaid eligibility as set forth in federal and State law, regulations and rules. The timelines vary in length depending on whether a functional/clinical eligibility determination is required. 5. “Clinical or functional eligibility” means the application of needs-based criteria to determine whether a person requires the level of care typically provided in an LTSS health institution as defined herein. 6. "Department of Human Services" or "DHS" means the State agency established under the provisions of R.I. Gen. Laws Chapter 40-1 that has been delegated the responsibility through an interagency service agreement with the Executive Office of Health and Human Services (EOHHS), the Medicaid Single State Agency, to determine Medicaid eligibility in accordance with applicable State and federal laws, rules and regulations. 7. "DHS-2 application form" means the principal paper application form for Medicaid LTSS. 8. "Eligibility pathway" means one of the various ways authorized under the State’s Medicaid State Plan and/or Section 1115 demonstration waiver that a person may be found eligible for LTSS. 9. "Executive Office of Health and Human Services" or "EOHHS" means the State agency established in 2006 under the provisions of R.I. Gen. Laws Chapter 42-7.2 which is designated as the “single State agency,” authorized under Title XIX of the U.S. Social Security Act (42 U.S.C. § 1396a et seq.) and, as such, is legally responsible for the program / fiscal management and administration of the Medicaid Program. 10. "Financial eligibility" means the process for determining whether an applicant meets the income and resources requirements for Medicaid eligibility. 11. "Home and community-based services" or "HCBS" means the services and supports provided to Medicaid LTSS beneficiaries at home or in a community-based setting who would require the level of care associated with one of the three institutions (health care facilities identified below) recognized in federal Medicaid law if they were not receiving these services and supports. 12. "Institution" means one of the long-term care institutions recognized in federal Medicaid law and is a State-licensed health care facility where health and/or social services are delivered on an inpatient basis. For the
purposes of this document, the term means long-term care hospitals and treatment facilities (LTHR), intermediate care facilities for persons with intellectual disabilities (ICF/ID), and nursing facilities (NF). 13. "Integrated eligibility system" or "IES" means the State’s health and human services computer eligibility system – known as RI Bridges – which processes applications for Medicaid as well as for the programs and services administered by the DHS. 14. "Long-term services and supports" or "LTSS" means a spectrum of services covered by the Medicaid program for people with functional impairments and/or chronic illness that provide assistance with activities of daily living (such as eating, bathing, and dressing) and instrumental activities of daily living (such as preparing meals, managing medication, and housekeeping). 15. "LTSS specialist" means a State agency representative responsible for determining eligibility for long-term services and supports, authorizing services, and/or providing assistance to people in navigating the Medicaid health care system. 16. "Needs-based criteria" means the basis for determinations of functional/ clinical eligibility for Medicaid LTSS including medical, social, functional and behavioral factors, and the availability of family support and financial resources. 17. "Supplemental forms" means the additional forms all LTSS applicants are required to complete. 18. "Types of LTSS" means the two forms of LTSS authorized under federal law and the State’s Medicaid State Plan and Section 1115 waiver: Medicaid LTSS in health care institutions (NFs, ICF/IDs, and LTHR) and Medicaid home and community-based LTSS. 4.4 Summary of LTSS Eligibility Determination Process A. Eligibility Factors. Evaluations of all applications for Medicaid LTSS are based on eligibility requirements or factors that fall into the following three categories: 1. General Eligibility Factors – Residency, citizenship and immigration status, third-party health coverage, age, health coverage, marital status, dependents (§ 40-05-1.9 of this Title). 2. Financial Eligibility Factors – Varies by eligibility pathway and the method for determining income eligibility in accordance with Part 40-00-3 of this Title.
3. Clinical/functional Eligibility – An applicant’s health care and functional health care needs are evaluated based on information obtained from providers using pre-set needs-based criteria. The needs-based criteria for the NF, ICF-ID, and LTHR vary in accordance with the needs of the population served. Separate criteria related to disability status and LOC are also used for children seeking Katie Beckett eligibility. (Subchapter 10 Part 3 of this Chapter). B. Planning and the Cost of Care. LTSS applicants/beneficiaries are also in engaged in several on-going and post-eligibility processes that ensure they participate in decisions about their care, and that necessary and appropriate services are authorized. Calculation of their liability to pay a share of the cost of LTSS care includes the spouse’s and/or dependents’ needs and other allowable expenses. 1. Person-centered Planning (PCP) – The person-centered planning process begins when an applicant decides to apply for Medicaid LTSS and continues throughout the eligibility determination process. The applicant/beneficiary and their health care preferences and goals drive the development of the plan (42 C.F.R. § 441, Subpart M). 2. Service Plan and Authorization – The service plan identifies the scope, amount and duration of services necessary to meet the new beneficiary’s needs as articulated in the PCP process and other assessments; authorization allows payments to be made for these services. 3. Post-eligibility Treatment of Income (PETI) -- This is the process in which the State determines how much money a beneficiary must pay each month toward the cost of care. Income is calculated and deductions are then taken (also known as “allowances”) to cover personal needs and non-Medicaid covered or incurred and unpaid health care expenses. The spousal impoverishment requirements in federal law are also applied, if appropriate, to exclude any of the beneficiary’s income that must be set aside to provide financial support for a spouse and/or dependents in the community. (Part 8 of this Subchapter; 42 C.F.R. §§ 435.217; 435.726; 435.236). 4.5 Starting the Application Process A. Applying for LTSS. All persons seeking initial Medicaid LTSS must apply, including existing Medicaid beneficiaries who are already covered through a non- LTSS pathway for parents/caretakers and adults eligible under the federal Affordable Care Act (ACA) expansion. Persons eligible for Community Medicaid (non-LTSS) are evaluated on a set of general, financial and functional/ clinical eligibility requirements in accordance with § 40-05-1.5.2 of this Title and Rhode Island’s Medicaid Section 1115 waiver. The information existing beneficiaries must provide when applying for LTSS is limited to only those eligibility factors
related to clinical / functional and financial eligibility not already known to the agency. B. Application Points. The State is committed to pursuing a “No Wrong Door” policy that offers consumers multiple application and renewal access points which all lead to the State’s IES. (§ 40-00-2.2 of this Title). 1. On-line, Self-Service – Persons seeking initial or continuing eligibility have the option of accessing the eligibility system on-line using a consumer self-service portal through links on the EOHHS (www.eohhs.ri.gov) and DHS (www.dhs.ri.gov) websites or directly through HSRI (HealthSourceRI.com). Supplemental forms and required documentation may be uploaded directly on-line or faxed, emailed or U.S. mailed. The information applicants provide on-line is entered directly into the IES and processed electronically in real-time. The initial steps for applying on-line are as follows: a. Account Creation. To initiate the application process, a person must create an account in the eligibility system. This can be done through the self-service portal by the applicant or with the help of an eligibility specialist or certified assister. (1) Identity proofing. The applicant must provide personally identifiable information when creating an on-line account as a form of identify proofing. Verification of this information is automated. b. Account matches. Once identity is verified, account matches are conducted to determine whether the applicant or members of the applicant’s household have other accounts or are currently receiving benefits. The IES draws on information in an applicant’s account when determining eligibility for other programs. This reduces the need for additional verification and supportive documentation in some circumstances. 2. Paper DHS-2 Applications – Paper forms may be completed on-site with assistance from LTSS eligibility specialists and/or submitted at various agencies, as indicated in § 4.5(D) of this Part below. Applications may also be mailed or faxed to the address identified on the DHS-2. Irrespective of point of receipt, all applications and supplemental forms are indexed scanned into the IES through the EOHHS central mail management system and assigned for review according to the type of assistance requested. C. Application Packet. The application packet contains the several forms requesting the information necessary to determine whether a person is eligible for Medicaid
LTSS. There are two types of forms required for Medicaid LTSS eligibility, however applying: 1. General Application Form – The DHS’ “Application of Assistance”, known as the “DHS-2”, is the principal application form a person must complete when applying for Medicaid LTSS. The paper version of the DHS-2 is available on-line at: at one of the DHS offices listed here. Community agencies and LTSS providers may also be able to provide copies of the DHS-2. The DHS-2 is used for LTSS and as the basis for determining eligibility for: Supplemental Nutrition Assistance Program (SNAP), Child Care Assistance Program (CCAP), Community Medicaid for elders and adults with disabilities (EAD) who are seeking long-term care, the Sherlock Plan for persons with disabilities who work (SP), the State- funded optional supplemental security program (SSP) and the RI Works Program. 2. Supplemental Forms – All applicants for LTSS must also complete additional forms that provide the information necessary to review the application and/or determine various eligibility factors. LTSS Required Supplemental Forms Name of Form Used in: Details Applicant sends to: DHS-2 Cover Sheet Application Identifies LTSS applicants and type of services requesting Agency with DHS-2 CP-12 Applicant Choice General Eligibility Applicant must attest that information about types of LTSS (institutional and HCBS) has been provided Agency with DHS-2 Clinical/functional evaluation by Health Care Provider, GW OMR PM 1 and supporting documentation Clinical/functiona l eligibility Form for health care provider to complete
Principal Health Care Provider (physician, NF, assisted living residence). Agency sends upon request and follows-up if no response by time of application review.
LTSS Required Supplemental Forms Name of Form Used in: Details Applicant sends to: Consent Form, DHS- 25M-CL Provider
Clinical/functiona l eligibility Supplemental form for health provider which authorizes release of health care information. Two copies included in the application packet to be sent to health care provider and/or community agency Provider Health Care Provider Authorization to Obtain or Release Confidential Information, DHS-25 (New consolidated form that incorporates DHS- 91) General/financial eligibility Release for non- medical confidential information Agency with DHS-2 3. Limits on Application Information – As the DHS-2 is an integrated application that is used across health and human services programs, applicants must answer questions that are sorted by program. Applicants are responsible for answering only those questions pertaining to eligibility for the programs for which they are applying: a. On the paper application, the relevant questions are marked with the acronym associated with the specific programs for which the applicant is applying. “KB” means Katie Beckett, “LTSS” means long-term services and supports b. Applicants using the electronic version of the DHS-2 may identify the programs for which they are applying upfront. The IES then automatically sorts the questions they must answer by their program(s) of choice. D. Application Assistance. DHS and EOHHS eligibility specialists provide application assistance in completing all necessary forms, obtaining and submitting required documentation, and responding to inquiries or requests for information. Assistance is also available through:
1. The Division of Developmental Disabilities in the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) for adults with developmental/intellectual disabilities seeking Medicaid. The division also provides specialized assistance and case management services to beneficiaries. 2. The Division of Elderly Affairs (DEA) of the DHS is an additional source of application services for persons seeking LTSS in the home and community-based setting. These services are provided through community agencies under contract with DEA which also provide needs assessments to applicants and case management services to beneficiaries. 3. Community-based certified assisters including State Health Insurance Assistance Program (SHIP) counselors working through local Senior Centers and THE POINT, the State’s Aging and Disabled Resource Center (ADRC). E. Applicant Rights. The State is responsible for upholding the following rights of Medicaid LTSS applicants: 1. Authorized Representatives – Applicants may designate someone to serve as an authorized representative to help or act on their behalf in dealing with agency eligibility and LTSS specialists. 2. Translation Services – An interpreter or translator is available to assist in the application process, upon request. 3. Protection of Privacy -- All information applicants provide is kept confidential unless the agency is otherwise authorized to share with other State and federal agencies for the purposes of verification and enrollment. 4. Appeals - The agency accepts appeals and holds hearings on actions related to eligibility decisions in accordance with Part 10-05-2 of this Title. 5. Non-discrimination – Applicants are treated in a manner that is free from discrimination based on race, color, national origin, sex, gender identity or sexual orientation, age or disability. 6. Non-LTSS Medicaid Beneficiaries – Existing Medicaid beneficiaries who are seeking to expand their coverage to include LTSS may initiate the application process by requesting a change in coverage through their on- line account or by contacting DHS eligibility specialists. 4.6 Submitting the Application A. Completion of Forms and Signature. All application forms must be complete and signed before being submitted. To ensure equity between people who apply on-
line versus through the DHS-2, an application that is not completed and signed will not be accepted and will be returned. The IES accepts electronic signatures. B. Valid Information. Information provided on the application must be validated in accordance with one or more of the following methods to determine eligibility: 1. Attestation – Applicants must attest to the truthfulness and accuracy of the information they provide by signing, under penalty of perjury, the paper application and supplemental forms in ink, or if applying on-line, through an electronic signature. An applicant’s responses on the signed application (so-called “attestations”) are accepted as valid without further verification or proof for a limited range of eligibility factors, such as State residency and marital status or relationship. 2. Electronic Data Matches – Applicant attestations related to income, immigration status, Medicare coverage, private health insurance, and several other eligibility factors are verified automatically through the IES using electronic matches with various federal, State, and commercially available data sources. Applicants are asked to provide their consent for these electronic data matches on the paper and on-line forms. If these matches fail to validate applicant attestations, the applicant will receive a written request for additional clarifying or supporting documentation before action is taken on eligibility through an ADR. 3. Supporting Paper Documentation/Proof – In instances in which eligibility factors cannot be electronically verified due to a lack of data sources or an information discrepancy, an applicant must submit additional documentation to prove the truthfulness and accuracy of attestations or the full scope of information necessary to evaluate an eligibility factor. The application forms for LTSS identify eligibility factors that require paper documentation. C. Privacy of Application Information – Application information must only be used to determine eligibility and the types of coverage a person is qualified to receive. Accordingly, the EOHHS, the agencies under its umbrella, and all other entities serving as its agents in the Medicaid eligibility process maintain the privacy and confidentiality of all application information in the manner required by applicable federal and State laws and regulations. 4.7 Application Cycle A. Application Receipt and Filing date. The date a signed and completed application form is manually or electronically date-stamped as received by the agency is the application filing date. The application filing date is used to determine the eligibility date for LTSS coverage. The eligibility date is the first day of the month in which an application is filed. Retroactive coverage is available if a person would have qualified for LTSS Medicaid for up to three (3) months prior to the
eligibility date. A signed, completed application form is submitted by any of the following means: 1. Electronically through the self-service portal; 2. A paper copy is date-stamped as received by State agency staff; 3. Electronically dated if uploaded, e-mailed, faxed, or scanned; 4. Delivered in-person and date-stamped by State agency staff. B. Application Data Entry and Tracking. Once an application has been filed, the State agency is responsible for ensuring all required information is scanned or entered into the IES and updated and tracked until eligibility is determined. C. Application Review Timeline. Under federal regulations, LTSS eligibility determinations are considered untimely if they are not made within the ninety (90) day timeframe beginning on the filing date provided all required sections of the application form(s) have been completed and signed, as appropriate, and submitted by that date, along with any documentation necessary to determine an applicant’s identity. 1. In accordance with 42 C.F.R. § 435.912, the State may not be able to determine eligibility within this timeframe in unusual circumstances, such as when the agency cannot reach a decision because: the applicant or health care provider delays or fails to take a required action, or there is an administrative or other emergency beyond the agency's control. 2. An application is considered incomplete until all the information required to determine eligibility has been date-stamped as received by the State. Additionally, State-only interim payments may be available in instances in which the State has not made a determination of eligibility on a complete application, as defined in § 4.8 of this Part. D. Application Open and Duty to Report Changes. An application must be open for the State to determine eligibility. An application remains open for 180 days from the date the application form is filed, including any reinstatement review period, as set forth in subpart § 4.9(B)(5) of this Part. Applications will be automatically withdrawn and closed at the end of the open period unless the State is responsible for delays in processing materials related to LTSS eligibility factors. Applicants must inform the agency of any changes in an eligibility factor, such as income, resources, health status, within ten (10) days of the date the change occurred during the 180-day period in which the application remains active. General information related to address, authorized representative, immigration status and the like must be updated/corrected as well as the following: 1. Functional/clinical eligibility factors -- In accordance with standing EOHHS rule pertaining to LTSS needs-based determinations, Part 5 of this
Subchapter information related to health and functional status must be no more than (ninety) 90 days old in order to make a fair and accurate assessment of functional/clinical eligibility. Therefore, the must be provided with any information from a health care provider that may in anyway be related to an applicant’s level of care needs within the ten-day reporting period. 2. Financial eligibility factors – Application information that is not verified by an electronic data source must be updated/corrected during the period in which an application is open within the required ten-days. This includes, but is not limited to, any information related to changes in income provided from outside the State, resources, home maintenance needs, and health care costs and expenses. 4.8 Application Completeness and Eligibility Determination Timelines A. Complete Application. Under State law, an LTSS application is considered complete when the application form and “attachments and supplemental information as necessary” provide the agency with sufficient information to determine eligibility. B. Scope of Information Required. The information required for an application to be considered complete is not fixed. An applicant’s unique circumstances dictate which factors must be considered when determining eligibility and, as such, when there is sufficient information to determine eligibility. By signing the application, the applicant self-attests to the truth of the information he or she provides on any required forms submitted to the agency. To the full extent feasible, this information is verified through electronic data sources. However, when no electronic sources are available, the applicant must provide various types of documentation as proof to support self-attestations. C. The full range of information that may be required for an application to be complete varies depending on the applicant’s situation and the type of verification/proof required. A list of eligibility factors and types of acceptable documentation are located on the EOHHS website at: http://www.eohhs.ri.gov/ProvidersPartners/FormsApplications.aspx and is also available on paper by contacting the DHS-LTSS coverage line at (401) 415- 8455. 4.9 Information Tracking and Pre-Eligibility Screening and Review A. Application Information Tracking. Once the application filing date is established, all information submitted to the agency is entered or scanned into the applicant’s account in the IES and tracked going forward. LTSS eligibility specialists may provide information, upon request, of the status of any application materials the agency receives after the filing date.
B. Review of application completeness. Within thirty-five days (35) after the application filing date, a review is conducted of any pending application. The purpose of this process is to identify any outstanding information and/or additional supporting documentation or proof that is necessary to determine eligibility. Based on this screening and review: 1. Additional Documentation Request (ADR) – The IES generates a written notice informing the applicant of any outstanding/additional information necessary to complete the application. 2. ADR Response –Applicants must respond to the ADR within fifteen (15) days (ten days (10) from date of the notice plus five (5) days to cover mailing time). Information may be emailed, faxed, mailed, uploaded into the applicant’s account or delivered in-person. At any time before the ADR response is due, an applicant may make contact the DHS office, at number indicated on the form, and request for a good cause extension. Such extensions are granted for an additional fifteen (15) days when the applicant provides proof that the inability to respond was due to returned mail, a debilitating health care condition or emergency situation, or the negligence or failure of a third-party. 3. Application Complete – If all requested information is received and the application is considered complete, the process for determining eligibility proceeds. While conducting the eligibility determination, an LTSS eligibility specialist may find that further information is required from the applicant and/or a current or prospective provider to establish a plan of care and/or authorize services. A supplemental ADR may be sent out at this juncture with an appropriate response time 4. Application Denial – If the information requested in an ADR is not received when due, the process for denying the application for non-cooperation is initiated. The applicant has the right to appeal the denial in accordance with the provisions of Part 10-05-2 of this Title. 5. Application reinstatement – An application denied on the basis of non- cooperation under this subpart may be reinstated if the information requested by the applicant is provided to the State within no more than thirty (30) days from the date the denial takes effect if there is time remaining in the ninety (90) day application review period. In such circumstances, a new application review period begins on the application reinstatement date and eligibility dates back to the original application filing date, providing all information subject to change has been updated. If the initial ninety (90) day application review period has expired, the reinstatement date is treated as a new application filing date and the start date of eligibility is determined accordingly.
4.10 Applicant and Agency Responsibilities A. Applicant responsibilities include: 1. Full responses -- Responding to all questions related to LTSS eligibility on the application and any required supplemental forms; 2. Providing any documentation requested to verify the information on the form at the time the application is submitted and at any point in which change reporting is due; 3. Promptly sending to health care providers the signed clinical evaluation forms and associated releases and ensuring these forms are returned in a timely manner. 4. Clinical status --Reporting any changes in health status, such as trauma or marked decline in functional ability, financial circumstances, such as sale of a home, asset loss or windfall, and/or household composition, such as death or divorce of a spouse, that may affect the determination of level of need after the initial application is submitted during the time the application is pending action by the State. 5. Signature and truthfulness -- Signing the form to provide consent for the determination of eligibility and the verification of information through electronic sources and to attest to the truthfulness of application responses. In the event of a death, the form may be signed by an authorized representative or next of kin. 6. Duty to Report -- Applicants must report changes in any information included on the application and supplemental forms within ten (10) days from the date the change takes effect while the application is open. Self- reports are permitted through the eligibility system consumer self-service portal as well as in person, via fax, or mail. Failure to report in a timely manner may result in the denial of an application based on non- cooperation. 7. Documentation/proof -- Applicants must provide any documentation or proof that otherwise cannot be obtained related to any eligibility factors subject to change upon written request. The information must be provided within the time frame specified in the notice stating the basis for making the agency’s request. Failure to respond in a timely manner and/or to provide the information requested without good cause is considered to be non-cooperation and is grounds for denial. 8. Financial resources -- Applicants must, as a condition of eligibility, take any necessary steps to obtain annuities, pensions, retirement and disability benefits along with any other forms of assistance available for
support and maintenance that may be identified by the agency, in writing, in accordance with § 40-00-2.5 of this Title. Good cause exceptions are considered when requested in writing. B. State Agency responsibilities include: 1. Assistance -- Applicants who are incapacitated or are otherwise unable to fulfill these responsibilities on their own or with the assistance of an authorized representative may request additional assistance from an LTSS eligibility specialist. The EOHHS reserves the discretion to authorize such assistance the Secretary or his or her designee deems appropriate. 2. Voluntary Withdrawal – An applicant may request that an application for Medicaid benefits be withdrawn at any time either through their secure on- line account or by submitting the request in writing via the U.S. Mail or fax to the EOHHS or DHS agency representative. The Medicaid agency sends a notice to the applicant verifying the time and date of the voluntary withdrawal and indicating that the applicant may re-apply at any time. 3. Privacy of Application Information – Application information must only be used to determine eligibility and the types of benefits a person is qualified to receive. Accordingly, the EOHHS, the agencies under its umbrella, and all other entities serving as its agents in the Medicaid eligibility process maintain the privacy and confidentiality of all application information and in the manner required by applicable federal and State laws and regulations. 4. Application Timeliness -An applicant may appeal and request a hearing on the basis of the timeliness if the State fails to provide notification of outstanding documentation and make a determination of eligibility on an application within the ninety (90) day review period. 5. State Payments - In accordance with R.I. Gen. Laws § 40-8-6.1, an LTSS provider may request State-only payment for LTSS if a determination of eligibility on a completed application, as defined herein, has been pending for more than ninety (90) days without action taken by the State. 4.11 Renewal of Medicaid LTSS Eligibility A. LTSS Medicaid financial and general eligibility must be re-evaluated at least once a year. This annual review is now referred to as a renewal. Federal regulations [42 C.F.R. 435.916(b)] require these annual reviews to consider only those eligibility factors that are subject to change and, to the full extent feasible, utilize electronic data sources for verification purposes. Accordingly, LTSS Medicaid renewals require beneficiaries to review information from the IES on key general and financial eligibility factors that has been updated by internal and external data sources, and report any inaccuracies or changes. The requirements for
general and financial eligibility renewals for Medicaid LTSS are conducted in accordance with § 40-00-2.7 of this Title. B. Clinical and functional eligibility re-evaluations are also required, but may be performed annually or less frequently depending on the expected scope and duration of the need for LTSS. The requirements for clinical and functional eligibility re-evaluations are conducted in accordance with Part 5 of this Subchapter.
210-RICR-50-00-4 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 - MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 - LONG-TERM SERVICES PART 4 - MEDICAID LONG-TERM SERVICES AND SUPPORTS APPLICATION AND RENEWAL PROCESS (210-RICR-50-00-4) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 08/28/2025 August 08, 2025 E-SIGNED by Richard Charest on 2025-08-08 14:48:24 EDT August 08, 2025 E-SIGNED by Department of State on 2025-08-08 14:56:18 EDT
210-RICR-50-00-5 TITLE 210 – Executive Office of Health and Human Services CHAPTER 50 - MEDICAID LONG-TERM SERVICES AND SUPPORTS (LTSS) Subchapter 00 - Long-Term Services Part 5 - Medicaid Long-Term Services and Supports: Functional/Clinical Eligibility 5.1 Overview
The process for determining function/clinical eligibility for long-term services and supports (LTSS) centers on a comprehensive evaluation that includes a functional assessment and consideration of each applicant's unique medical, social, physical and behavioral health needs. The results of this evaluation process are used to determine whether, and to what extent, an applicant has the need for the level of care typically provided in a nursing facility (NF), intermediate care facility for persons with intellectual or developmental disabilities (ICF-I/DD), or long-term care hospital (LTH). Under the terms of the Medicaid State Plan and the State's Title XIX, Section 1115 demonstration waiver, a person must have this level of need and meet both the non-financial and financial eligibility requirements set forth in this Part to qualify for Medicaid LTSS coverage in one of these institutions, at home, or in a community-based service (HCBS) setting. 5.2 Legal Authority A. This Part is promulgated pursuant to the following federal and state authorities: 1. Federal Law -- Title XIX of the U.S. Social Security Act 42 U.S.C. § 1396a, Sections 1115, 1902, 1903, 1905, 1915, 1919. 2. Federal Regulations -- 42 C.F.R. Part 440 including §§ 440.40, 440.70, 440.150, 440.155, 440.180, 440.181, 440.182. 3. The RI Medicaid State Plan and the Title XIX, Section 1115 (a) Demonstration Waiver (11-W-00242/1), effective through December 31, 2018. B. State Authority RI Gen. Laws §§ 40-8.9.9(c); 40-8.10-3; 40-8.13, 42-7.2-5(6)(v); 42-66.6, 40.1-22. 5.3 Definitions A. For the purposes of this Part, the following definitions apply:
“Activities of daily living" or "ADLs” means the routine activities that people tend do every day without needing assistance. There are six basic ADLs: eating, bathing, dressing, toileting, transferring, and mobility and ambulation. The need for assistance with medication management and personal hygiene is also considered an ADL. 2. “Community supported living services for I/DD” means one or more of the home and community-based Medicaid LTSS services and supports identified in §50-10-1 provided to assist an intellectually/ developmentally disabled person with the activities of daily living in a setting such as primary residence, the home of another, a BHDDH group home, or other community living setting arrangement where such services and supports are available. 3. "Department of Behavioral Healthcare, Hospitals, and Developmental Disabilities" or "BHDDH" means the entity within the executive branch of Rhode Island State government that serves as the mental health authority and administers LTSS programs funded in whole or in part by Medicaid for persons with intellectual or developmental disabilities and serious mental/behavioral health needs. 4. "Department of Children, Youth and Families" or "DCYF" means the State agency responsible for administering child protective and behavioral health services for children and youth, and their families, who are at-risk for or in the care and custody of the State, including several LTSS programs funded in part by Medicaid and CHIP. 5. "Department of Human Services" or "DHS" means the State agency that has been delegated responsibility for processing Medicaid LTSS eligibility through and providing functional assessments and case management services to certain applicants and beneficiaries in accordance with the terms and conditions of an interagency agreement with the EOHHS. 6. "Division of Elderly Affairs" or "DEA" means the unit within the DHS with responsibility for administering the State's HCBS co-pay program for persons who do not qualify for Medicaid LTSS as well as conducting assessments for certain Medicaid HCBS programs under RI General Laws and the terms and conditions of an interagency agreement with the EOHHS, the Medicaid Single State Agency in Rhode Island. 7. "Executive Office of Health and Human Services" or "EOHHS" means the entity within the executive branch of Rhode Island state government that is designated as the Medicaid Single State Agency in RI General Laws and the Medicaid State Plan and that, in this capacity, is responsible for overseeing the administration of all Medicaid-funded LTSS in collaboration
with the health and human services agencies under the office's jurisdiction. 8. “Functional disability” means a deficit or deficits in the capacity to perform the activities of daily living and/or the instrumental activities of daily living of sufficient magnitude that alone, or in conjunction with certain health conditions, constitutes a need for the level of care LTSS typically provided in an institutional setting. 9. “Instrumental activities of daily living" or "IADLs" means the skills a person needs to live safely and successfully in a residential setting of choice without outside supports. Such skills include, but are not limited to, using the telephone, traveling, shopping, preparing meals, doing housework, taking medications properly, and managing money. 10. “Level of care” means the amount of services and supports necessary to meet a person’s needs. When associated with a licensed health care institution, the term refers to the set of services and supports the institution is authorized and typically provides to people with a specific range of needs. 11. “Minimum Data Set” or “MDS” means a component of the federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. 12. “Needs-based criteria” means the health and functional status factors used in the determination of LTSS functional/clinical eligibility to assess a person’s need for the level of care provided in a nursing facility, ICF/ID, or certain hospital settings. 5.4 Assessments for Needs-Based Level of Care Determinations A. The scope of services accessible to a beneficiary varies in accordance with a person’s needs, including his or her goals and preferences, the range of services and supports available under the State’s Medicaid State Plan and Section 1115 demonstration waiver, as well as federal and State regulations, rules or laws. The range of available authorized service options varies with each type of health institution (NF, ICF/I-DD, LTH), as the populations they serve have a range of service and support needs that also vary. As indicated in the following sections, the service options available to a person who meets the functional/clinical eligibility requirements for LTSS associated with one of these institutions is tied to the scope of his or her service needs at the time of application and in subsequent reassessments of need.
B. The functional/clinical eligibility determination process uses needs-based criteria drawn from a variety of sources. The process is initiated when the information necessary to evaluate an applicant's current health status and functional service needs become available to the State through one or more of the following sources: 1. Health care practitioner evaluation --The application includes a clinical evaluation form that must be completed by a treating, licensed health care practitioner with first-hand knowledge about the health status and functional needs of an applicant. The signed and completed form, and any required associated documentation, provide the baseline for determining an applicant's needs level. 2. Health records and documentation -- Applicants must provide the State with the authorization to obtain health records and other forms of clinical documentation from health care providers and practitioners who have or are providing care to the applicant. 3. Health institution care/service plans -- Agency representatives from across the EOHHS agencies obtain information from health providers who assess and/or develop care/service plans for applicants who have or are receiving services or are about to be discharged. 4. HCBS functional assessment -- The State requires in-depth functional assessments of applicants seeking home and community-based services to ensure they can obtain the appropriate services safely and effectively in the setting of choice. The results of the assessments also assist in care planning and guide the authorization of services. As the State pursues a "no wrong door" approach, these assessments may be conducted by agency representative working for the State or various community entities using assessment tools that, although sometimes variable, focus on the same set of functional abilities and limitations. a. NF level of care- HCBS. Responsibilities for HCBS functional assessments are shared across the EOHHS agencies. b. ICF/I-DD level of care -HCBS -- Agency representatives in the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) conduct assessments of all applicants seeking the ICF/I-DD level of care without regard to setting. c. LT Hospital level of care -HCBS. The EOHHS agency representative that determine the NF level of care assess applicants for the HCBS Habilitation Program that serves people with severe disabilities that occur in adulthood. BHDDH agency representatives conduct assessments of persons with serious and
persistent behavioral health needs seeking Medicaid LTSS in a community-based congregate setting. 5.5 Development of Plan of Care, Service Planning and Authorization, and Case Management A. The development of a plan of care is a multifaceted and multilayered process that may start prior to making a request for Medicaid LTSS if a prospective applicant and his or her family are seeking LTSS information and referral or counseling on the available LTSS options. In instances in which an applicant by- passes these options, care planning typically starts at the point of application and continues after a determination of level of care has been completed and services have been authorized. The core elements of the care planning process include, but are not limited to: 1. Person-centered -- Irrespective of the type of Medicaid LTSS a person is seeking (health institution v. HCBS), the care planning process is driven by an applicant's health care goals, expectations and choices. 2. Health institutions and service planning -- Federal regulations require that health institutions providing Medicaid funded LTSS conduct in-depth evaluations that consider a prospective resident's needs, values, and preferences when establishing a plan of care. Agency representatives consider the results of these evaluations when determining level of care, assisting in the development of the plan of care, and authorizing services. In addition: a. NF and PASRR. In accordance with federal law, the State Preadmission Screening and Resident Review (PASRR) evaluation for all prospective NF residents focuses on cognitive, developmental and intellectual disabilities and behavioral health conditions that may require specialized services in a health institution. The results of this evaluation are used to incorporate specific services into the plan of care for applicants determined to have special needs as set forth in subsection § 5.7 of this Part below. The State must authorize payment for any such services included in the plan of care for Medicaid beneficiaries. b. HCBS transitions. Health institutions must inform prospective residents and patients, as well anyone about to be discharged, who needs continuous LTSS about HCBS options. This information must be considered and recorded in any continuity of care service plans. NF and ICF/I-DD health institutions must also report to EOHHS any Medicaid applicant or beneficiary expressing a preference for HCBS options, as indicated subsection § 5.5 of this Part.
2. HCBS care planning -- HCBS person-centered planning supports an individual's right and ability to share his or her desires and goals, to consider different options for support, and to learn about the benefits and risks of each option. The essential elements of this process are set forth in in Subchapter 10 Part 1 of this Chapter. B. For Medicaid LTSS coverage to begin, services must be authorized. Both the needs assessment and care planning process provide the critical information Agency representatives require to develop and authorize a service plan that meets the individual needs of a beneficiary. The scope of service planning from this point may be broadened or targeted more narrowly depending on whether a beneficiary is currently receiving or has chosen the type of LTSS and/or a service option. 1. Type of LTSS and service setting and delivery options - The Medicaid LTSS authorization of services is a function of the level of care determination and the applicant/beneficiary choice of the available LTSS type (health institution and/or HCBS) and service options therein. LTSS type and options are: health institution (NF, ICF/I-DD, LTH) or HCBS (assisted living residence, PACE, home care, shared living, IDD group home, habilitation at home or in a congregate setting, personal choice self-directed care). Availability of service options is based on the extent of a person's need for a particular institutional level of care -- that is, whether that need meets the applicable criteria to qualify as high or highest or some level within these categories for persons with intellectual/developmental disabilities. 2. Service plan – An agency representative or community representative includes a service plan that incorporates the results of the care planning process into the plan authorizing LTSS type and service option. Accordingly, the service plan identifies the scope of authorized services in a health institution (such as skilled v. custodial in a NF) or in an HCBS setting (such as degree of supervision, number of homemaker v. skilled hours, and/or the availability of direct supports.) C. Case management is a set of inter-related activities that ensure access to coordinated Medicaid LTSS and the monitoring of service needs and outcomes. Case management is an LTSS covered service under the Medicaid State Plan and Section 1115 waiver and may be provided by agency representatives, Medicaid managed care plans, community-based providers and organizations, and/or other contractual case management entities authorized by the State. Depending on the agency and the population served, this may be performed by multiple entities working in collaboration or a single entity. In addition: 1. Conflict-free -- Case management must be conflict free to the full extent feasible. Accordingly, persons or entities providing LTSS case
management services should not have a fiduciary interest in or influence over the scope, amount, or duration of Medicaid LTSS that beneficiaries receive. In instances in which such conflicts appear or may exist, the State is bound by federal law to establish firewalls that ensure that care management activities are performed independently, in accordance with State standards, and under the direction of agency representatives. The State reserves the discretion to limit or terminate any arrangement for case management services that does not operate in compliance with these firewalls or that otherwise fails to serve the best interests of beneficiaries. 2. Scope of Services -- Case management services include, but are not limited to, assisting in or conducting screening and/or more in-depth assessments prior to and during the eligibility determination process, facilitating the person-centered planning process, aiding in the development of service plans, conducting periodic reviews and reassessments of functional/clinical needs, and coordinating services with the beneficiary's primary care and community service providers, LTSS program representatives, agency LTSS specialists, and family members when appropriate. 5.6 Nursing Facility (NF) Needs-based Level of Care Determinations 5.6.1 Overview
Under Rhode Island law, any health care institution licensed as a NF and certified for Medicare and Medicaid is authorized to provide skilled nursing and custodial care. Many facilities in the State also have the authority and capacity to offer subacute care, typically in the form of rehabilitation services, limited skilled nursing, and/or hospice care. 5.6.2 NF Service Classifications A. The NF service classifications are designed to provide service options that reflect the scope and intensity of the beneficiary's need for the level of care typically provided in a nursing facility. 1. Highest need -- Beneficiaries in this classification have access to all the Medicaid LTSS covered services they need at home, in the community, or in a nursing facility, in accordance with their plan of care. 2. High need -- Beneficiaries in the high classification have needs that can be met safely and effectively at home or in a community-based Medicaid certified LTSS setting such as an assisted living or shared living residence. Accordingly, these beneficiaries have access to the full array of State Plan and Section 1115 demonstration waiver home and community
based services required to meet their needs as specified in the person- centered individual plan of care. B. To determine the level of care and appropriate service classification, agency representatives review the materials provided from the sources identified in § 5.4 of this Part and, as appropriate, the most current Minimum Data Set (MDS) Tool for NF care. To make the final determination of care needs, the results of this review are mapped against the needs-based and institutional level of care criteria. 5.6.3 Application of NF Needs-Based Criteria A. The NF level of care determination focuses on health status and functional abilities as well as social and environmental factors and the availability of personal supports. The needs-based criteria reflect both best practices across the state and the prevailing standards of care within the LTSS community in Rhode Island. 1. Functional criteria –The functional disability criteria focus on the scope of a person’s need for assistance with Activities of Daily Living (ADLs) such as bathing, toileting, dressing, transferring, ambulation, eating, personal hygiene, medication management, and bed mobility. To determine the scope of need, agency representatives consider the extent to which the level of assistance a person requires falls into one of the following categories: a. Total dependence (All Action by Caregiver): The person does not participate in any part of the activity. b. Extensive Assistance (Talk, Touch, & Lift): The person performs part of the activity, but caregiver provides physical assistance to lift, move, or shift individual. c. Limited Assistance (Talk and Touch): The person is highly involved in the activity but receives physical guided assistance that does not require lifting of any part of him or her. 2. Health Status Criteria –The needs-based health status criteria for a NF level of care deal with cognitive, behavioral and physical impairments and chronic conditions that require extensive personal care and/or skilled nursing assessment, monitoring and treatment on daily basis. B. Persons with highest need for a NF level of care have the choice of obtaining services in a NF or HCBS setting. 1. Needs-based criteria – A person is determined to have highest need when the results of the functional/clinical assessment indicate he or she:
a. Requires extensive assistance or total dependence with at least one of four specific ADLs – toileting, bed mobility, eating, or transferring and limited assistance with at least one other ADL; or b. Has one (1) or more unstable medical, behavioral, cognitive, psychiatric or chronic recurring conditions requiring nursing assistance, care and supervision daily; or c. Lacks awareness of needs or has a moderate impairment with decision-making skills AND has one (1) of the following symptoms/conditions, which occurs frequently and is not easily altered: wandering, verbally aggressive behavior, resisting care, physically aggressive behavior, or behavioral symptoms requiring extensive supervision; or d. Requires skilled nursing assessment, monitoring, and care daily for at least one of the following conditions or treatments: Stage 3 or 4 skin ulcers, ventilator, respirator, IV medications, naso-gastric tube feeding, end stage disease, parenteral feedings, 2nd or 3rd degree burns, suctioning, or gait evaluation and training; or e. Requires skilled nursing assessment, monitoring, and care on a daily basis for one or more unstable medical, behavioral or psychiatric conditions or chronic or reoccurring conditions related, but not limited to, at least one of the following: dehydration, internal bleeding, aphasia, transfusions, vomiting, wound care, quadriplegia, aspirations, chemotherapy, oxygen, septicemia, pneumonia, cerebral palsy, dialysis, respiratory therapy, multiple sclerosis, open lesions, tracheotomy, radiation therapy, gastric tube feeding, behavioral or psychiatric conditions that prevent recovery. 2. Exceptions -- Otherwise Medicaid LTSS-eligible persons who do not meet the needs-based criteria may be deemed to have the highest need for a NF level of care if an agency representative determines there is a critical need for Medicaid LTSS in a nursing facility due to special circumstances. These special circumstances must adversely affect the person’s health and safety and be related to one of the following: a. Loss of primary caregiver, due to hospitalization, debilitating illness, or death of a spouse, caretaker sibling, or adult child; b. Loss of living situation, due to a fire, flood, foreclosure, or sale of principal residence as the result of the inability to afford to maintain housing; c. A principal treating health care practitioner, or prior to ending an acute care hospital stay, a discharge planner indicates, based on a
functional/clinical assessment, that the health and welfare of the applicant/beneficiary is at imminent risk if services are not provided or if services are discontinued; d. The applicant/beneficiary met the highest NF level of care criteria on or before June 30, 2015 and chose to receive Medicaid LTSS at home or in a community-setting and the beneficiary reports he or she has experienced a failed placement that, if continued, may pose health or safety risks; or e. The beneficiary was admitted to a hospital from a NF and is being discharged to the same or another NF upon discharge within any given forty (40) day period. C. Persons with a high level of need for the NF level of care have a choice of HCBS service options but are restricted from receiving Medicaid LTSS in a NF. 1. Needs-based criteria -- Beneficiaries are deemed to have a high need for a NF level of care when one of the following is met: a. Require at least limited assistance daily with at least two of the following ADLs: bathing/personal hygiene, dressing, eating, toilet use, walking or transferring; or b. Require skilled teaching or rehabilitation daily to regain functional ability in at least one of the following: gait training, speech, range of motion, bowel or bladder control; or c. Have impaired decision-making skills requiring constant or frequent direction to perform at least one of the following: bathing, dressing, eating, toilet use, transferring, or personal hygiene; or d. Exhibit a need for a structured therapeutic environment, supportive interventions, and/or medical management to maintain health and safety. 2. Exceptions – a. An LTSS applicant who is currently receiving non-LTSS Medicaid coverage may qualify for HCBS expedited eligibility as set forth in Part 50-00-1 of this Title pending completion of a full determination of level of care for a period of no more than ninety (90) days. b. An applicant for Medicaid LTSS who is not a current beneficiary may qualify for HCBS expedited eligibility upon completion of a preliminary assessment by a treating health care practitioner
indicating that absent immediate access to this limited package of services, the applicant must be admitted to a health care institution. c. An LTSS applicant who is a current Medicaid beneficiary who has received expedited eligibility for a period of ninety (90) days may be deemed to meet the high level of care if: (1) A full level of care of determination has not been completed by the end of the expedited eligibility period; and (2) The applicant meets the financial eligibility requirements for an LTSS eligibility pathway identified in Subchapter 00 Part 1 of this Chapter; and (3) The applicant's treating health care practitioner indicates that the discontinuation of HCBS will adversely affect the applicant's health and safety and/or require immediate admission into a NF or hospital. 5.6.4 LTSS Preventive Services
LTSS Preventive Need. Beneficiaries who meet the needs-based criteria for the LTSS preventive level of care are eligible for a limited range of home and community-based services and supports along with the full range of IHCC group benefits they are entitled to receive. The goal of preventive services is to optimize health to delay or avert institutionalization or more extensive and intensive home and community-based care. Rules pertaining to the LTSS preventive level of need are located in Part 40-05-1 of this Title. 5.6.5 Transitions to HCBS
Nursing facilities are required to refer to EOHHS any LTSS beneficiary who expresses a preference to obtain LTSS at home or in a community-based setting. Specifically, a Medicaid beneficiary is entitled to receive transition counseling if responding affirmatively to MDS Section Q, question 0500.This question asks whether the beneficiary wants to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community. Agency representatives also pro-actively identify beneficiaries who may be interest in HCBS options. The team reviews functional and clinical data, including utilization, to identify possible candidates for a transition. 5.6.6 Reassessment of NF Level of Care Needs A. All Medicaid LTSS beneficiaries are re-assessed at set intervals after placement and at least annually to determine whether they are receiving the appropriate level of services in the most appropriate setting. A level of care re-evaluation is conducted when the findings of the reassessment indicate that the beneficiary's
needs have changed to such an extent that more intensive or specialized service options may be required. B. The reassessments for LTSS beneficiaries receiving the NF level of care proceed in accordance with the following: 1. Change in scope of need -- Beneficiaries determined to have a high need for a NF level of care at the time of an annual reassessment or an assessment done in conjunction with a change in health status are deemed to have the highest need if they meet any of the needs-based criteria established for highest need in §§ 5.6.2 and 5.6.3 of this Part. 2. Periodic reassessment of highest need – At the time a determination of highest need is made for a beneficiary who opts to reside in a nursing facility, agency representatives evaluate whether there is a possibility that the beneficiary's condition may improve within the succeeding two (2) month period. Based on this information, the agency representative notifies the beneficiary, any authorized representative(s) and the nursing facility, that NF care has been authorized and that the beneficiary's functional and health status will be re-evaluated in thirty (30) to sixty (60) days. At the time of reassessment, the LTSS eligibility specialist reviews all available information about clinical and functional status to determine whether a change in level of need and/or service options is required. 5.6.7 Preadmission Screening/Resident Review (PASRR) A. The PASRR is a federal requirement designed to: prevent the inappropriate placement of persons with serious mental or behavioral health conditions, intellectual disability or other developmental disability; and ensure that all NF applicants and residents regardless of payer source are identified, evaluated and determined to be appropriate for admission or continued stay and provided with specialized services (SS), if needed. B. There are two levels to the PASRR: 1. Level I -- Completed prior to NF admission. The purpose is to identify: all NF applicants who possibly have developmental/ intellectual disabilities (DD/ID) and serious and persistent mental/behavioral health (MBH) conditions; and, on that basis, determine whether NF placement is appropriate and if Level II Preadmission Screening (PAS) (for specialized services) is warranted. An assessment to determine if NF placement if appropriate must be done in accordance with the criteria set forth in 42 C.F.R. 483.132(a). a. In Rhode Island, BHDDH retains control and responsibility for PASRR, while certain PASRR responsibilities are delegated to EOHHS. For all persons seeking admission to a NF without regard
to payer, an EOHHS agency representative completes the PASRR Level I determination based upon information submitted by appropriately licensed or certified health care providers who are qualified by knowledge and/or experience in working with this population. BHDDH conducts all PASRR Level II evaluations, in consultation with EOHHS. 2. Level II -- The purpose of Level II is to comprehensively evaluate the need for specialized services persons found to be appropriate for NF placement. There are two types of level II evaluations -- one for new applicants and one for resident reviews conducted on an “as needed” basis or when a person receiving specialized services experiences a change in condition -- a. Pre-Admission Screening Determination (PAS). The state agency responsible must determine if an applicant has a physical and/or behavioral health condition that requires the NF level of care and if the NF is required to provide any specialized services to meet needs identified on the PAS. PAS determinations must be made in writing within an annual average of seven (7) to nine (9) working days of referral. If the applicant is seeking readmission to the NF due to an exempt hospital discharge (convalescent stay) that subsequently requires more than thirty (30) days of a NF level of care, a PASRR resident review is used and the determination must be conducted within forty (40) days of admission. b. Resident Review (RR). The State agency with PASRR authority for each NF resident must determine whether he or she continues to have the highest need for the level of services provided by a NF and whether or not specialized services authorized during the PAS should continue. Resident reviews for persons with ID/DD are conducted periodically and upon significant change; and for persons with MBH conditions when there is a significant change unless it is an exempted hospital discharge or other categorical determination. C. Under federal law, PASRR responsibilities are delegated as follows: 1. EOHHS -- The Medicaid single state agency is responsible for the following: a. Ensures that all requirements of federal law are met; b. Develops written agreements with the BHDDH, in its role as a PASRR authority;
c. Assures that the PASRR authorities fulfill their statutory responsibilities; d. Oversees NF compliance with any assigned PASRR functions established by the BHDDH in level II evaluations; e Requires that no person be admitted to a Medicaid certified NF without a PASRR level I PAS; f. Ensures any specialized services determined necessary in the PASRR evaluation process are made available; g. Notifies the NF resident related of the outcome of the PASRR determination and indicates whether specialized services are needed, the placement options available to the person, and appeal rights (See 42 C.F.R. §§ 483.130(k), 483.130(l)). h. Provides a system of appeals for persons affected by any PASRR determination; and i. Withholds Medicaid payment for any person who is living with a developmental disability or serious mental/behavioral health condition who is admitted to a NF without PASRR Level II or who remains in a NF contrary to PASRR rules. 2. BHDDH -- As the State's mental health authority, BHDDH retains control and responsibility for PASRR and must make timely level II evaluations. In addition, BHDDH ensures that all PASRR level II findings are issued in the form of a written evaluative report which is provided to the applicant/resident and their legal guardian, the admitting or retaining NF, the attending physician and where applicable the discharging hospital of the applicant or resident; and arranges for the provision of specialized services when appropriate in the NF setting or alternative placement option. 3. Nursing facilities -- NFs are responsible for the maintenance of all PASSR forms within a person’s record. In addition, to ensure documentation compliance, nursing facilities are required to maintain an active list of anyone within the PASRR MBH and DD/ID services. NFs must also: a. Care planning. NFs must also consider the PASRR, other related assessments and treatment recommendations within the care planning process. During the resident’s annual care planning process, the nursing facility must complete a full assessment and care plan update for anyone receiving PASRR-related services.
b. Immediate need. When there is a significant change in a resident's condition, a NF is required to initiate treatment to meet immediate needs and then begin a comprehensive reassessment. Treatment is geared to improvements when possible and prevention of avoidable decline, pending additional review and action by the State PASRR authorities. A comprehensive assessment must be completed by the 14th day after noting a significant change and the care plan must be revised accordingly within seven (7) days after its completion. The NF must also assure that any new or additional specialized services are provided pending a determination of whether a RR by the State is warranted during this twenty-one (21) day period. c. Notice for Resident Review. If, upon completing an assessment and associated care plan update, the NF determines that a resident review is or might be necessary due to a significant change or other situation, the nursing facility must promptly provide LTSS clinical specialist and/or the BHDDH PASRR authority with proper written notification. d. Interfacility Transfers. In cases of inter-facility transfers, the transferring NF is responsible for ensuring that PASRR evaluations accompany the resident when moved. 4. Specialized services for the NF population include: a. Specialized Services for Behavioral Health Conditions (1) Specialized services do not have to be provided by NFs. The term “Specialized Services” is equated with the level of care provided in psychiatric hospitals, or other intensive programs staffed with trained mental health professionals on a 24- hour/7-day basis. The patient’s care follows the aggressive implementation of a treatment plan developed by an interdisciplinary team including a physician and other qualified mental health professionals and incorporates therapies supervised by these professionals. Treatment is aimed at diagnosing and reducing behavioral symptoms to improve the patient’s level of functioning to a point that permits a reduction in intensity of services. While some of these services may be the same as those required to be provided by the nursing facility, it is the intensive level that sets these specialized services apart. b. Specialized Services for Persons with Intellectual/Developmental Disabilities are provided in accordance with the following:
(1) Specialized services take the form of a continuous program of specialized and generic training, treatment, health care, and related services and supports that aggressively and consistently: (AA) facilitates the acquisition of the behaviors necessary for the person to function with as much self- determination and independence as possible; and (BB) promotes the prevention or deceleration of regression or loss of current optimal functional status. Specialized services do not include services to maintain generally independent beneficiaries who are able to function with little supervision or in the absence of a continuous specialized services program. (2) BHDDH is responsible for the provision of specialized services that enhance the quality of life for persons with intellectual/developmental disabilities and maximize their potential for inclusion and participation in community life. The role of PASRR within this framework is to ensure and enhance the quality of care for persons with an I/DD who are residing in nursing facilities and to certify that a nursing facility is the most appropriate and least restrictive residential setting. D. Exemptions to PASRR are identified in federal regulations at 42 C.F.R. §§ 483.100 through 483.138. In accordance with BHDDH’s “advance group determination” wherein certain diagnoses and conditions that typically require NF admission are designated as exempt, the following classes are exempt from PASRR in Rhode Island: any person expected to be residing in a NF for less than thirty (30) days; any person in need of respite or emergency protective services; any person who has a terminal illness, severe or debilitating physical condition or illness, delirium, or dementia. 5.7 ICF/ID Needs-based Level of Care Determinations for Adults with Intellectual/Developmental Disabilities (IDD) 5.7.1 Overview A. In Rhode Island, the Medicaid ICF/I-DD level of care is reserved for persons with developmental disabilities who meet the criteria established in Part 40-00-1 of this Title. Although there are licensed ICF/I-DD health institutions operating in Rhode Island, they are limited in number and open only to new applicants who require intensive and continuous skilled services in a highly restricted setting.
Since the 1980s, the State has implemented a "community first" approach for adults with developmental disabilities who, were it not for access to HCBS, would require the level of care typically provided in an ICF/I-DD. B. In accordance with the principles established in the Olmstead decision (Olmstead v. L.C., 527 U.S. 581), BHDDH has developed service options that encourage independence and self-direction, facilitate supportive employment, and provide the appropriate level of care. The service classifications established by BHDDH are designed to ensure that the service options available to beneficiaries meet their needs in the least restrictive setting. 5.7.2 Assessments and Application of Needs-based Criteria A. The BHDDH Division of Developmental Disabilities (DDD) is responsible for determining whether an applicant for Medicaid LTSS meets the level of care for DD services under the terms of an interagency agreement with the EOHHS. In determining level of care, DDD eligibility specialists consider whether an applicant meets the criteria established in State law with respect to developmental/intellectual disabilities. The needs of applicants who meet this definition are then assessed using a Supports Intensity Scale – Adult Version (SIS-A), the nationally recognized instrument of choice for assessing the scope of ID/DD level of need. In addition, BHDDH uses the Situational Assessment of Need (SAN) tool to evaluate the scope of supervision a beneficiary requires as well as any other associated risk factors relevant in and across service settings. B. The SIS-A and SAN assessment instruments focus on different aspects of need: 1. The Supports Intensity Scale -- Adult Version (SIS-A) -- The SIS measures support requirements in 57 life activities and 28 behavioral and medical areas including, but not limited to, home living, community living, lifelong learning, employment, health and safety, social activities, and protection and advocacy. The assessment is conducted through an interview with the applicant and other persons who know the applicant well. a. Life activities. The SIS ranks each activity according to the frequency (refers to how often support is needed), amount (refers to how much time in one day another person is needed to provide support), and type of support (refers to what kind of support should be provided). b. Behavioral and medical health. The behavioral and medical section of the SIS-A rates exceptional medical and behavioral support needs. c. Supports Intensity Level (SIL). The SIL is determined based on the Total Support Needs Index, which is a standard score generated
from scores on all the items tested by the Scale. These results are organized into service classifications -- "tiers" -- that correspond to level of need and the available service options. 2. Situational Assessment of Need (SAN) -- The SAN is used to determine if a person with high needs levels requires the 24-hour supervision of a group home or shared living settings by evaluating behavioral health and legal risk factors. If the results of the SAN demonstrate that the person requires 24-hour supervision, then the beneficiary may be offered the option of placement in a community group home or shared living setting. The service options available do not change with the new placement, however. 5.7.3 Service Classifications A. The service classifications for Medicaid for LTSS for adults with disabilities are the tiers generated by the SIS assessment of needs levels. 1. Needs levels and associated tiers --The SIS assessment results are categorized as follows: a. Tier A (High)- Qualifying Disability with mild support needs b. Tier B (High)- Qualifying Disability with moderate support needs c. Tier C (Highest)- Qualifying Disability with identified medical/behavioral needs requiring significant supports d. Tier D (Highest)- Qualifying Disability with extraordinary medical issues requiring significant medical supports e. Tier E (Highest)- Qualifying Disability with extraordinary behavioral issues requiring significant behavioral supports 2. Service classifications -- The State has established service classifications based on the SIS tiers: a. Highest level of need. Tiers E, D and C: (1) Tier E (extraordinary needs) -- Adults at this tier have extraordinary behavioral issues requiring significant behavioral supports including one-to-one supervision for at least a significant portion of each day. Many persons at this tier have a mental health condition in addition to a developmental disability and may pose a safety risk to themselves and/or the community without continuous on-site support.
(2) Tier D (extraordinary needs) -- Adults at this tier include persons with the most extensive/complex medical support needs that require nurse management to minimize medical risk factors. Maximum assistance with activities of daily living is required to meet their extensive physical support needs and personal hygiene; including lifting/transferring and positioning. Feeding tubes and other feeding supports (e.g., aspiration risk management), oxygen therapy or breathing treatments, suctioning, and seizure management are common as well. Persons at this needs level may be medically unstable or receiving hospice services. (3) Tier C (significant needs) -- Adults at this tier have profound medical/behavioral needs requiring significant supports. Some time may be spent alone, engaging independently in certain community activities and/or with natural supports. b. High level of needs. Tiers B and A: (1) Tier B (moderate needs) -- Adults at this level require more hours of daily support than those with needs at Tier A. Even though members of this tier have a broader scope of personal needs than those in Tier A, 24/7 supports are not required as their needs are still considered minimal in a significant number of life areas. (2) Tier A (mild needs) -- Adults at this level are assessed as having mild support needs. Persons at this tier are capable of managing many aspects of their lives with limited supports and services. They do not require 24/7 paid supports as they are able to spend a significant amount of time on their own and/or engaging in the community with limited supports and services. 5.7.4 Service Options
A. Services in an ICF/I-DD health institution are reserved for beneficiaries determined to have the highest level of "extraordinary need" (Tier E) on the SIS who require intensive 24/7 care and, due to extenuating circumstances, may only be served in a highly restricted setting. Generally, medical conditions requiring continuous on-site skilled, rather than custodial care, prohibit applicants at this level from obtaining care in an HCBS setting. Persons with this level of need are served in an NF or LTH offering the same or a more robust service array. B. The HCBS service options available to beneficiaries with the needs levels at each service classification provide the appropriate care and supports in the least
restrictive setting. A summary of the service options available at each tier is as follows: DD/ID Needs-Based Service Tier Classifications and Options Tier Service Options Available Supports Tier D and E (Highest): Extraordinary Needs Living with family/caregiver Independent Living Shared Living Group Home/Specialized Group Home Community Supported Living Services Community Residential Support or access to overnight support services Integrated Employment Supports Integrated Community and/or Day supports Transportation Tier C (Highest): Significant Needs Living with family/caregiver Independent Living Shared Living Group Home Community Supported Living Services Community Residential Support or Access to overnight support services Integrated Employment Supports Integrated Community and/or Day supports
Transportation Tier B (High): Moderate Needs Living with family/ caregiver Independent Living Shared Living Community Supported Living Services Group Home (Only an available service option when the conditions set forth below in § 5.7.4 D are met). Integrated Employment supports Integrated Community and/or Day supports Access to overnight support services Transportation Tier A (High): Mild Needs Living with Family/Caregiver Independent Living Community Supported Living Services Group Home (Only an available service option when the conditions set forth below in § 5.7.4 D are met). Shared Living (Tier A will have access to Shared Living services if Integrated Employment supports Integrated Community and/or Day Supports Access to overnight support services Transportation
they meet at least one defined exception). C. Otherwise eligible persons who do not meet the needs-based criteria set forth above for the highest tier -- D and E -- may be placed in an alternative, more intensive care setting if certain special circumstances apply. In these situations, the scope of authorized supports remains tied to the tier associated with needs even though the setting has changed. Such circumstances include: 1. Loss of primary caregiver, such as hospitalization, debilitating illness, or death of spouse, caretaker sibling or adult child; 2. Loss of living situation, such as fire, flood, foreclosure, or sale of principal residence due to inability to maintain housing expenses; 3. A principal treating health care provider, or prior to ending an acute care hospital stay, a discharge planner indicates, based on a functional/clinical assessment, that the health and welfare of the applicant/beneficiary is at imminent risk if services are not provided or if services are discontinued; 4. The applicant/beneficiary met the highest level of care criteria on or before June 30, 2015 and chose to receive Medicaid LTSS at home or in a community-setting and the beneficiary reports he or she has experienced a failed placement that, if continued, may pose risks to the beneficiary's health and safety; 5. The beneficiary was admitted to a hospital or NF and is being discharged back to the original setting within any given forty (40) day period; or 6. There is a court order or other legal action requiring the provision of intensive supports or supervision that is only available in a residential supportive care setting. 5.7.5 Reassessments of the ICF/I-DD Level of Need
The BHDDH conducts reassessments of clinical and functional status at least annually and on an “as needed” basis. Unless these assessments warrant further review, redeterminations of clinical/functional eligibility and the level of need occur at five (5) year intervals. 5.8 Long-term Hospital Assessments and Level of Care Determinations A. Long-term hospitals and the related HCBS alternatives serve people who may have one or more of a diverse set of clinical and/or functional needs. In addition,
the intervals for re-determining level of care may differ depending on a beneficiary’s acuity needs. Accordingly, both the process and criteria for determining the LTH level of need vary across agencies and populations as follows: 1. HCB Habilitative Care – EOHHS LTSS specialists determine the level of need for applicants and beneficiaries seeking home and community based habilitative services. The NF needs-based criteria set forth in § 5.6.3 of this Part apply. Applicants and beneficiaries with the high and highest need have the choice of obtaining Medicaid HCBS services in a community residential care setting or at home. 2. Under 21 psychiatric care – Medicaid applicants and beneficiaries up to age twenty-one (21) may obtain LTH services in a licensed psychiatric residential treatment center or a hospital under the authority of the Early, Periodic, Screening, Detection and Treatment (EPSDT) requirements of Title XIX and the Medicaid State Plan. Assessments center on “medical necessity” and clinical/functional need and are conducted by treating health practitioners, the Medicaid managed care plans, and/or the DCYF, if the child or young adult is participating in one of the department’s programs. 3. Behavioral health services – The BHDDH and the State’s Community Mental Health Centers assess the clinical and functional needs of applicants/beneficiaries with serious and persistent behavioral health conditions and/or mental illnesses. This assessment is used to determine: a. Level of care. Whether the person requires the services and supports typically provided in an LTH to meet their clinical and functional needs; b. Service classification. What the scope and intensity of the person’s need for the LTH level of care are; and c. Service options. Whether the person’s needs can be met safely and effectively in the available HCBS alternatives, or require the more intensive services, supports, and supervision that can be accessed in a more restrictive health institution setting. B. Reassessments are conducted annually or on a more frequent basis, depending on need. Redeterminations of functional/clinical eligibility occur no more than once annually, and less frequently for Medicaid LTSS beneficiaries who have clinical and/or functional limitations that are not expected to change.
210-RICR-50-00-5 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 - MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 - LONG-TERM SERVICES PART 5 - “MEDICAID LONG-TERM SERVICES AND SUPPORTS: FUNCTIONAL/CLINICAL ELIGIBILITY” (210-RICR-50-00-5) Type of Filing: Refile Capabilities Department of State _________________________________________________________________ Regulation Effective Date Original Signing Date _________________________________________________________________ Department of State Initials Department of State Date 01/04/2022 09/10/2018 December 15, 2021 E-SIGNED by Department of State on 2021-12-15 16:23:45 EST
210-RICR-50-00-6 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 – MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 – LONG-TERM SERVICES PART 6 – Medicaid Long-Term Services And Supports: Financial Eligibility 6.1 Overview and Purpose A. Financial eligibility for Medicaid Long-Term Services and Supports (LTSS) is determined using a multi-faceted process that considers countable income and resources at the time of application, the allocation of joint spousal resources from the point the need for LTSS began, and financial transactions over a look-back period of up to five (5) years. The purpose of this process is not only to assess whether an applicant meets the applicable income and resource limits, but also to ensure that Federal requirements that both prohibit self-impoverishment and protect against spousal impoverishment are met. B. The LTSS financial eligibility requirements differ somewhat depending on whether a person is a current Medicaid beneficiary or a new applicant. The method required by Federal Regulations for evaluating income and resources is linked to the applicable category of Medicaid coverage: modified adjusted gross income (MAGI) method for Affordable Care Act (ACA) expansion adults in Medicaid Affordable Care Coverage (MACC) category or the Supplemental Security Income (SSI) method for adults over age twenty-one (21) in the Integrated Health Care Coverage (IHCC) category. 6.2 Legal Authority A. This Part is promulgated pursuant to the following Federal and State authorities: 1. Federal Law – Sections 1902, 1903,1905, 1915, 1917, 1919, 1924, 1934, and 1940 of Title XIX of the U.S. Social Security Act, 42 U.S.C. §§ 1396- 1396w-8. 2. Federal Regulations – 42 C.F.R. Parts 435, 441, and 460. 3. The Rhode Island Medicaid State Plan and the Section 1115 waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. B. State Authority – R.I. Gen. Laws Chapters 40-6; 40-8; 40-8.9; 40-8.10; and 42- 7.2.
6.3 Definitions A. For the purposes of this Part, the terms below are defined as follows: 1. “ACA expansion adult” means an adult between the ages of nineteen (19) and sixty-four (64) who is not eligible for or enrolled in Medicare or receiving SSI and qualifies for Medicaid coverage under the State Plan option established by the Federal Patient Protection and Affordable Care Act (ACA), Pub. Law No. 111-148. 2. “Annuity” means a purchased contract in which one (1) party (annuity issuer) agrees to pay the purchaser, or the person the purchaser designates (the payee or payees), a return on money deposited with the annuity issuer (either in the form of a single lump sum or several payments deposited over several months or years) according to the terms of the annuity contract. 3. “Authorized representative” means a person or entity whom an applicant or beneficiary designates to act responsibly on his or her behalf when applying for initial or continuing Medicaid eligibility and engaging with the agency on other ongoing communications. Such a designation requires the signed consent of the applicant or beneficiary, provided on paper or through any electronic signatures accepted by the State, unless conferred by court order or State law. 4. “Available resource” means that a person has the legal ability to access and use the resource(s) for support and maintenance. A resource is considered unavailable when there is a legal impediment that prevents the person from utilizing it for such purposes. 5. “Disqualifying transfer” means the divestment of an asset (liquid resource, prospective income, or real property) for less than fair market value or a fair market value that cannot be readily ascertained. 6. “Equity value” means the fair market value minus any encumbrances. 7. “Fair market value” or “FMV” means a certified appraisal or an amount equal to the price of the property or selling price of an asset on the open market in the locality that is readily ascertainable at the time of the transfer or contract for sale, or the application date if earlier. 8. “Financial responsibility unit” or “FRU” means the persons living with the applicant whose income and resources are considered available when determining financial eligibility. 9. “Guardian” means a person or institution appointed by a court in any state to act as a legal representative for another person, such as a minor or a person with disabilities.
10. “Medicaid eligibility group” means the total number of persons counted in a household – that is, the family size involved – when identifying the Federal Poverty Level (FPL) income level that applies when determining a person’s Medicaid eligibility. 11. “Ownership interest” means the Medicaid applicant holds sole or joint legal title to residential property or is a party to a legal covenant establishing property ownership, such as identified in § 6.9 of this Part. 12. “Principal place of residence” means the residential property where the beneficiary, and/or in the instances specified, the spouse or a dependent child of such a person, lives the majority of the year (i.e., one hundred eighty-three (183) days in the previous twelve (12) months). 13. “Real property” means land and generally whatever is erected, growing on, or affixed to land. 14. “Representative payee” means an individual, agency, or institution selected by a court or the Social Security Administration (SSA) to receive and manage benefits on behalf of another person. 15. “Trust” means property that is legally held or managed by a person or organization other than by its owners. 16. “Uncompensated value” or “UV” means the difference between the equity value and the actual value received in exchange for an asset. 6.4 LTSS Determination of Income A. In accordance with Subchapter 05 Part 1 of this Chapter, an applicant for Medicaid LTSS is both a financial responsibility unit (FRU) and a Medicaid eligibility unit of one (1) when determining financial eligibility once the joint resources of a couple have been allocated in the community spouse allocation of resources process in accordance with § 6.5.2 of this Part. There is also no spouse to spouse deeming of income in the LTSS financial eligibility determination process. B. The financial eligibility for current non-LTSS Medicaid beneficiaries is re- evaluated under this Part with information previously provided to the State by the beneficiary. As additional information from the beneficiary may be required, financial eligibility determination is not automatic unless the basis for coverage is receipt of SSI. C. Medicaid LTSS is available to applicants and beneficiaries who have countable income that does not exceed the limits established for one (1) or more of the following eligibility pathways:
1. ACA expansion adults – Adults between the ages of nineteen (19) and sixty-four (64) with income up to one hundred thirty-eight percent (138%) of the FPL, including the five percent (5%) disregard, using the MAGI method as set forth in Part 30-00-5 of this Title. The LTSS applicant is treated as a family of one (1) for LTSS eligibility purposes, irrespective of whether the applicant resides with a non-LTSS spouse and receives services at home, in a health institution or a community-based service setting. 2. Elders and adults with disabilities (EAD), including: a. SSI-eligible Medicaid beneficiaries; b. Adults between the ages of nineteen (19) and sixty-four (64). Medicare eligible or enrolled with countable income up to three hundred percent (300%) of the SSI rate using the method set forth in Part 40-00-3 of this Title; and c. Elders sixty-five (65) and older. Countable income up to three hundred percent (300%) of the SSI rate based on the SSI method in Part 40-00-3 of this Title. 3. LTSS medically needy adults – Adults with countable income above three hundred percent (300%) of the SSI rate may be eligible as medically needy if they meet the requirements set forth in Part 2 of this Subchapter. Except as provided herein, countable income is determined based on the SSI method in Part 40-00-3 of this Title. 4. Medicaid for working people with disabilities – Working adults with disabilities who buy into the Medicaid program through the Sherlock Plan or Ticket to Work Program set forth in Part 40-15-1 of this Title. D. The provisions in § 6.11 of this Part govern the treatment of income from trusts for applicants and beneficiaries of Medicaid LTSS. E. Financial eligibility for Medicaid LTSS is determined at the time of initial application and renewal. Applicants and beneficiaries are required to report changes to EOHHS about income and resources that may affect eligibility within ten (10) days of the date the change occurs. Failure to make a timely report is treated as non-cooperation and may result in the termination of Medicaid LTSS eligibility unless good cause for non-reporting exists. F. Distributions from long-term care insurance policies that are used to pay for long- term services and supports are not treated as income for the purposes of determining Medicaid LTSS eligibility. For these distributions to be exempt, the policy must be issued by an appropriately licensed and certified entity or under the auspices of a Qualified Long-Term Care Insurance Partnership (QLTCIP) program in this State or another State.
6.5 LTSS Determination of Countable Resources A. The State has established a four thousand dollar ($4,000.00) resource limit for Medicaid LTSS eligibility except for ACA expansion adults as indicated in § 6.5.1 below. These resource limits are used to determine financial eligibility only and are not protected or reserved for any purpose related to Medicaid LTSS access or coverage. Therefore, the State treats countable resources within these limits to be available to the applicant or beneficiary as indicated in Part 40-00-3 of this Title. B. The process for determining countable resources for LTSS purposes requires evaluating total assets at the time of application as well as a look-back period of five (5) years prior to the application date. The purpose of this five (5) year look- back period is to assess whether an applicant has transferred an asset (that is, resource or income) for less than or an unascertainable fair market value. 6.5.1 Resources and ACA Expansion Adults A. ACA expansion adults seeking Medicaid LTSS are exempt from the provisions in Title XIX requiring States to establish resource limits for eligibility. As indicated in Part 8 of this Subchapter, federal provisions related to the post-eligibility treatment of income also do not apply. B. ACA expansion adults are subject to Federal requirements related to the transfer of assets (i.e., liquid resources and real property) to prevent the divestiture of resources to gain access to Medicaid LTSS and ensure that a share of the applicant’s resources are protected for a spouse and dependents. Therefore, the only provisions set forth in this Part that apply to ACA expansion LTSS applicants are in §§ 6.6 to 6.12 of this Part. The provisions in Part 10-00-4 of this Title regarding estate recovery also apply. 6.5.2 Community Spouse Resource Allocation (CSRA) Process A. The Community Spouse Resource Allocation (CSRA) is one of several mechanisms established by the federal government to ensure that the costs of LTSS care do not impoverish the spouse and/or dependents of the person who is receiving LTSS. Toward this end, a CSRA assessment considers the couple’s total resources when LTSS began and allocates certain amounts, within the limits established under Section 1924 of the Social Security Act, 42 U.S.C. § 1396r-5, to both the LTSS recipient and their spouse. Hereinafter, the non-LTSS spouse is the person in a couple who is not receiving or applying for LTSS. Once the CSRA is completed, the amount allocated to the non-LTSS spouse is considered protected and is unavailable to pay for the Medicaid LTSS beneficiary’s cost of care. B. On and after the point at which one begins to receive LTSS on a continuous basis and/or applies for Medicaid LTSS, a CSRA assessment of combined
resources is conducted to determine the amount allocated to the non-LTSS or “community” spouse. For the purposes of this Part, the point of continuous LTSS (formerly referred to as the point of continuous institutionalization (POCI)) is: 1. Health institution – The first (1st) day of the month in which the LTSS applicant or beneficiary began to receive or is determined to have a need for services in a health institution that is expected to last for thirty (30) consecutive days or longer going forward. 2. Home and community-based services – The first (1st) day of the month that the State or its contractual agent determines, based on an assessment as defined in Part 5 of this Subchapter, that a person who has submitted a completed application for Medicaid LTSS requires or is receiving at least monthly one (1) or more of the Medicaid LTSS covered services identified in Part 10-1 of this Chapter. C. The CSRA assessment is optional for LTSS recipients in health institutions before applying for Medicaid and mandatory for all couples at the time of application without regard to the type of Medicaid LTSS they are seeking – that is, in a health institution or home and community-based setting (HCBS). 1. Optional, preliminary CSRA for LTSS in health institutions – At the beginning of a continuous period of LTSS in a health institution, either spouse, or a representative acting on behalf of either spouse, may request a preliminary CSRA assessment. The optional CSRA assessment serves only as a snapshot of the couple’s joint resources at the point in time in which it is completed. A CSRA is performed again, at the time of application, in most instances. a. Purpose. The optional assessment calculates the total value of the couple’s combined countable resources, owned either jointly or separately, as of the date on which continuous LTSS in the health institution began. The purpose of this assessment is to provide the couple with the information necessary for their financial planning in anticipation of Medicaid eligibility. b. Requirements. An application for Medicaid is not required in conjunction with the optional assessment. Accordingly, information for this CSRA is not verified. The State bases the assessment on information provided through attestations and any documents that may be submitted in conjunction with the request for the CSRA. A letter is sent to the person requesting the CSRA assessment by the State indicating the outcome. c. Limits. Due to federal requirements, the optional CSRA is not available for persons receiving long-term care in a HCBS setting until they have applied for Medicaid LTSS. The CSRA for a
Medicaid applicant seeking HCBS is never retrospective, as an applicant must be receiving at least one (1) Medicaid-covered LTSS service to qualify for eligibility. 2. Mandatory CSRA – In conjunction with the application for Medicaid, all countable resources owned by either spouse, jointly or separately, are pooled together as of either the date continuous LTSS began if in a health institution, or the date Medicaid LTSS eligibility will begin if not receiving LTSS or seeking HCBS coverage. Before the eligibility determination is made for the LTSS spouse, resources are allocated to the non-LTSS spouse up to the maximum allowed under Community Spouse Resource Standard set forth in Part 40-00-3 of this Title. D. To determine the allocation of resources for the LTSS spouse, the CSRA calculation includes the following steps: 1. Total countable resources – The countable resources of the couple are totaled. A resource is only included in the CSRA calculation if it is countable for eligibility purposes using the SSI method, as indicated in Part 40-00-3 of this Title or as specified in § 6.6.3 of this Part below. 2. Determination of Community Resource Allowance – The allocation of community resources for each spouse is determined by dividing the total countable resources for the couple by two (2). If necessary, the amounts are adjusted to ensure the non-LTSS spouse is allocated no less than the minimum but no more than the maximum allowed under the Community Spouse Resource Standard in Part 40-00-3 of this Title unless directed by a court order or fair hearing decision. Any amount exceeding the minimum or the maximum that may be allocated to the non-LTSS spouse as an allowance is considered available to the Medicaid LTSS applicant in the eligibility determination, regardless of which spouse owns the excess amount. 3. Medicaid LTSS resource eligibility – The amount of any excess resources after this calculation is compared to the four thousand dollar ($4,000.00) Medicaid LTSS resource eligibility limit. If the amount is equal to or below this limit, the LTSS spouse applying for Medicaid LTSS is resource- eligible; if the remaining resources exceed the eligibility standard, Medicaid LTSS eligibility is denied. Resource reduction is an option when resources exceed the limit, in accordance with § 6.5 of this Part. 4. Notice – The State provides timely and adequate notice of the results of the CSRA assessment that includes the right to appeal the manner and/or the amount of the assessment. 5. Allocation adjustment – If income of the non-LTSS spouse is below the minimum monthly maintenance of needs allowance, as determined during
the post-eligibility treatment of income process in Part 8 of this Subchapter, additional joint resources may be allocated from the LTSS applicant/beneficiary to the non-LTSS spouse to make up the difference. 6. Spousal transfers – An LTSS beneficiary has ninety (90) days from the date of the eligibility determination to transfer any resources necessary into the non-LTSS spouse’s name. After the initial ninety (90) day period is over, the State counts all resources that remain in the LTSS applicant/beneficiary's name in determining Medicaid LTSS eligibility. The State may extend the ninety (90) day period if any of the following conditions exist: a. Legal action. A court is involved in assigning the couple’s property through support actions; b. Appeal pending. An appeal of the CSRA has been filed and a decision has not been rendered; or c. Change in competency. The condition of the LTSS beneficiary requires the appointment of a conservator or guardian to act on his or her behalf. 7. Annual increases – The maximum amount of resources available under the Community Spouse Resource Standard for a non-LTSS spouse is increased annually on July 1 by the Federal government. No notice is required in conjunction with this adjustment unless the eligibility of the LTSS beneficiary is adversely affected. E. In instances in which the total countable resources of a couple are increased as the result of the sale or divestiture of an excluded resource, the assets are allocated equally to each spouse unless otherwise noted in the sales or divestiture agreement. F. Under Rhode Island law, the rights to spousal support are automatically assigned to the State upon application for and receipt of Medicaid. Accordingly, the CSRA process differs somewhat when spouses are estranged or the non-LTSS spouse refuses to make all or a portion of a couple’s joint resources available, as follows: 1. Estrangement – “Estrangement” means a breakdown to the point that the spouses would not be living together if one (1) was not receiving LTSS, whether in a health institution or the home and community-based setting. If the LTSS applicant is estranged from the non-LTSS spouse, eligibility is not denied due to excess resources or failure to cooperate if the applicant is able to demonstrate any of the following forms of hardship: a. Information unavailable. The LTSS applicant cannot obtain required information about the non-LTSS spouse’s resources after exploring all legal means.
b. Resources unavailable. The LTSS applicant is unable to access the estranged non-LTSS spouse’s resources after exploring all legal means, even though the non-LTSS spouse’s resources are sufficient in amount to cause a determination of ineligibility. 2. Spousal refusal – If the couple is not estranged and the non-LTSS spouse refuses to make resources available, eligibility is not denied on the basis of either the excess resources that are unavailable as a result of such refusal, or non-cooperation, as long as the LTSS applicant or beneficiary provides appropriate documentation of spousal refusal. 3. State recovery – Once eligibility has been determined, the State is authorized to pursue and recover from the non-LTSS spouse any of the couple’s joint resources that were unavailable due to spousal refusal to the extent required to reimburse the State for the cost of Medicaid provided to the spouse receiving Medicaid LTSS. 6.5.3 LTSS-Specific Factors Considered in the Treatment of Resources A. The provisions governing the evaluation and treatment of countable resources and the types of resources and related exclusions that apply when using the SSI method are set forth in Part 40-00-3 of this Title unless otherwise noted in this Part. B. LTSS-specific factors related to the treatment of resources include: 1. Home exclusion – The applicant’s primary residence and associated land are excluded if it has an equity value at or below the equity limit established in Part 40-00-3 of this Title. The provisions governing applicability of the home exclusion are set forth in Part 40-00-3 of this Title. A person who owns a primary residence with equity value in excess of the limit may request a hardship exemption in accordance with the criteria established in § 6.12 of this Part. a. Intent to return – The home exclusion applies when the LTSS applicant or beneficiary, the non-LTSS spouse and/or a dependent resides in the home or, when receiving LTSS outside of the home in a health institution or community-based setting, the LTSS applicant or beneficiary has an intent to return to the home as a primary residence. The following specific provisions also apply with respect to the intent to return: (1) One (1) established residence. The intent to return only applies to the one (1) home that has been established as the principal place of residence at the time of application for Medicaid LTSS. The exclusion does not apply to a home in which residency was not established at the time Medicaid
LTSS began, even if the person expresses an intent to return to that home. (2) Duration. The initial expression of the intent to return is not maintained indefinitely. At the time of application and with each subsequent eligibility renewal, the LTSS applicant/beneficiary or an authorized representative must provide a written expression of the intent to return for the home exclusion to apply. (3) Contrary acts. If the applicant or beneficiary acts in a manner that is inconsistent with the intent to return by attempting to transfer or sell ownership in the primary residence, the home exclusion may be withdrawn. The home is then treated as a countable resource. Timely and adequate notice by the State is provided prior to withdrawal of the exclusion. (4) Diminished capacity. If the State finds that the capacity of an applicant or beneficiary to express a clear expression of the intent to return is diminished, an authorized representative may submit a sworn affidavit of the intent to return on behalf of the applicant/beneficiary. Evidence of diminished capacity is required, such as a legal judgment of incompetence or a documentation of a medical or mental health condition. (5) Residence of spouse or dependents. Under § 1917(f) of the Social Security Act, 42 U.S.C. § 1396p, the entire value of a home is excluded, regardless of its equity value and without the need of an expression of the intent to return, if any of the following relatives of the LTSS applicant/beneficiary residing in a health institution is living in the property: (A) A spouse; or (B) A child who is younger than twenty-one (21) years old or who is blind or permanently and totally disabled. 2. Life estate – A life estate conveys the property of one (1) party (the life estate holder) for life and to a second (2nd) party (remainderman) when the life estate expires. The holder of the life estate agreement is entitled to all the income produced by the property unless the life estate specifies otherwise. The agreement that creates a life estate is a will, a deed or some other legal instrument. The following factors determine whether a life estate is treated as an excluded resource: a. Value of the life estate. The physical property has one value and the life estate has another, separate value. The value of the life
estate is based on the equity value of the property and the age of the life estate holder. The value is determined as follows: (1) Equity value. Determined by subtracting any encumbrances from the FMV of the real property (home). (2) Age of holder. Age of the estate holder rounded to the nearest year. (3) Life estate and remainder tables. These tables provide the value of a life estate and of a remainderman at any given age. The equity value of the real property is multiplied by the appropriate age figure from the tables. The State uses the life estate and remainder tables published by the U.S. Social Security Administration for the SSI program located in the Program Operations Manual System (POMS) at Section SI 01140.120. b. Excluded resource. The equity value of a life estate is an excluded resource if the provisions set forth in § 6.5.3(B)(1) of this Part are met with respect to: (1) Rhode Island residence -- The home is located in the State; (2) Equity value limit – The equity value of the life estate is at or below the limit set in Part 40-00-3 of this Title; and (3) Principal place of residence – The home is established as the principal place of residence and there is an intent to return to the home as specified in § 6.5.3(B)(2) of this Part. (4) Use of property – The life estate holder may use the property as a home or sell his or her ownership interest or may rent the property. If the life estate was purchased on or after July 1, 2006, the applicant or beneficiary must have resided in the home for a period of at least one (1) year for the home exclusion to apply. (5) Salability – If a life estate cannot be sold, then it is an unavailable resource and is excluded on that basis in accordance with the provisions in § 6.5.4 of this Part. c. Disqualifying transfer. The establishment of a life estate may be considered a disqualifying transfer which results in a penalty period as set forth in § 6.9 of this Part.
4. Qualified long-term care insurance partnership – Rhode Island has established a Qualified Long-Term Care Insurance Partnership (QLTCIP) program. The QLTCIP operates as follows: a. Resource disregard. A Medicaid applicant's resources are disregarded in an amount equal to the benefits paid by their QLTCIP policy as of the time of their application for Medicaid, and b. Estate recovery relief. The total amount paid by the QLTCIP policy at the time of death is disregarded in the determination of the amount to be recovered from a beneficiary's estate. This amount may be above the total amount disregarded at the time eligibility is determined if there are continuing QLTCIP policy payments after Medicaid eligibility is established, and the beneficiary gains assets that exceed total resources protected at the time of eligibility. c. Basis for the disregard. Long-term care insurance benefits that count toward the disregard include: (1) Benefits paid as direct reimbursement of LTSS expenses; (2) Benefits for LTSS paid to or on behalf of the beneficiary on a per diem, or other periodic basis, while the beneficiary is receiving LTSS services. d. Application of the disregard. It is not required that benefits available under a Partnership policy be fully exhausted before the disregard of resources can be applied. The use of a qualified partnership policy cannot be used to reduce the length of a penalty period resulting from a disqualifying transfer or a denial of Medicaid LTSS when an applicant’s equity interest in home property exceeds the limits set forth in Part 40-00-3 of this Title. e. Policies issue in other states. The State recognizes the validity of Partnership policies issued in other States. However, the State is not bound to accept the terms of these policies if they require that resource disregards or other financial exceptions be applied in a manner that exceeds or is inconsistent with the provisions set forth herein. 5. Other forms of LTSS insurance – The State provides a resource disregard for the payments of other forms of long-term care insurance issued by licensed/certified long-term care providers that meet national standards for actuarial soundness. Benefits from these insurance plans must be paid as a direct reimbursement for LTSS expenses provided to the Medicaid beneficiary. Estate recovery relief for payments disregarded is not available at the time of death if the insurance is not issued under the QLTCIP.
6. Trusts – The provisions in § 6.11 of this Part govern the treatment of resources from trusts for applicants and beneficiaries of Medicaid LTSS. 7. Retirement funds – The treatment of retirement funds, including individual retirement accounts (IRAs), of the LTSS applicant for determining countable income and resources is as set forth in Part 40-00-3 of this Title. a. For the purposes of determining the allocation of joint resources in accordance with § 6.5.2 of this Part above, a couple is treated as if they were living together when evaluating the availability and attribution of retirement funds irrespective of whether the LTSS applicant or beneficiary is residing in a health institution. The transfer of asset provisions set forth in §§ 6.6 to 6.12 of this Part apply if any funds withdrawn are divested for less than fair market value, or converted into another resource that is not actuarially sound or does not otherwise meet the criteria for an allowable transfer set forth therein. 6.5.4 Availability of Resources A. As a condition of eligibility for Medicaid LTSS under Federal law, an applicant or beneficiary must liquidate all available resources unless there is a specific exemption. B. When a person is legally entitled to a resource, the State considers it to be available on the application date or the date the resource is acquired, whichever is later. If a person so entitled cannot competently represent his or her interests, the resource is treated as available from the period beginning six (6) months after the date of application or the date the resource is acquired, whichever is later, in the following circumstances: 1. No legal representative – The applicant/beneficiary requires assistance to obtain the resource and has no guardian or conservator and an authorized representative (which may include a provider) is making a good-faith effort to secure the appointment of a competent guardian or conservator; or 2. Inaccessible trustee – The sole trustee of a Medicaid Qualifying Trust as defined in § 6.11 of this Part is incapacitated or unavailable and the applicant/beneficiary or an authorized representative is making a good- faith effort to contact the missing trustee or to secure the appointment of a competent trustee to act as the sole trustee. C. A resource is unavailable when the applicant or beneficiary has no legal access. The State does not count an unavailable resource when determining Medicaid eligibility, but only for the period in which there is no legal access. Unavailable resources include, but are not limited to:
1. Real Property – Real property may be considered unavailable when the ownership of it is the subject of legal proceedings such as probate or and divorce suits; 2. Life insurance – The cash-surrender value of life-insurance policies is treated as unavailable when the policy has been assigned to the issuing company for adjustment; and 3. Jointly owned financial instruments and holdings – The value of such financial instruments and holdings (stocks, bonds, CDs, etc.) is considered unavailable for both CSRA and the determination of financial eligibility when a sworn statement is provided indicating the applicant or beneficiary: a. Bonds jointly held. Is the named co-owner and does not have possession of the paper bond or the electronic transaction authority required to redeem the bond and the other co-owner will not redeem the bond, cannot be located, or refuses to provide the bond or transaction authority; b. Stocks and similar holdings and investment accounts. Is prohibited from selling the asset at its current value without the authorization of a co-owner and the co-owner cannot be located or refuses to provide such authorization. 6.5.5 Resource Reduction A. An applicant who is denied eligibility due to excess resources – that is, resources above the set limit allowed for financial eligibility – may become eligible for Medicaid LTSS through resource reduction. To become eligible using this process, an applicant must provide evidence that he or she paid an allowable health expenses that equals or exceeds the amount of excess resources. B. When using the resource reduction process, the Medicaid eligibility date is the date the applicant pays health expenses (medical bills) that reduce his or her total resources to the allowable limit. The following conditions apply: 1. Time-period – The resource reduction must occur in no more than thirty- five (35) days from the date on the eligibility denial notice, unless the applicant proves that he or she did not receive the notice in a timely manner. After the resource reduction time-period expires, a person must reapply for Medicaid LTSS. 2. Transfer of assets – An applicant must comply with the transfer of asset provisions set forth in § 6.6 of this Part below. A disqualifying transfer of assets is not accepted for resource reduction purposes in any circumstances.
3. No State payment – The State does not pay or otherwise reimburse any portion of the health expenses used for resource reduction. 4. Limits – To be used for resource reduction, the health expense must have been incurred during or after the retroactive period under Part 40-05-3 of this Title 4. Single use – The total amount or any portion of a health expense that is used for resource reduction must not be used for any other purpose in the determination of financial eligibility, including to meet an LTSS medically needy spenddown, or the post-eligibility treatment of income. 5. Adjustments – If a beneficiary submits an allowable health expense bill with a date that precedes the date eligibility is established through the resource reduction process, the State readjusts the date of eligibility if all the requirements set forth herein are met. 6.6 Transfer of Assets A. Section 1924 of the Social Security Act, 42 U.S.C. § 1396p, governs the treatment of assets in the Medicaid LTSS eligibility determination process. The law presumes transfers of assets for undiscernible or less than fair market value (FMV) prior to or at the time of applying for Medicaid LTSS coverage are transactions made for the principal purpose of gaining or maintaining eligibility. The law requires the States to treat all but a narrow range of these transactions as disqualifying transfers that result in a “penalty” period during which a person is ineligible for Medicaid LTSS coverage. For the purposes of this Section: 1. Assets – Includes all income and resources of an LTSS applicant and his or her spouse that is countable in the determination of Medicaid eligibility using the SSI method and the home (and associated land) when a person is seeking or receiving Medicaid LTSS. 2. Transfer – The conveyance of right, title, or interest in an asset from one person to another person or entity, the disclaiming, assignment or divestment of an income producing resource or other source of income, or disposal of a lump sum before it is treated as a countable resource or income. B. The State reviews asset transfers made by an LTSS applicant/beneficiary and/or the non-LTSS spouse in the five (5) year look back period prior to the first (1st) day of the month in which an application is filed. In determining whether a transfer is disqualifying, the State considers the date, amount of the asset, who is making the transfer, and the instrument used, as well FMV of the transaction, if discernable, as set forth below.
1. Allowed transfers – Federal law identifies the following transfers that are permissible in most circumstances and therefore exempt from a penalty period: a. Family transfers. Transfers from and between certain family members pursuant to § 1917(c)(2) of the Social Security Act. b. Fair market value. Transfers of assets for fair market value are allowed. c. Financial transfers. Transfers of assets using certain financial instruments such as Medicaid compliant annuities, loans of various kinds, and specific types of trust are not considered disqualifying transfers when they meet the requirements for allowed transfers set forth in §§ 6.7 to 6.11 of this Part. d. Prevent hardship. Assets for less than FMV or no discernable FMV may be allowed if the applicant/beneficiary can provide proof that the imposition of the penalty will pose a hardship as defined in § 6.12 of this Part. e. Other purposes. The applicant/beneficiary can prove to the State’s satisfaction that the transfer of assets was not made to gain or retain eligibility for Medicaid LTSS. See § 6.6.2 of this Part pertaining to rebuttal process. f. Asset return. The asset transferred for less than FMV is returned to the person who made the transfer. 2. Disqualifying transfers – Under State and Federal law, a transfer is considered disqualifying on its face unless allowed under § 6.6(B)(1) of this Part if it was made on or after February 8, 2006, within the sixty (60) month look-back period before an application is filed or on or after the date of application, and is a transfer for less than fair market value. Fair market value is customarily based on a certified appraisal or the amount equal to the last or average selling or purchase price on the open market on the date and in the location of the transfer transaction. A transfer is treated as disqualifying if the State cannot discern the FMV, and the transaction is between private parties, involves a promise to provide future payments or services, and there is no valid contract or agreement that is legally and reasonably enforceable by the applicant, beneficiary or non-LTSS spouse. The range of disqualifying transfers includes, but is not limited to: a. Gifts. A gift is considered a transfer of an asset for less than FMV and is subject to a penalty period unless the provisions set forth in § 6.6(B)(1) of this Part apply.
b. Sale or divesture. Selling or conveying an asset for less than FMV is a disqualifying transfer and is subject to a penalty. Divesting an ownership interest in an asset is also a disqualifying transfer even if it involves only the removal or change of a person’s name on a title or other ownership document and no money or goods of value are sold or exchanged. This includes the sale or divesture of real property such as a house, land, or vehicle as well as a business or service in which the Medicaid LTSS applicant or beneficiary and/or the non-LTSS spouse in some instances has an ownership interest. The State determines the FMV of a good or service sold or divested as the average sale or purchase price at the time of the transfer of ownership interest. c. Purchases and loans. The use of certain financial instruments to purchase or loan resources or transform them into an income stream is considered a disqualifying transfer for less than FMV unless the criteria indicated in §§ 6.7 to 6.11 of this Part apply. The range of disqualifying transfers in this category includes, but is not limited to, the purchase of an annuity that is not actuarily sound or a mortgage that over-values a property; acquiring a debt that reduces the value of an asset such as a home equity loan; and certain buying and lending practices, including entering into contracts for future goods and service, that encumber an asset, lower its FMV, or transform it from an available to unavailable resource. d. Trusts. The establishment of a trust for the benefit of someone other than the applicant, non-LTSS spouse, a dependent child or person with special needs is a disqualifying transfer in accordance with the provisions in § 6.11 of this Part. e. Refusing or transferring an inheritance or income stream. The State considers the refusal or transfer of lump sum resources or an income stream available to a Medicaid LTSS applicant through a trust, will or any other such source to be a disqualifying transfer. The penalty period in such cases in based on the total amount of the inheritance or income stream when establishing the penalty period without regard to its availability to the Medicaid LTSS applicant regardless of the source of the funds. C. If there is a disagreement over the State’s determination of FMV or the State is unable to discern the FMV by customary means, the onus is on the parties involved in the transaction to enter into a legally enforceable contract in which all agree to a certified appraisal of the transfer’s fair market value by an appropriately qualified independent third (3rd) party. Depending on the nature of the goods or services transferred, the range of independent third (3rd) party appraisers includes, but is not limited to, a licensed or certified real estate,
financial services, or insurance broker, home health or other service provider, public or private auditor, public accountant, actuary, or attorney. D. Any transfer that involves a promise to provide future payments or services is considered a disqualifying transfer of assets for less than fair market value if the State is unable to discern the FMV or if the transaction is not embodied in a valid contract that is legally and reasonably enforceable by the applicant, member, or spouse. E. The treatment of income or resources resulting from both allowable and disqualifying transfers is considered in the financial eligibility determination process. For disqualifying transfers, increases in the countable income and resources of the otherwise eligible LTSS recipient resulting from the transfer, or any subsequent transactions, may affect access to other non-LTSS forms of Medicaid during the penalty period or Medicaid LTSS eligibility once the penalty period expires. Redetermination of financial eligibility before Medicaid LTSS coverage begins may be required. F. When conducting the initial financial eligibility determination for Medicaid LTSS, and at the time of renewal, the State examines the value of assets on the first (1st) and last day of each month to identify transfers that may be disqualifying and subject to a penalty. In accordance with 42 U.S.C. § 1396w, an electronic asset verification system is used along with city property assessments, tax rolls and financial and legal documents during this review and verification process. G. A Medicaid LTSS beneficiary is required to report changes in assets in the interim between renewals within ten (10) days from the date the change occurs. Timely determinations of financial eligibility require that applicants provide all information and documentation requested at the time of application and during the period of review in accordance with the requirements set forth in Part 4 of this Subchapter. 6.6.1 Penalty Periods A. The State establishes a penalty for disqualifying transfers made during the look- back period. The penalty is a period of Medicaid LTSS ineligibility. During the penalty period, the State does not pay for LTSS provided in a health institution such as a nursing facility, or at home, or in a community setting, including community residences for people with intellectual/developmental disabilities, and shared living and assisted living residences. This provision does not impact eligibility for non-LTSS services such as physician, hospital, and other medical services. B. The look-back period and date a penalty period begins is a function of when a person applied for and began receiving Medicaid LTSS and several other factors as follows:
1. Before February 8, 2006 – For persons who applied for or began receiving Medicaid LTSS before this date, the look-back period extends back in time from the date of initial application for thirty-six (36) months. The penalty period begins on either the date of the disqualifying transfer or the first (1st) day of the month the person applied for Medicaid LTSS, whichever occurs later, and runs continuously even if long-term care services cease on an interim or permanent basis. 2. On or after February 8, 2006 – For persons who apply for and begin receiving Medicaid LTSS on or after this date, the penalty period begins on the date the State determines a person to be “otherwise eligible” for Medicaid or the date of the disqualifying transfer, whichever occurs later. “Otherwise eligible” means that Medicaid LTSS is being denied during a penalty period as a direct result of a disqualifying transfer. An applicant who does not meet any of the other requirements (general, financial, functional/clinical, etc.) for Medicaid LTSS eligibility must be denied on that basis and, therefore, is not considered otherwise eligible. a. Requirements. To be determined otherwise eligible, the applicant/beneficiary must be receiving LTSS in a health institution, or at least one (1) Medicaid LTSS covered service at home or in a community-based setting monthly, such as assisted living; and have applied for Medicaid LTSS and met all other eligibility requirements for Medicaid LTSS identified in Part 1 of this Subchapter, including having income within the allowable limits for Medicaid LTSS set forth in § 6.4(C) of this Part and resources at or below the four thousand dollar ($4,000.00) limit. b. Otherwise eligible date. The date a person is determined otherwise eligible is the effective date of the State’s denial of Medicaid LTSS eligibility. The date the denial takes effect is generally the first (1st) day of the month the application was filed. c. Benefits. During a penalty period, a person who has been determined otherwise eligible will not receive LTSS benefits. During this period, they may receive non-LTSS Medicaid benefits. d. Limits. To maintain non-LTSS Medicaid coverage during a penalty period, a beneficiary must meet the income and resource limits for the applicable eligibility category as of the first moment of the month and report any changes in financial or clinical/functional eligibility within ten (10) days from the date the change occurs. As the financial eligibility requirements and treatment of LTSS expenses during a penalty period vary across these coverage categories, eligibility for non-LTSS Medicaid coverage is not automatic and may not be advantageous if third-party health coverage is available.
C. The State determines the penalty period for disqualifying transfers made before February 8, 2006 as follows: 1. Determine the equity value of all assets transferred in the thirty-six (36) months before the applicant applied for Medicaid, other than those transferred to or by a trust. 2. Determine the equity value of all assets transferred into or by a trust in the sixty (60) months before the applicant applied for Medicaid. 3. Divide the total equity value of the transferred assets by the average monthly cost of nursing services at the time of application to determine the number of months of penalty. Drop any fraction remaining, so the result is in whole months. D. The State determines the penalty period for disqualifying transfers made on or after February 8, 2006 as follows: 1. Total uncompensated value – The total uncompensated value is calculated by adding the disqualifying transfers made by the Medicaid applicant/beneficiary and/or the non-LTSS spouse during the applicable look-back period if the transfer occurs prior to a determination of eligibility, or the application date if the transfer happens after eligibility is determined. 2. Penalty divisor – The UV of the disqualifying transfers is divided by the average daily/monthly cost of nursing facility care in Rhode Island, at the current statewide average private pay rate. As of April 2026, the average monthly private pay rate is $12,106 and the average daily private pay rate is $398. E. The State determines the penalty period of ineligibility in special circumstances as follows: 1. Transfer patterns – If the State detects a pattern of uncompensated transfers over a period of months that, when totaled, equal or exceed the resource limit, the State presumes these have been made to gain Medicaid LTSS eligibility and treats the amount in total as a disqualifying transfer, unless provided a reasonable rebuttal in accordance with § 6.6.2 of this Part. 2. Spousal eligibility – If the non-LTSS spouse becomes eligible for Medicaid LTSS after the penalty period is established, the State divides the period of ineligibility in half and applies one-half (1/2) of the penalty period to each spouse. If one (1) spouse dies before the penalty period is completed, the remaining period of ineligibility applies to the surviving spouse.
3. Multiple disqualifying transfers – The treatment of multiple disqualifying differs depending on the year the transfer occurred and whether there is overlap: a. Transfers before February 8, 2006. When more than one (1) disqualifying transfer is made prior to this date, the State treats each transfer separately and sets the start date for the penalty on the first (1st) day of the month when each transfer was made. If the penalty periods for the transfers would overlap, the start date for the penalty is the first (1st) day of the month that the first disqualifying transfer was made. b. On or after February 8, 2006. When multiple disqualifying transfers are made on or after this date, and within the five (5) year look-back period, the State considers the total UV of all the transfers when determining the penalty period. The penalty start date is the date the applicant or beneficiary is otherwise eligible or, in the event there is overlap, the first (1st) day of the month of the first (1st) transfer, whichever is later. 4. Penalty period of less than one month – If the penalty period of ineligibility is determined to be less than one (1) month, the State imposes a partial- month penalty and does not round down or disregard any fractional period of ineligibility. The date the penalty period begins is the date the person is otherwise eligible for Medicaid LTSS or the first (1st) day of the month during or after the disqualifying transfer. If a penalty period is in effect on that date, the penalty period is extended by the appropriate number of days. 5. Lump-sum income – When there is a disqualifying transfer of income in a lump sum, the State calculates the penalty period based on the lump-sum value. 6. Stream of income – The State calculates the penalty for each income payment that is periodically transferred. F. In instances in which disqualifying asset is returned in its entirety, the transfer penalty is expunged as of the first moment of the first day of the month after the return. When an asset transferred for less than FMV is returned in full in the same month, a period of ineligibility does not apply and the disqualifying transfer is treated as if it never occurred. If an asset transferred for less than FMV is returned in a subsequent month, the uncompensated value of the asset is recomputed to determine whether any period of ineligibility applies through the month of the return or subsequent months based on the adjusted uncompensated value.
G. During the penalty period, Medicaid LTSS coverage is unavailable, including Medicaid LTSS provided in a health institution as specified under Part 05-1 of this Chapter, and in home or community-based settings as set forth in Part 10-1 of this Chapter. All non-LTSS Medicaid State Plan and waiver services are available to a person subject to the penalty if otherwise eligible and enrolled in one of the coverage groups identified in Chapters 30 or 40 of this Title. H. The EOHHS reserves the discretion to refer to the appropriate State and/or Federal authorities any applicant who has transferred assets in a manner that indicates an attempt has or is being made to fraudulently gain Medicaid LTSS eligibility. 6.6.2 Rebuttal of Disqualifying Transfer Determination A. The State presumes that disqualifying transfers of assets during the look-back period were made to gain or retain eligibility for Medicaid LTSS. The State has established a process that provides an opportunity to rebut this presumption in accordance with § 1917(c)(2)(C) of the Social Security Act, 42 U.S.C. § 1396p(c)(2)(C). The burden of proof is on the LTSS applicant/beneficiary to prove that the assets were not transferred to meet eligibility requirements. B. There are certain factors the State takes into consideration when evaluating whether there is credible evidence that a disqualifying transfer was made for a reason other than to obtain Medicaid eligibility: 1. Unexpected need for LTSS – Transfers made before the applicant or beneficiary was diagnosed with a previously undetected disabling condition or experiences a sudden traumatic injury from an accident. 2. Financial calamity – Transfers made to cover unexpected loss of income or resources, including any deemed available from another person, necessary to meet financial obligations or prevent imminent risk to health and/or safety. 3. No impact on eligibility – Total countable resources would have been at or below the resource limit at all times from the month of disqualifying transfer through the present month even if the asset had been retained. 4. Court-ordered – Transfers made to satisfy a court-order, including any required to cover familiar support obligations or satisfy liens or debts. C. The person making the rebuttal, whether the applicant or beneficiary or an authorized representative making the rebuttal on his or her behalf, must provide a written statement that includes: 1. Reasons for the transfer – An explanation of why the asset was transferred and the relationship of the LTSS applicant’s/beneficiary to the person who received the transfer.
2. Value of the asset – Information establishing the fair market value and the equity value of the asset transferred and from an appropriately qualified independent, third (3rd) party appraiser when the FMV is disputed or cannot be discerned. 3. Proof of effort – Verification of an attempt to dispose of the asset for a fair market value and an explanation of why the transfer ultimately occurred for less than this amount. 4. Compensation terms – The terms of an agreement, contract, or other expectation established at the time of the transfer indicating that the applicant or beneficiary received or will receive compensation for the fair market value of the transfer. Compensation may be made in cash or other tender, real or personal property, food, shelter, or services received by an owner in exchange for an asset. (See § 6.10 of this Part for personal service/care contract provisions.) 5. Self-support – An explanation of how the applicant or beneficiary planned for self-support after the asset was transferred. D. Initiating a rebuttal does not restrict the right of the applicant, beneficiary, or an authorized representative thereof from requesting a hardship exemption in accordance with § 6.12 of this Part or making an appeal for a hearing pursuant to Part 10-05-2 of the Title. 6.7 Asset Transfers Involving Annuities A. This Section provides the criteria for determining whether annuity is treated as disqualifying transfer resulting in a period of ineligibility for Medicaid LTSS. Irrespective of whether the establishment of the annuity is considered a disqualifying transfer, the provisions pertaining to whether any income derived is countable for eligibility purposes under Part 40-00-3 of this Title apply. B. Annuities established before February 8, 2006: 1. Disqualifying transfer – The annuity was purchased before February 8, 2006, and the expected return on the annuity is not commensurate with a reasonable estimate of life expectancy, also referred to as “actuarially sound.” 2. Allowed transfer – When an annuity purchased before February 8, 2006, is “actuarially sound,” then it is not considered a transfer of assets for less than fair market value. The annuitant has just converted the resources to income. C. To determine whether the annuity is “actuarially sound,” the State uses the life expectancy tables compiled from information published by the Office of the Chief
Actuary of the Social Security Administration. These tables may be accessed at http://www.ssa.gov/OACT/STATS/table4c6.html. D. The average number of years of expected life remaining for the annuitant must coincide with the life of the annuity. If the annuitant is not reasonably expected to live as long as or longer than the guarantee period of the annuity, the annuitant will not receive fair market value for the annuity based on the projected return. In that case, the annuity is not actuarially sound and a disqualifying transfer has occurred. The penalty is assessed based on the disqualifying transfer at the time the annuity was purchased or the date the annuity became available as a countable resource, whichever is later. E. Annuities established on or after February 8, 2006. 1. Disqualifying transfer – Purchase of a Medicaid non-compliant annuity on or after February 8, 2006, by an LTSS applicant or beneficiary as the annuitant. An annuity is considered non-compliant if purchased at less than FMV or has no readily ascertainable FMV. The purchase of an annuity is treated as the disposal of an asset for less than fair market value if neither of the conditions in § 1917(c)(1)(F) of the Social Security Act, 42 U.S.C. 1396p(c)(1)(F), are met; 2. Allowed transfer – Purchase of a Medicaid compliant annuity as defined in § 1917(c)(1)(G) of the Social Security Act, § 1396p(c)(1)(G). F. Annuities purchased by a non-LTSS spouse: 1. Disqualifying transfer – Purchase of an annuity on or after February 8, 2006, by the non-LTSS spouse of a Medicaid LTSS applicant or beneficiary in which the spouse is the annuitant. 2. Allowed transfer – The annuity has the State of Rhode Island named as the remainder beneficiary for at least the total amount of Medicaid paid on behalf of the annuitant or the annuitant’s spouse, if either is currently receiving Medicaid LTSS. The State may be named as either: a. The remainder beneficiary in the first (1st) position; or b. The remainder beneficiary in the second (2nd) position, after the community spouse, minor child or disabled child, and in the first (1st) position if the spouse or a representative of the child does not dispose of the remainder for less than fair market value. 6.8 Asset Transfers Involving Loans – Promissory Notes, Mortgages and Commercial and Informal Lending Instruments A. Loans are financial instruments that allow an applicant or beneficiary to lend an asset to another person for a set period in exchange for fixed payments. Part 40-
00-3 of this Title contains the provisions for evaluating each of these instruments and the treatment of principal and interest when determining income and resource eligibility. B. The use of loans to borrow or lend assets during the Medicaid LTSS application look-back period, or on or after the date eligibility is established, is evaluated to determine whether a disqualifying transfer exists. Treatment is as follows: 1. Disqualifying transfer – The use of a loan to transfer assets on or after February 8, 2006 may be a disqualifying transfer if the transaction is for less than fair market value and in amount that cannot be reasonably paid back within the expected lifetime of the applicant or beneficiary or the non- LTSS spouse. Commercial and informal loans that do not meet the criteria set forth in Part 40-00-3 of this Title are treated as gifts and, therefore, as disqualifying transfers except as provided herein under § 6.6(B) of this Part. Mortgages made for less than fair market value are disqualifying transfers for Medicaid LTSS eligibility purposes. The penalty period for disqualifying transfers made using a loan is the total uncompensated value of the transfer including principal and interest amortized over the repayment period. 2. Allowed transfer – Use of one of these financial instruments is considered an exempt transfer when the loan agreement states the total amount of the debt, including principal and interest amortized over the life of the loan, and: a. Actuarily sound. The repayment terms are actuarially sound, as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration; b. Equal payments. The debt payments are made in equal amounts during the full term of the loan, with no deferral or balloon payments of principal or interest; c. Limits. The cancellation of the balance upon the death of the lender is prohibited. 3. Prepayment – Early payment of a debt incurred as an allowed asset transfer under § 6.8(B)(2) of this Part is subject to review by the State for a disqualifying transfer if it is the result of making higher, multiple, or unequal payments of principal and/or interest or otherwise violates the criteria therein. Unequal payments are only permitted when they are required under the terms of commercial loan that has variable interest rates.
6.9 Asset Transfers Involving Life Estates A. Life estate means a legal arrangement entitling the owner of the life estate (sometimes referred to as the “life tenant”) to possess, rent, and otherwise profit from real or personal property during their lifetime. The amount of a life estate that is countable depends on when it was established, whether the applicant has the legal right to sell the home, and the portion of the proceeds of the sale, if allowed, that are available. B. For all Medicaid LTSS applications and renewals after January 1, 2006, the establishment of a life estate for a home is treated as a transfer of assets. 1. Disqualifying transfer – A life estate may be a disqualifying transfer in the following instances: a. Applicant/beneficiary owns the property – When an applicant or beneficiary has an ownership interest in a home and establishes a life estate on his or her own behalf, the remainder interest is a disqualifying transfer. The remainder interest is the equity value of the property minus the value of the life estate as determined in accordance with § 6.5.3(B)(3) of this Part. b. Applicant/beneficiary purchases property – When an applicant/beneficiary purchases a life estate in the home of another person, and the payment made exceeds the FMV of the life estate, the difference between the amount paid and the FMV is treated as a disqualifying transfer. This transfer is disqualifying even if the applicant/beneficiary lives in the home of the life estate for one (1) year or more. c. Applicant/beneficiary gifts the property – In instances in which the applicant/beneficiary makes a gift or transfer of a life estate interest, the value of the life estate, as calculated under § 6.5.3(B)(3) of this Part, is considered a disqualifying transfer of assets. 2. Allowed transfer – When an applicant or beneficiary establishes a life estate for fair market value, the purchase price is an allowed transfer if he or she resides in the home for at least one (1) year after the life estate is established. If the home held in the life estate is not excluded in accordance with the provisions set forth in §§ 6.5.3(B)(1) and (2) of this Part, the value of the life estate is counted as a resource in determining Medicaid LTSS eligibility. C. A home held in a life estate may be excluded as a resource for Medicaid LTSS eligibility determination, providing the provisions of § 6.5.3(B)(3) of this Part have been met.
6.9.1 Life Estate with Enhanced Powers A. A deed containing a life estate with enhanced powers is also known as an “enhanced life estate deed” or a “Ladybird deed.” An enhanced life estate deed permits a person to reserve the rights to sell, convey, mortgage, revoke, amend, and otherwise dispose of the property while alive. Upon the life estate holder’s death, the life estate passes to a remainderman, without the need for probate. The deed specifies who will become the owner of the property upon death. B. On or after July 1, 2014, an applicant or beneficiary who holds a life estate with enhanced powers that serves as a primary residence is ineligible for Medicaid LTSS, unless or until the applicant/beneficiary: 1. Conveyance of the remainder interest – Exercises the retained power to convey all outstanding remainder interest to him or herself. 2. Basis of the transfer – Uses a warranty deed or quitclaim deed created, executed, and recorded to transfer the remainder interest. 3. Ownership – Holds the real estate, free and simple with no encumbrances. C. Upon assuming ownership of the remainder interest, a determination of whether the home exclusion applies is made in accordance with § 6.5.3 of this Part if the applicant or beneficiary is otherwise eligible. D. An applicant or beneficiary who has a reserved a life estate with enhanced powers with retained rights to revoke, amend, or re-designate the remainderman by a deed created, executed, and recorded prior to July 1, 2014 is not denied Medicaid eligibility based on that deed, regardless of whether the remainderman designated is a person or persons, a trust, or other entity. 6.10 Asset Transfer Involving Personal Service/Caregiver Contracts A. A personal service or caregiver contract is a formal written agreement between an applicant or beneficiary and an individual service/care provider. Under the terms of the contract, the service/care provider agrees to provide personal and/or managerial services in exchange for compensation paid by applicant or beneficiary who receives the services over a set period of time. Typically, the caregiver is, but is not required to be, an adult family member or friend of the applicant and the services covered range from home chores (such as housecleaning, grocery shopping, laundry, shoveling and like) to assisting with personal care needs (transportation to medical appointments, aiding in dressing and grooming, and so forth). B. Personal service/caregiver contracts are not a countable resource for Medicaid LTSS purposes. The purchase price – the amount to be paid over the life of the contract – is a treated as a transfer of assets. Accordingly, the State is required
to determine whether a personal service/caregiver contract is a transaction made for less than FMV that constitutes a disqualifying transfer. The State makes this determination as follows: 1. Disqualifying transfer – A personal service/caregiver contract is a disqualifying transfer if the payments are for services performed before the date of the transaction. A lump sum payment for services provided in the past is, therefore, a transfer for less than FMV. A contract that requires payment at the time the services/care are rendered is a disqualifying transfer if the services/care are covered by Medicaid or another third (3rd) party payer, or for a person other than a non-LTSS spouse, dependent child, or dependent with disabilities that has no alternative form of coverage. In addition, a contract that requires payment upfront at the time of the transaction for service/care to be provided at some point in the future is treated as a disqualifying transfer unless proof is provided that the services/care will not be covered by Medicaid or another third (3rd) party at the time they are rendered. All contracts based on the promise of services performed in the future are treated as disqualifying transfers if FMV cannot be discerned in accordance with § 6.6(B) of this Part. 2. Allowed transfer – A personal service/caregiver contract is an allowed transfer if the agreement is in writing, the payment is for services/care provided prospectively (after the contract is executed) and at the time they are performed, and the compensation for services/care provided is reasonable -- commensurate with the wage scale or customary fees that would be paid typically to a third (3rd) party performing for the same services/care in the State. Also, the services/care to be paid for under the contract must not be covered by Medicaid or another third (3rd) party payer. To ensure there is no overlapping coverage, the contract must specify the types of services/care to be provided, the location, and how often, as well as a start and end date, the form and frequency of compensation, the terms for altering the contract and the signatures of the parties involved. An agreement that includes these elements may be treated as a disqualifying transfer if the State determines the payments are being used for purposes other than those specified in the contract or made to persons or entities other than the persons or entities identified as the service/care provider(s) under the contract. 6.11 Treatment of Trusts and the Transfer of Assets A. A trust is an arrangement in which a person, known as the “grantor” transfers property to a trustee with the intention that it be held, managed, or administered by the trustee for the benefit of the grantor or certain designated beneficiaries. The term "trust" also includes any legal instrument or a device similar to a trust. The grantor (or grantor beneficiary) establishes or creates the trust upon signature.
B. The “property” transferred to the trust takes on the form of a fund and may be comprised of any type of a resource including liquid, non-liquid, and real property as well as income producing goods, services and businesses. Trusts and portions of trusts may be treated as available income, available resources, or as a transfer of assets for less than fair market value. C. For the purposes of this Part, the term “Medicaid LTSS applicant” refers to both a person seeking initial eligibility and current beneficiary so as to distinguish between a trust beneficiary. When a trust includes the assets of multiple persons, only the portion of trust that is attributable to the Medicaid LTSS applicant is considered in the eligibility process. D. The factors that affect the treatment of a trust in the Medicaid LTSS financial eligibility process are as follows: 1. Legally valid – A trust must be valid under Rhode Island law. 2. Date established – Under Federal law, trusts established prior to August 11, 1993 are treated differently than those established after that date. In addition, income and resources generated from trusts created before February 8, 2006 may be treated differently. 3. Types of trusts – Treatment of a trust varies depending on whether it is: a. Living trust versus testamentary trust. (1) A living trust or an inter-vivos trust – Set up during a person's lifetime and becomes effective when it is created. The State reviews Medicaid living trusts to determine whether and to what extent the instrument affects a person’s LTSS financial eligibility. (2) Testamentary trust – Generally established within a will and does not become effective until after the death of the “testator” who established the trust. A testamentary trust takes effect after the testator’s death. Testamentary trusts are not treated as trusts for Medicaid eligibility purposes and therefore are exempt from the provisions in this Section. b. Revocable versus irrevocable under Rhode Island law. (1) Revocable trusts – The grantor who established the trust retains ownership and control of the property in the trust and can change the terms, including the trustees and grantor beneficiaries. (2) Irrevocable trusts – The grantor who created the trust gives ownership and control of the property in the trust to one or
more other persons known as “trustees.” The grantor is thus unable to enact changes in the trust. 4. Principal versus earnings and interest – In general: a. Principal. The trust principal is the property placed in trust by the grantor that the trustee holds, subject to the rights of the trust beneficiary, plus any trust earnings paid into the trust and left to accumulate the month following the month of a distribution. b. Earnings or interest. Trust earnings/interest are amounts of income derived from trust principal, such as interest, dividends, royalties, or rents. These amounts are unearned income to the trust beneficiary if he or she is legally able to use them for personal support and maintenance. 5. Medicaid eligibility category – Available income and resources from a trust are counted only once during the determination of eligibility for Medicaid health coverage. Accordingly, the State does not reconsider available income and/or resources from a trust that was included in the determination of financial eligibility for SSI. 6.11.1 Qualifying Trusts – Established Prior to August 11, 1993 A. A trust, or similar legal device, is called a Medicaid qualifying trust (MQT) when the following conditions have been met: 1. Date – The trust was established prior to August 11, 1993; 2. Grantor – Established by the Medicaid LTSS applicant or someone acting on the applicant’s behalf including the applicant’s spouse, or a legal guardian or authorized representative; 3. Source – The source of the trust is either funds owned by the grantor or funds the grantor is entitled to use; 4. Type of trust – The trust is a living trust that was not established by a last will and testament; 5. Trust beneficiary – The trust names the Medicaid LTSS applicant to be the trust beneficiary of all or part the trust and the discretionary or required payments or distributions from the trust; 6. Distribution – Trustee discretion. The terms of distribution under the trust give one (1) or more trustees the discretion to distribute payments to the trust beneficiary and set limits on the discretion of the trustee(s) therein;
7. Use limits – There may be requirements in the trust related to the distribution of trust principal and interest/earnings but there are no limits on their “use”; and 8. Exceptions – Any trust or trust decree established prior to April 7, 1986 when solely for the benefit of person with an intellectual/development disability who resides in an intermediate care facility for persons with intellectual/developmental disabilities (ICF/IDD). 9. Purpose – The trust was created for a purpose other than to qualify for Medicaid. B. In the determination of Medicaid LTSS financial eligibility and in the post-eligibility treatment of income, the State determines the maximum amount that could be distributed from an MQT and then the amount of countable income and resources as follows: 1. Maximum distribution amount – The maximum amount of income and principal from an MQT is the total amount trustees are permitted to distribute to the trust beneficiary when exercising full discretion under the terms of the trust. 2. Available countable amount – The terms of the trust that specify the available income (interest/earnings) and resources (principal) determine the amount counted as available, regardless of whether any distributions are being made. For LTSS eligibility: a. Countable resource. The trust principal (including accumulated income) available to the trust beneficiary is a countable resource. b. Countable income. If the terms of the trust explicitly limit the amount of trust principal that is available on an annual (or specified less frequent) basis, the principal is countable income beginning the month it becomes available. c. Countable income or resource. Trust principal and earnings/interest available for daily living expenses (food, clothing or shelter), including items not typically considered to be essential to daily living, are countable and treated according to their source under the terms of the trust. If paid from trust principal, the payment is treated as resource; if paid from trust interest/earnings, the payment is treated as income. 3. Non-countable – Interest/earnings and principal available only to pay providers meeting non-basic needs are considered unavailable to the LTSS applicant when determining eligibility.
4. Health care specific – Trusts established for health care payments are considered to be a third (3rd) party resource. Principal and interest/earnings are not counted if the terms of the trust specify that they are available only for making health care-related payments. C. In both the determination of LTSS financial eligibility and the post-eligibility treatment of income a revocable trust established before August 11, 1993 is treated as follows: 1. Countable resources and income – The trust principal and earnings/interest are treated as countable resources and income, respectively. 2. Home and adjoining land – The fair market value of a primary residence or former primary residence of an LTSS applicant or spouse in a revocable trust does not qualify for the exclusions set forth in § 6.4(D)(3) of this Part and is treated as a countable resource. 6.11.2 Non-Qualifying Trusts – Established on or After August 11, 1993 A. The requirements for evaluating non-MQT differ when determining Medicaid LTSS eligibility. A trust other than a MQT is subject to the provisions of this Part when the following conditions are met: 1. Date – The trust was established on or after August 11, 1993; 2. Grantor – Established by the Medicaid LTSS applicant, or a grantor on the applicant’s behalf including a spouse, or a legal guardian or authorized representative; 3. Source – The source of the trust is either funds owned by the grantor or funds the grantor is entitled to use; 4. Type of trust – The trust is a living trust that was not established by a last will and testament; 5. Trust beneficiary – The trust names the Medicaid LTSS applicant to be the trust beneficiary and, as such, to receive distributions from the trust; 6. Distribution – The terms of the trust establishing the purposes and/or circumstances for which distributions of principal and earnings/interest may be made dictate treatment rather than the discretion of the trustee(s) therein; 7. Use limits – Restrictions on the timing of distributions or how the funds may be used are not a factor; and
8. Exceptions – Any trust or trust decree established prior to April 7, 1986 when solely for the benefit of person with an intellectual/development disability who resides in an ICF/IDD. 9. Purpose – The reason the trust was created is not considered. B. Whether such a trust is revocable or irrevocable affects how it is treated for Medicaid LTSS financial eligibility. A revocable trust is a trust under Rhode Island law that can be revoked by the grantor. A trust that authorizes a court of appropriate jurisdiction to modify or terminate all or some of its terms is revocable for the purposes of this Section because the grantor can petition the court to act. Similarly, a trust referred to as “irrevocable” is treated as revocable if it requires a trustee to terminate or modify distributions when the beneficiary takes a specific action such as leaving a nursing home, marrying or divorcing, or moving out of State. 1. Revocable trusts – The State treats revocable trusts as follows: a. Countable resource – The principal of the trust is treated as a countable resource. The primary residence or former primary residence of a Medicaid LTSS applicant held in a revocable trust established on or after December 1, 2000 is a countable resource and is therefore exempt from the home exclusion, regardless of the intent to remain, as set forth in § 6.5.3(B)(1) of this Part; b. Countable income – Payment distributions made from the trust to or for the benefit of the trust beneficiary are counted as available income; c. Transfer of assets – Any other distributions made from the trust within sixty (60) months immediately prior to or any time after the trust beneficiary applied for Medicaid LTSS are considered to be disqualifying transfers and are subject to a penalty as set forth in § 6.6.1 of this Part. 2. Irrevocable trusts – Irrevocable trusts are treated as follows: a. Countable income. Any payment distributions from trust principal or earnings/interest made to or for the benefit of the trust beneficiary are counted as income; b. Countable resource. Any portions of the principal that could be paid to or for the benefit of trust beneficiary for a circumstance or purpose allowed under the terms of the trust are treated as a countable resource. The primary residence or former primary residence of a trust beneficiary held in an irrevocable trust established on or after December 1, 2000 is not subject to the intent to return exclusion;
c. Distributions from countable resource trusts. The distributions of income or principal under the trust which could have been made to or for the benefit of the trust beneficiary, but are instead made to someone else and not for the benefit of the trust beneficiary, are considered disqualifying transfers as of the date of the distributions and are subject to a penalty pursuant to § 6.6 of this Part if those distributions were made within the sixty (60) months immediately prior to or at any time after the month the trust beneficiary both is receiving long-term care and has applied for Medicaid LTSS. d. Disqualifying transfers into non-countable irrevocable trusts – Portions of the trust which cannot under any circumstances be paid to or for the trust beneficiary are treated as disqualifying transfers as of the date the asset was transferred and are subject to a penalty pursuant to § 6.6 of this Part if the asset was transferred into the trust resource within sixty (60) months immediately prior to or any time after the month in which the trust beneficiary was both receiving long-term care and has applied for Medicaid LTSS. C. Any time there is a disqualifying transfer related to a non-MQT, the date of the transfer is the date the trust was established or, if later, the date payment to the trust beneficiary foreclosed. The uncompensated value of the disqualifying transfer can be no less that its value on the date of transfer. D. When funds are added to a trust, the additional funds are considered to be a disqualifying transfer, effective on the date the funds were added to that portion of the trust. 6.11.3 Special and Supplemental Needs Trusts A. Certain trusts established on behalf of a Medicaid applicant or beneficiary are treated differently due to their purpose or manner in which they were established. B. Special needs and pooled trusts. These trusts are established for persons who meet certain age and disability requirements. Assets placed in the trust are exempt from the provisions related to disqualifying transfers when the conditions specified below have been met. 1. Special needs trust – A special needs trust established under § 1917(d)(4)(A) of the Social Security Act, 42 U.S.C. § 1396p(d)(4)(A), has the following characteristics: a. Date. Established on or after August 10, 1993; b. Grantor. Established by or on the behalf of the Medicaid LTSS applicant by a parent, grandparent, legal guardian or other third party with the legal authority to act with respect to the person’s assets, or a court.
c. Source. The source of the trust is the assets owned by an LTSS applicant/beneficiary under age sixty-five (65) who has been determined to have a disability. The trust may also contain assets owned by other persons; d. Trust beneficiary. The trust beneficiary named is a Medicaid LTSS applicant or beneficiary who meets the disability criteria established by the U.S. Social Security Administration for SSI or Social Security Disability Insurance (SSDI) under § 1614(a)(3) of the Social Security Act, 42 U.S.C. § 1382c(a)(3). e. Distribution. Terms of the trust. Upon death of the beneficiary, any amounts remaining in the trust are paid to the State of Rhode Island up to the amount paid on behalf of the beneficiary by the Medicaid program unless amounts are owed to other States, in which case, payments are made proportionally to each State if there are insufficient funds to pay all States which provided Medicaid in full. The trust remains exempt from the transfer of asset provisions set forth herein once the trust beneficiary turns age sixty- five (65) providing there are no changes in trust prior to the date the trust beneficiary attains this age. The exemption does not apply to assets added to the trust once the beneficiary turns sixty-five (65). f. Purpose. The reason the trust is created is solely for the benefit of a trust beneficiary with a disability. 2. Pooled trusts – A pooled trust established for a person with a disability under § 1917(d)(4)(C) of the Social Security Act, 42 U.S.C. 1396p(d)(4)(C), is also exempt from the provisions related to disqualifying transfers. A pooled trust for a particular applicant/beneficiary is a subaccount within a master trust in which the assets of multiple persons are combined, or pooled, for investment and management purposes only. A pooled trust has the following characteristics: a. Date. Established on or after August 10, 1993. b. Grantor. Created and managed by a non-profit organization which maintains a separate account within a master trust that contains the assets and provisions specific to each beneficiary. Accounts in the trust are established for a person with a disability by or on the behalf of an applicant or beneficiary by a parent, grandparent, legal guardian or other third party with the legal authority to act with respect to the person’s assets, or a court. c. Source. The source of the trust is the assets owned by an LTSS applicant/beneficiary who has been determined to have a disability. The trust may also contain assets owned by other persons.
d. Trust beneficiary. The trust beneficiary named is of any age and is a Medicaid LTSS applicant or beneficiary who meets the disability criteria established by the U.S. Social Security Administration for SSI or Social Security Disability Insurance (SSDI) under § 1614(a)(3) of the Social Security Act, 42 U.S.C. § 1382c(a)(3). e. Distribution. Terms of the trust. Upon death of the beneficiary, to the extent that amounts remaining in the beneficiary’s account are not retained by the trust, the trust pays to the State of Rhode Island up to the amount paid on behalf of the beneficiary by the Medicaid program unless amounts are owed to other States, in which case, payments are made proportionally to each State if there are insufficient funds to pay all States which provided Medicaid in full. f. Purpose. The reason the trust is created is solely for the benefit of a trust beneficiary with a disability. C. Assets owned by others may be used to establish both testamentary and living trusts. In instances in which the grantor uses assets owned by someone other than the Medicaid LTSS applicant, and the Medicaid LTSS applicant’s access to those assets is dictated solely by the terms of the trust, then the trust is evaluated in accordance with this Part. D. In general, the terms of the trust determine the portions of principal and interest that are treated as income and resources. Terms of a trust related to the discretion of trustees and the extent to which funds must be distributed to meet the trust beneficiary’s basic needs – that is, for food, shelter, clothing, health maintenance and the like – determine whether trust income and resources are counted for Medicaid LTSS eligibility purposes: 1. Countable income and resources – Trust principal and earnings/interest are countable resources and income when the terms of the trust require the trustee to pay or to make available the funds necessary to meet the trust beneficiary’s basic needs. Both are also countable when the terms of the trust allow the beneficiary to withdraw trust principal and earnings/interest for basic needs. Principal is counted as resource and earnings/interest are treated as a countable income. 2. Countable income only – Trust principal and earnings/interests are countable income, but not a countable resource, when the terms of the trust allow the trustee to use trust principal or earnings/interests to pay for the basic needs of the beneficiary, and the trustee makes either available to cover those needs. 3. Countable income then resource – In the following circumstances, a trust treats income and resources as unavailable. For Medicaid financial eligibility purposes, any distributions made to the trust beneficiary in these
circumstances are treated as countable income in the period of intended use, and countable resources thereafter: a. Prohibited distributions. The terms of the trust prohibit the trustee from making either trust principal or earnings/interest available for the trust beneficiary’s basic needs and Medicaid is covering the costs of those needs; or b. Trustee discretion. The terms of the trust provide the trustee with the discretion to make distributions to cover the trust beneficiary’s basic needs, but the trustee does not make either principal or earnings/interest available for those basic needs and they are covered by Medicaid. 6.12 Hardship Exemption A. The State has established a process in which applicants and beneficiaries may seek hardship exemption of certain Medicaid LTSS financial eligibility requirements. B. To qualify for an exemption, the Medicaid LTSS applicant or beneficiary must show that complying with the requirement poses an undue hardship. The criteria for determining undue hardship vary as follows: 1. Jointly owned real property – The State may exclude otherwise countable real property, including a former primary residence, when it is jointly owned and the sale of the property by an applicant or beneficiary would cause the other owner(s) to lose housing. For this purpose, loss of housing is considered undue hardship if the property serves as the principal place of residence for one (1) (or more) of the other owners, its sale would result in loss of that residence, and no other alternative and appropriate housing is readily available for the displaced other owner. If such undue hardship ceases to exist, the property becomes a countable resource. 2. Excess equity in a home – The State may waive denial of the home exclusion due to excess equity value in the principal place of residence if undue hardship exists under § 1917(f)(4) of the Social Security Act, 42 U.S.C. § 1396p(f)(4). The applicant or beneficiary must provide evidence that ineligibility for Medicaid LTSS based on denial of the home exclusion: a. Risk to personal health or safety. The loss of Medicaid LTSS prevents access to or the continuation of services and supports necessary to ensure the health and safety of the applicant or beneficiary is not in jeopardy;
b. Deprivation. Evidence must be provided that without Medicaid LTSS the applicant or beneficiary would be deprived of food, shelter, clothing, or other necessities required to sustain personal health and safety; c. Prospective termination. The current LTSS provider has notified the applicant or beneficiary of the intent to initiate a discharge or cease providing services and supports; or prospective LTSS providers are unwilling to start services due to the lack of Medicaid coverage; d. No alternative. There is not an affordable option to Medicaid LTSS coverage available that meets the needs of the applicant/beneficiary; and e. Intent to live or return. The applicant or beneficiary lives in the home or intends to return to the home as required pursuant to § 6.5.3(B)(1)(a) of this Part. 3. Transfer penalty – An applicant or beneficiary may request a hardship exemption of the penalty period of Medicaid LTSS eligibility under § 1917(c)(2)(D) of the Social Security Act, 42 U.S.C. § 1396p(c)(2)(D). Undue hardship exists when the applicant or beneficiary provides proof that: a. Risk to personal health or safety. The loss of Medicaid LTSS prevents access to or the continuation of services and supports necessary to ensure the health and safety of the applicant or beneficiary is not in jeopardy; b. Recovery fails. All available strategies for recovering the asset(s) conveyed in a disqualifying transfer have been exhausted without success; c. Prospective termination. The current LTSS provider has notified the applicant or beneficiary of the intent to initiate a discharge or cease providing services and supports; or prospective LTSS providers are unwilling to start services due to the lack of Medicaid coverage; d. No alternative. There is not an affordable option to Medicaid LTSS coverage available that meets the needs of the applicant or beneficiary. e. Limited other resources. The applicant or beneficiary must have minimal remaining available resources after the CSRA is completed, if appropriate, as indicated in § 6.5.2 of this Part. For this purpose, the remaining resources must be less than the monthly statewide average cost of nursing facility services to a private pay-resident, excluding the value of:
(1) The primary residence, but only if the home exclusion in § 6.5.3(B) of this Part applies; (2) Household goods. (3) A vehicle required by the applicant or member for transportation. (4) Funds for burial of four thousand dollars ($4,000.00) or less. C. When claiming undue hardship, the applicant or beneficiary or an authorized person acting on his or her behalf must submit a written request and any supporting documentation including a statement from an attorney, if one was involved; proof of medical costs, and a statement from the trustee and/or transferee, if appropriate. 6.13 Severability A. If any provisions of these Regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable.
210-RICR-50-00-6 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 - MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 - LONG-TERM SERVICES PART 6 - “MEDICAID LONG-TERM SERVICES AND SUPPORTS: FINANCIAL ELIGIBILITY” Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 07/27/2026 July 07, 2026 E-SIGNED by Richard Charest on 2026-07-07 16:22:20 EDT July 07, 2026 E-SIGNED by Department of State on 2026-07-07 16:26:55 EDT
210-RICR-50-00-7 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 – MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 – LONG-TERM SERVICES PART 7 - Involuntary Discharge from a Long-Term Care Facility 7.1 Purpose and Overview
The purpose of this rule is to set forth requirements related to resident discharges and transfers initiated by state licensed long-term care facilities, without regard to the resident’s source of payment. All such transfer/ discharges that are taken by a long-term care facility without the agreement or consent of the resident or the resident representative are involuntary and are prohibited, except as provided herein. 7.2 Legal Authority A. State authorities: These rules are promulgated pursuant to the authority set forth in R.I. Gen. Laws Chapter 40-8, “Medical Assistance”; R.I. Gen. Laws Chapter 40-6, “Public Assistance Act”; R.I. Gen. Laws § 23-17-19.1, “Rights of Patients”; R.I. Gen. Laws Chapter 23-17.5, “Rights of Nursing Home Patients”; R.I. Gen. Laws § 23-17.5-17, “Transfer to Another Facility”; R.I. Gen. Laws Chapter 23- 17.4, “Assisted Living Residence Licensing Act”; R.I. Gen. Laws § 23-17.4-16, “Rights of Residents.” B. Federal authorities: Additional authority is derived from 42 C.F.R. § 483 Subpart B, “Requirements for Long Term Care Facilities”; Title XIX of the Social Security Act; 42 U.S.C. § 1396r, “An Act to Amend Title XIX of the Social Security Act to Prohibit Transfers or Discharges of Residents of Nursing Facilities as a Result of a Voluntary Withdrawal from Participation in the Medicaid Program”; the State’s Medicaid State Plan; and the Rhode Island Comprehensive Section 1115 Demonstration, as approved in final form on February 25, 2014, and as subsequently amended. 7.3 Definitions A. As used herein, the following terms are defined as follows: 1. “Assisted living residence” means a publicly or privately operated residence that provides directly or indirectly by means of contracts or arrangements personal assistance and may include the delivery of limited health services, as defined under R.I. Gen. Laws § 23-17.4-2(12), to meet
the resident's changing needs and preferences, lodging, and meals to six (6) or more adults who are unrelated to the licensee or administrator, excluding however, any privately operated establishment or facility licensed pursuant to R.I. Gen. Laws Chapter 23-17 and those facilities licensed by or under the jurisdiction of the Department of Behavioral Healthcare, Development Disabilities and Hospitals, the Department of Children, Youth, and Families, or any other state agency. 2. “Department of Human Services" or "DHS” means the State agency established under the provisions of R.I. Gen. Laws Chapter 40-1 that is empowered to administer certain human services. The DHS has been delegated the authority through an interagency service agreement with the Executive Office of Health and Human Services (EOHHS), the Medicaid Single State Agency, to determine Medicaid eligibility in accordance with applicable State and federal laws, rules and regulations. 3. “Executive Office of Health and Human Services" or "EOHHS” means the state agency established in 2006 under the provisions of R.I. Gen. Laws Chapter 42-7.2 within the executive branch of state government which serves as the principal agency for managing the Departments of Children, Youth, and Families (DCYF); Health (DOH); Human Services (DHS); and Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH). 4. “Intermediate care facility for persons with intellectual/developmental disabilities" or "ICF/ID” means a State-licensed health care facility that provides long-term services and supports to persons with intellectual/developmental disabilities. 5. “Long-term care facility” means and includes nursing facilities (NF), assisted living residences (ALR), long-term care hospitals (LTH), and intermediate care facilities for persons with intellectual/ developmental disabilities (ICF-I/DD). Assisted living residences are also included for this rule only, although not licensed as health care facilities under R.I. Gen. Laws Chapter 23-17. 6. “Nursing facility” means an institutional setting that provides long-term care and is licensed in accordance with R.I. Gen. Laws Chapter 23-17, “Licensing of Health Care Facilities.” 7. “Resident representative” means any of the following: a. An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications;
b. A person authorized by state or federal law (including but not limited to agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; c. Legal representative, as used in § 712 of the Older Americans Act (P.L. 114–144); or d. The court-appointed guardian or conservator of a resident. e. Nothing in this rule is intended to expand the scope of authority of any resident representative beyond that authority specifically authorized by the resident, state or federal law, or a court of competent jurisdiction. 8. “Transfer” or “discharge” means movement of a resident to a bed outside of the long-term care facility whether that bed is in the same physical plant or not. “Transfer” or “discharge” does not refer to the movement of a resident to a bed within the same long-term care facility. 7.4 Discharge Criteria A. The long-term care facility must permit each resident to remain in the long-term care facility, and not transfer or discharge the resident from the long-term care facility unless: 1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the long-term care facility; 2. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the long-term care facility; 3. The safety of individuals in the long-term care facility is endangered due to the clinical or behavioral status of the resident; 4. The health of individuals in the long-term care facility would otherwise be endangered; 5. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. a. Non-payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay.
b. For a resident who becomes eligible for Medicaid after admission to a long-term care facility, the long-term care facility may charge a resident only allowable charges under Medicaid; or 6. The long-term care facility ceases to operate. B. Each long-term care facility must display a notice which identifies these transfer and discharge criteria and informs residents of their appeal rights. The notice should be prominently posted along with the Resident’s Bill of Rights. C. This information must be provided to the individual both verbally and in a prominent manner in writing on a separate page at the time of admission. A written acknowledgment of the receipt of the notice, signed by the individual must be obtained. 7.5 DOCUMENTATION REQUIREMENTS A. In instances where a resident is being transferred or discharged, the long-term care facility must document in the resident’s clinical record the basis for the transfer or discharge. The resident's physician must document as follows: 1. The transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the long-term care facility; 2. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the long-term care facility; 3. The health of individuals in the long-term care facility would otherwise be endangered. B. In instances of a resident’s transfer, information provided to the receiving provider/facility must include a minimum of the following: 1. Contact information of the practitioner responsible for the care of the resident; 2. Resident representative information including contact information; 3. Advance Directive information; 4. All special instructions or precautions for ongoing care, as appropriate; 5. Comprehensive care plan goals; 6. All other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care.
7.6 PRE-TRANSFER/ DISCHARGE NOTICE A. Before transferring or discharging a resident, a long-term care facility must notify the resident (and, if known, a resident representative) of the transfer or discharge and of the reasons for the discharge in a language and manner they understand. The long-term care facility must also notify the Office of the State Long-Term Care Ombudsman. B. The written notice must include the following: 1. The reason for transfer or discharge; 2. The effective date of transfer or discharge; 3. The location to which the resident is transferred or discharged; 4. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity that receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; 5. The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; 6. For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities; and 7. For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. C. The long-term care facility must notify the resident at least thirty (30) days in advance of the resident's transfer or discharge. D. At the time the resident receives the discharge notice, s/he must receive a notice of appeal rights. E. Thirty (30) days advance notice is not required under the following circumstances: 1. In the event of danger to the safety or health of the individuals in the long- term care facility; 2. When the resident's health improves sufficiently to allow a more immediate transfer or discharge;
3. Where a more immediate transfer or discharge is necessitated by the resident's urgent medical needs; 4. When the resident has not resided in the long-term care facility for a period of at least thirty (30) days. 5. In the case of such exceptions (as above), notice must be given as many days before the date of the move as is practicable, and include all of the information set forth in § 7.6(B) of this Part. 7.7 RESIDENT APPEAL RIGHTS A. Long-term care facility residents who wish to challenge their transfers or discharges may appeal in accordance with the provisions of § 10-05-2.4.8 of this Title, “Appeals Process and Procedures for EOHHS Agencies and Programs.” B. The appeals process cannot be limited to Medicaid-eligible long-term care facility residents. EOHHS will conduct administrative hearings for any long-term care facility resident who wishes to appeal a transfer or discharge from the facility, regardless of source of payment. C. The long-term care facility may not transfer or discharge the resident while the appeal is pending, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the long-term care facility. 7.8 SEVERABILITY
If any provision in any section of this rule or the application thereof to any person or circumstances is held invalid, its invalidity does not affect other provisions or applications of the rule which can be given effect without the invalid provision or application, and to this end the provisions of this rule are declared to be severable.
210-RICR-50-00-7 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 - MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 - LONG-TERM SERVICES PART 7 - INVOLUNTARY DISCHARGE FROM A LONG-TERM CARE FACILITY (210- RICR-50-00-7) Type of Filing: Refile Capabilities Department of State _________________________________________________________________ Regulation Effective Date Original Signing Date _________________________________________________________________ Department of State Initials Department of State Date 01/04/2022 N/A December 15, 2021 E-SIGNED by Department of State on 2021-12-15 16:25:27 EST
210-RICR-50-00-8 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 50 – MEDICAID LONG-TERM SERVICES AND SUPPORTS SUBCHAPTER 00 – LONG-TERM SERVICES PART 8 – Post-Eligibility Treatment of Income (PETI) 8.1 Overview A. Medicaid LTSS beneficiaries are required by Federal law and Regulations, the State Plan, and the Section 1115 waiver to contribute income toward the Medicaid cost of care, irrespective of whether LTSS is provided in a health care institution or a home or community living arrangement. Only persons eligible for Medicaid LTSS on the basis of MAGI – the ACA adult expansion – are not required to pay toward the cost of care under Federal Regulations in effect as of March 1, 2018. B. To ensure the beneficiary and/or spouse remaining at home (the “community” spouse) and the dependents of the LTSS beneficiary (the “institutionalized” spouse) have sufficient income and resources to thrive, Congress established a process to prevent spousal impoverishment. One important aspect of this process is a re-evaluation of the beneficiary’s income – known as the post- eligibility treatment of income or “PETI” – to determine what, if any, amount remains available to be applied to the LTSS cost of care after certain amounts are set aside or “protected” to meet the financial needs of the beneficiary, spouses and/or dependents. The amount a beneficiary must pay toward the cost of care for Medicaid LTSS coverage is referred to hereinafter as “beneficiary liability." This section pertains to the PETI process and the determination of beneficiary liability. 8.2 Legal Authority and Scope and Purpose A. Federal Authorities: 1. Federal Law: Title XIX, of the Federal Social Security Act at: 42 U.S.C. §§ 1396a, 1396b, and 1396k; 2. Federal Regulations: 42 C.F.R. §§ 435.700 – 435.735; 435.800 – 435.832; 460.184 Parts I through G, including §§ 435.733, 435.735 and 484.10(e). 3. The Rhode Island Medicaid State Plan and the Title XIX, Section 1115(a) Demonstration Waiver (11-W-00242/1), effective through December 31, 2018.
D. PETI Standards – When determining the amount of an allowance in the PETI process the following standards apply: PETI Allowance Standards Standard Monthly Amount and Basis Personal needs allowance standard Non-veterans = Federal minimum plus State supplement program payment, total seventy-five dollars ($75.00) Veterans = Improved pension ninety dollars ($90.00) Therapeutic employment personal needs allowance An additional eighty-five dollars ($85.00) plus one half (1/2) of earned income allowance, after deducting certain employment expenses and fees Minimum Monthly Maintenance of Need Allowance – for non-LTSS spouse Based on one hundred fifty percent (150%) of the FPL for a family of two (2) Community Spouse Housing Allowance Amount established by the Federal government and the standard utility allowance for SNAP Home and Community-Based Services – Maintenance of Needs Allowance Three hundred percent (300%) of the SSI Federal Benefit rate State-only personal needs allowance for beneficiaries receiving the optional State supplemental payment to SSI Varies by living arrangement
PETI Allowance Standards Standard Monthly Amount and Basis Assisted Living Special Maintenance of Need Allowance for room and board The monthly special assisted living room and board allowance for Medicaid LTSS beneficiaries varies by eligibility status as indicated in § 8.6(B)(3) of this Part but in no case is less than the Federal Benefit Rate for one (1) plus three hundred thirty-two dollars ($332.00) less the applicable personal needs allowance. I/DD-Special Maintenance of Needs Allowance – habilitation and developmental disabilities programs HCBS maintenance of need allowance (three hundred percent (300%) of the SSI Federal Benefit rate) plus any earned income not to exceed three hundred percent (300%) of the SSI income standard Family Allowance One third (1/3) of the minimum monthly maintenance needs allowance per dependent family member Family Maintenance of Need Medically needy income limit adjusted for family size. Medicaid LTSS beneficiary living with family members is included in family size. LTSS Medicaid beneficiaries residing in institutional living arrangements are NOT included in family size Health Coverage and Expenses Actual costs but only if not paid for or reimbursed by Medicaid or a third (3rd) party and allowable expenses otherwise not covered by Medicaid, including Medicare and other health insurance premiums Special Incurred Expenses Within applicable limits See § 8.6(A)(2)(b) of this Part
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