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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.