Page 1

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: