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OMB #: 0938-0707

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Form CMS-R-211

2 APPLICATION FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:______________Rhode Island (Name of State/Territory) ________________________________

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b))

______________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Deborah J. Florio, Program Administration Position/Title: Administrator, Center for Child and Family Health Rhode Island Department of Human Services

Name: Tim McCormick, Financial Oversight Position/Title: Associate Director of Management Services Rhode Island Department of Human Services

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

3 SECTION 1. GENERAL DESCRIPTION AND PURPOSE OF THE STATE CHILD HEALTH PLANS AND STATE CHILD HEALTH PLAN REQUIREMENTS (SECTION 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box)

(42 CFR 457.70):

1.1.1

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3. A combination of both of the above.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date: October 1, 1997, although the effective date for the Section 1115 waiver was January 18, 2001.

Effective date for Amendment #1 expansion of eligibility up to 300 percent FPL is January 5, 1999.

Effective/Approval date for Amendment #2, Rhode Island’s compliance SPA is September 19, 2002.

Effective date for Amendment #3, Rhode Island’s separate child health program is November 1, 2002.

Effective date for Amendment #4, adding a $10,000 liquid asset limit for

4 eligibility, is October 1, 2006.

Effective date for Amendment #5, removing a $10,000 liquid asset limit for eligibility is July 1, 2007.

Effective date for Amendment #6, provide pregnancy-related services for targeted low-income pregnant women with family incomes up to including 250 percent of the Federal poverty level is December 9, 2009.

Effective date for Amendment #7, to an eligibility group of children who are otherwise eligible aliens lawfully residing in the United States as authorized by section 214 of the Children’s Health Insurance Reauthorization Act of 2009 is July 1, 2009.

Implementation date: October 1, 1997, although the various components of the program, including applicable amendment provisions, have been implemented since then.

Implementation date: Amendment #1 was not implemented.

Implementation date for Amendment #2, compliance SPA was per CMS regulation.

Implementation date for Amendment #3, Rhode Island’s separate child health program is November 1, 2002.

Implementation date for Amendment #4, adding a $10,000 liquid asset limit for eligibility is October 1, 2006. However, this amendment was not implemented.

Implementation date: for Amendment #5, removing a $10,000 liquid asset limit for eligibility is July 1, 2007.

Implementation date: for Amendment #6, provide pregnancy-related services for targeted low-income pregnant women with family incomes up to including 250 percent of the Federal poverty level is December 9, 2009.

Implementation date: for Amendment #7, to an eligibility group of children who are otherwise eligible aliens lawfully residing in the United States as authorized by section 214 of the Children’s Health Insurance Reauthorization Act of 2009 is July 1, 2009.

5 SECTION 2. GENERAL BACKGROUND AND DESCRIPTION OF STATE APPROACH TO CHILD HEALTH COVERAGE AND COORDINATION (SECTION 2102 (A)(1)-(3)) AND (SECTION 2105)(C)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public- private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

In November of 1993, the State of Rhode Island was granted a Section 1115 Waiver (11-W-00004/1) to develop and implement a mandatory Medicaid managed care demonstration program called RIte Care. RIte Care, implemented in August 1994, has the following general goals:

• To assure care as well as coverage to all eligible Medicaid families and children, all eligible pregnant women and all eligible uninsured children

• To control the rate of growth in the Medicaid budget for the eligible population

RIte Care was designed for the following groups to be enrolled in licensed health maintenance organizations (HMOs, or Health Plans):

• Family Independence Program (FIP)1

families • Pregnant women up to 250 percent of the Federal poverty level (FPL)

• Children up to age 6 in households with incomes up to 250 percent of the FPL who are uninsured

RIte Care has been expanded five times, with Federal approval, as follows:

• Effective March 1, 1996, to expand to children up to age 8 in households with incomes up to 250 percent of the FPL who are uninsured

• Effective May 1, 1997, to expand to children up to age 18 in households with incomes up to 250 percent of the FPL who are uninsured

1Originally Aid to Families with Dependent Children (AFDC)

6 • Effective November 1, 1998, to expand to families with children under age 18 including parents with incomes up to 185 to FPL (expansion under Section 1931)

• Effective July 1, 1999, to expand to children up to age 19 in households with incomes up to 250 percent of the FPL

• Effective December 1, 2000, to maximize children in foster care placements from fee for service Medicaid to RIte Care

The May 1997 and July 1, 1999 expansions, because they were implemented after March 15, 1997, qualify as eligible Medicaid expansions under Title XXI of the Social Security Act. By Section 1115 waiver approval, effective January 18, 2001, Section 1931 parents and relative caretakers and pregnant women between 185 and 250 percent of the FPL were covered under Title XXI. On December 20, 2002, the State submitted a draft amendment to provide prenatal care to unborn children, if other applicable State eligibility requirements are met, as a separate child health program. Thus, everywhere else in this State Child Health Insurance Program (SCHIP) Plan (Plan) where a separate child health program is referenced, it is only for this population. Otherwise, all other aspects of the State’s approved Plan are a Medicaid expansion. It should be noted that the State received approval on January 5, 1999 to expand to children under age 19 in households with income up to 300% of the FPL. The State has not yet implemented the approved amendment and has no immediate plans to do so due to budgetary constraints.

In addition to these covered populations, the RIte Care Health Plans must make coverage available to certain State funded or "buy-in" groups who pay 100 percent of the applicable premium; the first group’s premiums are supplemented by State-only funds:

• Pregnant women who are uninsured whose household income is between 250 and 350 percent of the FPL

• Children who are uninsured whose household income is in excess of 250 percent of the FPL

• Licensed family child care providers and their children under age 18

RIte Care has proved to be extremely successful as the following information indicates:

• Member Choice of Health Plan

 Enrolled approximately 118,000 members into one of three Health

7 Plans

 Ninety-three percent of enrollees chose their own Health Plan in the first year

 Only 4 percent changed Health Plans when given the opportunity to do so during the first open enrollment period; only 1 percent during the second open enrollment period; and only 3 percent during the third open enrollment period. Plans changes have remained low.

• Covered Uninsured Families

 Made comprehensive health coverage available to previously uninsured children up to age 19, up to 250 percent of the Federal poverty level and previously uninsured pregnant/postpartum women

 Made coverage available to parents and adult caretakers up to 185 percent of the FPL

• Improved Access to Primary Care

 Increased primary care physician participation from 350 to over 900 physicians

 Increased average per enrollee physician visits from two per year pre-RIte Care (1993) to five per year in RIte Care

 Decreased emergency room visits and hospital utilization each by more than one-third from 1993 to RIte Care

• Positive Impact on Maternal Health

 Increased the number of women on Medicaid waiting at least 18 months between births from 60 percent pre-RIte Care (1993-94) to 79 percent in 1999 completely closing the gap between Medicaid and commercially-insured women

 The percentage of pregnant women on Medicaid who smoked during pregnancy decreased significantly from 32 percent in 1993- 94 to 24 percent in 2000

• Improved Prenatal Care

8  The number of women on Medicaid who began prenatal care in the first trimester increased from 78 percent in 1993-94 to 84 percent in 2000

 The number of women on Medicaid receiving adequate prenatal care increased significantly from 57 percent in 1993-94 to 73 percent in 2000

• Improved Infant Health Outcomes

 In inner city areas of the State:

- The low birth weight infants born decreased from 10 percent in 1993 to 5 percent in 1995.

- The percentage of infants who had their first physician visit before two weeks increased significantly from 54.4 percent in 1993 to 70 percent in 1995.

- The percentage of infants who waited less than two weeks for specialty care increased significantly from 43.5 percent in 1993 to 71.4 percent in 1995.

• Improved Child Health

 Children in RIte Care have higher well-child visit rates than children enrolled in commercial insurance as well as children enrolled in Medicaid nationally

 In a study of 2-year-olds in RIte Care, 79 percent were screened for lead poisoning compared to only 19 percent in Medicaid nationally

• Excellent Member Satisfaction

 Overall, 98 percent of the respondents to the 2001 RIte Care Member Satisfaction Survey were ”very satisfied” or “satisfied” with RIte Care. This percentage has remained relatively constant since the State began enrolling individuals in RIte Care

 Survey responses stratified by Health Plans ranged from 96 to 98 percent who reported that overall they were “very satisfied” or “satisfied” with RIte Care

The State has built upon these successes by making RIte Care available to

9 expanded populations. Incrementally, as noted above and where permissible, including these expansion populations in the State Child Health Insurance Program (SCHIP).

According to the U.S. Bureau of the Census2, the number of persons covered and not covered by health insurance in the State of Rhode Island in 1996 was 940,000. Of this total, 93,000 (with a standard error of 13,000), or 9.9 percent (with a standard error of 1.3 percent), were not covered by insurance. Preliminary estimates3

, not adjusted for the uninsured or sample design, of the uninsured children in Rhode Island as if July 1, 1996, were as follows:

Percent with No Health Coverage, Ages 0 to 17, Rhode Island, 1996

Income Group

Percent Uninsured

<100% FPL

19.2%

100 to 199% FPL

13.1

200 to 299% FPL

7.5

300 to 399% FPL

1.6

>=400% FPL

1.0

Don’t Know

19.1

Refused

14.1

Total

9.5%

With an estimate of 235,283 children in Rhode Island as of July 1, 1996, this means that there were an estimated 22,352 without health insurance coverage as of July 1, 1996.

Although these estimates have not been adjusted, we believe that the number of uninsured children targeted under this Title XXI Program Plan would have been less than 14,0004

as of July 1, 1996. The State’s efforts have had a remarkable impact on the children uninsurance rate in the State. More recent CPS data show that in 2000, 6.2 percent of the overall population in Rhode Island lacked health insurance and 2.4 percent (this

2Bennefield, R.L. "Health Insurance Coverage: 1996", Current Population Reports: Consumer Income 3U.S. Bureau of the Census. "Estimates of the Population of the U.S., Region, and States by Selected Age Groups and Sex: Annual Time Series, July 1, 1990. to July 1, 1996," St-96-10 422,352 x 61.4% = 13,724

10 is a three-year average) of children lacked health insurance – both the lowest in the nation.5

As described in Section 5 of this Plan, the State has undertaken a well-defined outreach effort to identify and enroll uninsured children in RIte Care Health Plans. The State also implemented activities made possible by other changes in the Balanced Budget Act of 1997, to simplify the application and enrollment process. This was done to remove barriers associated with applying and enrolling through a "welfare" environment. An example of some of the outreach strategies implemented include:

• Accessing the National Governor’s Association sponsored “Insure Kids Now” hotline

• Providing funding for outreach workers to 32 community-based organizations to enroll new children each month

• Targeted mailings to community organizations and school-based personnel

• Distributing information to every school-aged child Kindergarten through 6th grade in the State

• Media coverage in professional newsletters and Rhode Island newspapers

• Using the Department of Human Services Web-site to disseminate information

• Providing public service announcements and radio and television interviews through the media

• Streamlining the mail-in application in both English and Spanish

• Supporting a bi-lingual information line.

2.2 Describe the current State efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2)

2.2.1. The steps the State is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance).

5 Griffin, J. Profiles and Trends of the Uninsured in Rhode Island: Characteristics of Uninsured Working-Age Adults in Rhode Island 1996-2000, MCH Evaluation, Inc. April 2002.

11 As noted earlier, the State has had an ongoing, active outreach program to enroll uninsured eligible children in RIte Care. This outreach effort is described in Section 5 of the Plan.

The State’s contracts with RIte Care Health Plans require that the Health Plans work to identify uninsured children for potential enrollment. Specifically, Section 2.05.01 of the Health Plan contract requires: "The Contractor, through members of its provider network, is encouraged to identify uninsured patients who may be RIte Care eligible and to make referrals to the State for eligibility determination." The contract also contains important coordination requirements. Specifically, Section 2.07 requires coordination with out-of-plan services and other health/social services available to members including:

• Special education

• Mental health services for seriously and persistently mentally ill adults (SPMI) and severely emotionally disturbed children (SED)— these are out-of-plan benefits

• Newborn Metabolic Screening Program

• Comprehensive Emergency Services Program

• Children’s Intensive Services Program

• Early Start Program

• Lead Program

• Adolescent Pregnancy and Parenting Service Network

• Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

In addition, Health Plans are required under Section 2.08.10 of the contract, to contract with the currently operating school-based clinics in the State and to contract with future school-based clinics that might be developed. Health Plans are also encouraged to contract with Title X providers and Federally qualified health centers (FQHCs).

With respect to the FQHCs, it is important to understand that Rhode Island does not have a service delivery system within its public health structure. Thus, the FQHCs, primarily, and hospitals, secondarily, have served as the historical safety net for the uninsured in the State. When RIte Care was being implemented, the FQHCs elected to form their own Health Plan—Neighborhood Health Plan of Rhode Island. However, all other RIte Care participating Health Plans have elected to include some of the FQHCs in their provider networks. In addition, FQHCs operate the

12 existing school-based clinics in the State. Thus, FQHCs are an integral component of RIte Care, without a mandate for their inclusion within networks.

Another important coordination feature of RIte Care is that Health Plans are responsible for certain Early Intervention (EI) services, subject to a stop-loss provision. Section 2.07.04.01 of the Health Plan contract stipulates that the Health Plan is responsible for the first $3,000 for medically necessary, appropriate speech, hearing, language, physical and occupational therapies under EI. The State covers any additional services on a fee-for-service basis, as billed by the Health Plans as stop-loss claims.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

RIte Share, Rhode Island’s new Premium Assistance Program, helps low- and middle-income families obtain health insurance coverage through their employer by paying the employee’s share of monthly premiums for family coverage.

Under RIte Share, individuals who are eligible for Medicaid/SCHIP and are employed by an employer that offers a “qualified” plan, enrolls in the ESI through their employer. In order for an applicant to be enrolled in RIte Share:

• The parents and/or their children are determined eligible for Medicaid/SCHIP (RIte Care), and

• One of the parents has access to ESI and works for an employer that offers an approved plan

The employer contribution to the cost of coverage remains unchanged. The State pays for the employee’s share of the health insurance premium either by paying the employer or by paying the employee. RIte Share members are eligible for “wrap around” services, which are Medicaid- covered services not included in the employer’s health plan, as well as for coverage of commercial insurance co-payments.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to

13 increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)); (42CFR 457.80(c))

The State has had an ongoing, active outreach program to identify and enroll uninsured eligibles in RIte Care. This outreach effort is described in detail in Section 5 of this document.

The State’s contracts with RIte care Health Plans require that the Health Plans work to identify uninsured individuals for potential enrollment. Specifically, Section 2.05.01 of the Health Plan contract requires: “The Contractor, through members of its provider network, is encouraged to identify uninsured patients who may be RIte Care eligible and to make referrals to the State for eligibility determination.” The contract also contains important coordination requirements. Specifically, Section 2.07 requires coordination with out-of-plan services and other health/social services available to members:

• Special education

• Mental health services for seriously mentally ill adults and seriously emotionally disturbed children

• Newborn Metabolic Screening Program

• Comprehensive Emergency Services Program

• Children’s Intensive Services Program

• Early Start Program

• Lead Program

• Adolescent Pregnancy and Parenting Service Network

• Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

• Family Outreach Program

In addition, Health Plans are required under Section 2.08.10 of the contract to contract with school-based health clinics. Health Plans are also encouraged to contract with Title X providers and Federally qualified health centers (FQHCs).

With respect to FQHCs, it is important to understand that Rhode Island does not have a service delivery system within its public health structure. Thus, the FQHCs, primarily, and hospitals, secondarily, have served as the historical safety

14 net for the uninsured in the State. When RIte Care was being implemented, the FQHCs elected to form their own Health Plan – Neighborhood Health Plan of Rhode Island (NHPRI). However, all other RIte Care participating Health Plans have elected to include some of the FQHCs in their provider networks. In addition, the FQHCs operate the existing school-based health clinics in the State. Thus, the FQHCs are an integral component of RIte Care.

Another important coordination feature of RIte Care is that Health Plans are responsible for certain Early Intervention (EI) services, subject to a stop-loss provision. Section 2.07.04.01 of the Health Plan contract stipulates that the

Health Plan is responsible for the first $3,000 for medically necessary, appropriate speech, hearing, language, physical and occupational therapies under EI. The State covers any additional services on a fee-for-service basis, as billed by the Health Plan as stop-loss claims.

15 SECTION 3. METHODS OF DELIVERY AND UTILIZATION CONTROLS (SECTION 2102)(A)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4); (42CFR 457.490(a))

The State will contract with licensed health maintenance organizations (HMOs, or Health Plans) for a comprehensive benefit package for the targeted low-income children and other populations (i.e., parents and adult caretakers and pregnant women). In Rhode Island, this also means that the HMOs are accredited by the National Committee for Quality Assurance (NCQA) as a requirement of State law. The licensed HMOs will be Health Plans participating in RIte Care and the comprehensive benefit package will be a Secretary-approved plan – the RIte Care benefit package.

The Health Plans are paid a monthly capitation rate to provide the comprehensive benefit package. Health Plans can earn payments over and above capitation payments, under a Performance Incentive Program that was put into place in July 1998, for the attainment of certain administrative, access, and clinical goals. In addition, there are several other nuances concerning the financing methods:

• Risk-Share Payments – The Rhode Island Department of Human Services (DHS) has entered into risk-share arrangements with two Health Plans – Coordinated Health Partners (CHP) and Neighborhood Health Plan of Rhode Island (NHPRI). The purpose of these arrangements is to assure RIte Care- eligible individuals have a choice of Health Plans in which to enrollee. Under the risk-sharing methodology, risk is shared according to whether the actual Medical Loss Ratio in any quarter is within agreed-upon ranges or “risk corridors.”

• Stop-Loss Payments -- Some services have been covered by the Health Plans on a partial-risk basis from the beginning. Currently, transplants (where Health Plans must cover all costs up to the actual transplant of a bodily organ), Early Intervention (EI, where Health Plans must cover the first $3,000 in benefits), mental health care (where Health Plans must cover the first 30 days of inpatient care and the first 30 outpatient visits), substance abuse treatment (where Health Plans must cover the first 30 days of inpatient rehabilitation and the first 30 outpatient visits), and nursing home care (where

16 Health Plans must cover the first 30 days of care) are the only services operating under RIte Care on a partial-risk basis. After these thresholds are reached, DHS reimburses the Health Plans for the cost of services above the threshold at 90 percent of the regular Medicaid fee-for-service rate or cost, whichever is less.

• Transportation – DHS has had an agreement with the Rhode Island Public Transportation Authority (RIPTA) since the beginning of RIte Care for RIPTA to provide bus passes and non-emergency paratransit services (e.g., taxis) to RIte Care-eligible individuals. DHS has had this arrangement with RIPTA because of the importance of transportation in assuring access to needed health care services by low-income individuals.

• Out-of-Plan Payments6

for Neonatal Intensive Care Unit (NICU) – When the RIte Care Health Plan Contracts were renegotiated in July 1998, Health Plans were given the option of DHS assuming the risk of NICU services rendered at Women’s & Infants Hospital versus the Health Plans retaining the risk for these services. This was done because of the historic, relatively high cost for these services for RIte Care-eligible individuals. Health Plans that elected to shift the risk for NICU services have a lower capitation rate for the under one age group. In addition, enrollees in RIte Care are eligible to receive out-of-plan services, covered under the Medicaid fee-for-service system. See Section 6.2 in this regard.

Besides paying a portion of employee-sponsored insurance (ESI) coverage, RIte Share covers co-payments and Medicaid benefits not covered by an enrollee’s ESI coverage once he or she is enrolled in RIte Share.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4); (42CFR 457.490(b))

The Health Plans will be at risk for the services provided to targeted low-income children and other populations. The Health Plans will use their own mechanisms to manage utilization. As noted above, the Health Plans are State-licensed HMOs and are NCQA-accredited.

6 The State provides other out-of-plan benefits to RIte Care eligible individuals that are not reflected in Table 2-5.

17 SECTION 4. ELIGIBILITY STANDARDS AND METHODOLOGY. (SECTION 2102(B))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)); (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan: Statewide 4.1.2.

Age: Conception to birth for unborn children 4.1.3.

Income: Up to 250% of the FPL 4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): Applicants living in the State with the intent to stay; this includes children under 19 as provided for in Section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) who are otherwise eligible aliens lawfully residing in the United States: such aliens consist of qualified aliens subject to the 5-year bar, aliens described in 8CFR 103.12(a)(4), and legal non- immigrants whose admission to the U.S. is not conditioned on having a permanent residence in a foreign country (such non- immigrants include citizens of the Compact of Free Association States who are considered permanent non- immigrants but does not include visitors for business or pleasure or students). The State assures that it will continue to verify the immigration status of this group of children to ensure they meet the eligibility requirements. 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): Not applicable 4.1.7.

Access to or coverage under other health coverage: Effective January 1, 2002, enrollment in RIte Share, the State’s premium assistance program, became mandatory for Medicaid-eligible individuals whose employers offered an approved health plan. For the separate child health program, applicants cannot be enrolled under a group health plan or health insurance coverage (including access to a State health benefits plan).

18

4.1.8.

Duration of eligibility: Same as Medicaid. 4.1.9.

Other standards (identify and describe): A Social Security Number (SSN) is required for Medicaid-eligible individuals. This does not apply to the separate child health program. At redetermination, proof of current immigration status will be required just as it is required for the initial eligibility determination.

4.1-P The following standards may be used to determine eligibility of targeted low-income pregnant women for health assistance under the plan. Please note whether any of the following standards apply. If applicable, describe the criteria that will be used to apply the standard (Section 2112).

4.1.1-P Geographic area served by the Plan: Statewide 4.1.2-P Age: the minimum age for targeted low-income pregnant women is 19 years old. 4.1.3-P Income: above 185% up to and including 250% of the FPL 4.1.4-P Resources: Not applicable 4.1.5-P Residency: Applicant living in the State with the intent to stay. 4.1.6-P Disability; Not applicable 4.1.7-P Access to or coverage under other health coverage: Enrollment in RIte Share, the State’s premium assistance program, is mandatory for Medicaid-eligible individuals whose employers offered an approved health plan. For the separate child health program, applicants cannot be enrolled under a group health plan or health insurance coverage (including access to a State health benefits plan) at the time of application. 4.1.8-P Duration of eligibility: For targeted low-income pregnant women, eligibility is during pregnancy and through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends. 4.1.9-P Other standards (identify and describe): For a pregnant woman, the pregnancy must be medically verified and there is no presumptive eligibility. These standards provide that if a child is born to a targeted low-income pregnant women who was receiving pregnancy-related assistance under this plan on the date of the child’s birth, the child shall be deemed to have applied for medical assistance under title XIX and to have been found eligible for such assistance under such title, as appropriate, on the date of such birth and to remain eligible for such assistance until the child attains 1 year of

19 age. (Section 2112(e))

4.1.10 Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to provide coverage to the following otherwise eligible individuals lawfully residing in the United States:

(1) “Qualified aliens” otherwise subject to the 5-year waiting period per section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996; (2) Citizens of a Compact of Free Association State (i.e., Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau) who have been admitted to the United States (U.S.) as non- immigrants and are permitted by the Department of Homeland Security to reside permanently or indefinitely in the U.S.; (3) Individuals described in 8 CFR 103.12(a)(4) who do not have a permanent residence in the country of their nationality and are in statuses that permit them to remain in the U.S. for an indefinite period of time pending adjustment of status. These individuals include: (a) Individuals currently in temporary resident status as Amnesty beneficiaries pursuant to section 210 or 245A of the Immigration and Nationality Act (INA); (b) Individuals currently under Temporary Protected Status pursuant to section 244 of the INA; (c) Family Unity beneficiaries pursuant to section 301 of Public Law 101-649 as amended, as well as pursuant to section 1504 of Pub. L. 106-554; (d) Individuals currently under Deferred Enforced Departure pursuant to a decision made by the President; and (e) Individuals who are the spouse or child of a U.S. citizen whose visa petition has been approved and who has a pending application for adjustment of status; and (4) Individuals in non-immigrant classifications under the INA who are permitted to remain in the U.S. for an indefinite period, including the following who are

20 specified in section 101(a)(15) of the INA: • Parents or children of individuals with special immigrant status under section 101(a)(27) of the INA as permitted under section 101(a)(15)(N) of the INA; • Fiancées of a citizen as permitted under section 101(a)(15)(K) of the INA; • Religious workers under section 101(a)(15)(R); • Individuals assisting the Department of Justice in a criminal investigation as permitted under section 101(a)(15)(U) of the INA; • Battered aliens; and • Individuals with a petition pending for 3 years or more as permitted under section 101(a)(15)(V) of the INA.

The State elects the CHIPRA section 214 option for children up to age 19

The State elects the CHIPRA section 214 option for pregnant women through the 60-day postpartum period

4.1.10.1

The State provides assurance that for individuals whom it enrolls in CHIP under the CHIPRA section 214 option that it has verified, both at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)); (42CFR 457.320(b))

4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income

21 children, these standards do not cover children of higher income families without covering children with a lower family income. These standards do not provide for a CHIP income eligibility level for pregnant women lower than the State’s Medicaid level. (Section 2112(b)(2)) These standards do not provide coverage for higher-income pregnant women without covering lower-income pregnant women. (Section 2112(b)(3)) These standards provide pregnancy-related assistance for targeted low-income pregnant women in the same manner, and subject to the same requirements, as they provide child health assistance for targeted low-income children under this plan and in addition to providing child health assistance to such women. (Section 2112(b)(4))

4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)); (42CFR 457.350)

Any person may request information about either RIte Care or RIte Share, either by telephone, mail, or in person. A request for information may be followed by an application for RIte Care, RIte Share, or another form of assistance. Authorized DHS staff must furnish information to the inquiring person in accordance with DHS policy and procedures. The DHS InfoLine staff also furnishes information upon request regarding RIte Care and RIte Share, and how to apply.

A formal application procedure is required to ensure a person’s right to apply without delay. It affords an opportunity to state her/his needs and to learn what DHS can do to assist her/him. It also affords DHS the opportunity to apprise the person of her/his responsibilities in relation to DHS and the programs, both as an applicant, and, should eligibility be established, as a recipient.

An applicant may be assisted in the application process, including completion of the application form, by one or more individuals of her/his choice, and when accompanied by such individual(s), may be represented by them.

DHS streamlined the RIte Care application process effective November 1, 1998 by introducing a shortened, mail-in application and by eliminating most verification requirements. This application is in English/Spanish and is widely available at community agencies or by contacting DHS.

22 Family Assistance Program (formerly AFDC) cash recipients access RIte Care by virtue of their cash eligibility as determined through the Family Independence Program application process. Medical Assistance Only (MAO) cases and non-MA unborn children access RIte Care and RIte Share through the mail-in application. No separate screening or application process is required.

Applicants for RIte Care and RIte Share may mail in applications to DHS or submit applications at any DHS district office or any site designated by DHS. Under Medicaid law, DHS is required to outstation eligibility workers in community settings. DHS, along with the Department of Health, provides funding to the RI Health Center Association (RIHCA) to meet this requirement. Each health center employs a Family Resource Counselor on its premises. These FRCs are of the culture and/or speak the language of the community in which they serve. The FRCs are trained to screen families/pregnant women for RIte Care/RIte Share; assist potentially eligible families in the completion and filing of the mail-in application; provide follow-up to applicants as appropriate; check the Recipient Eligibility Verification System (REVS) to determine the outcome of the application; and assist recipients with the annual renewal process. They are also responsible for screening and referring families for the cash assistance, Food Stamps, WIC and childcare services. DHS is an active participant in the regular training sessions in which all FRCs are mandated to participate. This ensures that the FRCs are aware of any changes to the State’s assistance programs.

Applications are acted upon promptly. A decision on eligibility or ineligibility must be made within 30 days of an application filing date. This standard is not used as a waiting period nor as a basis for denial of an application. The applicant must be informed of the reason for any delay in a decision and her/his right to a hearing, if delay is beyond 30 days.

When the applicant is found to be eligible, the acceptance date for medical coverage is the first day of the month of application. When the applicant is found ineligible or the applicant makes the decision after signing the application the she/he does not want assistance, DHS notifies the applicant in writing of the rejection. This letter informs the applicant at the same time of her/his right to appeal the decision and the method by which the applicant can request a hearing.

The program provides for 12 months continuous coverage for infants, regardless of income changes, except for death, voluntary withdrawal from the program, removal from the State, or failure to pay the applicable premium share. For an unborn child, upon birth the child will be automatically eligible as a Medicaid expansion case until the child’s first

23 birthday. At that point, the child’s continuing eligibility will be re-determined just like any other Medicaid expansion case. For other than infants, eligibility is re-determined every 12 months. If there is a change of income in the interim and DHS becomes aware of it, re-determination will occur at that time.

These standards assure that the State shall verify that eligible children under 19 as provided for in Section 214 of CHIPRA who are otherwise eligible aliens lawfully residing in the United States continue to lawfully reside in the United States using the documentation presented to the State by the individual on initial enrollment. If the State cannot successfully verify that the individual is lawfully residing in the United States in this manner, it shall require that the individual provide the State with further documentation or other evidence to verify that the individual is lawfully residing in the United States. (Section 1903(v)(a)(4)(c) of the Act).

The State assures that by choosing to provide for the optional coverage of children under 19 as provided for by Section 214 of CHIPRA who are otherwise eligible aliens lawfully residing in the United State: The State has elected the option to apply such coverage with respect to such category of children under Title XIX (Section 2107(e)(1)(E))

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)); (Section 2112(b)(7)); (42CFR 457.305(b))

Check here if this section does not apply to your state.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)); (42 CFR 457.310(b), 42CFR 457.350(a)(1), 457.80(c)(3))

At eligibility determination and redetermination, all applications are reviewed for coverage under a group health plan, or health insurance coverage, for access to a State health benefits plan, and for Medicaid eligibility prior to enrollment in a Title XXI separate child health program.

These standards do not apply any exclusion of benefits for

24 pregnancy-related assistance based on any preexisting condition or any waiting period, including any waiting period imposed to carry out section 2102(b)(3)(C) for receipt of such assistance. (Section 2112(b)(5))

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)); (42CFR 457.350(a)(2))

Screening procedures identify any applicant or enrollee who would be potentially eligible for Medicaid eligibility based on his or her mother under one of the poverty level groups described in Section 1902(1) of the Social Security Act, Section 1931 of the Act, or Medicaid demonstration project under Section 1115 of the Act.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)); (42CFR 431.636(b)(4))

Any applicant who is found ineligible for Medicaid and appears to be eligible for the separate child health program is automatically reviewed for separate child health program eligibility.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)); (42CFR 457.805, 42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

The principal method is to monitor the availability of private health insurance at the time of initial application (and at re-determination). This ties to RIte Share now being mandatory. In addition, the State established a Business Advisory Committee. Finally, the two commercial Health Plans participating in RIte Care monitor their commercial enrollment levels carefully.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

25

See Section 4.4.4.1.

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution. The State has not yet implemented its approved amendment to cover targeted low-income children up to 300% of the FPL.

4.4.4.4. If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period. Qualification does not require that a family be without coverage for a defined waiting period. This is because families cannot drop coverage to enroll in RIte Care due to Rhode Island’s requirement that any applicant or enrollee with access to qualifying coverage must maintain or enroll in that coverage, and the State will reimburse the family for their monthly premium share, as a condition of Medicaid (separate child health program) eligibility.

The minimum employer contribution. There is no minimum employer contribution.

The cost-effectiveness determination. Cost- effectiveness is determined on an employer plan- specific basis, as opposed to an individual- or family- specific basis. This method ensures that the cost to the State for those enrolled in the premium assistance program (RIte Share) is less than enrolling those same individuals or families in RIte Care.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native.

(Section 2102)(b)(3)(D)); (42 CFR 457.125(a))

RIte Care and RIte Share are available to targeted low-income individuals in the State who are American Indians and Alaskan Natives, except as noted in Section 8.6, cost-sharing does not apply to American Indians and Alaskan natives. Otherwise, the programs

26 are identical in all respects. Also see Section 9.9.1 for involvement of the Narragansett Tribe, the only Federally recognized tribe in the State of Rhode Island.

27 SECTION 5. OUTREACH (SECTION 2102(C))

Describe the procedures used by the state to accomplish:

5.1 Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)); (42CFR 457.90)

When RIte Care expanded eligibility to include uninsured children aged 8 to 18 up to 250 percent of the FPL, the State embarked on a multifaceted outreach plan to enroll these children. The purpose of this outreach plan was to build upon prior efforts to enroll the targeted low-income child populations in RIte Care. To effectively reach target populations, multiple outreach methods took place with a total investment of $1.8M by the Department of Human Services (DHS), a considerable investment given the size of the State. Outreach was coordinated very closely with Rhode Island's Covering Kids grant. The first phase of the outreach campaign began early in 1999, when DHS established performance- based contracts with 32 community-based agencies and community health centers to fund outreach workers to find and enroll eligible children. These contracts were in place until June 2000. The second major phase of the outreach campaign was a comprehensive school-based initiative over the 1999- 2000 academic year.

TYPES OF OUTREACH

The following outreach activities have occurred as part of the public information campaign.

Targeted mailings Print material, such as brochures, flyers, and inserts, have been developed and mailed or distributed to the groups that have contact with the targeted low- income child population. RIte Care Info Line telephone numbers are included on all print materials.

The targeted mailings included:

• Community Organizations  State/government agencies and programs  Non-profit community organizations  Hospitals, health center organizations, Health Plans

• School superintendents, principals, parent teacher organizations

28

• School nurses, school social workers, school psychologists, special education directors

• Head Start Directors, licensed preschools and nursery schools

Distribution of Materials to Every School-Age Child in Rhode Island Similar to South Carolina’s efforts for Partners for Health Children program, a RIte Care brochure was distributed to every (K through 6th grade) child in the State. This was undertaken in cooperation with the 347 schools in the State, with the schools actually handling the distribution of materials to each child.

Print Media Media coverage on this expanded eligibility was promoted in professional newsletters and Rhode Island newspapers during the public information campaign.

Internet Information on the eligibility expansion of RIte Care was be added to the Department of Human Services (DHS) Website.

Piggyback mailings When possible, information on the eligibility expansion has been inserted and mailed with other State or local mailings when appropriate, e.g., unemployment checks.

Public Service Announcements Announcements for radio that were developed by HCFA have been used for this public information campaign. Airtime was purchased rather than relying on PSAs.

Press Conference A kick-off press conference has announced the beginning of each eligibility expansion and initiation of the Covering Kids Project in Rhode Island.

Television and Radio Interviews Interviews on television and radio shows were set up for DHS and Center for Child and Family Health (CCFH) staff.

OUTREACH TO NON-ENGLISH SPEAKING POPULATIONS

Hispanic Outreach All print materials for the general public have been translated into Spanish and distributed to known Hispanic organizations throughout the State. Newspaper advertisements (in Spanish) were developed and placed in Hispanic

29 newspapers. A Hispanic outreach subcommittee was formed and provided recommendations to DHS. This group has also been working closely with one of the Covering Kids' groups on immigrants. The RIte Care Application has been translated into Spanish.

Other Non-English Speaking Outreach Contact has been made with community leaders in minority groups other than Spanish. Information was be distributed in English and then translated by community representatives into their language.

OUTREACH TO THE NARRAGANSETT TRIBE

DHS staff has met with tribal leaders as well as representatives of the Narragansett Indian Health Center.

COMMUNITY-BASED OUTREACH

In addition to the above activities, the State contracted with 32 community-based organizations (CBOs) to help find and enroll eligible children and families. These contracts combined base staffing of outreach workers plus incentive funds for successfully enrolled children. In addition, DHS contracted with the Rhode Island community health centers to also help enroll children. These activities were not, however, funded with Title XXI funds.

SIMPLIFICATION OF ELIGIBILITY/ENROLLMENT PROCEDURES

Efforts were made to simplify the eligibility and enrollment process for RIte Care, in order to de-stigmatize the program. Under these revised processes, potential enrollees sign up for RIte Care by mail and do not need to make a visit to the local welfare offices. The 32 contracted CBOs also served as sites where potential enrollees can receive an application and also receive help in completing it. In addition, 14 community-based health centers and 3 hospitals are helping to enroll potential members.

30 SECTION 6. COVERAGE REQUIREMENTS FOR CHILDREN’S HEALTH INSURANCE (SECTION 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment; (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in

42 CFR 457.431. See instructions.

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and

42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

31 6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe)

6.2. The state elects to provide the following forms of coverage to children (including unborn children) and targeted low-income pregnant women: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)); (42CFR 457.490) -- Most services are covered without limits, except as medically necessary. See the enclosed Attachments A and B from the RIte Care Health Plan Contract, for a delineation of the amount, duration and scope of in- and out-of-plan benefits for the Secretary-approved coverage.

6.2.1.

Inpatient services (Section 2110(a)(1)) 6.2.2.

Outpatient services (Section 2110(a)(2)) 6.2.3.

Physician services (Section 2110(a)(3)) 6.2.4.

Surgical services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9)) For the optional group of pregnant women covered under this plan, services include postpartum services through the end of the month in which the 60-day period (beginning on the last day of the pregnancy) ends. (Section 2112(f)(2)

32 6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community- based services (Section 2110(a)(11) 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

Disposable medical supplies (Section 2110(a)(13)) 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

Dental services (Section 2110(a)(17)) These services are covered to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions. (Section 2103(c)(5) 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20.

Case management services (Section 2110(a)(20)) 6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.

Hospice care (Section 2110(a)(23)) 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) – Premium share for RIte Share; see Section 8.1 6.2.26.

Medical transportation (Section 2110(a)(26)) 6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27))

33 6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)); (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following

(42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage

34 that would otherwise be provided for the coverage described above.; Describe the cost of such coverage on an average per child basis.

(Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)); (42CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)); (42CFR 457.1010(b))

6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

35 SECTION 7. QUALITY AND APPROPRIATENESS OF CARE

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (Section 2102(a)(7)(A));(42CFR 457.495(a))

The methods used for quality and appropriateness of care are the same as RIte Care. From the very beginning of RIte Care, the State has taken to heart the fact that it is a demonstration initiative. DHS developed a plan for monitoring7

RIte Care Health Plans early on. The plan included the following mechanisms for monitoring 12 areas of Health Plan operations: • Annual Site Visit Protocol • Disenrollment Grievance Log • Informal Complaints and Grievance and Appeals Log • Primary Care Provider (PCP) Survey • Enhanced Services Report • MMIS Special “Runs” • Member Satisfaction Survey • Self-Assessment Tool For Health Plan Internal Quality Assurance Plan Compliance With HCQIS • Access Study Format • PCP Open Practice Report • Other Provider Report • Financial Reporting Requirements • Third-Party Liability Report

The State also crafted and has implemented an extensive research and evaluation program to determine how well RIte Care has done in accomplishing its goals. In fact, research began before RIte Care was actually implemented in order to have some baseline data for comparison with demonstration results.

The Components of the State’s Quality Strategy

The following constitute the various components of the State’s strategy for quality

7 The latest version is: Birch & Davis Health Management Corporation. Plan For Monitoring RIte Care Health Plans, August 1996.

36 assessment and performance improvement.

1 Performance Incentive Program

In the RIte Care Health Plan Contracts effective July 1, 1998, the State established a performance incentive program, under which Health Plans can earn payments over and above capitation and SOBRA payments for the attainment of certain administrative, access, and clinical goals. The State did so “to improve care by using available health plan data on access and outcomes” and “to improve the quality of health plan performance data.”8 This was part of an ongoing strategy of partnership with the Health Plans, with both the State and the Health Plans committed to continuous quality improvement for RIte Care. The “approach leverages a comparatively small amount of money in spotlight areas that DHS considers important.”9

The program began with 21 measures in three areas of focus: 9 for the administrative are, 5 for the access to care area, and 7 for the clinical care area. Five “pilot measures” were added in 2000 and include the following areas:

• Postpartum visit after delivery • First outpatient pediatric visit for infants born into RIte Care • Emergency room visits by child enrollees with asthma • Outpatient visit after discharge for a mental health diagnosis • Translation assistance

Each measure is clearly defined, has a numeric “standard” to be achieved, and has “scoring guidelines.”

Data on the administrative measures are collected during on-site reviews of each Health Plan. The Encounter Data System provides the information for the access and clinical measures. Data from 1998 established the baseline against which later performance is compared. DHS offers each Health Plan monetary incentives10

as a reward for improvements in performance, information accuracy, and the completeness of data submitted. In 2001, DHS received a Purchaser Award from the National Health Care Purchasing Institute for the program to recognize DHS’ “value purchasing” management philosophy.

2 Encounter Data System

8 Dyer, M.B., M. Bailit, and C. Kokenyesi. Working Paper: Are Incentives Effective in Improving the Performance of Managed Care Plans?, Center for Health Care Strategies, March 2002. 9 Rhode Island Department of Human Services. Rhode Island Medicaid Program: Annual Report Fiscal Year 2001, 42. 10 The total incentive pool equals approximately one percent of total capitation payments made to the Health Plans.

37 The RIte Care Health Plans have worked diligently to implement an encounter data reporting system. Such a reporting system is one of the Special Terms and Conditions imposed by the Federal Government in granting the State the waivers necessary to implement RIte Care. An encounter data system is designed to identify services provided to an individual and track utilization over time and across service categories, provider types, and treatment facilities. Unique features and functional components of encounter data include:

• Episode-specific: services associated with a particular episode of care are grouped together

• Person-level: able to track individuals though the system

• Standardized: all Health Plans are reporting using the same definition

• Longitudinal: able to track people across reporting period

• Comprehensive: able to track people across service and treatment categories

Tracking medical encounters from a point of service (e.g., a physician’s office) through claim processing by the Health Plans to a data processing component to functional analytical files presents many operational challenges. As the Federal Government, Rhode Island, and the other waiver States have learned, it takes at least three years to achieve a level of consistency in reporting by Heath Plans in order to have usable encounter data.

Information from the Rhode Island Encounter Data System has been reported since 1998, when a level of reporting consistency was reached and data were verified. Besides supporting the performance incentive program, the Encounter data System is also used to monitor utilization. Monitoring utilization is important in assuring that enrollees have access to needed services. Since June 2001, encounter data have been used to prepare RIte Stats – a bimonthly publication of the DHS Center for Child and Family Health (which administers RIte Care and RIte Share) to provide information to the public on the health care provided under RIte Care.

Whenever possible, encounter data analyses are compared to comparable national benchmarks such as from:

• National Ambulatory Medical Survey • National Health Interview Survey • National Hospital Ambulatory Medical Care Survey • National Medicaid HEDIS Database/Benchmark Project • Treatment Episode Data Set

38

3 Risk-Share Reporting

As noted in Section 3.1, DHS has entered into risk-share arrangements with two Health Plans – CHP and NHPRI. The purpose of these arrangements is to assure RIte Care- eligible individuals have a choice of Health Plans in which to enroll11. Under the risk- sharing methodology, risk is shared according to whether the actual Medical Loss Ratio12

in any quarter is within agreed-upon ranges or “risk corridors.” The risk-share arrangements require that the Health Plans report monthly to DHS on the following:

• Utilization data, including hospital admissions, length of stay, days per 1,000 enrollees, and maternity stays

• Claims payable and claims statistics, including claims received, claims processed, and average processing time in days

• Financial information

These reporting requirements are currently being renegotiated with the Health Plans to partition the utilization data into the following categories: (1) institutional services (behavioral health and medical services by admissions, total days, and length of stay, emergency visits, ambulatory surgery, and other outpatient services reported as visits); (2) professional services (primary care, specialty services, emergency room physician visits, and behavioral health visits; (3) pharmacy (number of prescriptions); and (4) all other services used.

4 RIte Care Annual Member Satisfaction Survey

Each year, since 1996, ACS/Birch & Davis, under contract to DHS, has conducted an Annual Member Satisfaction Survey. Satisfaction data provide a commentary by enrollees on the services they receive. Each annual survey is comprised of a random sample of RIte Care members, who are selected as representative of the RIte Care enrolled population. The samples are designed to be effective at a 25 percent response rate (plus or minus 5 percent) in measuring member satisfaction at the RIte Care program level at a 95 percent confidence.

Each survey sample is mailed a survey questionnaire. The questionnaire is developed, in collaboration with the RIte Care Consumer Advisory Council, for this survey to reflect RIte care-specific program concerns. Questionnaires are pre-tested and modified accordingly. There are adult and child versions of the questionnaire. Adults answer on

11 Federal regulations require that enrollees have a choice of plans in which to enroll. 12 Medical Loss Ratio means Medical Expenses divided by Premium.

39 behalf of child members. Both versions are in English and Spanish. Sample members who did not respond to the initial mailing are sent a replacement mailing of the questionnaire. Responses received after a specified date each year are not included in the data analysis.

Each Annual Member Satisfaction Survey collects information on the following dimensions13

: • Regular doctor – other than whether the member has a regular doctor, information about:

– Doctor’s location – How long it has been since last seen – Ability to talk to or see when sick – Waiting time for appointment when sick – Waiting time for appointment to begin – Ability to reach after hours and on holidays and weekends – Overall satisfaction

• Prevention services – information about areas discussed by regular doctor, such as the following for adults:

– Tobacco, alcohol, or drug use – Diet, exercise, or seat belt use – Stress, depression, or anxiety – Family planning

• Pharmacy services – problems getting prescriptions filled

• Specialty services

– Satisfaction with getting a referral – Problems experienced if dissatisfied

• Emergency services

– Satisfaction, if ER services were used – Problems experienced, if dissatisfied

• Member services – helpfulness of plan staff, if a problem arose

• Member rights

13 It should be noted that dimensions, or questions, may change somewhat from year to year

40

– Been denied services – Know how to appeal coverage decisions – Know about RIte Care Consumer Advisory Committee

• Transportation services

– Satisfaction with RIte Care transportation benefits, if used – Availability of car seat for child under 3, if taxi or van used

• Interpreter services – needed one for a visit, but one not offered

• Overall satisfaction

Data from the survey are item-analyzed separately for adult and child versions of the questionnaire. Responses are analyzed by Health Plan and for English-speaking versus Spanish-speaking respondents. Where possible, responses are compared over time to examine trends.

5 Complaint, Grievance, and Appeals Reporting by the Health Plans

Enrollees may file a complaint, grievance, or appeal with their Health Plan14

at any time. Health Plans have, since RIte Care enrollment began, submitted quarterly reports to DHS summarizing the types of complaints made and whether or not they were resolved. Health Plans have also submitted a Grievance and Appeal Log quarterly from the beginning that itemizes, by enrollee, the nature of the grievance or appeal, how long it took to resolve, how it was resolved, and how long it took to notify the enrollee of the resolution. Data are summarized periodically. In addition to reporting by the Health Plans, complaints from enrollees (or their representatives, providers, advocates, other State agencies, and others can come to DHS directly through the bilingual DHS InfoLine or to DHS staff. Complaints may also go the RIte Care Consumer Advisory Committee. In addition, enrollees may avail themselves of the DHS Fair Hearing process at any time

6. Provider Network Data

Access to care has multiple dimensions. One dimension, for example, is providing access to care for individuals who had no or limited access due to being uninsured. Another dimension, for example, is improving access for those who had coverage but nonetheless had difficulty obtaining the services they needed.

14 Enrollees may also register complaints with the State at any time including availing themselves of the DHS Fair Hearing process.

41 The State monitors the adequacy of the service delivery system on a continuous basis. Provider network listings are updated monthly, from information submitted by the Health Plans. Among the items of information submitted is whether or not a provider’s practice is open to new members. Another item, for example, is language(s) spoken. The listings are matched, as necessary, with enrollee/ applicant listings to assess any network gaps in primary care provider (PCP) availability, for example. Geo-access analyses have also been performed periodically.

Provider network data analysis is also considered in light Annual Member Satisfaction Survey and complaint, grievance, and appeals analyses, to present a broader picture of the adequacy and appropriateness of the provider networks.

7. NCQA Information

As noted in Section 3.1, RIte Care-participating Health Plans must be State-licensed HMOs and must be, by State law, accredited by NCQA. Accreditation information is provided to the State by the Health Plans. Health Plan Employer Data and Information Set (HEDIS) are also provided to the State by the Health Plans. HEDIS data encompasses the following domains:

• Effectiveness of Care • Access/Availability of Care • Satisfaction with the Experience of Care15 • Health Plan Stability

• Use of Services • Cost of Care • Informed Health Care Choice • Health Plan Descriptive Information

The Effectiveness of Care domain includes, for example:

• Childhood immunization status • Adolescent immunization status • Breast cancer screening • Cervical cancer screening • Chlamydia screening in women • Prenatal care in the first trimester • Check-ups after delivery • Controlling high blood pressure • Comprehensive diabetes care • Use of appropriate medications for people with asthma

15 This is actually the Consumer Assessment of Health Plans Survey (CAHPS).

42 The Access/Availability of Care domain includes:

• Adult’s access to preventive/ambulatory health services • Children’s access to primary care practitioners

It should be noted that NCQA may rotate some of the measures from one year to the next, to reduce the burden on the Health Plans. NCQA requires an audit of HEDIS results by an independent agency (certified by NCQA) to ensure that HEDIS specifications have been met.

The similarity between some of the HEDIS measures and the RIte Care performance incentive program is not coincidental. Where possible, the performance incentive program used HEDIS specifications for a given measure since the Health Plans were already collecting information in this manner. It is important to note, however, that except for NHPRI, the HEDIS data reported by the Health Plans are not RIte Care-, or more precisely, Medicaid-specific.

The HEDIS results reported back to the Health Plans by NCQA (and, in turn, submitted to the State) show the results not for the Health Plan itself, but in comparison to “HEDIS national percentiles” at the 90th, 75th, 50th, and 25th levels, where available. The results are also shown for the Health Plan for prior years and in comparison to pre-set Health Plan goals, where applicable.

8. External Quality Review Organization (EQRO) Studies

One of the Special Terms and Conditions for the RIte Care waiver is that the State must contract with an EQRO. The State has used its EQRO to validate encounter data as well as to perform clinical focused studies. The clinical focused studies, which are based on detailed review of a sample of medical and other records, have included the following clinical areas:

• Neonatal intensive care unit (NICU) utilization • Emergency room (ER) utilization • Behavioral health care

The State is in the process of procuring a new EQRO contract. In addition to the conduct of clinical focused studies, the State expects the EQRO will be used to perform analytical studies using already available data.

9. Medicaid Management Information System (MMIS) Data

Because RIte Care enrollees are covered by the Medicaid fee-for-service system (FFS) for out-of-plan services (i.e., services not covered by the capitation payments to the Health Plans), ad hoc reports from the MMIS are prepared to analyze utilization of these

43 services. In addition, the MMIS provides the basic demographic information on enrollees (e.g., age, gender, and race). This latter information is actually imported into the MMIS from the State’s eligibility system.

10. Transportation Data

As noted in Section 3.1, DHS has had an agreement with the Rhode Island Public Transportation Authority (RIPTA) since the beginning of RIte Care for RIPTA to provide bus passes and non-emergency paratransit services (e.g., taxis) to RIte Care-eligible individuals. DHS has had this arrangement with RIPTA because of the importance of transportation in assuring access to needed health care services by low-income individuals. RIPTA submits reports to DHS quarterly on the number of bus passes issued and on the utilization of paratransit services. These data are analyzed periodically.

11. Special Studies

As noted above, the State has implemented an extensive research and evaluation (R&E) program for RIte Care. This program has included a variety of special studies, undertaken as a particular need has arisen or part of the “planned” R&E effort. Among the studies performed have been:

• Behavioral Health Care Access Study – This study16

was completed and submitted to CMS in 1998 and included intensive, on-site review of Health Plan compliance with behavioral health contract provisions established to address concerns related to provider specialization and the multiethnic, multilingual nature of the enrolled RIte Care population. • Prenatal Care and Birth Outcome Study – This study17, originally based on data through 1995 and reported in RIte Care Program Quarterly Report: October 1996 through December 1996, was updated using Calendar Year 1999 birth certificate date from the Office of Vital Statistics of the Rhode Island Department of Health. Study results, using the 1995 data, were also published in the American Journal of Public Health18

. • Infant Health Survey – This survey19

16 Birch & Davis Health Management Corporation. RIte care Behavioral Health Access Study, 1998. was conducted to assess the impact of RIte Care on access to and the quality of pediatric primary care in an inner city high-risk population. The study was initiated prior to individuals enrolling 17 Griffin, J. The Impact of RIte Care on Adequacy of Prenatal Care and the Health of Newborns, MCH Evaluation, Inc., March 2001. 18 Griffin, J. F., et. al. “the Effect of a Medicaid Managed Care Program on the Adequacy of Prenatal Care Utilization in Rhode Island,” American Journal of Public Health, 89(4), April 1999, 497 – 501. 19 Griffin, J. Changes in Access and Quality of Pediatric Health Care in Inner City Providence from 1993 to 1995: Results of the RIte Care Infant Health Survey, MCH Evaluation, Inc., April 28, 1998.

44 in RIte Care Health Plans, so that the effects of RIte Care could be clearly discerned. Specifically, the sample for this study involved two inner city birth cohorts. The first, 1993 Cohort (i.e., pre-RIte Care), consisted of all resident births for Providence inner city census tracts 1 through 7, 12 through 14, 19 and 26 that occurred from March 1, 1993 through July 30, 1993. The second, 1995 Cohort (i.e., post-RIte Care), consisted of all inner city births from the same census tracts and born from March 1, 1995 through July 30, 1995.

In 1998, Rhode Island received a demonstration grant from the Robert Wood Johnson Foundation’s Center on Health Care Strategies to develop a Health Indication System for Rhode Islanders on Medicaid20

. This project brought fundamental change through the establishment of the Evaluation Studies Workgroup and the emergence of a partnership between program staff and the Workgroup. The Workgroup includes researchers from Brown University, DOH, DHS, and contracted evaluation services (with MCH Evaluation, Inc.) This project produces health outcome measures from existing databases and surveys, and through special studies. The existing databases and surveys include: • MMIS • Linked Infant Birth/Death File • Birth File • Hospital Discharge File • Health Interview Survey • Behavioral Risk Factor Surveillance Survey

Among some of the special studies have been:

• A study21

of immunization status of 19- to 35-month-old children who had been continuously enrolled in RIte Care for at least one year, based upon medical record reviews • A study22

of a documented blood lead screen test of children aged 19 to 35 months who had been continuously enrolled in RIte Care for at least one year had, also based on medical record reviews Special studies will continue to be performed as part of the State’s quality strategy.

12 Contract Requirements

20 For more information on Rhode Islanders indicators, please see: http://dhs.state.ri.us/dhs/reports/dhcresys.htm. 21 Vivier, P. M., et.al. “An Analysis of the immunization status of preschool children enrolled in a statewide Medicaid managed care program,” The Journal of Pediatrics, 139(5), November 2001, 624-629. 22 Vivier, P.M., et.al. “A Statewide Assessment of Lead Screening Histories of Preschool Children Managed in a Medicaid Managed care Program,” Pediatrics, 108(2), 2001.

45 One of the guiding principles for the State’s quality strategy is having properly aligned contract requirements for the Health Plans, obligating them to be active participants in quality assessment and performance improvement. Some of these obligations have been described above (e.g., encounter data reporting and complaints, grievances, and appeals reporting). Two other long-standing contractual obligations have been for each Health Plan to perform at least three quality improvement studies each year and for each Health Plan to conduct its own member satisfaction survey.

DHS has amended the RIte Care Health Plan Contract multiple times to ensure the Federal requirements and STCs, at least those that can be contractually based, were met. In June 2001, the RIte Care Health Plan Contract were amended to conform to what the State believed were the managed care provisions of the Balanced Budget Act of 1997 (BBA). Thus, 16 changes were made to the contracts with the Health Plans at that time.

In reviewing the details of the June 14, 2002 Final Rule implementing the managed care provisions of the BBA, the State finds that it will need to make additional changes to the RIte Care Health Plan Contract. These changes are due mostly to the Final Rule’s language differing somewhat from the actual language in the statute. Thus, one component of the State’s quality strategy is to amend the RIte Care Health Plan Contracts prior to June 16, 2003 to bring them into compliance with the provisions of the Final Rule.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1.

Quality standards 7.1.2.

Performance measurement 7.1.3.

Information strategies 7.1.4.

Quality improvement strategies

7.2. Describe the methods used, including monitoring, to assure: (Section 2102(a)(7)(B)); (42CFR 57.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)); (42CFR 457.495(a))

Same as RIte Care.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)); 42CFR 457.495(b))

Same as RIte Care.

46

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of- network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)); (42CFR 457.495(c))

Same as RIte Care.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)); (42CFR 457.495(d))

Same as RIte Care.

47 SECTION 8. COST SHARING AND PAYMENT (SECTION 2103(E))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)); (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.1. Premiums: Effective January 1, 2002, all families in the RIte Care (and RIte Share) have been required to pay a portion of the cost of premiums for their health insurance coverage if their income is above 150 percent of the FPL as follows:

Income Level

Monthly Family Premium (as of 8/1/02) 150-185% of FPL

$61 185-200% of FPL

$77 200-250% of FPL

$92

8.2.2. Deductibles: 8.2.3. Coinsurance or copayments: 8.2.4. Other: These standards provide pregnancy-related assistance to a targeted low-income women consistent with the cost- sharing protections under secition 2103(e) and apply the limitation on total annual aggregate cost-sharing. (Section 2112(b)(6)) Enrollee cost-sharing is not required for preventative or pregnancy-related services.

8.3. Describe how the public will be notified, including the public schedule, of this cost-sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)); (42CFR 457.505(b))

The public is notified about cost-sharing and changes in cost-sharing in

48 the same manner as RIte Care. The public is notified of any changes in cost-sharing through the State’s Administrative Procedures Act process. In addition, individuals directly affected by any change (i.e., those currently paying a premium share) are notified in writing prior to any proposed change in premium share amounts.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)); (42CFR 457.530) 8.4.2.

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)); (42CFR 457.520) 8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)); (42CFR 457.515(f))

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)); (42CFR 457.560(b) and 457.505(e))

The premium share amount is set well below 5 percent of family income. There is no variable cost-sharing (e.g., point-of-service co-pays) that could increase family contribution to over 5 percent of income.

8.6 Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)); (42CFR 457.535)

Anyone identifying herself or himself as American Indian (or Alaskan Native) during the eligibility determination process is “flagged” for non- liability for any otherwise applicable premium share amount based upon income.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

An enrollee/family who does not pay the premium share amount for a period of two months will be disenrolled from Medical Assistance or the

49 separate child health program. The member is notified of this action through a closure notice, which is generated in the middle of the second month of arrears. The notice identifies the amount and months for which payment is owed, the dates of the disenrollment period, and the members affected. The notice also informs the family that they can prevent this action from taking place by making payment in full on or before the last day of the month.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non payment of cost- sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost- sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)); (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5); (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)); (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)); (42CFR 457.622(b)(5))

50

8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)); (42CFR 457.475)

51 SECTION 9. STRATEGIC OBJECTIVES AND PERFORMANCE GOALS AND PLAN ADMINISTRATION (SECTION 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)); (42CFR 457.710(b))

Increasing creditable health care coverage among targeted low-income children and other low-income children through RIte Care will be accomplished through four (4) key strategic objectives:

• Outreach and enrollment of eligible low-income children

• Increasing access to health care coverage and use of health care services

• Improving continuity and quality of care

• Containing medical costs

Each of these strategic objectives will be achieved by reaching a series of performance goals (See Section 9.2).

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)); (42CFR 457.710(c))

The performance goals for each one of the objectives delineated in Section 9.1 are shown in Tables 2 through 5 below:

Table 2 Outreach Performance Goals Improve Outreach Efforts as Measured By: • Increase the number of Medicaid-eligibles enrolled in RIte Care • Reduce the percentage of uninsured children • Reduce the percentage of uninsured adults

Table 3 Access Performance Goals Increase Continuity and Quality of Care as Measured by: • Increase the number of enrollees who report that they have improved access to the health care • Facilitate access to specialty resources through PCP referrals • Improve access to health care by removing barriers including:

52  Location  Transportation  Appointment waiting time  Language • Enhance the benefit package and coverage available to eligible children

Table 4 Continuity and Quality Performance Goals Improve Continuity and Quality of Care as Measured by: • Improve use of age-appropriate prevention care • Increase the number of primary care visits • Reduce the number of lead poisoned children • Increase preventive dental care

Table 5 Cost Containment Performance Goals Contain Medical Costs as Measured by: • Constrain the rate of increase in Medicaid expenditures per capita • Decrease the inappropriate use of hospital emergency rooms • Decrease inappropriate or preventable hospitalization (e.g., PID, asthma, otitis media, pneumonia, dehydration)

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the states performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)); (42CFR 457.710(d))

Program evaluation, the final component of the quality monitoring strategy for RIte Care, is important for assessing whether RIte Care has achieved the performance goals it has established for RIte Care as written in Section 9.2. Progress or lack of progress toward these performance goals would dictate a need for any one or more of the following:

• Change in the Health Plan’s or the Center for Child and Family Health’s operational processes or priorities

• Reassessment and refinement of quality review methodologies

• Increase Health Plan accountability for noncompliance

• Revision or addenda to RIte Care Health Plan contracts or policies

53

• Revision of the program goals and objectives

Ninety days before the end of each fiscal year, CCFH staff will begin compiling information on the attainment of the performance goals specified in Tables 2 through 5. This will be done as an amalgam of the quality improvement and other monitoring activities to be undertaken.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as:

9.3.7.1. Immunizations 9.3.7.2. Well childcare 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list: Pap smears, mammograms

9.3.8.

Performance measures for special targeted populations.

9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)); (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the states plan for these annual assessments and reports. (Section 2107(b)(2));

54 (42CFR 457.750)

The State will compile the Framework for Annual Report of the Child’s Health Insurance Plans Under Title XXI of the Social Security Act for each Federal fiscal year and submit it to CMS by January 1st of each year.

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)); (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)); (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)); (42CFR 457.120(a) and (b))

This process was co-led, under the overall aegis of the Director of the Department of Human Services, by the Administrator of the Center for Child and Family Health and the Co-Chair of the RIte Care Consumer Advisory Council. An initial public meeting was held on December 3, 1997, to explain to the public the opportunities and constraints provided for under Title XXI as well as to elicit public opinion on the directions the State’s Title XXI program should take. It was the consensus of those in attendance at this meeting that the State should pursue the incremental approach to Title XXI reflected in the initial Plan submission, then to submit an amended Plan after conclusion of the public planning process. Subsequent public meetings were held on January 7 and 22, 1998. A Title XXI committee of the State's Federal Legislative Task Force was formed and met either monthly or bi-monthly through 1998 and 1999.

The Title XXI planning process has also entailed meetings with the other State

55 agencies having historic involvement with Medicaid:

• Department of Children, Youth and Families (DCYF)

• Department of Education (DOE) • Department of Health (DOH)

• Department of Mental Health, Retardation and Hospitals (MHRH)

In addition, the Title XXI committee has included some 100 individuals representing an array of public and private interests including, for example:

• Governor’s Office • Legislative representatives • State agencies • RIte Care Consumer Advisory Council • Office of Child Advocate • RI ARC • Urban League of Rhode Island • RI KIDS COUNT • Westbay Community Action • Campaign to Eliminate Childhood Poverty • RI Health Center Association • United Way • Family Voices • RI Coalition for the Homeless • Ocean State Action • Health Plans

This is a similar group through which DHS worked in planning for welfare reform in the State. Thus, the Title XXI planning process had broad-based public input. The specific recommendations reflected in this Plan Amendment were adopted by the Title XXI Workgroup of the Federal Legislative Task Force, by consensus, at its September 1999 meeting.

During the Title XXI implementation phase, public involvement has been assured through the RIte Care Consumer Advisory Council which meets monthly. This is consistent with the State’s approach to Title XXI by expanding RIte Care. The Consumer Advisory Council provides the public forum for addressing any aspect of RIte Care. In addition, the Consumer Advisory Council plays a critical role in reviewing State-developed materials to be sent to potential applicants/enrollees and in certain evaluation activities e.g., annual Member Satisfaction Survey.

DHS also established a Business Advisory Committee to provide advice and guidance or various aspects of the Section 1115 waiver.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)); (42CFR 457.120(c))

56 In 1999, the Rhode Island Department of Human Services (DHS) and the Narragansett Native American Tribe (Tribe) signed a formal consultation agreement to encourage the free exchange of information to improve collaboration between the State and the Tribe with regard to health services.

The State has sought comments from the Tribe on its Section 1115 waiver (and amendments) and SCHIP plans through a SCHIP planning committee and continues to encourage participation from the Tribe in RIte Care’s ongoing Consumer Advisory Committee.

DHS has also developed an ongoing partnership to:

• Streamline the payment claims system for RIte Care members

• Facilitate meeting meetings between NHPRI and the Indian Health Center to allow the center to participate in NHPRI’s provider network

• Exempt Native Americans from cost-sharing

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 457.65(b) through (d).

Coverage of pregnant women above 185 percent of the FPL up to and including 250 percent of the FPL has been established law in Rhode Island for many years under Section 42-12.3-3 of the General Laws of Rhode Island and provided the basis for the State’s coverage of such women under its CHIP Section 1115 waiver that expired September 30, 2008. The amendment relating to benefits merely clarifies what has been existing coverage under CHIP since October 1, 1997.

Coverage of eligible children under 19 as provided for in Section 214 of the Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA) who are otherwise eligible aliens lawfully residing in the United States was authorized by the Rhode Island General Assemble in approving the 2010 State Budget, thus the public was informed through the State’s customary legislative process.

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)); (42CFR 457.140)

Planned use of funds, including –

• Projected amount to be spent on health services;

57

• Projected amount to be spent on administrative costs; and

• Assumptions on which the budget is based, including cost per individual and expected enrollment.

Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. Cost-sharing payments have been accounted for and the Net Benefit Costs are net of cost-sharing.

The non-Federal source of funding for the budget is State appropriations. The assumptions used for the budget the separate child health program for pregnant women component of the CHIP State plan are as follows:

• 100 pregnant women at an estimated cost of $886.80 per member per month; this includes payment for capitation, for labor and delivery, and for other pregnancy-related services.

58 Addition of SCHIP Coverage for Prenatal Care & Associated Health Care Services PREGNANT WOMEN** OTHER COVERED POPULATIONS

Total

FFY2009 FFY2009

State's enhanced FMAP rate

66.84% 66.84%

66.84%

Member Months

600.00 98,415.27

99,015.27 Benefit Costs

Payments to Managed Care Plans

$167,712 $12,126,202 $12,293,914 Insurance Payments (RIteShare)

per member/per month rate @ # of eligibles

$279.52 $123.21 $124.16 Fee for Service

$364,371 $19,545,716 $19,910,086 Total Benefit Costs

$532,082 $31,671,918 $32,204,001 Offsetting beneficiary cost sharing payments (Prem Coll'n) 0

Net Benefit Costs

$532,082 $31,671,918 $32,204,001 per member/per month rate @ # of eligibles

$886.80 $321.82

Administration Costs

Personnel

$9,449 $562,465 $571,914 General administration

$7,689 $457,691 $465,380 Contractors/Brokers

$40,431 $2,406,580 $2,447,011 Claims Processing

$1,436 $85,504 $86,940 Outreach/marketing costs

$79 $4,698 $4,777 Other

$36 $2,168 $2,204 Total Administration Costs

$59,120 $3,519,102 $3,578,222 10% Administrative Cap

$59,120 $3,519,102 $3,578,222

Federal Share

$395,160 $23,521,678 $23,916,838 State Share

$196,043 $11,669,342 $11,865,385 TOTAL COSTS OF APPROVED SCHIP PLAN

$591,203 $35,191,020 $35,782,223

**Budget Projection for SFY09 includes expenses from April 2009 thru Sept 2009.

59

SECTION 10. ANNUAL REPORTS AND EVALUATIONS (SECTION 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)); (42CFR 457.750)

10.1.1. The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.1.2. The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.1.3 The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

60 SECTION 11. PROGRAM INTEGRITY (SECTION 2101(A))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)); (42CFR 457.940(b))

11.2.

The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9)

11.2.1. 42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2. Section 1124 (relating to disclosure of ownership and related information) 11.2.3. Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4. Section 1128A (relating to civil monetary penalties) 11.2.5. Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6. Section 1128E (relating to the National health care fraud and abuse data collection program)

61 SECTION 12. APPLICANT AND ENROLLEE PROTECTIONS (SECTIONS 2101(A))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

The review process for eligibility and enrollment matters is the Medicaid (DHS) Fair Hearing process. The DHS Fair Hearing process is available to any applicant or enrollee for review of denial of eligibility, failure to make timely determination of eligibility, and suspension or termination of enrollment including disenrollment for failure to pay cost-sharing. An expedited DHS Fair Hearing when there is an immediate need for health services. The procedures for review assure:

• Reviews are conducted by an impartial person in accordance with 42 CFR 457.1150

• Review decisions are timely in accordance 42 CFR 457.1160

• Applicants and enrollees have an opportunity to:

 Represent themselves or have representatives of their choosing in the review

 Timely review their files and other applicable information relevant to the review of the decision

 Fully participate in the review process, whether the review is conducted in person or in writing, including presenting supplemental information during the review process

 Receive continued enrollment in accordance with 42 CFR 457.1170

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

There are multiple avenues for an enrollee for external review of a delay, denial, reduction, suspension, or termination of health services in whole or in part, including determination about the type and level of services, and failure to

62 approve, furnish, or provide payment for health services in a timely manner. The enrollee may avail herself or himself of the DHS Fair Hearing process described in Section 12.1. The enrollee may also avail herself or himself of the external review process through the Rhode Island Department of Health, provided for under State law.

These reviews are completed in accordance with the medical needs of the patient, and are completed within the timeframes specified in 42 CFR 457.1160.

Enrollees may also avail themselves of Health Plan internal review processes, although such reviews need not be conducted prior to enrollees availing themselves of DHS Fair Hearings or DOH external reviews.

Premium Assistance Programs

12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

All enrollees in RIte Share may avail themselves of the Medicaid (DHS) Fair Hearing process.

63 ATTACHMENT A

SCHEDULE OF IN-PLAN BENEFITS

Page 1 of 8

SERVICE SCOPE OF BENEFIT (ANNUAL)

PLAN CAPITATED FOR BENEFIT

Inpatient Hospital Care Up to 365 days per year based on medical necessity

Yes 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. (Health Plans have the option to deliver these types of services in other appropriate settings.)

Yes Physician Services Covered as needed, based on medical necessity; up to three GYN visits annually to a network provider is covered without a PCP referral

Yes Family Planning Services Women covered as described in Attachment F (non-extended family planning group receives same family planning benefit as extended family planning group)

Yes

64

65 ATTACHMENT A

Page 2 of 8

SERVICE SCOPE OF BENEFIT (ANNUAL)

PLAN CAPITATED FOR BENEFIT

Prescription Drugs Covered when prescribed by a Health Plan physician/provider (or other physician for SED and SPMI) Generic substitution required unless specified otherwise by physician.

Yes Non-Prescription Drugs

Covered when prescribed by a Health Plan physician/provider; limited to non-prescription drugs covered by the Rhode Island Medical Assistance Program

Yes Laboratory Services Covered when ordered by a Health Plan physician/provider (or other physician for SED and SPMI), including urine screens

Yes Radiology Services Covered when ordered by a Health Plan physician/provider

Yes Diagnostic Services Covered when ordered by a Health Plan physician/provider (or other physician for SED and SPMI)

Yes

66 ATTACHMENT A

Page 3 of 8

SERVICE SCOPE OF BENEFIT (ANNUAL)

PLAN CAPITATED FOR BENEFIT

Mental Health and Substance Abuse Services- Outpatient Both short- and long-term treatment covered as needed based on medical necessity, subject to stop-loss limitations in Definition Section 1.30 and groups/services out-of-plan in Attachment B. Includes methadone maintenance, outpatient methadone detoxification, collateral visits, and medically necessary court- ordered services subject to limitations described in Attachment B Yes, except for groups screened- out as described in Attachment B and subject to stop- loss in Section 1.30 Mental Health and Substance Abuse Services- Inpatient Both short- and long-term treatment covered as needed, based on medical necessity. (Butler Hospital may be used for services). Includes day treatment, partial hospitalization, and residential treatment, except for residential treatment for children ordered by DCYF, and except for residential substance abuse treatment for children age 13 to 17. 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"). Covered services subject to limitations described in Attachment B

Yes, except for groups screened- out, as described in Attachment B and subject to stop-loss provisions in Section 1.30

67 ATTACHMENT A

Page 4 of 8

SERVICE SCOPE OF BENEFIT (ANNUAL)

PLAN CAPITATED FOR BENEFIT

EPSDT Services Provided to all children and young adults up to age 21, (described in greater detail in Section 2.06.02.02) Includes tracking, follow-up and outreach to children for initial visits, preventive visits, and follow-up visits. Includes interperiodic screens as medically indicated. Includes multi- disciplinary evaluation and treatment for children with significant developmental disabilities or developmental delays

Yes, for all EPSDT services except those described in Attachment 2.B

68 ATTACHMENT A

Page 5 of 8

SERVICE

SCOPE OF BENEFIT (ANNUAL)

PLAN CAPITATED FOR BENEFIT

Home Health Services Covered if ordered by a Health Plan physician. Includes private duty nursing and homemaking/personal care services when medically necessary. Personal care/ homemaking services include such tasks as assisting the client with personal hygiene, dressing, feeding, transfer, ambulatory needs, and household tasks incidental to the client’s health needs. These homemaking tasks might include making the client’s bed, cleaning the client’s living areas such as bedroom and bathroom, and doing the client’s laundry and shopping. These services may be provided for RIte Care members and his/her children if the member is unable, because of illness or disability, to provide caretaking functions for herself/himself and her/his child(ren). Does not include respite care, relief care, or day care. Yes School-Based Clinic Services Covered as medically necessary at four designated sites

Yes

69

70 ATTACHMENT A

Page 6 of 8

SERVICE

SCOPE OF BENEFIT (ANNUAL)

PLAN CAPITATED FOR BENEFIT

Emergency Room Services and Emergency Transportation Services Covered, for emergency services (Section 2.09.03), or when authorized by a Health Plan Provider, or in order to assess whether a condition warrants treatment as an emergency service

Yes Nursing Facility Care Covered when ordered by a Health Plan physician

Yes, subject to stop-loss provisions in Section 1.30

*Services of Other Practitioners Covered if referred by a Health Plan physician

Yes Podiatry Services Covered as ordered by Health Plan physician

Yes Optometry Services For adults 21 and older, benefit is limited to examinations that include refractions and provision of eyeglasses if needed once every two years, and other medically necessary treatment visits for illness or injury to the eye. For children under 21, covered as medically necessary with no other limits

Yes

*Practitioners certified and licensed by the State of Rhode Island including nurse practitioners, physician assistants, social workers, licensed dieticians, psychologists, and licensed nurse midwives.

71 ATTACHMENT A

Page 7 of 8

SERVICE

SCOPE OF BENEFIT (ANNUAL)

PLAN CAPITATED FOR BENEFIT

Hospice Services Up to 210 days lifetime maximum as ordered by a Health Plan physician. Services limited to those covered by Medicare

Yes Durable Medical Equipment Covered as ordered by a Health Plan physician. Includes surgical appliances, prosthetic devices, orthotic devices, and medical supplies. Includes hearing aids and molded shoes

Yes Early Intervention Covered as included within the IFSP as described in Section 2.07.04.01, subject to stop-loss limitations in Section 1.30 Yes, up to the first $3000 for speech, language, hearing, physical, and occupational therapies

Nutrition Services Covered as delivered by a licensed dietitian for certain medical conditions as defined in Attachment E and as referred by a Health Plan physician

Yes Group Education/Programs Including childbirth education classes, parenting classes, and smoking cessation programs and services

Yes

72 ATTACHMENT A

Page 8 of 8

SERVICE

SCOPE OF BENEFIT (ANNUAL)

PLAN CAPITATED FOR BENEFIT

Transportation Services (Non-Emergency) Covered non-emergency transportation services include bus passes, and also includes para-transit services, when authorized/arranged by the Health Plan through RIPTA Coordinator Yes Interpreter Services Covered if a Health Plan has more than 100 members or 10 percent of its RIte Care membership, whichever is less, who speak a single language other than English as a primary language

Yes Transplant Services Covered when ordered by a Health Plan physician Yes, subject to stop-loss limitations in Section 1.30

73 ATTACHMENT B

SCHEDULE OF OUT-OF-PLAN BENEFITS

Page 1 of 4

These benefits are not included in the capitated benefit and are not the responsibility of the Health Plan to provide or arrange. The Health Plan is expected to refer to and coordinate with these services as appropriate. These services will be provided by existing Medicaid-approved providers who will be reimbursed directly by the State on a fee-for-service or contractual basis

ELIGIBLE GROUP

BENEFIT(S) PROVIDED OUT-OF-PLAN All RIte Care Enrollees Dental services

Court ordered mental health and substance abuse services in which the court order specifies a non-network provider

AIDS non-medical case management Children All out-of-plan benefits listed above in “All RIte Care Enrollees”

Early intervention in natural settings or center- based health and education programs for children at risk for being developmentally delayed, in excess of plan limits

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

Non-medical case management for Head Start children

74 Page 2 of 4

ELIGIBLE GROUP

BENEFIT(S) PROVIDED OUT-OF-PLAN Children (Continued) Residential substance abuse treatment services for adolescents aged 13 to 17

Residential Treatment for children ordered by DCYF; covered benefits exclude room and board except in a JCAHO-accredited facility

Children’s Intensive Services (administered by DCYF)

Comprehensive Emergency Services (administered by DCYF)

Child sexual abuse evaluations, parent/child evaluations, and DCYF-ordered emergency room evaluations prior-approved by the State, (medically necessary follow up therapy is an in-plan benefit)

DCYF ordered administratively necessary inpatient days prior-approved by the State

Intensive community-based treatment prior approved by the State (administered by DCYF)

Early Start Programs (administered by DCYF)

The following services are not covered by the Rhode Island State Medicaid Plan, but are Medicaid covered services as defined by the Social Security act. They are covered if medically necessary for RIte Care eligible children under age 21, subject to prior approval from the State and will be paid on a fee-for-service basis, and include:

• Chiropractic services

75 Page 3 of 4

ELIGIBLE GROUP

BENEFIT (S) PROVIDED OUT-OF-PLAN Women All out-of-plan benefits listed above in “All RIte Care Enrollees”

Adolescent Self-Sufficiency Collaborative Seriously and Persistently Mentally Ill (SPMI) Adults and Seriously Emotionally Disturbed (SED) Children

In accordance with Sections 2.07.03.01 and 2.07.03.02, at such time that SPMI and SED individuals are identified , these individuals will have all out-of-plan benefits listed above in “All RIte Care Enrollees” and, in addition will receive the following mental health services out-of-plan:

• Individual, group, and family therapy

• Acute psychiatric inpatient hospitalization

• Emergency room visits for psychiatric emergencies

• Day treatment

• Inpatient psychiatric facility services for individuals under age 21 or 22 if confined beyond 21st birthday

• Community psychiatric supportive treatment

76 ATTACHMENT B

Page 4 of 4

ELIGIBLE GROUP

BENEFIT (S) PROVIDED OUT-OF-PLAN Seriously and Persistently Mentally Ill (SPMI) Adults and Seriously Emotionally Disturbed (SED) Children (Continued) • Multi-disciplinary psychiatric treatment planning

• Mobile treatment team

• Crisis intervention

Seriously Emotionally Disturbed Children, in addition to receiving all above mental health benefits out-of-plan, will also receive all benefits listed in “Children” above Postpartum Women Enrolled in Extended Family Planning Only No out-of-plan benefits for this group Pregnant Women Who Do Not Meet Current Medical Assistance Citizenship or Residency Requirements, or Who Are Greater than 250 Percent of the FPL No out-of-plan benefits for this group

RHODE ISLAND TITLE XXI STATE PLAN FACT SHEET

Name of Plan:

RIte Care

Date State Plan Submitted:

January 05, 1998 Date State Plan Approved:

May 08, 1998 Date State Plan Effective:

October 01, 1997

Date Amendment 1 Submitted: November 10, 1998 Date Amendment 1 Approved: January 05, 1999 Date Amendment 1 Effective: Not yet implemented

Date Amendment 2 Submitted: June 27, 2002 Date Amendment 2 Approved: September 19, 2002

Date Amendment 3 Submitted: February 05, 2003 Date Amendment 3 Approved: April 17, 2003 Date Amendment 3 Effective:

November 01, 2002

Date Amendment 4 Submitted: August 22, 2006 Date Amendment 4 Approved: October 25, 2006 Date Amendment 4 Effective:

October 01, 2006

Date Amendment 5 Submitted: February 05, 2008 Date Amendment 5 Approved: April 30, 2008

Date Amendment 5 Effective:

July 01, 2007

Date Amendment 6 Submitted: April 16, 2009 Date Amendment 6 Approved: December 29, 2009 Date Amendment 6 Effective:

December 9, 2009

Date Amendment 7 Submitted: August 04, 2009 Date Amendment 7 Approved: October 29, 2009 Date Amendment 7 Effective:

July 01, 2009

2 Background On January 5, 1998, the Rhode Island Department of Human Services submitted a title XXI State Plan to expand its Medicaid program. Rhode Island's Medicaid expansion covers uninsured children between the ages of 8 and 19, in families with incomes up to 250 percent of the Federal Poverty Level (FPL). The State's Medicaid section 1115 waiver program, entitled "RIte Care," was amended effective May 1, 1997, to include this population. The following groups of children are eligible for enhanced matching payments under Rhode Island's title XXI program:

1) children between the ages of 8 and 15 with family incomes between 100 percent and 250 percent of FPL; 2) children between the ages of 15 and 19 with family incomes up to 250 percent of the FPL; and, 3) children between conception and birth with family incomes up to including 250 percent of the FPL. The following group of pregnant women is eligible for enhance matching payments under Rhode Island’s title XXI program: Pregnant women who are uninsured prior to enrollment, with family incomes from 185 percent up to including 250 percent of the Federal poverty level (FPL). Amendments 1. On November 10, 1998, the Rhode Island Department of Human Services submitted an amendment to expand benefits under Rhode Island's title XXI program for uninsured children up to age 19 to 300 percent of FPL. The expansion will be accomplished in two ways: (1) using section 2110 of Subtitle J of the Balanced Budget Act of 1997 to cover uninsured children up to age 8 up to 300 percent of the FPL; and (2) using income disregards to cover children aged 8 to 19 up to 300 percent of the FPL. This expansion has not been implemented. 2. Rhode Island submitted its second amendment on June 27, 2002. This amendment updated and amended the CHIP state plan to indicate the State’s compliance with the final Children’s Health Insurance Program (CHIP) regulations.

3. On February 5, 2003, Rhode Island submitted its third amendment to its title XXI state plan to add coverage for unborn children with family incomes up to and including 250 percent of the FPL and not eligible for Medicaid. Coverage is under a separate child health program and will include prenatal care and associated health services for children from conception through birth.

3 4. On August 22, 2006, Rhode Island submitted its fourth amendment to its title XXI state plan to institute a $10,000 liquid asset limit for eligibility, for children in title XXI.

5. On February 5, 2008, Rhode Island submitted its fifth amendment to its title XXI state plan to eliminate the $10,000 liquid asset limit for eligibility.

6. On April 16, 2009, Rhode Island submitted its sixth amendment to its title XXI state plan to provide for pregnancy-related services for targeted low-income pregnant women with family incomes between 185 percent of the FPL, up to including 250 percent of the FPL.

7. On August 4, 2009, Rhode Island submitted its seventh amendment to its title XXI state plan to expand eligibility to lawfully residing children up to including 250 percent of the Federal poverty level (FPL), as authorized under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA).

Children Covered Under the Program In FFY 2008, the State reported that 26,031 children were ever enrolled in CHIP. Administration The CHIP program is administered by the Rhode Island Department of Human Services. Health Care Delivery System Enrollees receive health services through RIte Care, the State's section 1115 Medicaid managed care demonstration. Under this demonstration program, the State contracts with licensed health maintenance organizations (HMOs), which participate in RIte Care to provide a comprehensive set of benefits to enrollees. Enrollees that are dependents of an employee who is employed where there is a “qualified” health plan are enrolled in RIte Share, the State’s premium assistance program. Enrollees receive health services through the employer’s health plan. Benefit Package Enrollees in CHIP Medicaid expansion receive the Medicaid benefit package. Enrollees in the CHIP separate child health program receive Secretary-approved coverage that is the same as coverage provided under Medicaid.

4 Cost Sharing All families in RIte Care and RIte Share with family incomes between 185 and 250 percent of the FPL pay a premium on a sliding scale according to family income level. The State informs families of the 5-percent limit on cost sharing. When a family reaches the 5-percent threshold, it must notify the State and the State directs the health plans to cease collection of cost-sharing amounts. Crowd-Out Strategy Children must be uninsured at the time of application to be eligible for the program. Mandatory enrollment in the RIte Share, the State’s premium assistance program, if the CHIP or Medicaid-eligible individual has access to employer sponsored insurance (ESI). Data matching with the insurers in the State is part of the crowd-out strategy. Coordination between CHIP and Medicaid The processes are identical. Outreach Activities Outreach activities include targeted mailings, distribution of materials to every school-age child in the State, coverage in the print media and professional newsletters, the Internet, piggy-back mailings with other State or local mailings, and public service announcements. A kick-off press conference has announced the beginning of each expansion in eligibility and television and radio interviews for staff were arranged. The State also has outreach activities planned for its non-English speaking populations. All printed materials that are available to the general public as well as the application have been translated into Spanish and distributed to Hispanic organizations throughout the State. Newspaper advertisements also have been placed in Hispanic newspapers and a Hispanic Outreach Subcommittee was created to provide recommendations to the Rhode Island Department of Human Services. Financial Information Total FFY 2010 CHIP Allotment – $75,435,997 FFY 2010 Enhanced Federal Matching Rate – 66.84%

Date Last Updated: January 6, 2010

_____________________________________________________________________________

Table of Contents

State/Territory Name: Rhode Island

State Plan Amendment (SPA) #: RI-13-023

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Rhode Island consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: 2-26-12 Cc M Ss

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAL a: Cite selevICES

Children and Adults Health Programs Group

APR 1 1 2014

Deborah J. Florio, Administrator

Center for Child and Family Health

Rhode Island Department of Human Services Hazard Bldg #74 1st Floor

74 West Road

Cranston, RI 02920

Dear Ms. Florio:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number RI-13-023, submitted on December 12, 2013, with additional information provided on April 4, 2014, and related Modified Adjusted Gross Income (MAGI) Eligibility, with an effective date of January 1, 2014.

In SPA number RI-13-023, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS9 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover children from conception to birth when the mother is not eligible for Medicaid. Page CS13 indicates that the state elects to cover as deemed newborns children born to mothers enrolled in the section 1115 demonstration, Rhode Island Comprehensive Demonstration. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS9 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. A copy of the approved CS13 is attached and should be incorporated within under Section 4.3 of the state’s approved CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services

7500 Security Boulevard, Mail Stop $2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Page 2 — Ms. Deborah J. Florio

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator (ARA) in our Boston Regional Office. Mr. McGreal’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 Sudbury Street, Room 2325

Boston, MA 02203

If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of

State Coverage Programs at (410) 786-5920. We look forward to continuing to work with you and your staff.

Sincerely, Eliot Fishman Director Enclosure cc:

Richard McGreal, ARA, CMS Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility RI.0585.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Rhode Island State Funds: $ Federal Funds: $ Submitted By: Jodi DiBernardo Last Revision Date: Apr 2, 2014 Submit Date: Dec 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. RI-13-023 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.10, 457.360, Sections 2110(b)(2)(B), (b), (b)(6); Section 2112; and Section 2112(e) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:33 out of 2000 CHIP MAGI Eligibility and Methods Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/29/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/29/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

coms CHIP Eligibility

OMB Control Number: 0938-1148

Separate Child Healt MAGI-Based Ing

Expiration date: 10/31/2014

CS15

2102(b)(1)(B\v) of the SSA and 42 CFR 457.315

The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31. 2013, MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later.

If the state covers pregnant women, in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. @ The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: EX] Include a prorated portion of the reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size.

I:xcept as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Household income includes actually available cash support. exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. es

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

An attachment is submitted.

PRA Disclosure Statement

SPA# RI-13-023 Approval Date: APR L L 2014 Effective Date: January 1, 2014 Page | of 2

coms CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

APR i 1 2014

SPA# RI-13-023 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CcCmMsS CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS8

Separate Eligibility

Section 2112 of the SSA

Ir Targeted Low-Income Pregnant Women - Uninsured pregnant women who do not have access to public employee coverage and whose household income is within standards established by the state.

The CHIP Agency operates this covered group in accordance with the following provisions: Age Standards for Pregnant Women The state provides coverage to pregnant women:

Select an age range:

C From age 19. up to the following age:

@ With no age restriction. C Another age range:

If there is no age restriction or if the age range overlaps with the qualifying ages for children, describe how the determination is made as to whether the applicant will be provided coverage as a child or as a pregnant woman.

If the applicant is eligible as both a child and a pregnant woman, they are covered first as a pregnant woman, if possible

[M] Must be pregnant or post-partum

Income Standards

Pregnant women coverage may only be provided if children's qualifying income standard under the plan is at least up to 200% of FPL for all age ranges.

Income standard is applied statewide

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income standard or a

. . 0 county income standard?

Statewide Income Standard

CHIP coverage for pregnant women may only be provided if the qualifying income standard under Medicaid for pregnant women is at least up to 185%.

The highest income level for pregnant women cannot be higher than the highest income level for children.

Above 190} % FPL up to and including 253 ae FPL py V5

1-6

SPA# RI-13-023 Approval Date:

Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# RI-13-023 Approval Date: APR { { 2014 Effective Date: January 1, 2014

Page 2 of 2

coms. CHIP Eligibility

OMB Control Number: 0938-1148 xpiration date: 10/31/2014

cso

Separate Child H [Eligibility - Cov

42 CFR 457.10

[mW] Coverage From Conception to Birth - Coverage from conception to birth when the mother is not eligible for Medicaid. The CHIP Agency operates this covered group in accordance with the following provisions: Age Standard

From conception through birth.

Does the state have an additional age definition or other age-related conditions? [No

Income Standards

Income standards are applied statewide. |Yes

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income standard or a No county income standard?

Statewide Income Standard

The statewide income standard is: From zero up to |253 % FPL

[m] Exempted from requirement of providing or applying for a Social Security Number.

[i Exempted from requirement of verifying citizenship status.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

SPA# RI-13-023 Approval Date: APR 1 1 2014 Effective Date: January 1, 2014 Page I of 1

coms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS13

Separate Child I IEligibility

Section 2112(c) of the SSA and 42 CFR 457.360

iw Deemed Newborns - Children born to targeted low-income pregnant women are deemed to have applied for and be eligible for CHIP or Medicaid until the child turns one.

The state operates this covered group in accordance with the following provisions: [lM] The child was born to an eligible targeted low-income pregnant woman under section 2112 of the SSA.

wl The child is deemed to have applied for and been found eligible for CHIP or Medicaid, as appropriate, as of the date of the child's birth, and remains eligible without regard to changes in circumstances until the child's first birthday.

The state elects the following option(s):

oO The state elects to cover as a deemed newborn a child born to a mother who is covered as a targeted low-income child under the state's separate CHIP on the date of the newborn's birth.

Oo The state elects to recognize a child's deemed newborn status from another state and provides benefits in accordance with the requirements of section 2112(e) of the SSA.

4 The state elects to cover as a deemed newborn a child born to a mother who is covered under Medicaid or CHIP through the authority of the state’s section 1115 demonstration on the date of the newborn’s birth.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05. Baltimore, Maryland 21244-1850.

SPA# RI-13-023 Approval Date: APR 1 L 2044

Effective Date: January 1, 2014

Page | of 1

_____________________________________________________________________________

Table of Contents

State/Territory Name: Rhode Island

State Plan Amendment (SPA) #: RI-13-024

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Rhode Island consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (CMS 7500 Security Boulevard, Mail Stop: S2-26-12 coms sacate amet naces

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 0 7 2014

Deborah J. Florio, Administrator

Center for Child and Family Health

Rhode Island Department of Human Services Hazard Bldg #74 1st Floor

74 West Road

Cranston, RI 02920 .

Dear Ms. Florio:

I am pleased to inform you that the Centers for Medicare &Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number RI-13-024, submitted on December 12, 2013, and related Modified Adjusted Gross Income (MAGI) Eligibility, with an effective date of January 1, 2014.

The SPA number RI-13-024 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator (ARA) in our Boston Regional Office. Mr. McGreal’s address is:

Page 2 — Ms. Deborah J. Florio

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 Sudbury Street, Room 2325

Boston, MA 02203

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely, Eliot Fishman Director Enclosure ce:

Richard McGreal, ARA, CMS Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility RI.0586.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Rhode Island State Funds: $ Federal Funds: $ Submitted By: Jodi DiBernardo Last Revision Date: Feb 26, 2014 Submit Date: Dec 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. RI-13-024 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:22 out of 2000 XXI Medicaid Expansion Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 06/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

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coms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

C83

Eligibility for Medic

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) * lio I 190 261 + 6 142 261 + Ilo 19 109 261

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

“e SPA# RI-13-024 Approval Date: MAR 0 7 2014 Effective Date: January 1, 2014

Page | of 1

_____________________________________________________________________________

Table of Contents

State/Territory Name: Rhode Island

State Plan Amendment (SPA) #: RI-13-0026

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Rhode Island consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMS

7500 Security Boulevard, Mail Stop: S2-26-12 Cc M Ss CENTERS FOR MEDICARE & MEDICAID SERVICES.

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 2 6 2014

Ms. Deborah J. Florio

Administrator, Center for Child and Family Health R.I. Department of Human Services

Hazard Bldg #74, 1st Floor

74 West Road

Cranston, RI 02920

Dear Ms. Florio:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved Rhode Island’s Children’s Health Insurance Program (CHIP) state plan amendment (SPA), RI-13-0026, submitted on December, 12, 2013. This SPA incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The state is using interim alternative single streamlined paper and online applications and by December 31, 2014, will implement revised alternative single streamlined paper and online applications that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following CS24 state plan pages and attachments to be incorporated within a separate section at the end of Rhode Island’s approved state plan:

CS24 Attachment 1 — Statement of use with respect to the alternative single streamlined paper application

e Attachment 2 — Statement of use with respect to the alternative single streamlined online application

This approval and the enclosures supercede the following sections-of the current CHIP State Plan:

e Section 4.3: Single Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

Page 2 — Ms. Deborah J. Florio

The CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment and other CHIP-related issues. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: $2-01-16

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator (ARA) in our Boston Regional Office. Mr. McGreal’s address is:

Mr. Richard McGreal

Office of the Regional Administrator JFK Federal Building, Suite 2325 Boston, MA 02203-0003

If you have additional questions, please contact Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143.

We look forward to continuing to work with you and your staff.

Sincerely,

Eliot Fishman Director

Enclosure

ce: Mr. Richard McGreal, Associate Regional Administrator, CMS Region I, Boston

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

CCM: SERVICES

CENTER FOR MEDICAID & CHIP SERVICES

MAR 26 2014

Ms. Deborah J. Florio

Administrator, Center for Child and Family Health R.I. Department of Human Services

Hazard Bldg #74, Ist Floor

74 West Road

Cranston, RI 02920 —

RE: CS24 — Eligibility Process State Plan Amendment (SPA), RI-13-0026

Dear Ms. Florio:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) RI-13-0026, which was submitted to CMS on December 12, 2013. Our review of this submission included a review of the alternative single

streamlined paper and online applications developed by the state.

Until December 31, 2014, the state is using interim alternative single streamlined paper and online applications. These interim applications need to be revised to reflect the following

changes.

Necessary changes:

Completion Date:

Paper Application

applicants.

The questions about disability and foster care will only be asked of | December 31, 2014

Necessary changes:

Completion Date:

and SSN) will be removed.

The detailed questions regarding an absent parent (name, address, | December 31, 2014

Page 2 — Ms. Deborah Florio

Online Application

The questions regarding citizenship and immigration status, as well | December 31, 2014 as questions regarding disabilities and foster care, will not be asked of non-applicants.

The request for Social Security Numbers will be clearly optional December 31, 2014 for non-applicant household members.

In the question about other insurance enrollment, the state will add | December 31, 2014 an option for Tricare.

Please submit the revised alternative single streamlined online application to CMS for review no later than December 1, 2014, to ensure approval by December 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167.

We look forward to continuing to work with you and your staff.

Sincerel

Linda Nablo Director, Division of State Coverage Programs

ce: Mr. Richard McGreal, ARA, CMS Region 1, Boston

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility RI.0588.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Rhode Island State Funds: $ Federal Funds: $ Submitted By: Siani Kayani Last Revision Date: Oct 14, 2014 Submit Date: Dec 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. RI-13-026 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457 subpart C; Section 2102(b)(3); Section 2107(e)(1)(O) of the Social Security Act Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:24 out of 2000 CHIP Eligibility Process Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

C1] Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

RI-13-0026 Rhode Island

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

ElPaper Application OOnline Application TRANSMITTAL NUMBER: STATE: RI-13-0026 Rhode Island

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference

into the state plan.

CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

|

Application Processing

Indicate which application the agency uses for individuals apply ing for coverage who may be eligible based on the applicable modified adjusted gross income standard:

Oo The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

Ba An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the [7] agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means. , (C) Other electronic means: Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low-

income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and

f=

ry Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

5-2 _anat SPA# RI-13-0026 Approval Date: MAK 4 0 2014 Effective Date: October 1, 2013 Page 1 of 2

CHIP Eligibility

rr Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single streamlined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced

premium tax credits in accordance with section 1943(b)(2) of the SSA. Yes

Redetermination Processing

Redeterm inations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[MH] Once every 12 months.

im Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency.

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional [Mi] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42

CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42

CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for

CHIP.

Check all types of agencies that apply:

(] The Exchange

KK] Medicaid

[7] Other agency administering insurance affordability programs

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# RI-13-0026 Approval Date: MAR 2 6 2014 Effective Date: October 1, 2013

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Rhode Island

State Plan Amendment (SPA) #: RI-13-027

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Rhode Island consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services (CMS 7500 Security Boulevard, Mail Stop: $2-26-12 Ptwreetientiben evaliinmall

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 05 2014

Deborah J. Florio

Administrator

Center for Child and Family Health

Rhode Island Department of Human Services Hazard Bldg #74 1st Floor

74 West Road

Cranston, RI 02920 .

Dear Ms. Florio:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number RI-13-027, submitted on December 12, 2013, and related Modified Adjusted Gross Income (MAGI) Eligibility, with an effective date of January 1, 2014.

Non-Financial Eligibility:

The SPA number RI-13-027 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, and non-payment of premiums. Copies of the approved state plan pages are attached and these approved pages supersede sections of Rhode Island’s current state plan as detailed below:

New State Plan Page Impact on Current State Plan Section CS17: Non-Financial Eligibility — Residency Section 4.1.5 CS18: Non-Financial Eligibility — Citizenship Section 4.1.0; 4.1-LR; 4.1.1-LR CS19: Non-Financial Eligibility — Social Security Number | Section 4.1.9.1 C820: Non-Financial Eligibility — Substitution of Section 4.4.4 Coverage C821: Non-Financial Eligibility - Non-Payment of Section 8.7 Premiums

Your title XX] project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop $2-01-16 Baltimore, MD 21244-1850

Page 2 — Ms. Deborah J. Florio

Telephone: (410) 786-3246 Facsimile: (410) 786-5882 E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator in our Boston Regional Office. Mr. McGreal’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 Sudbury Street, Room 2325

Boston, MA 02203

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely, Eliot Fishman Director Enclosures ce:

Richard McGreal, ARA, CMS Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility RI.0589.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Rhode Island State Funds: $ Federal Funds: $ Submitted By: Jodi DiBernardo Last Revision Date: Feb 26, 2014 Submit Date: Dec 12, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. RI-13-027 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.310(b)(2) and (3), 457.320(a)(9), 457.320, 457.320(b)(6), 457.320(c), 457.320(d), 45 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:30 out of 2000 CHIP Non-Financial Eligibility Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/07/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/07/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS17

Separate C Non-Financial Eligibili

42 CFR 457.320

Residency

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. :

A child is considered to be a resident of the state under the following conditions:

ry A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

|. Intends to reside in the state, including without a fixed address, or 2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [mA non-institutionalized child not described above and a child who is not a ward of the state:

|. Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides.

im An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[ml] A child who is a ward of the state regardless of where the child lives, or

ri A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [fm] A non-institutionalized pregnant woman who is living in the state and: |. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

iw An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

i An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

= A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA# RI-13-027 Approval Date: MAR 05 2014

Effective Date: January 1, 2014 Page | of 2

CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions'for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltithore, Maryland 21244-1850.

MAR 05 2014

SPA# RI-13-027 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

ccMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS18

Separate Child Healt! Non-Financial

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory imynigration status.

[@] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation

Act (PRWORA) (8 U.S.C. $1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the No verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date . we : aren Yes earlier than the date the notice is received by the individual.

The date benefits are furnished is: C The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

@ Other date, as described:

Once a person has been determined eligible, coverage is effective back to the first of the month of which they applied.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing

in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). Yes

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing a mi x also covered under the state's Medicaid program.

SPA# RI-13-027 Approval Date: Effective Date: January 1, 2014

Page | of 3

CHIP Eligibility

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

No

i An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

[B] An individual is considered to be lawfully present in the United States if he or she is:

|. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws

(as defined in 8 U.S.C. 1101(a)(17));

3. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than I year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted temporary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)(): 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

MAR 05 2014

SPA# RI-13-027 Approval Date: Effective Date: January 1, 2014

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CHIP Eligibility

CTE FEM AME AT AED UNE T

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

MAR 05 2014

SPA# RI-13-027 Approval Date: Effective Date: January 1, 2014

Page 3 of 3

ccms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS19

Separate Child Heal Non-Financial Eligil

42 CFR 457.340(b)

Social Security Number As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as

determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

tm The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[mM] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the

Pa individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their Ves SSN.

When requesting an SSN for non-applicant household members, the state assures that:

cH At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

i The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

MAR 05 2014

SPA# RI-13-027 Approval Date: Effective Date: January 1, 2014

Page | of 2

cms. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# RI-13-027 Approval bate__ MAR 0 3 2044

Effective Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

820

Separate Child Health In Non-Financial Eligibi

457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

erage

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[lm] Substitution of coverage prevention strategy:

Name of policy Description _. |Health Source RI RI employs a unified eligibility system that determines + whether a person qualifies for publicly funded xX

coverage or commercial health insurance.

Rite Share This is a premium assistance program that enables low-income people afford health insurance through their employer rather than enrolling in publicly funded |, + coverage. Rite Share accomplishes this by paying for x

some or all of the employee's cost. Participation in : Rite Share is mandatory: a person must take employee-sponsored coverage if Medicaid determines it more cost-effective than public coverage.

A waiting period during which an individual is ineligible due to having dropped group health coverage. No

If the state covers pregnant women, the waiting period does not apply to pregnant women.

If the state elects to offer dental only supplemental coverage, the following assurances apply:

Oo The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

[J The waiting period does not apply to children eligible for dental only supplemental coverage.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130718

MAR 05 2014

SPA# RI-13-027 Approval Date: Effective Date: January 1, 2014

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ccMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Separate Child Healt cal Non-Financial Eli

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? No

. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

SPA# RI-13-027 Approval Date: MAR 05 2014

Effective Date: January 1, 2014

Page | of |

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 @ Mi & Baltimore, MD 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

AUG 09 2019

Patrick Tigue

Medicaid Director

Executive Office of Health and Human Services 74 West Road, 1° Floor

Hazard Building

Cranston, RI 02920

Dear Mr. Tigue:

I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA), RI-19-0004, has been approved. RI-19-0004 demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L for utilization of a managed care delivery system. This SPA has an effective date of July 1, 2018 with the exception of the changes described below.

Sections 2101(a), 2103(f)(3), 2107(b), and 2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. Rhode Island has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state's separate child health plan as of the effective date of the SPA, except that the state came into compliance with the requirements to develop consistent terminology, model enrollee handbooks, and model enrollee notices described in section 3.5.4 of the state plan and 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4) on July 1, 2019. In addition, the state will come into compliance with provider screening and enrollment described in section 3.10.7 of the state plan and 42 CFR 457.1285 by January 1, 2020.

This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state's CHIP populations. All managed care contracts for CHIP populations in effect as of the state fiscal year beginning on or after July 1, 2018 must comply with the CHIP managed care regulations and be submitted for CMS review.

Your title XXI project officer is Ms. Mary Hines. She is available to answer questions concerning this amendment and other CHIP-related issues. Her contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-0435

E-mail: Mary.Hines@cms.hhs.gov

Page 2 — Mr. Patrick Tigue

Official communications regarding program matters should be sent simultaneously to Ms. Hines and to Mr. Francis McCullough, Director of the Division of Medicaid Field Operations East. Mr. McCollough’s address is:

Centers for Medicare & Medicaid Services Division of Medicaid Field Operations East JFK Federal Building

15 New Sudbury St, Room 2325

Boston, MA 02203-0003

If you have additional questions, please contact Ms. Amy Lutzky, Director, Division of State

Coverage Programs at (410) 786-0721. We look forward to continuing to work with you and your staff.

Sincerely, SN

/signed Anne Marie Costello/

Anne Marie Costello Director

ce: Mr. Francis McCullough, Director, Division of Medicaid Field Operations East

SECTION 1. GENERAL DESCRIPTION AND PURPOSE OF THE STATE CHILD HEALTH PLANS AND STATE CHILD HEALTH PLAN REQUIREMENTS (SECTION 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box)

(42 CFR 457.70):

1.1.1

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3. A combination of both of the above.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date: October 1, 1997, although the effective date for the Section 1115 waiver was January 18, 2001.

Effective date for Amendment #1 expansion of eligibility up to 300 percent FPL is January 5, 1999.

Effective/Approval date for Amendment #2, Rhode Island’s compliance SPA is September 19, 2002.

Effective date for Amendment #3, Rhode Island’s separate child health program is November 1, 2002.

Effective date for Amendment #4, adding a $10,000 liquid asset limit for

eligibility, is October 1, 2006.

Effective date for Amendment #5, removing a $10,000 liquid asset limit for eligibility is July 1, 2007.

Effective date for Amendment #7, to an eligibility group of children who are otherwise eligible aliens lawfully residing in the United States as authorized by section 214 of the Children’s Health Insurance Reauthorization Act of 2009 is July 1, 2009.

Effective date for Amendment #8, to eliminate CHIP premiums, is 1 July 2014.

Implementation date: October 1, 1997, although the various components of the program, including applicable amendment provisions, have been implemented since then.

Implementation date: Amendment #1 was not implemented.

Implementation date for Amendment #2, compliance SPA was per CMS regulation.

Implementation date for Amendment #3, Rhode Island’s separate child health program is November 1, 2002.

Implementation date for Amendment #4, adding a $10,000 liquid asset limit for eligibility is October 1, 2006. However, this amendment was not implemented.

Implementation date for Amendment #5, removing a $10,000 liquid asset limit for eligibility is July 1, 2007.

Implementation date for Amendment #7, to an eligibility group of children who are otherwise eligible aliens lawfully residing in the United States as authorized by section 214 of the Children’s Health Insurance Reauthorization Act of 2009 is July 1, 2009.

Implementation date for Amendment #8, to eliminate CHIP premiums, is 1 July 2014.

Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) RI-13-023

Effective/Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS15

CS8

CS9

CS13 MAGI-Based Income Methodologies

Eligibility – Targeted Low Income Pregnant Women

Eligibility – Coverage from Conception to Birth

Eligibility – Deemed Newborns Incorporate within a separate subsection under section 4.3

Supersedes the current sections Geographic Area 4.1.1-P; Age 4.1.2-P; and Income 4.1.3-P

Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3

Supersedes the current section 4.1.9-P regarding deeming and incorporate within a separate subsection under section 4.3 RI-13-024

Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 RI-13-025

Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 RI-13-026

Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4 RI-13-027

Effective/Implementation Date: January 1, 2014 Non- Financial Eligibility CS17

CS18

CS19

CS20 Non-Financial Eligibility – Residency

Non-Financial Eligibility – Citizenship

Non-Financial Eligibility – Social Supersedes the current section 4.1.5

Supersedes the current sections 4.1.0; 4.1.1- LR; 4.1.1-LR

Supersedes the current section 4.1.9.1

Transmittal Number SPA Group PDF # Description Superseded Plan Section(s)

CS21 Security Number

Non-Financial Eligibility – Substitution of Coverage

Non-Financial Eligibility – Non- Payment of Premiums

Supersedes the current section 4.4.4

Supersedes the current section 8.7 RI – 18-005

Effective/Implementation Date: October 2, 2017

MHPAEA Compliance

Document compliance with the MHPAEA of 2008 Supersedes the current section 6

Supersedes the current section 8 RI – 19-004

Effective/Implementation Date: July 1, 2018

Approval Date: Managed Care Final Rule Compliance

Document compliance with the Medicaid and CHIP Managed Care Final Rule Supersedes the current section 3

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4 (Eligibility Standards and Methodology).

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee- for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

care delivery system below in Section 3.1.2. Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

Neonatal Intensive Care Unit (NICU) Services are provided in Fee-For Service, as are Special Education services as defined in a child’s Individual Education Plan (IEP) and Lead Program Home Assessment and Non-Medical Case Management provided by the Department of Health or Lead Centers for lead poisoned children. If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment

Describe population served: Children and families under 136% Federal Poverty Level (FPL), children under nineteen (19) years of age under 250% FPL, pregnant women under 250% FPL, Extended Family Planning population, Children with Special Health Care Needs, children in Foster Care, and Former Foster Care youth.

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

Describe population served: Dental services for Medicaid and CHIP eligible children and young adults born after May 1, 2000.

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). • The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). • The provision against provider discrimination in 42 CFR 457.1208. • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. • The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

The Medical MCO is required to pay remittances, the Dental PAHP is not required to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. The Dental PAHP is not required to pay remittances, however this will be included as a requirement in the contract amendment effective July 1, 2019. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

remittance, taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)) 3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider-beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008)

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include 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 or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)):

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter; • If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)) 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(1))

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

3.5.3 X]

3.5.4]

3.5.5 K]

3.5.6 KX]

State: Rhode Island

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites.

The State assures that it has developed and requires each MCO, PIHP,. PAHP and PCCM entity to use:

e Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207.

cross-referencing to 42 CFR 438.10(c)(4)) @ The State will come into compliance with this provision by July 1, 2019. +——{ Formatted: Indent: Left: 1.75", No bullets or numbering _)

If the State, MCOs, PIHPs. PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that:

© The format is readily accessible;

e The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible;

e The information is provided in an electronic form which can be electronically retained and printed:

e The information is consistent with the content and language requirements in 42 CFR 438.10; and

e The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days.

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to:

e Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area;

e Making oral interpretation available in all languages and written translation available in each prevalent non-English language:

e Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non- English languages in its particular service area:

e Making interpretation services available to each potential enrollee and

Approval Date. Effective Date January 1, 2019

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: • Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care; • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program; • The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; • The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that: • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items: • Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

the State about how to access these services; • The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled; • Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; • Any restrictions on the enrollee's freedom of choice among network providers; • The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of-network providers; • Cost sharing, if any is imposed under the State plan; • Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; • The process of selecting and changing the enrollee's primary care provider; • Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State-approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; • How to access auxiliary aids and services, including additional information in alternative formats or languages; • The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and • Information on how to report suspected fraud or abuse.

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(4)) 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross- referencing to 42 CFR 438.10(i), including: • Which medications are covered (both generic and name brand); and • What tier each medication is on. 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross- referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18).

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260) 3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.3

The State assures that it: • Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; • Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross- referencing 42 CFR 438.68(e))

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20. 3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: • A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities; • Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and • Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: • Requiring the contract to adequately and timely cover out-of-network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; • Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services; • Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees; • Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary; • Establishing mechanisms to ensure compliance by network providers; • Monitoring network providers regularly to determine compliance; • Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207) 3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area: • Offers an appropriate range of preventative, primary care and specialty services; and • Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross-referencing to 42 CFR 438.207(b)) 3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: • Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and • Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts) 3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: • The MCO, PIHP, or PAHP and its subcontractors have in place and

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

follow written policies and procedures; • The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and • Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts) 3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c)) 3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e)) 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62) 3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including: • Ensure that each enrollee has an ongoing source of care appropriate to his or her needs; • Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee; • Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services; • Coordinate the services the MCO, PIHP, or PAHP furnishes to the

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers; • Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees; • Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs; • Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and • Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(b)) Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care services, whether a particular PIHP or PAHP is required to implement the mechanisms for identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(a)(2)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. 3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(2)) 3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs: • Is in accordance with applicable State quality assurance and utilization review standards;

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

• Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3)) 3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)) 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross- referencing 42 CFR 438.12 and 438.214, including that: Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(a)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that: The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3). 3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d))

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e)) 3.8 Beneficiary Protections 3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)) 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following: • The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a)) • Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross-

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

referencing to 42 CFR 438.106(b)) • Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(c)) 3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits. 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)) 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)) 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)) 3.9.4. Does the state offer and arrange for an external medical review? Yes No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5). 3.9.5

The State assures that the external medical review is: • At the enrollee's option and not required before or used as a deterrent to proceeding to the State review; • Independent of both the State and MCO, PIHP, or PAHP; • Offered without any cost to the enrollee; and • Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i))

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)) 3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. 3.9.10

The State assures that the notice of an adverse benefit determination explains: • The adverse benefit determination. • The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review. • The procedures for exercising the rights specified above under this assurance. • The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b)) 3.9.11

The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)) 3.9.12

The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease: • An appeal of a denial that is based on lack of medical necessity. • A grievance regarding denial of expedited resolution of an appeal. • A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination. Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals. The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)) 3.9.14

The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b)) 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)) 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross- referencing to 42 CFR 438.410(c)(1)) 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following: • Make reasonable efforts to give the enrollee prompt oral notice of the delay. • Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision. • Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c)) 3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3)) 3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1))

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items: • The results of the resolution process and the date it was completed; and • For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so. o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)) 3.9.23

The State assures that if it offers an external medical review: • The review is at the enrollee's option and is not required before or used as a deterrent to proceeding to the State review; • The review is independent of both the State and MCO, PIHP, or PAHP; and • The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)) 3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)) 3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes: • The right to file grievances and appeals; • The requirements and timeframes for filing a grievance or appeal; • The availability of assistance in the filing process; • The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and • The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414) 3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a)) 3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10. Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including:

Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards;

Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and

Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate,

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58) 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: • A compliance program that include all of the elements described in 42 CFR 438.608(a)(1); • Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State; • Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility; • Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP; • Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis; • In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers; • Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and • Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)) 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)) 3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b)) The State will come into compliance with this provision by January 1, 2020. 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f)) 3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act) 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a))

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)) 3.10.15

The State assures that services are provided in an effective and efficient manner. (Section 2101(a)) 3.10.16

The State assures that it operates a Web site that provides: • The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services; • Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and • The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)). 3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).

Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4). 3.11.4 Does the State establish intermediate sanctions for PCCMs or PCCM entities? Yes No

Guidance: Only states with MCOs and states that answered yes to assurance 3.11.4 need to complete the next three assurances (3.11.5 through 3.11.7). 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a)) 3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub-sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250. 3.12.1 Quality Strategy Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1. 3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items: • The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical practice guidelines the State requires in accordance with 42 CFR 438.236; • A description of: o The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP; • Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract; • A description of the State's transition of care policy required under 42 CFR 438.62(b)(3); • The State's plan to identify, evaluate, and reduce, to the extent

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

practicable, health disparities based on age, race, ethnicity, sex, and primary language; • For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438; • A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity; • The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs); • Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation activity is comparable to such EQR-related activities; • Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and • The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)) 3.12.1.2

The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3

The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)) 3.12.1.4

The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)) 3.12.1.5

The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6

The State assures that it will submit to CMS: • A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and • A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)) 3.12.1.7

Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it will: • Make the strategy available for public comment; and • If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)) 3.12.1.8

The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)) 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least: • Standard performance measures specified by the State;

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

• Any measures and programs required by CMS (42 CFR 438.330(a)(2); • Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d); • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c); • Mechanisms to detect both underutilization and overutilization of services; and • Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1))

Guidance: A State may request an exemption from including the performance measures or performance improvement programs established by CMS under 42 CFR 438.330(a)(2), by submitting a written request to CMS explaining the basis for such request. 3.12.2.1.2 The State assures that each MCO, PIHP, and PAHP’s performance improvement projects are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction. The performance improvement projects include at least the following elements: • Measurement of performance using objective quality indicators; • Implementation of interventions to achieve improvement in the access to and quality of care; • Evaluation of the effectiveness of the interventions based on the performance measures specified in 42 CFR 438.330(d)(2)(i); and • Planning and initiation of activities for increasing or sustaining improvement. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(2)) Guidance: Only states with a PCCM entity whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes need to, complete the next assurance (3.12.2.1.3).

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.12.2.1.3 The State assures that it requires that each PCCM entity establishes and implements an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The assessment and program must include: • Standard performance measures specified by the State; • Mechanisms to detect both underutilization and overutilization of services; and • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c). (42 CFR 457.1240(a) and (b), cross referencing to 42 CFR 438.330(b)(3) and (c)) 3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.2.2. 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)) 3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

• The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) 3.12.3 Accreditation Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.3. 3.12.3.1

The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)). 3.12.3.2

The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c)) 3.12.4 Quality Rating Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4.

The State assures that it will implement and operate a quality rating system that issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d)) Guidance: States will be required to comply with this assurance within 3 years after CMS, in consultation with States and other Stakeholders and after providing public notice and opportunity for comment, has identified performance measures and a

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

methodology for a Medicaid and CHIP managed care quality rating system in the Federal Register. 3.12.5 Quality Review Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1.

The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR) for each contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a)) 3.12.5.1 External Quality Review Organization 3.12.5.1.1 The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)) 3.12.5.1.2 The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)) 3.12.5.2 External Quality Review-Related Activities Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next three assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a), the State, or its agent or EQRO, must conduct the EQR-related activity under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP, or PAHP’s network adequacy during the preceding 12 months; however, the State may permit its contracted MCO, PIHP, and PAHPs to use information from a private accreditation review in lieu of any or all the EQR-related activities under 42 CFR 438.358(b)(1)(i) through (iii) (relating to the validation of performance improvement projects, validation of performance measures, and compliance review).

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.12.5.2.1 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects, validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1))

3.12.5.2.2 The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340) 3.12.5.2.3 The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an MCO, PIHP, or PAHP will be furnished to the EQRO for analysis and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b)) Guidance: Only states with PCCM entities need to complete the next assurance (3.12.5.2.4). 3.12.5.2.4 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR 438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM entities, which include: • Validation of PCCM entity performance measures required in accordance with 42 CFR 438.330(b)(2) or PCCM entity performance measures calculated by the State during the preceding 12 months; and • A review, conducted within the previous 3-year period, to determine the PCCM entity’s compliance with the standards set forth in subpart D of 42 CFR part 438 and the quality assessment and performance improvement requirements described in 42 CFR 438.330. (42 CFR 457.1250(a), cross

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

referencing to 438.358(b)(2))

3.12.5.3 External Quality Review Report Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5.3. 3.12.5.3.1 The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2))

3.12.5.3.2 The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met: • The EQRO has sufficient information to use in performing the review; • The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358 and, if applicable, from a private accreditation review as described in 42 CFR 438.360; • For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the elements described in 42 CFR 438.364(a)(2)(i) through (iv); and • The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b) through (e)) 3.12.5.3.4 The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

access and quality of care. The report includes at least the following items: • A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2)); • For each EQR-related activity (mandatory or optional) conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data; • An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support improvement in the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and • An assessment of the degree to which each MCO, PIHP, PAHP, or PCCM entity has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(f) and 438.364(a)) 3.12.5.3.5 The State assures that it does not substantively revise the content of the final EQR technical report without evidence of error or omission. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(b))

STATE PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

State: Rhode Island

TN # 19-004 Approval Date_____________ Effective Date January 1, 2019

3.12.5.3.6 The State assures that it finalizes the annual EQR technical report by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(1)) 3.12.5.3.7 The State assures that it posts the most recent copy of the annual EQR technical report on the Web site required under 42 CFR 438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(i)) 3.12.5.3.8 The State assures that it provides printed or electronic copies of the information specified in 42 CFR 438.364(a) for the annual EQR technical report, upon request, to interested parties such as participating health care providers, enrollees and potential enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary advocacy groups, and members of the general public. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii)) 3.12.5.3.9 The State assures that it makes the information specified in 42 CFR 438.364(a) for the annual EQR technical report available in alternative formats for persons with disabilities, when requested. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3)) 3.12.5.3.10 The State assures that information released under 42 CFR 438.364 for the annual EQR technical report does not disclose the identity or other protected health information of any patient. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(d))

In 1999, the Rhode Island Department of Human Services (DHS) and the Narragansett Native American Tribe (Tribe) signed a formal consultation agreement to encourage the free exchange of information to improve collaboration between the State and the Tribe with regard to health services. The State has sought comments from the Tribe on its Section 1115 waiver (and amendments) and SCHIP plans through a SCHIP planning committee and continues to encourage participation from the Tribe in Rite Care's ongoing Consumer Advisory Committee. DHS has also developed an ongoing partnership to: • Streamline the payment claims system for Rite Care members • Facilitate meeting meetings between NHPRl and the Indian Health Center to allow the center to participate in NHPRI’s provider network • Exempt Native Americans from cost-sharing 9.9.1 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 457.65(b) through (d). Coverage of eligible children under 19 as provided for in Section 214 of the Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA) who are otherwise eligible aliens lawfully residing in the United States was authorized by the Rhode Island General Assemble in approving the 2010 State Budget, thus the public was informed through the State’s customary legislative process. 9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: • Planned use of funds, including - • Projected amount to be spent on health services; • Projected amount to be spent on administrative costs, such as outreach, • child health initiatives, and evaluation; and • Assumptions on which the budget is based, including cost per child and expected enrollment.

Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. Cost-sharing payments have been accounted for and the Net Benefit Costs are net of cost-sharing. ® The State estimates that 2,700 iegai permanent resident children at an estimated cost of $223.82 per member per month in FFY 2009 and $226.12 in FFY 2010; this includes payments

CHIP Budget STATE: FFY Budget Federal Fiscal Year 2019 State’s enhanced FMAP rate 89.80% Benefit Costs Insurance payments $0

Managed care including allocation of FQHC Wrap Payments & Risk Share to CHIP

$92.148.924

per member/per month rate

Fee for Service $7,087.194 Total Benefit Costs $99,236,118 (Offsetting beneficiary cost sharing ayments $0 Net Benefit Costs $99,236,118 Cost of Proposed SPA Changes — Benefit Administration Costs Personnel $8.171 General administration 0 Contractors/Brokers $407.150 Claims Processing 0 Outreach/marketing costs i) Health Services Initiatives $2,970,405 Other Q Total Administration Costs 3.385.726

10% Administrative Cap

$10,220,652

Cost of Proposed SPA Changes

$415,322

Federal Share

$92,154,416

State Share $10.467.428 Total Costs of Approved CHIP Plan $102.621.844

+——| Formatted Table

+——| Formatted: Centered

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Rhode Island RI-20-0009

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

September 2, 2020

Ben Shaffer Medicaid Director Executive Office, Health and Human Services 3 West Road, Virks Building Cranston, RI 02920

Dear Mr. Shaffer:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number RI-20-0009, has been approved. Through this SPA, Rhode Island has demonstrated compliance with section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. This SPA has an effective date of October 1, 2019.

Section 5022 of the SUPPORT Act added Section 2103(c)(5) to the Social Security Act (the Act) and requires child health and pregnancy related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. Additionally, Section 2103(c)(5)(B) of the Act requires that these behavioral health services be delivered in a culturally and linguistically appropriate manner. Rhode Island demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner.

Your Project Officer is Tess Hines. She is available to answer your questions concerning this amendment and other CHIP-related matters. Ms. Hines’ contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-0435 E-mail: mary.hines@cms.hhs.gov

Page 2- Mr. Ben Shaffer

If you have additional questions, please contact Meg Barry, Acting Division Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Amy Lutzky Acting Deputy Director /Signed by Amy Lutzky/

1

OMB #: 0938-0707

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Form CMS-R-211

2

3 APPLICATION FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:______________Rhode Island________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b))

______________________________________________________________________ __ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Deborah J. Florio, Program Administration

Position/Title: Administrator, Center for Child and Family Health

Rhode Island Executive Office of Health and Human Services

Name: Lawrence Ross, Financial Oversight

Position/Title: Assistant Director of Financial and Contract Management

Rhode Island Executive Office of Health and Human Services

4 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

5 SECTION 1. GENERAL DESCRIPTION AND PURPOSE OF THE STATE CHILD HEALTH PLANS AND STATE CHILD HEALTH PLAN REQUIREMENTS (SECTION 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box)

(42 CFR 457.70):

1.1.1

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3. A combination of both of the above.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4

Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date: October 1, 1997, although the effective date for the Section 1115 waiver was January 18, 2001.

Effective date for Amendment #1 expansion of eligibility up to 300 percent FPL is January 5, 1999.

Effective/Approval date for Amendment #2, Rhode Island’s compliance SPA is September 19, 2002.

Effective date for Amendment #3, Rhode Island’s separate child health program is November 1, 2002.

6

Effective date for Amendment #4, adding a $10,000 liquid asset limit for eligibility, is October 1, 2006.

Effective date for Amendment #5, removing a $10,000 liquid asset limit for eligibility is July 1, 2007.

Effective date for Amendment #7, to an eligibility group of children who are otherwise eligible aliens lawfully residing in the United States as authorized by section 214 of the Children’s Health Insurance Reauthorization Act of 2009 is July 1, 2009.

Effective date for Amendment #8, to eliminate CHIP premiums, is 1 July 2014.

Effective date for RI-20-002, to extend renewals for emergencies, is March 16, 2020

Effective date for RI-20-002, to temporarily delay acting on certain changes in circumstances affecting CHIP eligibility for CHIP beneficiaries who reside and/or work in a State or Federally declared disaster area, is March 16, 2020.

Effective date for RI-20-002, to provide for an extension of the reasonable opportunity period for non-citizens declaring to be in a satisfactory immigration status, is March 16, 2020.

Implementation date: October 1, 1997, although the various components of the program, including applicable amendment provisions, have been implemented since then.

Implementation date: Amendment #1 was not implemented.

Implementation date for Amendment #2, compliance SPA was per CMS regulation.

Implementation date for Amendment #3, Rhode Island’s separate child health program is November 1, 2002.

Implementation date for Amendment #4, adding a $10,000 liquid asset limit for eligibility is October 1, 2006. However, this amendment was not implemented.

7 Implementation date for Amendment #5, removing a $10,000 liquid asset limit for eligibility is July 1, 2007.

Implementation date for Amendment #7, to an eligibility group of children who are otherwise eligible aliens lawfully residing in the United States as authorized by section 214 of the Children’s Health Insurance Reauthorization Act of 2009 is July 1, 2009.

Implementation date for Amendment #8, to eliminate CHIP premiums, is 1 July 2014.

Implementation date for RI-20-002, to extend renewals for emergencies, is for up to the duration of the emergency, or at state discretion, a shorter period of time.

Implementation date for RI-20-002, to temporarily delay acting on certain changes in circumstances affecting CHIP eligibility for CHIP beneficiaries who reside and/or work in a State or Federally declared disaster area, is for up to the duration of the emergency, or at state discretion, a shorter period of time.

Implementation date for RI-20-002, to provide for an extension of the reasonable opportunity period for non-citizens declaring to be in a satisfactory immigration status, is for up to the duration of the emergency, or at state discretion, a shorter period of time.

Implementation date for RI-20-0009, updating to be compliant with the SUPPORT ACT, is October 1, 2019.

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

RI-20-0002: To address the COVID19 public health emergency, the state seeks a waiver under section 1135 of the Act to modify the tribal consultation process by shortening the number of days before submission of the SPA and/or conducting consultation after submission of the SPA.”

RI-20-0009 Tribal Notice May 26,2020

8 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) RI-13-023

Effective/Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS15

CS8

CS9

CS13 MAGI-Based Income Methodologies

Eligibility – Targeted Low Income Pregnant Women

Eligibility – Coverage from Conception to Birth

Eligibility – Deemed Newborns Incorporate within a separate subsection under section 4.3

Supersedes the current sections Geographic Area 4.1.1-P; Age 4.1.2-P; and Income 4.1.3-P

Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3

Supersedes the current section 4.1.9-P regarding deeming and incorporate within a separate subsection under section 4.3 RI-13-024

Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 RI-13-025

Effective/Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 RI-13-026

Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4 RI-13-027

Effective/Implementation Date: January 1, 2014 Non- Financial Eligibility CS17

CS18

CS19 Non-Financial Eligibility – Residency

Non-Financial Eligibility – Citizenship Supersedes the current section 4.1.5

Supersedes the current sections 4.1.0; 4.1.1- LR; 4.1.1-LR

9 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s)

CS20

CS21

Non-Financial Eligibility – Social Security Number

Non-Financial Eligibility – Substitution of Coverage

Non-Financial Eligibility – Non- Payment of Premiums

Supersedes the current section 4.1.9.1

Supersedes the current section 4.4.4

Supersedes the current section 8.7 RI – 18-005

Effective/Implementation Date: October 2, 2017

MHPAEA Compliance

Document compliance with the MHPAEA of 2008 Supersedes the current section 6

Supersedes the current section 8 RI – 19-004

Effective/Implementation Date: July 1, 2018

Approval Date: Managed Care Final Rule Compliance

Document compliance with the Medicaid and CHIP Managed Care Final Rule Supersedes the current section 3 RI-20-0009 SUPPORT ACT

10 SECTION 2. GENERAL BACKGROUND AND DESCRIPTION OF STATE APPROACH TO CHILD HEALTH COVERAGE AND COORDINATION (SECTION 2102 (A)(1)-(3)) AND (SECTION 2105)(C)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public- private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

In November of 1993, the State of Rhode Island was granted a Section 1115 Waiver (11-W-00004/1) to develop and implement a mandatory Medicaid managed care demonstration program called RIte Care. RIte Care, implemented in August 1994, has the following general goals:

• To assure care as well as coverage to all eligible Medicaid families and children, all eligible pregnant women and all eligible uninsured children

• To control the rate of growth in the Medicaid budget for the eligible population

RIte Care was designed for the following groups to be enrolled in licensed health maintenance organizations (HMOs, or Health Plans):

• Family Independence Program (FIP)1 families

• Pregnant women up to 250 percent of the Federal poverty level (FPL)

• Children up to age 6 in households with incomes up to 250 percent of the FPL who are uninsured

RIte Care has been expanded five times, with Federal approval, as follows:

• Effective March 1, 1996, to expand to children up to age 8 in households with incomes up to 250 percent of the FPL who are uninsured

• Effective May 1, 1997, to expand to children up to age 18 in households with incomes up to 250 percent of the FPL who are uninsured

1Originally Aid to Families with Dependent Children (AFDC)

11 • Effective November 1, 1998, to expand to families with children under age 18 including parents with incomes up to 185 to FPL (expansion under Section 1931)

• Effective July 1, 1999, to expand to children up to age 19 in households with incomes up to 250 percent of the FPL

• Effective December 1, 2000, to maximize children in foster care placements from fee for service Medicaid to RIte Care

The May 1997 and July 1, 1999 expansions, because they were implemented after March 15, 1997, qualify as eligible Medicaid expansions under Title XXI of the Social Security Act. By Section 1115 waiver approval, effective January 18, 2001, Section 1931 parents and relative caretakers and pregnant women between 185 and 250 percent of the FPL were covered under Title XXI. On December 20, 2002, the State submitted a draft amendment to provide prenatal care to unborn children, if other applicable State eligibility requirements are met, as a separate child health program. Thus, everywhere else in this State Child Health Insurance Program (SCHIP) Plan (Plan) where a separate child health program is referenced, it is only for this population. Otherwise, all other aspects of the State’s approved Plan are a Medicaid expansion. It should be noted that the State received approval on January 5, 1999 to expand to children under age 19 in households with income up to 300% of the FPL. The State has not yet implemented the approved amendment and has no immediate plans to do so due to budgetary constraints.

In addition to these covered populations, the RIte Care Health Plans must make coverage available to certain State funded or "buy-in" groups who pay 100 percent of the applicable premium; the first group’s premiums are supplemented by State-only funds:

• Pregnant women who are uninsured whose household income is between 250 and 350 percent of the FPL

• Children who are uninsured whose household income is in excess of 250 percent of the FPL

• Licensed family child-care providers and their children under age 18

RIte Care has proved to be extremely successful as the following information indicates:

• Member Choice of Health Plan

12  Enrolled approximately 118,000 members into one of three Health Plans

 Ninety-three percent of enrollees chose their own Health Plan in the first year

 Only 4 percent changed Health Plans when given the opportunity to do so during the first open enrollment period; only 1 percent during the second open enrollment period; and only 3 percent during the third open enrollment period. Plans changes have remained low.

• Covered Uninsured Families

 Made comprehensive health coverage available to previously uninsured children up to age 19, up to 250 percent of the Federal poverty level and previously uninsured pregnant/postpartum women

 Made coverage available to parents and adult caretakers up to 185 percent of the FPL

• Improved Access to Primary Care

 Increased primary care physician participation from 350 to over 900 physicians

 Increased average per enrollee physician visits from two per year pre-RIte Care (1993) to five per year in RIte Care

 Decreased emergency room visits and hospital utilization each by more than one-third from 1993 to RIte Care

• Positive Impact on Maternal Health

 Increased the number of women on Medicaid waiting at least 18 months between births from 60 percent pre-RIte Care (1993-94) to 79 percent in 1999 completely closing the gap between Medicaid and commercially-insured women

 The percentage of pregnant women on Medicaid who smoked during pregnancy decreased significantly from 32 percent in 1993- 94 to 24 percent in 2000

13 • Improved Prenatal Care

 The number of women on Medicaid who began prenatal care in the first trimester increased from 78 percent in 1993-94 to 84 percent in 2000

 The number of women on Medicaid receiving adequate prenatal care increased significantly from 57 percent in 1993-94 to 73 percent in 2000

• Improved Infant Health Outcomes

 In inner city areas of the State:

- The low birth weight infants born decreased from 10 percent in 1993 to 5 percent in 1995.

- The percentage of infants who had their first physician visit before two weeks increased significantly from 54.4 percent in 1993 to 70 percent in 1995.

- The percentage of infants who waited less than two weeks for specialty care increased significantly from 43.5 percent in 1993 to 71.4 percent in 1995.

• Improved Child Health

 Children in RIte Care have higher well-child visit rates than children enrolled in commercial insurance as well as children enrolled in Medicaid nationally

 In a study of 2-year-olds in RIte Care, 79 percent were screened for lead poisoning compared to only 19 percent in Medicaid nationally

• Excellent Member Satisfaction

 Overall, 98 percent of the respondents to the 2001 RIte Care Member Satisfaction Survey were ”very satisfied” or “satisfied” with RIte Care. This percentage has remained relatively constant since the State began enrolling individuals in RIte Care

 Survey responses stratified by Health Plans ranged from 96 to 98 percent who reported that overall they were “very satisfied” or “satisfied” with RIte Care

14

The State has built upon these successes by making RIte Care available to expanded populations. Incrementally, as noted above and where permissible, including these expansion populations in the State Child Health Insurance Program (SCHIP).

According to the U.S. Bureau of the Census2, the number of persons covered and not covered by health insurance in the State of Rhode Island in 1996 was 940,000. Of this total, 93,000 (with a standard error of 13,000), or 9.9 percent (with a standard error of 1.3 percent), were not covered by insurance. Preliminary estimates3, not adjusted for the uninsured or sample design, of the uninsured children in Rhode Island as if July 1, 1996, were as follows:

Percent with No Health Coverage, Ages 0 to 17, Rhode Island, 1996

Income Group

Percent Uninsured

<100% FPL

19.2%

100 to 199% FPL

13.1

200 to 299% FPL

7.5

300 to 399% FPL

1.6

>=400% FPL

1.0

Don’t Know

19.1

Refused

14.1

Total

9.5%

With an estimate of 235,283 children in Rhode Island as of July 1, 1996, this means that there were an estimated 22,352 without health insurance coverage as of July 1, 1996.

Although these estimates have not been adjusted, we believe that the number of uninsured children targeted under this Title XXI Program Plan would have been less than 14,0004 as of July 1, 1996.

2Bennefield, R.L. "Health Insurance Coverage: 1996", Current Population Reports: Consumer Income 3U.S. Bureau of the Census. "Estimates of the Population of the U.S., Region, and States by Selected Age Groups and Sex: Annual Time Series, July 1, 1990. to July 1, 1996," St-96-10 422,352 x 61.4% = 13,724

15 The State’s efforts have had a remarkable impact on the children uninsurance rate in the State. More recent CPS data show that in 2000, 6.2 percent of the overall population in Rhode Island lacked health insurance and 2.4 percent (this is a three-year average) of children lacked health insurance – both the lowest in the nation.5

As described in Section 5 of this Plan, the State has undertaken a well-defined outreach effort to identify and enroll uninsured children in RIte Care Health Plans. The State also implemented activities made possible by other changes in the Balanced Budget Act of 1997, to simplify the application and enrollment process. This was done to remove barriers associated with applying and enrolling through a "welfare" environment. An example of some of the outreach strategies implemented include:

• Accessing the National Governor’s Association sponsored “Insure Kids Now” hotline

• Providing funding for outreach workers to 32 community-based organizations to enroll new children each month

• Targeted mailings to community organizations and school-based personnel

• Distributing information to every school-aged child Kindergarten through 6th grade in the State

• Media coverage in professional newsletters and Rhode Island newspapers

• Using the Department of Human Services Web-site to disseminate information

• Providing public service announcements and radio and television interviews through the media

• Streamlining the mail-in application in both English and Spanish

• Supporting a bi-lingual information line.

2.2 Describe the current State efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2)

5 Griffin, J. Profiles and Trends of the Uninsured in Rhode Island: Characteristics of Uninsured Working-Age Adults in Rhode Island 1996-2000, MCH Evaluation, Inc. April 2002.

16 2.2.1. The steps the State is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance).

As noted earlier, the State has had an ongoing, active outreach program to enroll uninsured eligible children in RIte Care. This outreach effort is described in Section 5 of the Plan.

The State’s contracts with RIte Care Health Plans require that the Health Plans work to identify uninsured children for potential enrollment. Specifically, Section 2.05.01 of the Health Plan contract requires: "The Contractor, through members of its provider network, is encouraged to identify uninsured patients who may be RIte Care eligible and to make referrals to the State for eligibility determination." The contract also contains important coordination requirements. Specifically, Section 2.07 requires coordination with out-of-plan services and other health/social services available to members including:

• Special education

• Mental health services for seriously and persistently mentally ill adults (SPMI) and severely emotionally disturbed children (SED)— these are out-of-plan benefits

• Newborn Metabolic Screening Program

• Comprehensive Emergency Services Program

• Children’s Intensive Services Program

• Early Start Program

• Lead Program

• Adolescent Pregnancy and Parenting Service Network

• Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

In addition, Health Plans are required under Section 2.08.10 of the contract, to contract with the currently operating school-based clinics in the State and to contract with future school-based clinics that might be developed. Health Plans are also encouraged to contract with Title X providers and Federally qualified health centers (FQHCs).

With respect to the FQHCs, it is important to understand that Rhode Island does not have a service delivery system within its public health structure. Thus, the FQHCs, primarily, and hospitals, secondarily, have served as

17 the historical safety net for the uninsured in the State. When RIte Care was being implemented, the FQHCs elected to form their own Health Plan—Neighborhood Health Plan of Rhode Island. However, all other RIte Care participating Health Plans have elected to include some of the FQHCs in their provider networks. In addition, FQHCs operate the existing school-based clinics in the State. Thus, FQHCs are an integral component of RIte Care, without a mandate for their inclusion within networks.

Another important coordination feature of RIte Care is that Health Plans are responsible for certain Early Intervention (EI) services, subject to a stop-loss provision. Section 2.07.04.01 of the Health Plan contract stipulates that the Health Plan is responsible for the first $3,000 for medically necessary, appropriate speech, hearing, language, physical and occupational therapies under EI. The State covers any additional services on a fee-for-service basis, as billed by the Health Plans as stop-loss claims.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

RIte Share, Rhode Island’s new Premium Assistance Program, helps low- and middle-income families obtain health insurance coverage through their employer by paying the employee’s share of monthly premiums for family coverage.

Under RIte Share, individuals who are eligible for Medicaid/SCHIP and are employed by an employer that offers a “qualified” plan, enrolls in the ESI through their employer. In order for an applicant to be enrolled in RIte Share:

• The parents and/or their children are determined eligible for Medicaid/SCHIP (RIte Care), and

• One of the parents has access to ESI and works for an employer that offers an approved plan

The employer contribution to the cost of coverage remains unchanged. The State pays for the employee’s share of the health insurance premium either by paying the employer or by paying the employee. RIte Share members are eligible for “wrap around” services, which are Medicaid- covered services not included in the employer’s health plan, as well as for

18 coverage of commercial insurance co-payments.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)); (42CFR 457.80(c))

The State has had an ongoing, active outreach program to identify and enroll uninsured eligibles in RIte Care. This outreach effort is described in detail in Section 5 of this document.

The State’s contracts with RIte care Health Plans require that the Health Plans work to identify uninsured individuals for potential enrollment. Specifically, Section 2.05.01 of the Health Plan contract requires: “The Contractor, through members of its provider network, is encouraged to identify uninsured patients who may be RIte Care eligible and to make referrals to the State for eligibility determination.” The contract also contains important coordination requirements. Specifically, Section 2.07 requires coordination with out-of-plan services and other health/social services available to members:

• Special education

• Mental health services for seriously mentally ill adults and seriously emotionally disturbed children

• Newborn Metabolic Screening Program

• Comprehensive Emergency Services Program

• Children’s Intensive Services Program

• Early Start Program

• Lead Program

• Adolescent Pregnancy and Parenting Service Network

• Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

• Family Outreach Program

19 In addition, Health Plans are required under Section 2.08.10 of the contract to contract with school-based health clinics. Health Plans are also encouraged to contract with Title X providers and Federally qualified health centers (FQHCs).

With respect to FQHCs, it is important to understand that Rhode Island does not have a service delivery system within its public health structure. Thus, the FQHCs, primarily, and hospitals, secondarily, have served as the historical safety net for the uninsured in the State. When RIte Care was being implemented, the FQHCs elected to form their own Health Plan – Neighborhood Health Plan of Rhode Island (NHPRI). However, all other RIte Care participating Health Plans have elected to include some of the FQHCs in their provider networks. In addition, the FQHCs operate the existing school-based health clinics in the State. Thus, the FQHCs are an integral component of RIte Care.

Another important coordination feature of RIte Care is that Health Plans are responsible for certain Early Intervention (EI) services, subject to a stop-loss provision. Section 2.07.04.01 of the Health Plan contract stipulates that the

Health Plan is responsible for the first $3,000 for medically necessary, appropriate speech, hearing, language, physical and occupational therapies under EI. The State covers any additional services on a fee-for-service basis, as billed by the Health Plan as stop-loss claims.

20 SECTION 3. METHODS OF DELIVERY AND UTILIZATION CONTROLS (SECTION 2102)(A)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee-for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s

21 managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost- effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations.

22 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes

Neonatal Intensive Care Unit (NICU) Services are provided in Fee-For Service, as are Special Education services as defined in a child’s Individual Education Plan (IEP) and Lead Program Home Assessment and Non-Medical Case Management provided by the Department of Health or Lead Centers for lead poisoned children. If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for- service. Examples of carved out services may include transportation and dental, among others. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: Managed care organization (MCO) (42 CFR 457.10) Capitation payment

Describe population served: Children and families under 136% Federal Poverty Level (FPL), children under nineteen (19) years of age under 250% FPL, pregnant women under 250% FPL, Extended Family Planning population, Children with Special Health Care Needs, children in Foster Care, and Former Foster Care youth.

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation

23 (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served: Dental services for Medicaid and CHIP eligible children and young adults born after May 1, 2000.

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement

24 Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non-emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). • The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). • The provision against provider discrimination in 42 CFR 457.1208. • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. • The PAHP standards in 42 CFR 438.206(b)(1), as cross- referenced by 42 CFR 457.1230(a) (about availability of

25 services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are:

26 Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

27 The Medical MCO is required to pay remittances, the Dental PAHP is not required to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. The Dental PAHP is not required to pay remittances, however this will be included as a requirement in the contract amendment effective July 1, 2019. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of

28 race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross- referencing to 438.3(d)(4)) 3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider- beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude

29 any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or

30 because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross- referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: