210-RICR-30-00-1 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 – MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 – AFFORDABLE COVERAGE GROUPS PART 1 – Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways 1.1 Overview A. The principal purpose of the Federal Patient Protection and Affordable Care Act (ACA), Pub. Law No. 111-148, was to increase access to health care by leveraging resources, expanding choice, and removing the administrative, financial, and legal barriers that have prevented people from obtaining the coverage they need. Toward this end, the ACA: 1. Consolidated many of the existing Medicaid coverage groups associated with the now defunct Federal Aid to Families with Dependent Children Program (AFDC) into three (3) broad categories: children, pregnant people and newborns, and parents/caretaker relatives; 2. Created an optional Medicaid coverage group for adults between the ages of nineteen (19) and sixty-four (64) who otherwise do not qualify for Medicaid and are not eligible for or enrolled in Medicare; 3. Established a new income counting methodology – Modified Adjusted Gross Income (MAGI) - for evaluating income eligibility for Medicaid and other publicly supported forms of affordable commercial coverage across these populations; 4. Eliminated distinctions in the financial criteria and standardized the income eligibility requirements for the Medicaid populations subject to the MAGI. This, in turn, made it possible for the States to reorganize the MAGI-eligible populations with similar characteristics into distinct, easily identifiable, Medicaid affordable care coverage (MACC) groups; 5. Mandated that the States automate the application and renewal process for populations subject to the MAGI methodology by building the capacity to determine eligibility on-line and conduct electronic verifications through a variety of government approved data sources; and 6. Applied these changes not only to Medicaid, but also to the Children’s Health Insurance Program (CHIP), which is administered through the Medicaid program in Rhode Island, and HealthSource RI (HSRI), the State’s health insurance marketplace.

1.2 Scope and Purpose A. The purpose of this Rule is to establish the Medicaid Affordable Care Coverage (MACC) groups and the eligibility pathways for individuals who share one (1) or more of their characteristics and are exempt from the MAGI methodology and/or the provisions for the Integrated Health Care Coverage (IHCC) groups under Chapter 40 of this Title. B. In Rhode Island, CHIP eligibility is administered as an expansion through the Medicaid program rather than through a separate State program as the principal distinction for most eligibility pathways relates to claiming of Title XIX versus Title XXI Federal financial participation rates. The exceptions, as indicated in this Rule, are the CHIP-only eligibility pathways for lawfully present qualified non-citizen children up to the age of nineteen (19) and qualified and non-qualified pregnant women who meet the income limits set forth herein. 1.3 Legal Authority A. This Part is promulgated pursuant to Federal authorities as follows: 1. Federal Law: § 1115 of the Social Security Act, 42 U.S.C. § 1315; Title XIX of the Social Security Act, 42 U.S.C. §§ 1396a-1396w-8; Title XXI of the Social Security Act, 42 U.S.C. §§ 1397aa-1397mm; 42 U.S.C. § 1396k; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. Law No. 111-148. 2. Federal Regulations: 42 C.F.R. Parts 431, 435, 440, and 441. 3. The Medicaid State Plan and the Section 1115 Demonstration Waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. B. Applicable State authority is derived from R.I. Gen. Laws Chapters 40-8, 40-8.4, 40-8.12, and 42- 12.3. 1.4 Incorporated Materials A. These regulations hereby adopt and incorporate 42 C.F.R. § 435.1110 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. 1.5 Definitions A. For the purposes of Medicaid MACC and non-MAGI eligibility groups covered under this Part, the following definitions apply: 1. “ACA expansion adults” means the eligibility pathway established by the Federal Patient Protection and Affordable Care Act (ACA), Pub. Law No. 111-148, and by R.I. Gen. Laws Chapter 40-8.12, for persons between the ages of nineteen (19) and sixty-four (64) who

are not eligible for or enrolled in Medicare and do not qualify for Medicaid in any other eligibility group. 2. "CHIPRA 214" means the Children's Health Insurance Program Reauthorization Act of 2009, Pub. Law No. 111-3. 3. “Dependent child” means a child under the age of eighteen (18) or under the age of nineteen (19), if enrolled full-time in school. 4. "Extended Medicaid" or "Transitional Medicaid" means Medicaid eligibility granted to certain individuals who previously qualified for benefits pursuant to § 1931 of the Social Security Act, 42 U.S.C. § 1396u-1, but no longer qualify due to excess income. 5. “Hospital presumptive eligibility” means the temporary and time-limited Medicaid eligibility pathway for persons who meet certain requirements and are receiving care in a hospital pending submission of a complete application. 6. “Managed care organization” or “MCO” means a health plan system that integrates an efficient financing mechanism with quality service delivery and a "medical home" to assure appropriate preventive care and deter unnecessary services. 7. “Medicaid Affordable Care Coverage Group” or “MACC” means a classification of persons eligible to receive Medicaid based on similar characteristics who are subject to the MAGI income counting methodology for determining income eligibility. 8. “Rhode Island Code of Regulations” or “RICR” means the compilation of Rules governing the Rhode Island Medicaid program promulgated in accordance with the State’s Administrative Procedures Act (R.I. Gen. Laws Chapter 42-35). 9. “Medicaid member” means a Medicaid beneficiary enrolled in a managed care plan. 10. “Modified adjusted gross income” or “MAGI” means income, adjusted by any amount excluded from gross income under 26 U.S.C. § 911, and any interest accrued. 11. “Navigator” means a person working for a State-contracted organization that provides certified assisters who have expertise in Medicaid eligibility and enrollment. 12. “Non-citizen” means anyone who is not a U.S. citizen at the time of application including lawfully present immigrants and persons born in other countries who are present in the U.S. without documentation. 13. “Non-MAGI coverage group” means a Medicaid coverage group that is not subject to the modified adjusted gross income counting methodology for eligibility determination purposes. For the purposes of this Part, it includes Medicaid for persons who qualify for Medicaid based on their eligibility for another publicly funded program, including children in the substitute care under the auspices of the DCYF such as current, and some

instances, former foster care recipients and anyone receiving Supplemental Security Income (SSI). 14. “Qualified non-citizen” means a person legally present in the United States based on immigration status who, if otherwise eligible for Medicaid, is prohibited or “barred” under Federal law from receiving Medicaid coverage for a period of five (5) years from the date the immigration status was secured from the United States Citizenship and Immigration services (USCIS). Certain qualified non-citizens are exempt from the five (5) year Medicaid ban. 15. “Rhody Health Partners” means the Medicaid managed care delivery system for ACA expansion adults (see Subchapter 05 Part 2 of this Chapter) and adults with disabilities (See Chapter 40 of this Title). 16. “RIte Share” means the Medicaid premium assistance program for eligible individuals and families who have access to cost-effective commercial health insurance plans coverage. 17. "Section 1115 Waiver" means the waiver authorized pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315. 18. "Section 1931" or "§ 1931" means § 1931 of Title XIX of the Social Security Act, 42 U.S.C. § 1396u-1. 19. “Self-attestation” means the act of a person affirming through an electronic or written signature that the statements the person made when applying for Medicaid eligibility are truthful and correct. 20. "Title IV-E" means Title IV-E of the Social Security Act, 42 U.S.C. §§ 670-679c. 21. “Title XIX” means Title XIX of the U.S. Social Security Act, 42 U.S.C. §§ 1396-1396w-8, that established the Medicaid program and provides the legal basis for providing services and benefits to certain populations in each MACC group. 22. “Title XXI” means Title XXI of the U.S. Social Security Act, 42 U.S.C. §§ 1397aa-1397mm, that established the Children’s Health Insurance Program (CHIP) and provides the legal basis for providing services and benefits to certain targeted low-income children and pregnant women through Medicaid. 1.6 Eligibility Pathways for MACC and Non-MAGI Groups A. Rhode Island’s Medicaid MACC groups are comprised of individuals who share an eligibility characteristic, such as age or relationship as follows, unless otherwise indicated below. MACC group members do not have access to retroactive coverage under the terms and conditions of the State’s Section 1115 Waiver.

1. Parents/Caretaker Relatives. The defining characteristic of this coverage group is a relationship with a child up to the age of eighteen (18), or the age of nineteen (19) if enrolled in school full-time, who is eligible for Medicaid. Parent/caretaker eligibility is a function of how the eligible child is claimed for tax purposes as a dependent when constructing a MAGI household. This coverage group includes: a. Parents/caretaker relatives who are eligible under the Medicaid State Plan through the authority provided by § 1931 with income up to the threshold described in the table at § 1.6(B) of this Part. b. Other parents/caretaker relatives with income up to the threshold described in the table at § 1.6(B) of this Part. c. Parents/caretakers with income from one hundred thirty-three percent (133%) to one hundred seventy-five percent (175%) of the FPL, not including the five percent (5%) disregard, who would have been eligible for Medicaid on December 31, 2013, may qualify for the Rhode Island Affordable Health Care Coverage Assistance Program. Parents/caretakers eligible for this program may obtain a State subsidized “silver” commercial plan through the Rhode Island’s health insurance marketplace as specified in Subchapter 10 Part 1 of this Chapter. The State’s integrated eligibility system automatically evaluates the parents/caretakers of Medicaid-eligible children for this Program if they do not qualify for coverage under this Part. 2. Pregnant people. Members of this coverage group can be of any age. The pregnant person and each expected child are counted separately when constructing the household and determining family size. Eligibility extends for the duration of the pregnancy and, as of October 1, 2022, twelve (12) months post-partum. The coverage group includes all pregnant people with income up to the threshold described in the table at § 1.6(B) of this Part. Retroactive medical coverage is available for up to ninety (90) days prior to the eligibility date for otherwise eligible pregnant people. a. Pregnant people are eligible for coverage through Medicaid if they meet Medicaid requirements for citizenship and immigration (described in further detail below at § 1.7 of this Part) and either: 1. Have income under 190% FPL; or 2. Have income under 253% FPL and also have third-party liability insurance. b. Pregnant people are eligible for coverage through CHIP if they: 1. Meet Medicaid citizenship and immigration requirements (see § 1.7 of this Part) have income between 190 and 253% FPL, and do not have third party liability insurance; or

2. Meet requirements under CHIPRA 214 for lawful presence but do not meet Medicaid's citizenship and immigration requirements (see § 1.7 of this Part) have income under 253% FPL, and do not have third party liability insurance. c. CHIP medical coverage for those pregnant people who do not meet Medicaid or CHIP requirements for citizenship/immigration status (see § 1.7 of this Part) is based on the eligibility status of the unborn child. d. As of October 1, 2022, twelve (12) month post-partum coverage shall be extended to people who: 1. Are not eligible for Medicaid under another Medicaid eligibility category; or 2. Do not have qualified non-citizen status for Medicaid, whose births are financed by Medicaid through coverage of the child and who, before October 1, 2022, were only eligible to receive State-only extended family planning benefits postpartum, as outlined in Subchapter 05 Part 2 of this Chapter. 3. Children. Age is the defining characteristic of members of this MACC group. This coverage group includes: a. Infants under age one (1) unless a deemed newborn (see § 1.7(A) of this Part) up to age nineteen (19) who have family income up to the threshold described in the table at § 1.6(B) of this Part; and b. All children, including all non-citizen children not legally present, up to the age of nineteen (19), who have income up to the threshold described in the table at § 1.6(B) of this Part. 4. ACA Expansion Adults – The group consists of citizens and qualified non-citizens with income up to the threshold described in the table at § 1.6(B) of this Part who meet the age characteristic and are not otherwise eligible for, or enrolled in, Medicare or Medicaid under any other State plan or Section 1115 waiver coverage group. Adults found eligible awaiting a determination for Supplemental Security Income (SSI) or the receipt of Social Security benefits are also eligible under this coverage group during the two (2) year application pending and benefit waiting periods. B. MACC Group Income Eligibility – The income thresholds and ceilings for the MACC groups eligible through these pathways are summarized as follows:

MACC Group Income Threshold – As percent of the FPL Income Ceiling with the five percent (5%) disregard – As a percent of the FPL a. § 1931 Parents/Caretakers 116% 121% b. Other Parents/Caretakers 133% 138% c. Pregnant People 253% 258% d. Children up to age nineteen (19) (through age eighteen (18)) 261% 266% e. ACA Expansion Adults 133% 138% C. There are currently multiple Medicaid coverage groups that are not subject to the MAGI methodology. Eligibility for adults who are nineteen (19) years of age and older who are not subject to the MAGI methodology is set forth as follows: 1. Persons twenty-one (21) years of age and older eligible for Medicaid based on receipt of Supplemental Security Income (SSI), Optional State Supplemental Payments (SSP), and/or SSI-protected status – Part 40-00-1 of this Title; 2. Low income elders sixty-five (65) and older, and adults with disabilities (EAD) between the ages of nineteen (19) and sixty-four (64) with income up to one hundred percent (100%) of the FPL to who do not qualify for SSI and are eligible for or enrolled in in Medicare – Part 40-00-1 of this Title; 3. Full or partial Medicare-Medicaid dual eligible beneficiaries participating in the Medicare Premium Payment Program – Part 40-00-1 of this Title; 4. People eligible for Medicaid through the Breast and Cervical Cancer Treatment Program (BCCTP) – Part 40-00-1 of this Title; 5. Adults seeking initial or continuing eligibility for Medicaid long-term services and supports (LTSS) who are eligible for or enrolled in Medicare or are age sixty-five (65) and older with service needs requiring the level of care typically provided in health institutions –Part 50-00-1 of this Title;

6. Otherwise ineligible children with serious disabilities up to age nineteen (19) who qualify under Katie Beckett process because they are receiving the level of care at home that is typically provided in a health institution - Part 50-10-3 of this Title; 7. Medically needy eligible persons who become eligible for Medicaid by spending down excess income on allowable health expenses – Part 40-00-1 of this Title. D. People exempt from the MAGI income counting methodology with eligibility covered under this Part are as set forth below: 1. No income determination required – Individuals and families up to age twenty-one (21) whose eligibility does not require an income determination for Medicaid, including those eligible on the basis of: a. Supplemental Security Income (SSI). Children and young adults with disabilities determined by the Federal Social Security Administration (SSA) to be eligible for SSI benefits who are up to age nineteen (19) or in the custody of the State, up to age twenty-one (21), including those residing in health institutions; and b. DCYF programs. Children and youth eligible on the basis of their participation in a DCYF foster care, kinship or guardian program whether in a home-based, residential or institutional setting, including young adults aging out of foster care in Rhode Island, up to age twenty-six (26) who are eligible under the Federal Foster Care Independence Act of 1999 (Chafee Act) as amended by the Patient Protection and Affordable Care Act, Pub. Law No. 111-148 and the SUPPORT for Patients and Communities Act, Pub. Law No. 115-271. c. Former Foster Youth Status. Children and youth eligible on the basis of their participation in foster care in a state or Tribe within a state other than Rhode Island, up to age twenty-six (26) who are eligible under the SUPPORT for Patients and Communities Act, Pub. Law No. 115-271. 2. Deemed eligibility - Infants born to Medicaid-eligible pregnant people are deemed eligible from date of birth to age one (1) without regard to changes in income or other factors as long as they remain residents of the State. 3. Transitional/extended Medicaid –§ 1931 Parent/Caretakers who no longer qualify for Medicaid coverage under § 1931 due to earnings from work, including recipients of the RI Works Program administered by the Rhode Island Department of Human Services, as well as any children in their household and their spouse, may qualify for continued coverage through this pathway. Eligibility for extended Medicaid is for twelve (12) months.

1.7 MACC Group General Eligibility Requirements A. All applicants for MACC Group eligibility must meet State residency requirements. Applicants for MACC Group eligibility who are over the age of nineteen (19) must meet citizenship/immigration status requirements. There are also certain cooperation requirements. Adults must typically meet the cooperation requirements, whether applying for themselves or on behalf of a dependent child. Verification of these requirements is an automated process conducted through electronic data matches. Failure to meet Medicaid general eligibility requirements or provide supporting documentation upon request is considered non- cooperation and generally results in the denial or discontinuation of eligibility. Children are exempt from sanctions due to non-cooperation. The scope and application of each of these eligibility requirements are as follows: 1. Age – “Age” is one of the principal factors affecting eligibility for Medicaid and assignment to the appropriate Medicaid service delivery system MACC group. 2. MACC Group Age Limits – The age requirements associated with each of the MACC groups are as follows: MACC Coverage Groups Age Requirements Parents/Caretakers Parents/Caretakers (of any age) with a dependent child up to age eighteen (18) or nineteen (19) if enrolled in school full-time Pregnant People Any age Children Up to age nineteen (19) ACA Expansion Adults Ages nineteen (19) to sixty-five (65) a. Verification – An applicant’s self-attestation of age and identity is accepted at the time of application. Post-eligibility electronic verification of date of birth is conducted through the U.S. Social Security Administration (SSA) and/or the Rhode Island Department of Health, Division of Vital Statistics. This information is used to determine capitation rates for enrollees in Medicaid managed care plans; these rates vary by age. If electronic verification is unsuccessful, submission of paper documentation may be required for these purposes. See Part 5 of this Subchapter for satisfactory forms of documentation. 3. Social Security Number – To support verification of age, income, and citizenship/immigration status, individual applying for Medicaid who have been

assigned a Social Security Number (including children) shall provide their Social Security Number (SSN) as a condition of eligibility for the program. a. Only members of a household who are applying for Medicaid coverage are required to provide an SSN. An SSN of a non-applicant may be requested to electronically verify income. However, unwillingness on the part of a non- applicant to provide an SSN upon request shall not be used as the basis for denying eligibility to an applicant who has provided an SSN. If an SSN is unavailable, other proof of income shall be accepted. b. Limits on Use – Applicants shall also be informed that an SSN can be utilized only in the administration of the Medicaid program, including for use in verifying age and income eligibility. c. Verification – An SSN is verified through an electronic data-match with the SSA. Applicants (not including children) must provide documentation of SSN if the data match fails. Acceptable forms of documentation are identified in Part 5 of this Subchapter. 4. State Residency – Anyone who is applying for eligibility must be a resident of the State. Any person living in the State voluntarily, who intends to reside in Rhode Island for any reason is considered a resident of the State. Under Federal Regulations a person does not need a fixed address in the State to be considered a Rhode Island resident. Therefore, homelessness is not a bar to eligibility. a. For individuals who are twenty-one (21) years of age or older, or under the age of twenty-one (21) and capable of expressing intent as an emancipated or married individual – If the applicant is not living in an institution, the State of residence is the State where the applicant is living voluntarily with the intention to reside; or entered voluntarily with a job commitment or seeking employment, whether or not currently employed. b. For individuals under the age of twenty-one (21) who are not emancipated or married – If the applicant is not living in an institution, the State of residence is the State where the child/young adult resides or the State of the parent/care- taker with whom the child lives. Under the requirements of this provision, the residence of a pregnant person's unborn child is, the State in which the pregnant person resides. A non-citizen pregnant person who lives in Rhode Island is considered to be a resident, irrespective of whether the person's immigration status indicates they are in the country permanently or for a limited time (i.e., in the United States on a temporary visa of any kind). c. For individuals living in institutions – Most Medicaid applicants living in institutional settings are not included in the MACC groups.

d. Disputes – If there is a dispute over residency for determining Medicaid eligibility, the applicant is a resident of the State in which the applicant is physically located. The MAGI standard of the State where the applicant is physically located applies when determining eligibility. e. Verification – Self-attestation of the intent to remain in the State is accepted. Evidence that an applicant is receiving public benefits in another State may result in a denial of eligibility if paper documentation of residency is not provided. 5. Citizenship and Immigration Status – The citizenship requirements for Medicaid eligibility for individuals and families in MACC groups vary depending on the basis of eligibility. Some non-citizens are not eligible for Medicaid; some are eligible for Medicaid only after a five (5) year waiting period; and some are eligible without a waiting period. Children up to the age of nineteen (19) are not subject to citizenship requirements to be eligible for Medicaid, and pregnant people are not subject to citizenship requirements under CHIP. a. Non-Citizens ineligible Except in Emergency Situations (1) Non-qualified non-citizens. The non-qualified category of non-citizens includes citizens of other nations who are not considered to be immigrants under current Federal law, including those in the United States on temporary or time-limited visa (such as visitors and students) and those who are present in the country without proper documentation (includes people with no or expired status). (2) Non-qualified non-citizens who are adults are not eligible for Medicaid, except in emergency situations (Part 10-00-3 of this Title). Non- emergency services may be obtained through Federally Qualified Community Health Centers. See Rhode Island Community Health Association at www.richa.org. b. Non-Citizens barred from Medicaid During Five (5) Year Waiting Period (1) Qualified non-citizens. The qualified non-citizens category includes persons who are citizens of other nations who are lawfully present in the United States. Qualified non-citizens are barred from Medicaid for a waiting period of five (5) years under Federal law. Certain exemptions from the bar apply: c. Non-Citizens Exempt from the Five (5) Year Waiting Period (1) Qualified non-citizen children up to the age of nineteen (19) who are lawfully present in the United States but who were born in another nation are eligible for Medicaid as members of the MACC group for

children and young adults. Children in this subcategory of qualified non- citizens are eligible during the five (5) year bar under an option contained in Title XXI, the Children’s Health Insurance Program (CHIP). Qualified non-citizen pregnant people are also eligible for Medicaid in the MACC group, under an option in CHIP. (2) There are several other subcategories of non-citizens who are exempt from the five (5) year bar as specified in Part 10-00-3 of this Title. All non-exempt qualified non-citizens are eligible to obtain coverage through State and Federal health insurance marketplaces, such as HealthSource RI.com in Rhode Island, and may be qualified for certain tax credits. d. Non-qualified non-citizen pregnant people in the applicable MACC group are eligible for Medicaid coverage. The pregnant person's eligibility is tied to the eligibility of the baby they are carrying. For the purposes of MACC group eligibility, the baby in utero is deemed to be a United States citizen and Rhode Island resident and remains so as a newborn as long as the birth occurs in Rhode Island. e. Verification of citizenship/immigration status — All members of a household applying for Medicaid coverage shall provide their immigration and citizenship status. However, no adverse eligibility determination shall be made regarding children up to the age of nineteen (19) for whom citizenship/immigration status is not provided. Non-applicants are exempt from this requirement. Any information provided by an applicant or obtained through electronic verification under § 1.7(A)(5)(e) of this Part shall only be used to verify status. Under the ACA, citizenship and immigration status are verified: (1) Electronically. The Medicaid agency shall use electronic verification through the Federal hub (see Part 5 of this Subchapter) to the full extent feasible through: (AA) Social Security Administration (SSA) or Rhode Island Department of Health, Division of Vital Statistics for citizens. (BB) U.S. Citizenship and Immigration Services (USCIS) for non–U.S. adult citizens via the Systematic Alien Verification for Entitlements (SAVE) database. (2) Non-electronic. If unable to verify immigration status electronically, enrollees have an opportunity to provide other documents or to fix the records. (3) Self-Attestation. An applicant’s attestation is accepted without electronic verification providing appropriate paper documentation is

provided to the Medicaid agency within ninety (90) days of the eligibility determination. Failure to provide the required documentation within that period results in a termination of Medicaid and the initiation of the Medicaid recoupment process. 6. Relationship – The State evaluates the relationship of household members applying for the MACC group for parent/caretakers using the following: a. Caretaker Relative – For the purposes of MACC group eligibility, parent/caretaker is any adult living with a Medicaid-eligible dependent child who has assumed primary responsibility for that child. This definition includes, but is not limited to: (1) Father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew or niece; (2) The spouse of such parent or relative, even after the marriage is terminated by death or divorce; or (3) Another relative of the child based on blood, adoption or marriage; domestic partner of parent or other caretaker relative. If the parents are in the household, it is presumed that other members in the household are not assuming primary responsibility for the child’s care. (4) Dependent child – For the purposes of determining eligibility the members of the MACC group for parents/caretakers, a dependent child is a child under the age of eighteen (18) or under the age of nineteen (19) if enrolled full-time in school. b. Verification – Self-attestation on the application is accepted as verification of relationship, except for deeming of newborns. 1.8 MACC and Non-MAGI Special Eligibility Categories A. Deemed Newborn Eligibility – Babies born to Medicaid-eligible pregnant people who are residents of Rhode Island are deemed eligible from the date of birth. Once deemed eligible as a newborn, the infant remains eligible for one (1) year and, as such, has eligibility through a non- MAGI eligibility pathway. Accordingly, retroactive coverage is available for periods prior to the application date if the newborn was otherwise deemed eligible. The Medicaid-eligible parent of the newborn must comply with the following: 1. Enumeration – The parent/caretaker of a newborn must obtain an SSN for a newborn. Failure to enumerate the child results in a sanction against the parent/caretaker, not the child. The child will remain eligible even if lacking an SSN because of parent/caretaker's failure to cooperate. The sanction against the mother is loss of her eligibility for failure

to cooperate. This sanction will be removed once the mother meets the enumeration requirements; or 2. Record of birth – If the newborn’s SSN is not provided at birth, Medicaid eligibility is provided under the mother’s SSN if the hospital record of birth is submitted by the parents. The hospital record of birth is a written document indicating that the newborn was discharged in the mother's care and information related to date of birth and verifying citizenship. The hospital record of birth must be signed by the appropriate authorized representative of the hospital. If the infant was not born in a hospital, proof of application for an SSN, self-attestation and signed attestation of an attending health provider or birthing assistant may be accepted as a record of birth. 3. Verification – The birth may be reported by the parent/caretaker, or another family member or friend, the parent/caretaker's Medicaid managed care plan, or the hospital in which the child was born. See § 1.8(A)(2) of this Part above for information pertaining to the hospital record of birth. B. Federal law and Regulations prohibit the use of Federal matching funds for health care provided on the premises of correctional facilities to otherwise MACC-eligible persons while incarcerated. Accordingly, full Medicaid health coverage of such persons is suspended during periods of incarceration. While the suspension remains in effect, the State is responsible for reimbursing costs related to acute care hospital stays of twenty-four (24) or more hours, but only when the otherwise Medicaid-eligible incarcerated person receives that care off the premises of the correctional facility. 1. Reinstatement upon Release. Medicaid health coverage that has been suspended due to incarceration must be reinstated promptly by the Medicaid agency upon the person’s release from a correctional facility. 2. Residency. Suspension of Medicaid health coverage is limited to Rhode Island residents while incarcerated in correctional facilities. Medicaid health coverage for Rhode Islanders incarcerated in the correctional facilities of other States or in a Federal penitentiary is terminated in accordance with the residency requirements set forth herein. C. Infants. An infant born to an incarcerated pregnant person with suspended eligibility is treated as a deemed newborn in accordance with § 1.8(A) of this Part above and is qualified to receive Medicaid health coverage until the end of the month of the infant’s first (1st) birthday. D. Hospital Presumptive Eligibility – Under 42 C.F.R. § 435.1110 (2023), States must allow qualified hospitals to provide presumptive Medicaid eligibility to individuals who are not already Medicaid members for a limited period. This form of “presumptive eligibility” is only available in certain circumstances when a qualified hospital determines, on the basis of preliminary information, that an individual has the characteristics for Medicaid eligibility. Such individuals are “presumed eligible” for Medicaid until the end of the following month or the date full

eligibility is determined, whichever comes first. The State will make presumptive eligibility available to persons who have been determined by a qualified hospital to meet the characteristics of one (1) of the MACC groups eligible for Title XIX coverage. Persons eligible under CHIP are excluded. See Part 4 of this Subchapter, Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals, promulgated by EOHHS for additional detail on the provisions governing hospital presumptive eligibility determinations in Rhode Island. E. Section 1931 Extended/Transitional Medicaid –Parents/caretakers eligible for Medicaid under § 1931 may be eligible for extended Medicaid for twelve (12) months when their income exceeds the § 1931 family eligibility limit . Requirements for extended Medicaid are as follows: 1. Eligibility Criteria – A parent/caretaker who becomes ineligible for § 1931 Medicaid benefits may be eligible for extended Medicaid if: a. The parent/caretaker has a child living in the home who is under the age of eighteen (18) or between the age of eighteen (18) and nineteen (19) if the child is a full-time student in a secondary school, or at the equivalent level of vocational or technical training, and is reasonably expected to complete the program before or in the month of their nineteenth (19th) birthday. A student attending summer school full time, as defined by school authorities, is considered a full-time student for these purposes; and b. Eligibility for § 1931 Medicaid coverage was discontinued because of earned income of a parent/caretaker or other member of the family due to: employment; increased hours of employment; or an increase in wages. While there must be a relationship between earned income and the loss of eligibility for § 1931 Medicaid to qualify for extended Medicaid, the increase in earned income need not be the only factor causing the loss. Often employment linked with other changes such as changes in the household composition combine to cause the loss of eligibility. c. The parent/caretaker and the child in the home continue to be Rhode Island Residents 2. EOHHS evaluates all household members for Medicaid and CHIP eligibility on all bases before evaluating eligibility for extended Medicaid. Extended Medicaid is provided to those beneficiaries who are ineligible on all other bases and: a. Are living in the household and whose needs and income were included in determining § 1931 eligibility of the assistance unit at the time such benefits were discontinued; b. Have needs and income that would be taken into account in determining § 1931 Medicaid eligibility using the MAGI income counting methodology if the family were applying for either of these programs in the current month. A child born after § 1931 benefits are discontinued, or a child, parent, or step-parent who

returns home after § 1931 benefits are discontinued, is included as a member of the family for purposes of providing extended Medicaid. 3. Extended Medicaid is not provided to any beneficiary who has been legally determined to be ineligible for cash assistance because of fraud at any time during the last prior six (6) months in which the family received benefits. 4. Notice Requirements and Beneficiary Responsibilities – A notice is sent informing the family of the right to extended Medicaid for twelve (12) months. The notice also sets forth the following beneficiary responsibilities. The family must: c. Report circumstances which could result in the discontinuance of extended benefits (e.g., no age appropriate child in the family or a move out-of-State). 5. Start of Extended Medicaid– The first (1st) month of extended Medicaid is the first (1st) full or partial month in which the parent/caretaker loses § 1931 eligibility. 6. Limits – An Extended Medicaid period is limited to twelve (12) months. The Medicaid agency must provide a notice of closing if eligibility is discontinued prior to the end of the twelve (12) month limit. Eligibility is always discontinued on the last day of a month. 7. Prior to termination of extended Medicaid, each member of the family is evaluated for Medicaid coverage in every other possible MACC and IHCC group category as well as for commercial coverage subsidized by the Federal and/or State government offered through HealthSource RI, the State’s health insurance market. Notice to the beneficiary indicates the alternative forms of coverage available and how to enroll or if additional information is required to determine whether eligibility for these other cover options exists. F. Children with Special Circumstances 1. This category includes children and youth who are or were in the care and custody of the Rhode Island Department of Children, Youth and Family and, by virtue of that status, are automatically eligible for Medicaid without a MAGI-based income determination. They are included in this Rule as they share the characteristics of the MACC group coverage group for children and youth though eligible through a non-MAGI pathway. However, members of these groups may be eligible for up to ninety (90) days of retroactive coverage prior to the eligibility date. 2. The DCYF is responsible for certifying the eligibility of children and youth in the coverage group and in making the referral for Medicaid to the appropriate unit of the designated State agency and for notifying the agency when there is a change in circumstances that may affect a child’s Medicaid eligibility, coverage, or service delivery options. The change in circumstance could be related to placement, the child’s financial status, or a return to the family and/or termination of participation in the applicable programs. Prior to any change that may result in the end of Medicaid eligibility, the DCYF must

ensure that the beneficiary and/or their family or guardians are aware that alternative forms of Medicaid are available and provide assistance as appropriate. 3. Adoption Subsidy/IV-E Foster Children – This non-MAGI coverage group is the eligibility pathway for children in DCYF substitute care under the authority of Title IV-E of the U.S. Social Security Act. The coverage group includes foster children, children in kinship guardianship care and adopted children whose Medicaid eligibility is based on participation in the following DCYF administered, Title IV-E programs: a. The Foster Care Maintenance Program – This Program provides federally-funded foster care payments on behalf of the following children: Children previously eligible under the Federal Foster Care Maintenance Program under Title IV-A of the Social Security Act, 42 U.S.C. §§ 601-619; Certain children voluntarily placed or involuntarily removed from their homes; and Children in public non- detention type facilities housing no more than twenty-five (25) children. Children for whom a cash payment is made under the foster care program are deemed eligible for Medicaid. Medicaid eligibility for children in the Foster Care Maintenance program exists as long as the Title IV-E payment continues to be made for them or up to the age of twenty-one (21) if still in foster care. b. The Adoption Assistance Program – The Title IV-E authorized and funded adoption assistance program provides Federal funding for continuing payments for hard-to-place children with special needs. Children in this Program must be SSI beneficiaries at the time of adoption. An adoption subsidy cash payment is not a necessary condition of Medicaid eligibility for these adoption assistance children. They continue to be eligible for Medicaid as long as a Title IV-E adoption assistance agreement is in effect. An interlocutory order or final decree also need not exist. c. Residency requirements – Title IV-E adoption assistance children, kinship guardianship assistance children, and Title IV-E foster care children are eligible for Medicaid in their States of residence. Accordingly, Rhode Island is required to provide Medicaid coverage to children eligible under this pathway as long as they remain residents of the State and under the care and custody of DCYF, even if services are being provided in a jurisdiction of another State. 4. Non IV-E Foster Child Under 18 – This coverage group includes children under the age of eighteen (18), or if a child is eighteen (18) years old, the child will complete high school before their nineteenth (19th) birthday, who are in foster family care or in a kinship guardianship care and are not eligible for Title IV-E. 5. Non IV-E, State Adoption Assistance – This coverage group is hard-to-place children for whom the State provides adoption/guardianship assistance and who are not eligible for Title IV-E. The basis of eligibility for Medicaid is deprivation of parental support occasioned by the child's separation from their family.

6. The determination of financial need. When a child is not living in a home maintained by the child's parents, the State considers only the child's own income and resources. 7. Age Limit. Medicaid under this coverage group may be provided until the child reaches the age of twenty-one (21). 8. Post Foster Care Medicaid Eligibility for individuals born before January 1, 2005 – The Foster Care Independence Act of 1999 established the John H. Chafee Foster Care Independence Program, 42 U.S.C. § 1396a(a)(10). This Medicaid eligibility pathway is open to youth who were in foster care in Rhode Island on their eighteenth (18th) birthday. Medicaid eligibility for youth qualifying for this coverage continues until the age of twenty-six (26) as long as the individuals remain residents of the State. a. Living arrangement. A post foster care adolescent may be residing independently or with others (including family members). b. Renewal. A renewal of Medicaid eligibility is completed once in a twelve (12) month period to ensure that the beneficiary eligible in this group is a resident of Rhode Island. c. Limits. Under the terms of the Chafee Act, young adults may only qualify for Medicaid under this group if not otherwise eligible through SSI or as aged, blind or disabled and/or in need of long term services and supports. In addition, although eligible for the full scope of Medicaid State Plan and Section 1115 waiver services available to all adults, the EPSDT benefit for children continues up to the age of twenty-one (21) only. 9. Post Foster Care Medicaid Eligibility for individuals born on or after January 1, 2005 – The Foster Care Independence Act of 1999 established the John H. Chafee Foster Care Independence Program, 42 U.S.C. § 1396a(a)(10), and was later amended by the Patient Protection and Affordable Care Act, Pub. Law No. 111-148, and the SUPPORT for Patients and Communities Act, Pub. Law No. 115-271. This Medicaid eligibility pathway is open to individuals between the ages of 18 and 26 who were in foster care under the responsibility of a state or a Tribe within a state, including children who were cared for under the unaccompanied refugee minor program, and were enrolled in Medicaid upon the time their foster care assistance ended. An individual may qualify for this eligibility pathway even if the individual was in foster care in a state or Tribe within a state other than Rhode Island. Medicaid eligibility for youth qualifying for this coverage continues until the age of twenty-six (26) as long as the individual remains a resident of the State. a. Living arrangement. A post foster care youth may be residing independently or with others (including family members). b. Renewal. A renewal of Medicaid eligibility is completed once in a twelve (12) month period to ensure that the beneficiary eligible in this group is a resident of Rhode Island.

c. Limits: Individuals may only qualify for this group if they are not enrolled through a different Medicaid eligibility pathway, even if they meet the eligibility requirements of another eligibility pathway. Although eligible for the full scope of Medicaid State Plan and Section 1115 waiver services available to all adults, the EPSDT benefit for children continues up to the age of twenty-one (21) only. 1.9 Cooperation Requirements A. All applicants and beneficiaries subject to this Part must cooperate with an array of requirements as a condition of obtaining or retaining (post-eligibility) eligibility. Specific requirements related to application and renewal are located in Part 3 of this Subchapter and for the purposes of evaluating and verifying income are set forth in Part 5 of this Subchapter. B. Cooperation requirements applicable across populations are as follows: 1. Third Party Liability (TPL) – Third Party Liability refers to any individual, entity (e.g., insurance company) or program (e.g., Medicare) that may be liable for all or part of a Medicaid applicant’s coverage. Under § 1902(a)(25) of the Social Security Act, 42 U.S.C. § 1396a(a)(25), the State is required to take all reasonable measures to identify legally liable third (3rd) parties and treat verified TPL as a resource of the Medicaid beneficiary once determined eligible. Applicants/beneficiaries must furnish information about all sources of TPL. The State and Medicaid managed care organizations, under contractual agreements with the State, are responsible for identifying and pursuing TPL for beneficiaries covered by employer-sponsored health insurance plans through the RIte Share program. Failure to cooperate with the TPL requirement or to enroll in a RIte Share plan as required in Subchapter 05 Part 3 of this Chapter results in the ineligibility of the parent. 2. Referral to Office of Child Support Services (OCSS) – All applicants reporting an absent parent are referred to the Office of Child Support Services within the Department of Human Services, once they have been determined eligible for Medicaid and received appropriate notice. Compliance with the OCSS requirement is a condition of retaining eligibility. As a condition of eligibility, an applicant who can legally assign rights for a dependent child born out of wedlock is required to do so and cooperate in establishing the parentage of that child for the purposes of obtaining medical care support and medical care payments for both the applicant and the child. Failure to cooperate in assigning rights results in a determination of ineligibility for the parent, unless a good cause exemption has been granted by the State. In instances when domestic violence may be the basis for an exemption to the cooperation requirement, referral to the Family Violence Option Project may be made to assist the parent seeking an exemption. 3. RIte Share Premium Assistance Program – Individuals and families determined to have access to cost-effective employer-sponsored health insurance (ESI) are required to enroll in the ESI plan if so directed by the State. Members of the MACC groups with access to ESI who are eligible for Medicaid will be permitted to enroll in a Medicaid

managed care plan, as appropriate. The Medicaid agency will conduct a post-enrollment review of those members with access to ESI to determine whether participation in RIte Share is required. The provisions governing the RIte Share program are located in Subchapter 05 Part 3 of this Chapter. C. Duty to Report – All Medicaid applicants and beneficiaries have a duty to report changes in income, family size, address, and access to ESI within ten (10) days of the date the change takes effect. Failure to make timely reports may result in the denial or discontinuation of Medicaid eligibility. D. A Medicaid applicant or member must have the opportunity to claim good cause for refusing to cooperate. Good cause may be claimed by contacting a DHS or EOHHS agency representative. To claim good cause, a person must state the basis of the claim in writing and present corroborative evidence within twenty (20) days of the claim; provide sufficient information to enable the investigation of the existence of the circumstance that is alleged as the cause for non-cooperation; or, provide sworn statements from other individuals supporting the claim. E. Basis for Claim. A determination of good cause is based on the evidence establishing or supporting the claim and/or an investigation by Medicaid agency staff of the circumstances used as justification for the claim of good cause for non-cooperation. F. State Requirements. The determination as to whether good cause exists must be made within thirty (30) days of the date the claim was made unless the agency needs additional time because the information required to verify the claim cannot be obtained within the time standard. The person making the claim must be notified accordingly, provided with the reason for the decision, and the right to appeal through the EOHHS Administrative Fair Hearing Process specified in Part 10-05-2 of this Title. G. A Medicaid beneficiary may terminate Medicaid eligibility at any time. Such requests must be made in writing and submitted to a State agency or HSRI representative in-person, via U.S. Mail, fax, on-line via the beneficiary’s secure account, or made by telephone to HSRI when telephonic recording capabilities exist. The Medicaid agency is responsible for providing the Medicaid beneficiary with a formal notice of the voluntary termination of Medicaid eligibility that indicates the effective date, the impact of terminating eligibility for each member of the household, and the right of the beneficiary to reapply for Medicaid health coverage at any time. 1.10 Information A. For Further Information or to Obtain Assistance 1. Applications for affordable coverage are available online on the following websites: a. www.eohhs.ri.gov b. www.dhs.ri.gov

c. www.HealthSourceRI.com 2. Applicants may also apply in person at one of the Department of Human Services offices or by U.S. Mail. Request an application by calling 1-855-697-4347 and TTY 1-888-657- 3173.3. For assistance finding a place to apply or for assistance completing the application, please call: 1- 855-840-HSRI (4774). 1.11 Severability A. If any provisions of these Regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable.

210-RICR-30-00-1 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 - AFFORDABLE COVERAGE GROUPS PART 1 - MEDICAID AFFORDABLE CARE COVERAGE GROUPS OVERVIEW AND ELIGIBILITY PATHWAYS (210-RICR-30-00-1) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 08/17/2025 July 28, 2025 E-SIGNED by Richard Charest on 2025-07-28 10:40:49 EDT July 28, 2025 E-SIGNED by Department of State on 2025-07-28 10:42:26 EDT

210-RICR-30-00-5 TITLE 210 – EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 – MEDICAID FOR CHILDREN, FAMILIES AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 – AFFORDABLE COVERAGE GROUPS PART 5 – MEDICAID MAGI FINANCIAL ELIGIBILITY DETERMINATIONS AND VERIFICATION 5.1 Scope and Legal Authority A. The purpose of this rule is to describe the Modified Adjust Gross Income (MAGI) standard and explain how it is applied; and establish the role and responsibilities of the State and consumers when determining MAGI-related eligibility for the Medicaid Affordable Care Coverage (MACC) groups identified in Part 1 of this Subchapter. B. This Part is promulgated pursuant to: 1. Federal authorities as follows: a. Federal Laws: § 1115 of the Social Security Act, 42 U.S.C. § 1315; Title IV of the Social Security Act, 42 U.S.C. §§ 601-687; Title XIX of the Social Security Act, 42 U.S.C. §§ 1396a-1396w-8; Title XXI of the Social Security Act, §§ 42 U.S.C. 1397aa 1397mm; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148; § 1004 of the Health Care and Education Reconciliation Act of 2010, Pub. Law 111-115; Title I § 11051(c) of the Tax Cuts and Jobs Act of 2017, Pub. Law 115-197, § 5112 of the Consolidated Appropriations Act, Pub. Law 117-328. b. Federal Regulations – 42 C.F.R. §§ 435.603; 435.902-910; 435.916; and 435.1005 c. The Medicaid State Plan and the Section 1115 Demonstration Waiver. granted pursuant to § 1115 of the Social Security Act, 42 U.S.C § 1315 2. State authorities – R.I. Gen. Laws Chapters 40-6, 40-8, and 42-7.2.

5.2 Incorporated Materials A. These regulations hereby adopt and incorporate 42 C.F.R. § 435.603 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. B. These regulations hereby adopt and incorporate 42 C.F.R. § 435.902-910 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. C. These regulations hereby adopt and incorporate 42 C.F.R. § 435.916 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. D. These regulations hereby adopt and incorporate 42 C.F.R. § 435.1005 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. E. These regulations hereby adopt and incorporate 42 C.F.R. § 435.948-949 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations. 5.3 Definitions A. As used herein, the following terms shall be defined as follows: 1. “Affordable Care Act” or “ACA” means the federal Patient Protection and Affordable Care Act of 2010. 2. “Attestation” means the act of a person affirming through an electronic or written signature that the statements the person made when applying for Medicaid eligibility are truthful and correct. 3. “Caretaker” or “Caretaker relative” means any adult living with a Medicaid- eligible dependent child that has assumed primary responsibility for that child as defined in Part 1 of this Subchapter. 4. “Continuous eligibility” or “CE” means a period of eligibility during which a member cannot be disenrolled due to changes in circumstances with certain exceptions. Exceptions include a request for disenrollment by the beneficiary, the beneficiary is no longer a resident of the state, the agency determines that eligibility was erroneously granted at the most recent determination, redetermination, or renewal due to agency error or fraud, abuse, or perjury attributed to the beneficiary, or the beneficiary is deceased.

5. “Custodial parent” means a relationship that is defined by a court order or binding separation, divorce or custody agreement establishing physical custody of a minor child. If no order or agreement exists, or in the event of a shared custody agreement, the custodial parent is the parent with whom the child spends most nights. 6. “Federal poverty level” or “FPL”, as used herein, means the most recently published federal poverty level by the U.S. Department of Health and Human Services. 7. “Federal data hub” or “Data hub” means the database of the United States population built by the U.S. Internal Revenue Service (IRS) and Health and Human Services (HHS) used to facilitate determinations for coverage, including Medicaid, under the ACA. 8. “HealthSource RI” means the entity that allows persons, families, and small businesses to access insurance, as well as federal subsidies to assist in the payment of that coverage. 9. “Household composition” means, for the purposes of determining MAGI eligibility, the person(s) filing taxes, whether jointly or separately, and anyone included as a tax dependent of the person(s) filing taxes. Special relationship rules for household composition may apply when the person filing taxes is not the custodial parent of the tax dependent. 10. “MAGI” means modified adjusted gross income, adjusted by any amount excluded from gross income under 26 U.S.C. § 36B of the IRS Code, and any interest accrued. 11. “Medicaid Affordable Care Coverage Group” or “MACC” means a classification of persons eligible to receive Medicaid based on similar characteristics who are subject to the MAGI standard for determining income eligibility. 12. “Non-MAGI coverage group” means a Medicaid coverage group that is not subject to the modified adjusted gross income standard for eligibility determination. 13. “Reasonable compatibility” means an allowable difference or discrepancy between the information provided in the application and the information reported by an electronic data source. 14. “Reconciliation” means the point in the verification process when discrepancies between an applicant’s attestation and information from data sources are resolved.

5.4 MAGI Household Construction A. The principal factor for determining MAGI-based eligibility is tax filing status and household composition and size, based on the rules for household construction. 1. General rules of household construction – For the purposes of calculating MAGI, a household consists of an applicant and the people the applicant claims as a deduction for a personal exemption when filing federal income taxes. Under IRS rules, the taxpayer may claim a personal exemption deduction for him/herself, a spouse, and tax dependents. Non-family members may be included as tax dependents under certain circumstances and are treated as part of the tax household accordingly. 2. Special Medicaid rules of household construction – The following rules for constructing a household are applied when making MAGI-based Medicaid eligibility determinations: a. “Relationship-based” rules are used when an applicant is neither filing taxes nor being claimed as a tax dependent, and under the exceptions outlined in § 5.5 of this Part. b. Medicaid household rules are “person specific” within a family. Therefore, a Medicaid household must be constructed for each person within a family. c. For married couples living together, each spouse must be included in the household of the other spouse, regardless of whether they expect to file a joint federal tax return or whether one (1) spouse expects to be claimed as a tax dependent by the other spouse. d. If a pregnant person is applying for coverage or is part of another applicant’s household, the household size must be adjusted to reflect the number of children that they are expecting. Specifically, the pregnant person is counted as one (1) plus the number of children they expect to deliver. This pregnancy-adjusted household size is used to determine the applicable FPL for the pregnant person as well as for other members of their household. 5.5 Exceptions Requiring Application of Relationship Household Rules A. Relationship-based household composition rules must be applied when an applicant meets the criteria for an exception from the tax-based household rules. These alternative relationship-based rules must be used to determine both household size and the income of the household members included as part of total household income.

1. Relationship-based rules – The household is determined based upon the family members who live with the applicant. The rules vary slightly for children versus adults. a. Adults. The relationship-based rules for adults require that the household consist of the following persons: (1) The adult applying for coverage; (2) The applicant’s spouse, if living with the applicant; (3) The applicant’s biological, adopted, and step-children under age nineteen (19) years, if living with the applicant. b. Children under age nineteen (19). The relationship-based rules for minor children require that the household consist of the following persons: (1) The child applying for coverage; and the child’s parents (including step-parents), if living with the child; (2) Any of the child’s siblings (including step-siblings), if living with the child. 2. Triggers – The exceptions that trigger the use of relationship-based rules are as follows: a. Applicant does not plan to file taxes and does not expect to be claimed as a tax dependent by another tax filer. Full information on who is required to file taxes under federal law is located in IRS Publication 501 (IRS Publication 501 is available at: http://www.irs.gov/publications/p501/ar02.html#en_US_2012_publi nk1000220851). b. Tax dependents meet specified criteria. In situations in which an applicant will be claimed as a tax dependent on another person’s federal tax form, the relationship-based rules apply if the applicant meets any of the following criteria: (1) Applicant is claimed or expects to be claimed by a tax filer who is not the applicant’s parent or step-parent. (2) Applicant lives with both parents, but only one (1) parent will claim the child as a tax dependent. In this case, child refers to the parent-child relationship and not the age of the applicant.

(3) Applicant is a child under nineteen (19) who lives with a custodial parent but will be claimed as a tax dependent by a non-custodial parent. 3.

Summary of Application of Relationship-Based Rules Applicant is not planning to file taxes and is not claimed as a tax dependent by another tax filer Applicant is claimed as a dependent by a tax filer who is not the applicant’s parent Applicant is a child under nineteen (19) who lives with both parents, but only one (1) parent will claim the child as a tax dependent Applicant is a child under nineteen (19) who lives with a custodial parent, but will be claimed as a tax dependent by the non-custodial parent 5.6 Determination of Household Income A. To be eligible for Medicaid using the MAGI standards, an applicant’s current monthly household income must meet the standard applicable to the applicant’s MACC group which can be found in Part 30-00-1 of this Title. B. When calculating whether an applicant is income-eligible for Medicaid under one of these coverage groups, the following factors must be considered: the members of the applicant’s household that must be included; types of countable income; current income and reasonably predicted changes; and conversion of monthly income to the FPL standards. 1. Countable household income – The Subsection below identifies all forms of countable income included when determining MAGI-based Medicaid eligibility, including those that are specific to Medicaid eligibility only. a. Adjusted Gross Income (AGI). Adjusted gross income is gross income adjusted by “above-the-line” deductions. AGI includes wages and salaries and income from a broad array of other sources, such as unemployment benefits, alimony, taxable interest, and capital gains. “Above-the-line” deductions are the adjustments people can make to their gross income. These include alimony payments, interest on student loans, and other items that appear on page one (1) of Form 1040. However, they do not include charitable

contributions, mortgage interest and other “below-the-line” deductions. b. Social Security benefits. All Social Security income benefits are considered countable income when using the MAGI standard to determine eligibility for affordable coverage. This includes Social Security benefits that are considered both taxable and non-taxable income for federal tax purposes. c. Interest Income. Income received from bank accounts, money market accounts, certificates of deposit, and deposited insurance dividends are considered countable taxable income. Additionally, interest on some bonds issued by and used to finance state and local government operations is also counted for the MAGI even though treated as tax-exempt for federal tax purposes. d. Foreign earned income. Foreign earned income is countable for the MAGI. This includes all income received from sources within a foreign country or countries earned for services when either performed by: a U.S. citizen and a bona fide resident of a foreign country for an uninterrupted period of time that includes an entire tax year; or a U.S. citizen or resident who, during any period of twelve (12) consecutive months, is present in a foreign country for at least three hundred thirty (330) full days during that period. e. Medicaid specific adjustments to income. Special Medicaid adjustments are as follows: (1) Taxable lump sum payments (such as gifts, prizes, income and property tax refunds) are counted only in the month received. (2) Educational scholarships, awards or fellowships used for education purposes are excluded from consideration as income. (3) Certain types of income for American Indian/Alaska Native persons are excluded. f. Treatment of other sources of income for Medicaid eligibility are summarized in the table that follows:

MAGI-Based Medicaid Eligibility Rules Income Source Treatment of Income Self-employment income Counted with deductions for most expenses, depreciation, and business losses Salary deferrals (flexible spending, cafeteria and 401(k) plans) Not counted Child support received Not counted Alimony paid Alimony payments under separation or divorce agreements finalized after December 31, 2018 are not deductible by the payer. Alimony payments under separation or divorce agreement finalized on or before December 31, 2018 continue to be deductible by the payer except when such agreement is modified and when such modification expressly states that alimony is not deductible to the payer or includible in the income of the recipient Veterans’ benefits Not counted Workers’ compensation Not counted Gifts and inheritances Not counted TANF and SSI Not counted Qualified Lump Sum Income Winnings less than eighty thousand dollars ($80,000) are

MAGI-Based Medicaid Eligibility Rules Income Source Treatment of Income counted as income in the month received. Winnings of at least eighty thousand dollars ($80,000) but less than ninety thousand dollars ($90,000) are counted as income in equal installments over two months. For every additional ten thousand dollars ($10,000) in winnings over ninety thousand dollars ($90,000), one (1) month is added to the period over which total winnings are divided, in equal installments, and counted as income. Discharged Student Loan Debt Not counted Moving Expenses Not counted Alimony Received Alimony payments under separation or divorce agreements finalized after December 31, 2018 are not included in the income of the recipient. Alimony payments under separation or divorce agreements finalized on or before December 31, 2018 continue to be included in the income of the recipient for the duration of the agreement except when such agreement is modified, when such modification expressly states that alimony is not deductible to the payer or includible in the income of the recipient

2. Household members included in MAGI calculation – An individual’s household income is the sum of the MAGI-based income of every individual included in the individual’s household who is expected to be required to file a tax return. These rules are based on whether or not a person is “expected” to be required to file a tax return; it does not matter whether they eventually do so or not. 3. Use of current income and accounting for reasonably predicted changes – For new Medicaid applicants, the State must use a household’s current monthly income and household size when evaluating eligibility. A prorated portion of reasonably predictable changes in income, if there is a basis for anticipating the changes, such as a signed contract for employment, a clear history of predictable fluctuations in income, or other indications of future changes in income may be considered in determining eligibility. Future changes in income and household size must be verified in accordance with the verification and reasonable compatibility requirements as delineated in this Part. 4. Comparing household income to the FPL – To determine income eligibility for Medicaid based on the MAGI calculation, the State must compare a household’s current monthly income to the FPL guidelines for the appropriate household size. The State must use the most recently published FPL level in effect in the month during which an applicant applies for coverage. If an applicant’s FPL level is within five (5) percentage points over the FPL for the coverage group for which they would be eligible, a disregard of five (5) percentage points of the FPL shall be added to the highest income eligibility standard listed above for that coverage group. 5.7 Verification of Income Using the MAGI Methodology A. To achieve the ACA’s goal of improving and streamlining access to all forms of affordable coverage, including Medicaid, the federal government established a data hub containing information related to various eligibility factors. The federal data hub facilitates the electronic information exchange necessary to verify eligibility both at the time of initial application and during annual renewals thereafter. States have the flexibility to augment the electronic verification process the federal data hub uses with any additional data bases deemed appropriate. Rhode Island has elected to combine the use of electronic data sources for income verification including those that are commercially available, available through federal partners, and those that are available at the state-level to ensure accuracy, timeliness and completeness. B. The purpose of § 5.8 of this Part is to identify the principal facets of the verification process, including the electronic matches made through the federal data hub, and State-automated data bases and alternatives. In addition, the provisions of this rule also set forth the respective roles and responsibilities of the

EOHHS, in its capacity as the Single State Medicaid Agency and applicants in assuring this process functions in the most secure, effective, and efficient manner possible. 5.8 Verification Process A. As indicated in Part 10-00-3 of this Title, attestations are accepted without verification for residency, household composition, pregnancy and caretaker relative status. In general, this verification process proceeds as follows: 1. Data matching – The State must assure that an applicant’s information is entered into the integrated eligibility system (IES) and matched electronically to the full extent feasible through the federal data hub, State data sources, and commercial data sources. a. Federal Data Hub. The federal data hub contains electronic information from various agencies of the United States government, including the IRS, Social Security Administration (SSA), HHS (Centers for Medicare and Medicaid Services (CMS) and other agencies), Department of Homeland Security (USDHS), Department of Veterans Affairs (VA), Department of Defense (DoD), Peace Corps, and Office of Personnel Management (OPM). Various categories of data from these sources are used to match on income, employment, health, entitlements, citizenship, and criminal history. A full list of the data included in the federal hub and the rules governing its use are located in 42 C.F.R. §§ 435.948 and 435.949. b. State data sources. The State draws from databases from an array of public agencies to verify income including the RI Department of Labor and Training (DLT), Divisions of Revenue and Motor Vehicles, and EOHHS agencies including Department of Human Services (DHS). Specific databases include State Wage Information Collection Agency (SWICA) and State unemployment compensation information (UI). c. Commercial wage verification. The State may contract with one of several commercially available products/resources for a comprehensive detailing of wage data from some of the nation's largest employers. 2. Reasonable compatibility – The State must use a reasonable compatibility standard, or an allowable difference, to match data sources with self- reported application information. If the data sources match the applicant’s attestation, or are found “reasonably compatible,” the State must ensure that the IES bases the determination on the information in the application.

The State uses this standard for income verification and may apply it to other eligibility factors in the future. 3. Reasonable explanation – The State must provide the applicant with the opportunity to provide an explanation and documentation if the data sources do not match the attestation or are not reasonably compatible. Accordingly, the IES issues a request to the applicant for this information and provides a list of reasonable explanation options. 4. Reconciliation process – The explanation provided by an applicant must be used to determine whether it is feasible to reconcile a discrepancy between an attestation and data matches to determine whether reconciliation is feasible. If the applicant provides a reasonable explanation, the final determination of eligibility will be based on the information the applicant provided. If the applicant is unable to provide a reasonable explanation, documentation will then be required to verify or correct the attestation and reconcile the discrepancy. 5. Privacy – The verification process utilizes personally identifiable information (PII) from both the federal data hub and State data sources. An account is maintained for each person who completes and submits an application through the State’s IES. This account includes PII and other eligibility-related information used in the determination and annual renewal process. The State must assure the privacy of the information in these accounts in accordance with the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information and R.I. Gen. Laws §§ 40-6-12 and 40-6- 12.1. Also, the State must limit any use of account information to matters related to the administration of the Medicaid program including eligibility determinations, Medicaid health plan enrollment, appeals, and customer services. See also Part 10-05-1 of this Title, Confidentiality Rule. 6. Account Duration – Once an account in the IES is established, a person seeking Medicaid has ninety (90) days to complete and submit the application for a determination. The IES eliminates the account and all eligibility information from all sources, federal and State, if an application has not been completed by the end of that period. The State must determine eligibility within thirty (30) days from the date the competed application is submitted. 7. Post-eligibility verification – See § 5.15 of this Part. B. The following lists key eligibility factors, the types of verification required for attestations, if any, and the verification sources for MACC Group applicants/ beneficiaries:

1. Identity – An applicant must provide proof of identity when applying through the IES or filing a paper application. The requirements related to identify proofing are set forth in Part 30-00-3 of this Title. Certain applicants may not be able to obtain identity proofing through the federal hub due to data limitations. Pre-eligibility verification is required through an alternative electronic paper documentation source in these instances to establish an account. 2. Income – Electronic verification of attested income is required by the State. Multiple electronic data sources may be used for this purpose.. The reasonable compatibility standard applies when there are discrepancies between the applicant’s income self-attestation and information from electronic data sources. 3. General Eligibility – Non-Financial Factors – (Social Security Numbers, Age, Citizenship, Death, Date of Birth, Residency, and Incarceration). Information on these eligibility factors is verified against various State and federal data sources. Information specific to verification requirements for MAGI populations is located in Part 30-00-3 of this Title; for Medicaid and CHIP-funded eligibility more generally, the applicable provisions are set forth in Part 30-00-3 of this Title. 5.9 Medicaid Reasonable Compatibility Standards A. When information obtained through the federal data hub, State data sources and commercial data sources is found reasonably compatible with the applicant’s attestation, no further verification is required, and the eligibility determination will proceed. The reasonable compatibility standards set forth below by the State are applicable to income verification. The term “data” refers to information obtained through electronic data matches across federal and State sources. B. Overview of Standards Medicaid Reasonable Compatibility Standards for Income Attestation and Data Scenario Reasonable Compatibility Standard Attestation and income data from external sources are below applicant’s Medicaid eligibility levels. Reasonably Compatible: Person eligible for Medicaid

Medicaid Reasonable Compatibility Standards for Income Attestation and Data Scenario Reasonable Compatibility Standard Attestation and income data from external sources are above applicant’s Medicaid eligibility levels. Reasonably Compatible: Person ineligible for Medicaid; eligibility for a qualified health plan (QHP) is determined The attestation is below the applicant’s Medicaid eligibility level and the income data from external sources are above the applicant’s Medicaid eligibility level, and the difference between the attestation and data is ten percent (10%) or less. Reasonably Compatible: Person eligible for Medicaid The attestation is below the applicant’s Medicaid eligibility level and the income data from external sources are above the applicant’s Medicaid eligibility level, and the difference between the attestation and data is greater than ten percent (10%). Not Reasonably Compatible: pursue discrepancy reconciliation. Person may provide a reasonable explanation and/or provide the State with documentation of current income. 1. Income attestation and data are both below Medicaid eligibility levels – Attestation and data sources are reasonably compatible if the difference or discrepancy between the two (2) does not affect the eligibility of the applicant. In other words, even if there is a difference between what an applicant says he or she earned and what the data shows was actually earned, the attestation and data are considered reasonably compatible if both are below Medicaid eligibility levels. 2. Attestation and data are both above Medicaid eligibility levels – Attestation and data sources are reasonably compatible if they are both above the Medicaid eligibility levels. Under such a scenario, the person would be found ineligible for Medicaid. For example, this would occur if an applicant attests to income above the eligibility ceiling for the applicable MACC

group and electronic data-based verification indicates that the applicant’s income is higher than that amount. The applicant is not eligible for Medicaid in either case. Eligibility for affordable care with federal advance premium tax credits and cost-sharing reductions is then reviewed. 3. Income attestation – The difference between the income attestation and the data is less than ten percent (10%) – An income attestation and data from electronic sources are considered reasonably compatible if the difference between the applicant’s attestation and the data sources is less than ten percent (10%). The applicant is eligible, provided all other eligibility criteria are met. 4. Income attestation – The difference between the income attestation and data sources is greater than ten percent (10%). An income attestation and data on income sources are considered to be not reasonably compatible if the difference between the applicant’s attestation and data sources is greater than ten percent (10%); a reasonable explanation is pursued. 5.10 Reasonable Explanations A. When attestation and data sources are not reasonably compatible, the IES provides the applicant with prompts for resolving any identified discrepancies. The applicant is asked first to provide an explanation. Before an eligibility determination is made, the applicant will be afforded an opportunity to explain any discrepancies between their income attestation and the income source data. B. The following chart is a list of acceptable explanations when there is a discrepancy between an income attestation and data sources. If the applicant provides any one (1) of these explanations, eligibility will be based on their attestation and no further verification is required. The State has only implemented reasonable explanation options for income discrepancies. Reasonable Explanations for Discrepancy in Income Lost job Decrease in hours Multiple employers Self-employed Do not file taxes Have not filed taxes yet Homeless Fluctuating income Work on commissions Income from capital gains Income from dividends Income from royalties Seasonal worker Divorce or marriage

Reasonable Explanations for Discrepancy in Income Victim of domestic violence Victim of natural disaster Death in family Victim of identity theft 5.11 Reconciliation Period A. If the applicant’s data verification is not reasonably compatible with the attested information and the applicant has been unable to provide a reasonable explanation for discrepancies, applicants will be given a thirty (30) day application period to submit satisfactory documentation. Medicaid eligibility is only available during the reconciliation period as specified § 5.12 of this Part below. 5.12 Satisfactory Documentation and Alternative Forms of Verification A. During the reconciliation process, applicants will be asked to submit satisfactory documentation to verify income eligibility as indicated below: Income Verification Sources Pay stubs representative of the last four (4) weeks of income Earnings Statement Employment Letter Book Keeping Records Property Unit Proof Owner Occupied Proof Monthly Rental Income Proof Reports from Social Security, Veteran’s Administration, and other agencies When the applicant is unable to obtain the information requested, Departmental forms (Wage Report, AP-50; Bank Clearance, AP-91; Clearance with VA, AP-150 and AP-151) are used.

Income Verification Sources Mortgage Breakdown Proof Income Tax Returns B. The State may provide an alternate verification process. This alternative process is available when one (1) or more of the following conditions apply: 1. The IRS’s only tax data for the applicant is over two (2) years old; 2. The applicant attests that the family size or family members have changed since the tax information being used for the determination was filed; 3. The applicant attests that a change in circumstances has occurred or is reasonably expected to occur that may affect eligibility; 4. The applicant attests to a change in tax filing status that has or is reasonably expected to change the tax filer’s annual income; or 5. An applicant in the tax filer’s family has applied for unemployment benefits. 5.13 Post-Eligibility Verification (PEV) by the Integrated Eligibility System (IES) A. The IES will conduct post-eligibility verification of the beneficiary’s information. The IES runs post-eligibility verifications on the following beneficiary information: 1. Factors reviewed: a. Incarceration status (Rhode Island Department of Corrections data) b. Death data (Department of Health Vital Records data) c. Current Income – Wages (electronic data sources) d. Current Income – Unemployment Income (UI) (Department of Labor and Training) 2. Timelines: a. Post-eligibility verification for incarceration, death data, and current unemployment insurance information will be checked monthly.

b. Post-eligibility verification for current income/wages runs approximately every ninety (90) days (such as February, May, August, and November). 3. PEV Results – The State may take the following action or actions based upon the PEV process: a. All information is current and accurate and the difference between the total attested income supplied by the beneficiary and the information supplied by an external data source(s) is within the state’s established reasonable compatibility standard, no action on the part of the State or the beneficiary is required. The beneficiary continues to receive benefits without interruption. b. During the post-eligibility verification process, if the income from electronic data sources is above the applicable Medicaid eligibility threshold, and the difference between the electronic data source and the total attested income is more than ten percent (10%), the IES will check each line of income and send out a notice to the beneficiary(ies) indicating the source of income that cannot be verified and requesting that it be reviewed and verification documentation related to current income be provided. (1) The beneficiary will have ten (10) days to respond to such a notice. The ten (10) day period begins on the fifth day after the notice was mailed by the State. The beneficiary may either log onto the automated account (www.healthyrhode.ri.gov) and change information, send via U.S. mail, or bring the documentation to a local DHS office. Upon receipt of the verification documentation, the State will redetermine eligibility. (2) After the time period to provide documentation has elapsed, if the person has not provided documentation or reported a change, the State will redetermine eligibility using the data from external sources. (3) If any member of the beneficiary’s household has died or if there is a change in the household composition, the State will seek further information from the beneficiary before terminating coverage. If terminated, the beneficiary will then have to re-apply (i.e., log onto the automated account (www.healthyrhode.ri.gov); send via U.S. mail; or bring the documentation to a local DHS office).

(4) A notice of the beneficiary’s new eligibility status will be sent, along with a Medicaid termination notice with appeal rights (Part 10-05-2 of this Title, as applicable). B. A beneficiary will not be terminated by the State based on a change in income without first considering other possible categories of eligibility based on factors including age, disability status, and level-of-care needs. C. All children found eligible for CHIP or Medicaid will be granted one (1) year of continuous eligibility (CE) from the date they are found eligible. During their CE period, children will not be disenrolled due to changes in circumstances. The following are the only exceptions to the CE provision: 1. The child attains age 19; 2. The child or child’s representative requests a voluntary termination of eligibility; 3. The child ceases to be a resident of the state; 4. The agency determines that eligibility was erroneously granted at the most recent determination, redetermination, or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child’s representative; or 5. The child is deceased. 6. The child is found eligible for Medicaid (applies only to those initially eligible via CHIP).

210-RICR-30-00-5 TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE ACT (ACA) ADULTS SUBCHAPTER 00 - AFFORDABLE COVERAGE GROUPS PART 5 - “MEDICAID MAGI FINANCIAL ELIGIBILITY DETERMINATIONS AND VERIFICATION” (210-RICR-30-00-5) Type of Filing: Amendment Agency Signature _________________________________________________________________ Agency Head Signature Agency Signing Date Department of State ____________________________ Regulation Effective Date _________________________________________________________________ Department of State Initials Department of State Date 08/28/2025 August 08, 2025 E-SIGNED by Richard Charest on 2025-08-08 14:49:46 EDT August 08, 2025 E-SIGNED by Department of State on 2025-08-08 14:58:19 EDT