reglab/statecodes huggingface dataset:
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 6 - Medicaid Long-Term Services and Supports: Financial Eligibility › Section 210-RICR-50-00-6.5 - LTSS Determination of Countable Resources

Current through June 14, 2024
A. The
				  State has established a four thousand dollar ($4,000.00) resource limit for
				  Medicaid LTSS eligibility for family size of one (1) - that is, a single
				  individual - except for ACA expansion adults as indicated in §6.5.1 below.
				  These resource limits are used to determine financial eligibility only and are
				  not protected or reserved for any purpose related to Medicaid LTSS access or
				  coverage. Therefore, the State treats countable resources within these limits
				  to be available to the applicant or beneficiary as indicated in §40-00-3
				  of this Title.
B. The process for
				  determining countable resources for LTSS purposes requires evaluating total
				  assets at the time of application as well as a look-back period of five (5)
				  years prior to the application date. The purpose of this five (5) year lookback
				  period is to assess whether an applicant has transferred an asset (that is,
				  resource or income) for less than or an unascertainable fair market value and
				  to ensure that the resources available to the applicant/beneficiary do not
				  exceed any limits that apply. As indicated below, resource limits do not apply
				  to applicants seeking LTSS through the eligibility pathway for ACA expansion
				  adults.
6.5.1
Resources and
				  ACA Expansion Adults
A. The Centers
				  for Medicare and Medicaid Services (CMS), the Federal agency that oversees the
				  Medicaid program, has issued guidance stating the ACA expansion adults seeking
				  Medicaid LTSS are exempt from the provisions in Title XIX requiring States to
				  establish resource limits for eligibility that are no more restrictive than
				  those that apply for SSI recipients. As indicated in Part 8 of this Subchapter,
				  Medicaid Long-Term Services and Supports (LTSS) Post-Eligibility Treatment of
				  Income (PETI), the provisions in Title XIX related to the poste-ligibility
				  treatment also do not apply.
B. CMS
				  has determined that ACA expansion adults are subject to Federal requirements
				  related to the transfer of assets (i.e., liquid resources and real property) to
				  prevent the divestiture of resources to gain access to Medicaid LTSS and ensure
				  that a share of the applicant's resources are protected for a spouse and
				  dependents. Therefore, the only provisions set forth in this section that apply
				  to ACA expansion LTSS applicants are in §§
											6.6  to
				   6.12   of this Part.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 6 - Medicaid Long-Term Services and Supports: Financial Eligibility › Section 210-RICR-50-00-6.6 - Transfer of Assets

Current through June 14, 2024
A. The Federal
				  Deficit Reduction Act (DRA) of 2005 (42 U.S.C. §
											1305) governs the treatment of assets in the
				  Medicaid LTSS eligibility determination process. The law presumes transfers of
				  assets for undiscernible or less than fair market value (FMV) prior to or at
				  the time of applying for Medicaid LTSS coverage are transactions made for the
				  principal purpose of gaining or maintaining eligibility. The DRA requires the
				  States to treat all but a narrow range of these transactions as disqualifying
				  transfers that result in a "penalty" period during which a person is ineligible
				  for Medicaid LTSS coverage. For the purposes of this section:
1. Assets - Includes all income and resources
				  of an LTSS applicant and his or her spouse that is countable in the
				  determination of Medicaid eligibility using the SSI method and the home (and
				  associated land) when a person is seeking or receiving Medicaid LTSS.
2. Transfer - The conveyance of right, title,
				  or interest in an asset from one person to another person or entity, the
				  disclaiming, assignment or divestment of an income producing resource or other
				  source of income, or disposal of a lump sum before it is treated as a countable
				  resource or income.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 6 - Medicaid Long-Term Services and Supports: Financial Eligibility › Section 210-RICR-50-00-6.7 - Asset Transfers Involving Annuities

Current through June 14, 2024
A. An annuity
				  is a contract reflecting payment to an insurance company, bank, charitable
				  organization, or other registered or licensed entity; it may also be a private
				  contract between two (2) parties. This section provides the criteria for
				  determining whether annuity is treated as disqualifying transfer resulting in a
				  period of ineligibility for Medicaid LTSS. Irrespective of whether the
				  establishment of the annuity is considered a disqualifying transfer, the
				  provisions pertaining to whether any income derived is counted or excluded for
				  eligibility purposes is located in §40-00-3.5 .5(A)(2)(a) of this Title
				  are applied.
B. Annuities
				  established pre-DRA- Before February 8, 2006:
1. Disqualifying transfer - The annuity was
				  purchased before February 8, 2006, and the expected return on the annuity is
				  not commensurate with a reasonable estimate of life expectancy, also referred
				  to as "actuarially sound."
2.
				  Allowed transfer - When an annuity purchased before February 8, 2006, is
				  "actuarially sound," then it is not considered a transfer of assets for less
				  than fair market value. The annuitant has just converted the resources to
				  income.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 6 - Medicaid Long-Term Services and Supports: Financial Eligibility › Section 210-RICR-50-00-6.9 - Asset Transfers Involving Life Estates

Current through June 14, 2024
A.
				  Life estate means a legal arrangement entitling the owner of the life estate
				  (sometimes referred to as the "life tenant") to possess, rent, and otherwise
				  profit from real or personal property during their lifetime. The amount of a
				  life estate that is countable depends on when it was established, whether the
				  applicant(s) have the legal right to sell the home, and the portion of the
				  proceeds of the sale, if allowed, that are available.
B. For all Medicaid LTSS applications and
				  renewals after January 1, 2006, the establishment of a life estate for a home
				  is treated as a transfer of assets.
1.
				  Disqualifying transfer - A life estate may be a disqualifying transfer in the
				  following instances:
a. Applicant/beneficiary
				  owns the property - When an applicant or beneficiary has an ownership interest
				  in a home and establishes the life estate on his or her own behalf, the
				  remainder interest is a disqualifying transfer. The remainder interest is the
				  equity value of the property minus the value of the life estate as determined
				  in accordance with §
												6.3(B)(3)   of
				  this Part.
b. Applicant/beneficiary
				  purchases property - When an applicant/beneficiary purchases a life estate in
				  the home of another person, and the payment made exceeds the FMV of the life
				  estate, the difference between the amount paid and the FMV is treated as a
				  disqualifying transfer. This transfer is disqualifying even if the
				  applicant/beneficiary lives in the home of the life estate for one (1) year or
				  more.
c. Applicant/beneficiary
				  gifts the property - In instances in which the applicant/beneficiary makes a
				  gift or transfer of a life estate interest, the value of the life estate, as
				  calculated under §
												6.3(B)(3)   of
				  this Part, is considered a disqualifying transfer of assets.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 7 - Involuntary Discharge from a Long-Term Care Facility (210-RICR-50-00-7) › Section 210-RICR-50-00-7.1 - Purpose and Overview

Current through June 14, 2024
The purpose of this rule is to set forth requirements
					 related to resident discharges and transfers initiated by state licensed
					 long-term care facilities, without regard to the resident's source of payment.
					 All such transfer/ discharges that are taken by a long-term care facility
					 without the agreement or consent of the resident or the resident representative
					 are involuntary and are prohibited, except as provided
					 herein.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 7 - Involuntary Discharge from a Long-Term Care Facility (210-RICR-50-00-7) › Section 210-RICR-50-00-7.2 - Legal Authority

Current through June 14, 2024
A. State
				  authorities: These rules are promulgated pursuant to the authority set forth in
				  R.I. Gen. Laws Chapter 40-8, "Medical Assistance"; R.I. Gen. Laws Chapter 40-6,
				  "Public Assistance Act"; R.I. Gen. Laws §
										23-17-19.1,
				  "Rights of Patients"; R.I. Gen. Laws Chapter 23-17.5, "Rights of Nursing Home
				  Patients"; R.I. Gen. Laws §
										23-17.5-17,
				  "Transfer to Another Facility"; R.I. Gen. Laws Chapter 23-17.4, "Assisted
				  Living Residence Licensing Act"; R.I. Gen. Laws §
										23-17.4-16,
				  "Rights of Residents."
B. Federal
				  authorities: Additional authority is derived from  42 C.F.R. §
											483  Subpart
				  B, "Requirements for Long Term Care Facilities"; Title XIX of the Social
				  Security Act;
				   42 U.S.C. §
											1396r, "An Act to Amend Title XIX of the
				  Social Security Act to Prohibit Transfers or Discharges of Residents of Nursing
				  Facilities as a Result of a Voluntary Withdrawal from Participation in the
				  Medicaid Program"; the State's Medicaid State Plan; and the Rhode Island
				  Comprehensive Section 1115 D emonstration, as approved in final form on
				  February 25, 2014, and as subsequently amended.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 7 - Involuntary Discharge from a Long-Term Care Facility (210-RICR-50-00-7) › Section 210-RICR-50-00-7.4 - Discharge Criteria

Current through June 14, 2024
A. The long-term
				  care facility must permit each resident to remain in the long-term care
				  facility, and not transfer or discharge the resident from the long-term care
				  facility unless:
1. The transfer or discharge
				  is necessary for the resident's welfare and the resident's needs cannot be met
				  in the long-term care facility;
2.
				  The transfer or discharge is appropriate because the resident's health has
				  improved sufficiently so the resident no longer needs the services provided by
				  the long-term care facility;
3. The
				  safety of individuals in the long-term care facility is endangered due to the
				  clinical or behavioral status of the resident;
4. The health of individuals in the long-term
				  care facility would otherwise be endangered;
5. The resident has failed, after reasonable
				  and appropriate notice, to pay for (or to have paid under Medicare or Medicaid)
				  a stay at the facility.
a. Non-payment
				  applies if the resident does not submit the necessary paperwork for third party
				  payment or after the third party, including Medicare or Medicaid, denies the
				  claim and the resident refuses to pay for his or her stay.
b. For a resident who becomes eligible for
				  Medicaid after admission to a long-term care facility, the long-term care
				  facility may charge a resident only allowable charges under Medicaid;
				  or
6. The long-term care
				  facility ceases to operate.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 7 - Involuntary Discharge from a Long-Term Care Facility (210-RICR-50-00-7) › Section 210-RICR-50-00-7.5 - DOCUMENTATION REQUIREMENTS

Current through June 14, 2024
A. In instances
				  where a resident is being transferred or discharged, the long-term care
				  facility must document in the resident's clinical record the basis for the
				  transfer or discharge. The resident's physician must document as follows:
1. The transfer or discharge is necessary to
				  meet the resident's welfare and the resident's welfare cannot be met in the
				  long-term care facility;
2. The
				  transfer or discharge is appropriate because the resident's health has improved
				  sufficiently so the resident no longer needs the services provided by the
				  long-term care facility;
3. The
				  health of individuals in the long-term care facility would otherwise be
				  endangered.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 7 - Involuntary Discharge from a Long-Term Care Facility (210-RICR-50-00-7) › Section 210-RICR-50-00-7.6 - PRE-TRANSFER/ DISCHARGE NOTICE

Current through June 14, 2024
A. Before
				  transferring or discharging a resident, a long-term care facility must notify
				  the resident (and, if known, a resident representative) of the transfer or
				  discharge and of the reasons for the discharge in a language and manner they
				  understand. The long-term care facility must also notify the Office of the
				  State Long-Term Care Ombudsman.
B.
				  The written notice must include the following:
1. The reason for transfer or
				  discharge;
2. The effective date of
				  transfer or discharge;
3. The
				  location to which the resident is transferred or discharged;
4. A statement of the resident's appeal
				  rights, including the name, address (mailing and email), and telephone number
				  of the entity that receives such requests; and information on how to obtain an
				  appeal form and assistance in completing the form and submitting the appeal
				  hearing request;
5. The name,
				  address (mailing and email) and telephone number of the Office of the State
				  Long-Term Care Ombudsman;
6. For
				  nursing facility residents with intellectual and developmental disabilities or
				  related disabilities, the mailing and email address and telephone number of the
				  agency responsible for the protection and advocacy of individuals with
				  developmental disabilities; and
7.
				  For nursing facility residents with a mental disorder or related disabilities,
				  the mailing and email address and telephone number of the agency responsible
				  for the protection and advocacy of individuals with a mental
				  disorder.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 7 - Involuntary Discharge from a Long-Term Care Facility (210-RICR-50-00-7) › Section 210-RICR-50-00-7.7 - RESIDENT APPEAL RIGHTS

Current through June 14, 2024
A. Long-term care
				  facility residents who wish to challenge their transfers or discharges may
				  appeal in accordance with the provisions of §10-05-2.4.8 of this Title,
				  "Appeals Process and Procedures for EOHHS Agencies and Programs."
B. The appeals process cannot be limited to
				  Medicaid-eligible long-term care facility residents. EOHHS will conduct
				  administrative hearings for any long-term care facility resident who wishes to
				  appeal a transfer or discharge from the facility, regardless of source of
				  payment.
C. The long-term care
				  facility may not transfer or discharge the resident while the appeal is
				  pending, when a resident exercises his or her right to appeal a transfer or
				  discharge notice from the facility, unless the failure to discharge or transfer
				  would endanger the health or safety of the resident or other individuals in the
				  long-term care facility.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 7 - Involuntary Discharge from a Long-Term Care Facility (210-RICR-50-00-7) › Section 210-RICR-50-00-7.8 - SEVERABILITY

Current through June 14, 2024
If any provision in any section of this rule or the
					 application thereof to any person or circumstances is held invalid, its
					 invalidity does not affect other provisions or applications of the rule which
					 can be given effect without the invalid provision or application, and to this
					 end the provisions of this rule are declared to be severable.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 8 - Post-Eligibility Treatment of Income (PETI) › Section 210-RICR-50-00-8.1 - Overview

Current through June 14, 2024
A. Medicaid LTSS beneficiaries are required
				  by Federal law and Regulations, the State Plan, and the Section
				  1115 waiver to contribute
				  income toward the Medicaid cost of care, irrespective of whether LTSS is
				  provided in a health care institution or a home or community living
				  arrangement. Only persons eligible for Medicaid LTSS on the basis of MAGI - the
				  ACA adult expansion - are not required to pay toward the cost of care under
				  Federal Regulations in effect as of March 1, 2018.
B. To ensure the beneficiary and/or spouse
				  remaining at home (the "community" spouse) and the dependents of the LTSS
				  beneficiary (the "institutionalized" spouse) have sufficient income and
				  resources to thrive, Congress established a process to prevent spousal
				  impoverishment. One important aspect of this process is a re-evaluation of the
				  beneficiary's income - known as the post eligibility treatment of income or
				  "PETI" - to determine what, if any, amount remains available to be applied to
				  the LTSS cost of care after certain amounts are set aside or "protected" to
				  meet the financial needs of the beneficiary, spouses and/or dependents. The
				  amount a beneficiary must pay toward the cost of care for Medicaid LTSS
				  coverage is referred to hereinafter as "beneficiary liability." This section
				  pertains to the PETI process and the determination of beneficiary
				  liability.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 8 - Post-Eligibility Treatment of Income (PETI) › Section 210-RICR-50-00-8.2 - Legal Authority and Scope and Purpose

Current through June 14, 2024
A.
				  Federal Authorities:
1. Federal Law: Title
				  XIX, of the Federal Social Security Act at:
				   42 U.S.C. §§
												1396a, 1396b, and 1396k;
2. Federal Regulations:
				   42 C.F.R. §§
												435.700- 435.735; 435.800 - 435.832; 460.184  Parts I through G,
				  including §§435.733,
				  435.735 and
				  484.10(e).
3. The Rhode Island Medicaid State Plan and
				  the Title XIX, Section
				  1115(a)
				  Demonstration Waiver (11-W-00242/1), effective through December 31,
				  2018.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 8 - Post-Eligibility Treatment of Income (PETI) › Section 210-RICR-50-00-8.3 - Exclusions and Exemptions

Current through June 14, 2024
A. There are certain
				  beneficiaries receiving Medicaid LTSS coverage that are either excluded from
				  the PETI or are exempt in certain circumstances, as indicated below:
1. Children and Youth Up to Age Nineteen (19)
				  - Children receiving Medicaid LTSS, irrespective of eligibility pathway, are
				  not subject to PETI. Although there are some differences in the way beneficiary
				  liability is determined by setting, the same general Rules in this section
				  apply irrespective of eligibility pathway or whether LTSS is provided in a
				  health institution or at home or in the community.
2. SSI Beneficiaries - 1619(b) status -
				  Irrespective of LTSS living arrangement, Medicaid beneficiaries who are working
				  and have SSI 1619(b) status are exempt from the PETI process. Earned income is
				  treated as invisible in the allocation process.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 8 - Post-Eligibility Treatment of Income (PETI) › Section 210-RICR-50-00-8.5 - Income for Post-Eligibility Purposes

Current through June 14, 2024
A. PETI
				  Income. During the post-eligibility review process, income is treated
				  differently than during earlier steps in the LTSS eligibility sequence.
1. General Rules - The treatment and
				  availability of income in the PETI is conducted in accordance with the
				  following:
a. Only the income allocated to the
				  LTSS beneficiary is considered available in the beneficiary liability
				  determination.
b. During any month
				  in which a Medicaid LTSS beneficiary is receiving covered services, the income
				  of beneficiary's spouse is treated as unavailable.
c. In the case of an LTSS beneficiary who has
				  no spouse, only the income of the beneficiary is considered in determining
				  beneficiary liability.
d. Spouses
				  separated by a continuous period of LTSS, regardless of living arrangement, are
				  considered for PETI purposes to be living apart starting in the month the LTSS
				  beneficiary begins to receive Medicaid LTSS.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 8 - Post-Eligibility Treatment of Income (PETI) › Section 210-RICR-50-00-8.6 - Personal and Family Maintenance of Need Allowances

Current through June 14, 2024
A. Personal Needs Allowances. In general,
				  LTSS beneficiaries receiving services in a health care institution receive a
				  monthly personal needs allowance to cover the costs of daily needs that are not
				  covered by the facility such as grooming, reading materials, cell phone fees
				  and the like. A personal needs allowance is also provided to LTSS beneficiaries
				  living in community settings such as Medicaid-certified assisted living
				  residences under certain circumstances - that is, when eligible to receive the
				  optional State supplement payment for low-income beneficiaries. The amount of
				  the personal needs allowance is also a function of whether the LTSS beneficiary
				  was receiving a pension from the Veterans Administration and has no spouse or
				  dependents or qualifies as a surviving spouse.
1. Personal Need Allowance - A personal needs
				  allowance is provided to LTSS beneficiaries who reside in a health care
				  institution. (The maintenance of need allowances set aside for Medicaid LTSS
				  beneficiaries residing in certain HCBS living arrangements are set forth in
				  §
											8.6(B)   of
				  this Part below). The personal needs allowance amounts indicated below include
				  optional State supplemental payments as well as required Federal amounts,
				  except as provided for veterans:
a. Monthly
				  Personal Needs Allowance of seventy-five dollars ($75.00). LTSS beneficiaries
				  residing in a NF, ICF-ID, or hospital providing long-term services receive a
				  personal needs allowance of seventy-five dollars ($75.00). The personal needs
				  allowance consists of a mandated Federal allowance of thirty dollars ($30.00)
				  and the State-only - personal needs allowance through State supplement payment
				  of forty-five dollars ($45.00) per month.
b. Veterans Personal Needs Allowance of
				  Ninety Dollars ($90.00). The Veterans Benefit Act of 1992,
				  Pub. Law
				  102-568(U.S.C. Title 38), entitles veterans who
				  had received a pension to obtain what is known as the "veteran's improved
				  pension" of ninety dollars ($90.00) per month when residing in a health care
				  institution. This ninety dollar ($90.00) benefit is treated as a personal needs
				  allowance and is deducted from income when determining liability for veterans
				  who are Medicaid LTSS beneficiaries. The ninety dollar ($90.00) veteran's
				  improved pension is available to Medicaid LTSS beneficiaries who are veterans
				  and do not have a spouse or dependent child; or are the surviving spouse of a
				  veteran who does not have a dependent child(ren). The improved pension is
				  provided instead of the seventy-five dollar ($75.00) monthly personal needs
				  allowance for non-veteran Medicaid LTSS beneficiaries.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 8 - Post-Eligibility Treatment of Income (PETI) › Section 210-RICR-50-00-8.8 - Institutional Limited Home Maintenance Allowance

Current through June 14, 2024
A. A
				  home maintenance allowance is available for either a single LTSS beneficiary,
				  in addition to the personal needs allowance, when residing in a health care
				  institution and if there is an intent to return home. The allowance is equal to
				  up to one hundred percent (100%) of the FPL for a family size of one (1). The
				  home maintenance allowance counts toward the maximum monthly maintenance of
				  standard.
1. Access to the Home Maintenance
				  Allowance - To obtain the home maintenance allowance, the following conditions
				  apply:
a. Time limits. The deduction from
				  income resulting from the home maintenance allowance cannot be allocated for
				  more than six (6) months in any continuous period of Medicaid LTSS in a health
				  care institution.
b. Certification.
				  A licensed physician must certify that either LTSS beneficiary or both are
				  likely to return to the home during the six (6) month period. The allowance
				  ceases once a beneficiary is discharged and returns to the home.
c. Home Expenses. The LTSS beneficiary or
				  beneficiaries has expenses that are required to maintain a residence (owned or
				  rented) in the community including, but not limited to, taxes, rent, mortgage
				  payments, utilities, and insurance; and
d. Other Resident Family Members. A spouse,
				  dependent child or other person who is or could be claimed as a dependent for
				  Federal income tax purposes was not residing in the home at the time the
				  beneficiary was admitted to the LTSS health care institution; or, if both
				  spouses are LTSS beneficiaries, they were admitted to a health care institution
				  on the same day.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 1 - Medicaid Long-Term Services and Supports: Institutionally Based LTSS (210-RICR-50-05-1) › Section 210-RICR-50-05-1.1 - Overview and Purpose

Current through June 14, 2024
A. Medicaid covers
				  certain inpatient, comprehensive services, subacute and long-term services and
				  supports as institutional? benefits. The word "institutional" with respect to
				  federal Medicaid? requirements applies to benefits authorized under Title XIX
				  of the federal Social Security Act. For the purposes of LTSS, Medicaid
				  recognizes three distinct health institutions all of which must be licensed
				  under State law - nursing facilities (NF), intermediate care facilities for
				  persons with intellectual or developmental disabilities (ICF/I-DD), and
				  long-term care hospitals (LTH), including psychiatric care facilities for
				  children and youth under age twenty-one (21), and the Eleanor Slater Hospital.
				  In Rhode Island, these institutions are licensed by the Department of Health as
				  "health care facilities" under R.I. Gen. Laws Chapter 23-17.
B. The characteristics of health institutions
				  for Medicaid LTSS coverage purposes are as follows:
1. They operate as residential facilities and
				  assume total care of a person who is admitted.
2. The comprehensive care provided includes
				  room and board. Medicaid LTSS provided in a home or community-based setting is
				  specifically prohibited under Title XIX from covering room and board.
3. The comprehensive services health
				  institutions provide are billed and reimbursed as a single bundled payment. The
				  State may vary the services included as part of the bundled rate across
				  institutions. Therefore, a covered service included as part of a bundled rate
				  in one institutional setting may be billed as a separate service in another
				  setting.
4. Medicaid payment is
				  only available if the State licensed or certified health institution meets
				  applicable federal standards to qualify for federal financial participation
				  under the Medicaid State Plan.
5.
				  Health institutions are subject to regulatory oversight, including surveys at
				  regular intervals, to maintain their certification, license to operate, and
				  status as Medicaid providers; and
6. The rights and safety of patients and
				  residents are protected in accordance with Title XIX of the Social Security Act
				  at 42 U.S.C. §§ 1902(i), 1902(y) and 1919(h) and R.I. Gen. Laws
				  Chapter
				  23-17-19.1.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 1 - Medicaid Long-Term Services and Supports: Institutionally Based LTSS (210-RICR-50-05-1) › Section 210-RICR-50-05-1.2 - Legal Authority

Current through June 14, 2024
A. This Part is
				  promulgated pursuant to the following federal and state authorities:
1. Federal Law -- Title XIX of the U.S.
				  Social Security Act
				   42 U.S.C. §§
												1396a, 1902(a), 1905, 1913, 1915(c)-(k),
				  1917(f), 1919,
				  1922.
2. Federal Regulations --
				   42 C.F.R. §§
												431.151, 433.15, 433.36(h), 435.1110, 440.160, 441.154, 447.15   and 20-21,
				  447.257,
				  447.204,
				  456.600-665,
				  483.440,
				  and 488.430-442.
3. The RI Medicaid
				  State Plan and the Title XIX, Section 1115(a) Demonstration Waiver
				  (11-W-00242/1), effective through December 31, 2018.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 1 - Medicaid Long-Term Services and Supports: Institutionally Based LTSS (210-RICR-50-05-1) › Section 210-RICR-50-05-1.3 - Definitions

Current through June 14, 2024
A. For the purposes of this Part, the terms
				  below are defined as follows:
1. "Institute
				  for Mental Disease" or "IMD" means any hospital, nursing facility, or other
				  licensed health facility or institution of more than sixteen (16) beds, that is
				  primarily engaged in providing diagnosis, treatment, or care of persons with
				  mental diseases, including medical attention, nursing care, and related
				  services.
2. "IMD exclusion" means
				  the provision in Section 1905(a)(B) of Title XIX of the Social Security Act,
				  the federal Medicaid law, that prohibits federal matching payments for
				  psychiatric, behavioral health, or substance use treatment services provided
				  for any person in an IMD who is under sixty-five (65) years of age except for
				  inpatient psychiatric hospital services for children and youth under age
				  twenty-one (21).
3. "Preadmission
				  Screening and Resident Review" or "PASRR" means the evaluation for serious
				  mental illness and/or intellectual disability that is conducted by a NF and
				  reviewed by the State for all persons seeking admission to a NF as set forth in
				  Subchapter 00 Part 5 of this Chapter.
4. "Primary care essential benefits" means
				  and includes non-LTSS Medicaid health coverage, and includes an array of acute,
				  subacute, and specialty essential benefits, as identified under the Medicaid
				  State Plan, provided by licensed health professionals. These essential benefits
				  include, but are not limited to: health promotion, disease prevention, health
				  maintenance, counseling, patient education, various specialty services and
				  diagnosis and treatment of acute and chronic medical and behavioral health
				  illnesses and conditions in a variety of health care settings (such as office
				  visits, inpatient, home care, day care).
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 1 - Medicaid Long-Term Services and Supports: Institutionally Based LTSS (210-RICR-50-05-1) › Section 210-RICR-50-05-1.4 - Accessing Medicaid in Health Institutions

Current through June 14, 2024
A.
				  Medicaid LTSS is available to applicants and beneficiaries who meet the
				  non-financial, financial and functional/clinical eligibility criteria for
				  eligibility set forth in Subchapter 00 Part 5 of this Chapter.
1. Continuous need for LTSS - A person must
				  have an established need for continuous LTSS as set forth in Subchapter 00 Part
				  1 of this Chapter to qualify for LTSS in a health institution.
2. Highest need for LTSS -- As indicated in
				  the provisions on functional/clinical eligibility in Subchapter 00 Part 5 of
				  this Chapter, access to LTSS in health institutions is tied to the level of
				  need. Under the terms of the State's Section 1115 demonstration, an applicant
				  or beneficiary must have the highest need for an institutional level of care to
				  access care in a nursing facility, ICF/I-DD or long-term hospital.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 1 - Medicaid Long-Term Services and Supports: Institutionally Based LTSS (210-RICR-50-05-1) › Section 210-RICR-50-05-1.5 - Medicaid LTSS in Nursing Facilities

Current through June 14, 2024
A. In general,
				  licensed nursing facilities provide a mix of the following services:
1. Skilled nursing -- Intermittent or
				  continuous skilled nursing or medical care and related services to address a
				  clinical condition and/or functional limitation;
2. Subacute care -- Rehabilitative services
				  needed due to injury, disability, or illness;
3. Long term services and supports --
				  Health-related services and supports (above the level of room and board) needed
				  regularly due to a clinical or functional disability. Previously referred to as
				  "custodial care";
4. Hospice care -
				  An array of services furnished to terminally ill beneficiaries including,
				  nursing, medical social services, physician services, counseling services for
				  the beneficiary, family members, and/or other care givers. When provided in a
				  NF, hospice is an elective service in which the beneficiary waives access to
				  treatments to cure the terminal illness in favor of palliative care. This
				  election may be revoked at any time.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 1 - Medicaid Long-Term Services and Supports: Institutionally Based LTSS (210-RICR-50-05-1) › Section 210-RICR-50-05-1.6 - Medicaid in an ICF/I-DD

Current through June 14, 2024
A. Intermediate
				  care facility services for people with intellectual/developmental disabilities
				  (ICF/I-DD) is an optional Medicaid benefit that provides comprehensive and
				  individualized health care and rehabilitation services to optimize the
				  functional status and independence of beneficiaries. In Rhode Island, ICF/I-DDs
				  are licensed health care facilities that serve a limited number of
				  beneficiaries in need of, and receiving, active treatment (AT) services.
B. The ICF/I-DD service is the
				  most comprehensive benefit in Medicaid LTSS. In general, ICF/I-DD Medicaid
				  covered services include, but are not limited to:
1. Active treatment - In an ICF/I-DD, AT is a
				  continuous, aggressive, and consistent implementation of a program of
				  specialized and generic training, treatment, and health or related services,
				  directed toward helping a beneficiary function with as much self-determination
				  and independence as possible. All services including health care services and
				  nutrition are part of the AT, which is based on an evaluation and
				  individualized program plan (IPP) by an interdisciplinary team. AT provides a
				  continuous program of habilitation that excludes services to maintain generally
				  independent beneficiaries who are able to function with little
				  supervision.
2. Day programs --
				  ICF/I-DD residents work in the community, with supports, or participate in
				  vocational or other activities outside of the residence and engage in community
				  interests of their choice. These activities are collectively often referred to
				  as "day programs" and are often included as AT, though they may be covered
				  separately as an HCBS core service for a beneficiary transitioning from an
				  ICF/I-DD to a community setting.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 1 - Medicaid Long-Term Services and Supports: Institutionally Based LTSS (210-RICR-50-05-1) › Section 210-RICR-50-05-1.7 - Medicaid LTSS in a Hospital

Current through June 14, 2024
A. Medicaid LTSS in
				  a hospital is a Medicaid State Plan covered service for certain applicants and
				  beneficiaries who meet age and need requirements. Access is limited by the
				  provision in federal law which defines any health institution which provides
				  behavioral health, psychiatric, substance use or related services to more than
				  sixteen (16) beds as an "Institute for Mental Disease." Federal Medicaid
				  matching funds are not available for LTSS provided in an IMD for beneficiaries
				  aged 21 through 64. In addition, the State does not currently license any
				  health institutions as "long-term acute care treatment (LTAC) facilities." This
				  is the category of licensure for hospitals that provide an array of LTSS for
				  people with non-IMD chronic and disabling conditions. Within these limitations,
				  Medicaid LTSS hospital services are available only as follows:
1. Habilitation - Persons who have highest
				  level of need for habilitative services may access the care they need in a
				  hospital setting if HCBS options are unavailable.
2. Psychiatric Services Under Age 21 --
				  Medicaid covered hospital services are covered for children and youth through
				  age twenty-one (21) in psychiatric residential treatment facilities (PRTFs). A
				  PRTF provides intensive, short term comprehensive mental and behavioral health
				  services for a range of clinical conditions that can most effectively be
				  addressed in a residential treatment facility in collaboration with family
				  members, other agencies, and the community to offer strengths-based, culturally
				  competent, medically appropriate treatment for mental illness and emotional and
				  behavioral issues.
3. Over age 65 -
				  Medicaid LTSS covers IMD services in a hospital or NF for persons sixty-five
				  (65) and older. To access these services, an applicant or beneficiary must be
				  found in the PASSR evaluation process to require services for a mental illness
				  or intellectual disability in accordance with Subchapter 00 Part 5 of this
				  Chapter. Medicaid covered services are based on need and include the full range
				  of State Plan and waiver services required by the PASSR care plan.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 1 - Medicaid Long-Term Services and Supports: Institutionally Based LTSS (210-RICR-50-05-1) › Section 210-RICR-50-05-1.8 - Medicaid LTSS Beneficiaries Receiving SSI

Current through June 14, 2024
A. SSI
				  recipients who are receiving Medicaid LTSS in a health institution may continue
				  to receive full SSI benefits for up to three (3) months if they have an intent
				  to return to the community within ninety (90) days. A treating, licensed health
				  care practitioner must certify to both the State and the federal Social
				  Security Administration (SSA) that the period of LTSS in the health institution
				  is not expected to exceed ninety (90) days and that continuation of the SSI
				  benefit is necessary for the beneficiary with SSI to retain his or her home. If
				  the beneficiary remains in the health institution for a longer period than
				  expected, the SSA terminates or reduces the SSI payment as
				  appropriate.
B. SSI payments for
				  adults with disabilities who are working and qualify for Section 1619(b) of
				  Title XX, may receive up to two (2) months of continuing SSI benefits when
				  admitted to a health institution if there is an expectation that the
				  beneficiary will continue to work or resume working within the sixty (60) day
				  period.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 2 - Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities, ICF/DD Facilities, and Assisted Living Residences › Section 210-RICR-50-05-2.1 - Introduction and Overview

Current through June 14, 2024
Use of and accountability for funds of residents residing
					 in community medical care, ICF/DD facilities and nursing facilities is an
					 essential requirement for the protection of the residents' rights. In order to
					 ensure proper program and fiscal accountability for these funds and to meet
					 federal law and regulations, the following procedures must be in effect in all
					 nursing facilities for whom EOHHS is responsible for payment through the Title
					 XIX Medicaid Program.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 2 - Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities, ICF/DD Facilities, and Assisted Living Residences › Section 210-RICR-50-05-2.2 - Legal Basis

Current through June 14, 2024
These rules are promulgated pursuant to the authority set
					 forth in R.I. Gen. Laws Chapter
					 40-8 (Medical Assistance) and
					 various sections in the R.I. Gen. Laws including §§40-8-32 and
					 23-17.5-15 related to rights of
					 nursing facility residents;  42 C.F.R. §
											483.10; and Title
					 XIX of the Social Security Act,
					  42 U.S.C. §§
											1396 - 1396w - 7. Additional
					 authority is derived from the State's Medicaid State Plan and the Rhode Island
					 Comprehensive Section
					 1115 D emonstration, as
					 approved in final form on February 25, 2014, and as subsequently
					 amended.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 05 - Institutionally Based LTSS › Part 2 - Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities, ICF/DD Facilities, and Assisted Living Residences › Section 210-RICR-50-05-2.3 - Definitions

Current through June 14, 2024
A. "Applied income" means the amount of
				  income a Medicaid beneficiary is required to contribute to the cost of his or
				  her care.
B. "Assisted living
				  residence" or "ALR" means a publicly or privately operated residence that
				  provides directly or indirectly by means of contracts or arrangements personal
				  assistance and may include the delivery of limited health services, as defined
				  under R.I. Gen. Laws §
										23-17.4-2(12), to
				  meet the resident's changing needs and preferences, lodging, and meals to six
				  (6) or more adults who are unrelated to the licensee or administrator,
				  excluding however, any privately operated establishment or facility licensed
				  pursuant to R.I. Gen. Laws Chapter
				  23-17 and those facilities
				  licensed by or under the jurisdiction of the Department of Behavioral
				  Healthcare, Development Disabilities and Hospitals, the Department of Children,
				  Youth, and Families, or any other state agency.
C. "Cost of care" means the costs of
				  providing care to a resident of a nursing facility, including nursing care,
				  personal care, meals, transportation and any other costs, charges, and expenses
				  incurred by a nursing facility in providing care to a resident. Costs of care
				  shall not exceed the customary rate the nursing facility charges to a resident
				  who pays for his or her care directly rather than through a governmental or
				  other third-party payor.
D.
				  "Executive Office of Health and Human Services" or "EOHHS" means the state
				  agency established in 2006 under the provisions of R.I. Gen. Laws Chapter 427.2
				  within the executive branch of state government and serves as the principal
				  agency for the purposes of managing the Departments of Children, Youth, and
				  Families (DCYF); Health (DOH); Human Services (DHS); and Behavioral Healthcare,
				  Developmental Disabilities, and Hospitals (BHDDH). The EOHHS is designated as
				  the "single state agency," authorized under Title XIX of the U.S. Social
				  Security Act (42 U.S.C. §
											1396a
et seq
.) and,
				  as such, is legally responsible for the program/fiscal management and
				  administration of the Medicaid Program.
E. "Intermediate Care Facility for Persons
				  with Intellectual/Developmental Disabilities" or "ICF/IDD" means a
				  State-licensed health care facility that provides long-term care and services
				  to persons with intellectual /developmental disabilities.
F. "Nursing facility" means a nursing
				  facility licensed under R.I. Gen. Laws Chapter
				  23-17, which is a participating
				  provider in the Rhode Island Medicaid Program.