Rhode Island Code of Regulations › 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 › Section 210-RICR-30-00-1.8 - Cooperation Requirements

Current through June 14, 2024
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.