Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 00 - Integrated Coverage Groups › Part 1 - Overview of Medicaid Integrated Care Coverage (210-RICR-40-00-1) › Section 210-RICR-40-00-1.4 - Definitions

Current through June 14, 2024
A. For the purposes of this chapter, the
				  following definitions apply:
1. "Affordable
				  Care Act (ACA)" means The Patient Protection and Affordable Care Act of 2010 (Pub. L.
				  111-148), as amended by the Health Care and
				  Education Reconciliation Act of 2010 (Pub.
				  111-152), as amended by the Three Percent
				  Withholding Repeal and Job Creation Act (Pub. L.
				  112-56).
2. "Applicant" means the person in the
				  household who, if determined eligible, would qualify for Medicaid in one of the
				  Integrated Health Care Coverage groups on the basis of the provisions set forth
				  herein.
3. "Calendar quarter" means
				  a period of three full calendar months beginning with January, April, July, or
				  October.
4. "Community Medicaid"
				  means the term used to refer to IHCC groups that are provided with Medicaid
				  health coverage for essential primary care and limited preventive services in
				  some circumstances, but does not include more than thirty (30) days of
				  continuous LTSS.
5. "Executive
				  Office of Health and Human Services (EOHHS)" means the state agency that is
				  designated under the Medicaid State Plan as the Single State Agency responsible
				  for the administration of the Title XIX Medicaid Program.
6. "Dual Eligible Beneficiary" means a person
				  who is enrolled in Medicaid and Medicare. The term includes elders and adults
				  with disabilities who are enrolled in Medicare and receive Medicaid health
				  coverage and/or financial assistance through the State's Medicare Premium
				  Payment Program (MPPP).
7. "Income
				  Standard" means the maximum amount of countable income a person can have for
				  Medicaid health coverage through an eligibility pathway or coverage group
				  subsequent to all required exclusions, disregards, and deductions. Also
				  referred to as the "income limit."
8. "Long-Term Services and Supports (LTSS)"
				  means a spectrum of services covered by the Rhode Island Medicaid program for
				  persons with clinical and functional impairments and/or chronic illness that
				  require the level of care typically provided in a health care institution.
				  Medicaid LTSS includes skilled or custodial nursing facility care, therapeutic
				  day services, and personal care as well as various home and community-based
				  services. Medicaid beneficiaries eligible for LTSS are also provided with
				  primary care essential benefits.
9.
				  "Managed Care Arrangement (MCA)" means a system, often a managed care
				  organization (MCO) that uses capitated financing to deliver high quality
				  services and promote healthy outcomes through a medical home. Such an
				  arrangement also includes services and supports that optimize the health and
				  independence of beneficiaries who are determined to need or be at risk for
				  Medicaid funded LTSS. Section §
											1.5   of this Part identifies
				  the Medicaid managed care arrangements that serve IHCC elders, adults with
				  disabilities and beneficiaries requiring LTSS; Medicaid Code of Administrative
				  Rules Sections: RIte Care, Rhody Health Program, Enrollment, RIte Share
				  Program, and Communities of Care pertain to managed Medicaid delivery systems
				  for the MACC populations without regard to the basis for eligibility - MAGI,
				  SSI, special requirements, etc.
10.
				  "Medicaid Affordable Care Coverage (MACC) Groups" means the populations whose
				  income eligibility for Medicaid is determined on the basis of the Modified
				  Adjusted Gross Income (MAGI) standard. Includes children up to age 19,
				  parents/caretakers, pregnant women, and otherwise ineligible adults 19 to 64 in
				  accordance with the provisions established in the Medicaid Code of
				  Administrative Rules, Overview of the Affordable Care Coverage Groups.
11. "Medicaid Code of
				  Administrative Rules (MCAR)" means the collection of administrative rules
				  governing the Medicaid program in Rhode Island.
12. "Primary Care Essential Benefits" means
				  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 (e.g., office
				  visits, inpatient, home care, day care, etc.).
13. "Primary Care Provider" means a health
				  care practitioner who is licensed as:
a. a
				  physician with a primary specialty designation of family medicine, internal
				  medicine, geriatric medicine, or pediatric medicine and is responsible for
				  monitoring a beneficiary's overall health; or
b. a nurse practitioner, clinical nurse
				  specialist, or physician assistant and, to the extent licensure allows, is
				  responsible for, or collaborates with a physician, monitoring a beneficiary's
				  overall health.
14.
				  "Resource Standard" means the maximum amount of resources a person can have for
				  Medicaid health coverage through an eligibility pathway or coverage group
				  subsequent to the application of all required exclusions. Also referred to as
				  the "resource limit."
15.
				  "Wrap-around Coverage" means the Medicaid benefits provided to a beneficiary
				  who has another form of health insurance - e.g., Medicare or commercial plan -
				  that serves as the principal payer for his or her health care, but that does
				  not cover those benefits.