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 1 - Medicaid Long-Term Services and Supports Overview and Eligibility Pathways › Section 210-RICR-50-00-1.3 - Definitions

Current through June 14, 2024
A. For the purposes of LTSS Medicaid, the
				  following definitions apply:
1. "Department of
				  Behavioral Healthcare, Developmental Disabilities, and Hospitals" or "BHDDH"
				  means the State agency established under the provisions of R.I. Gen. Laws
				  Chapter 40.1-1 whose duty it is to serve
				  as the State's mental health authority and establish and promulgate the overall
				  plans, policies, objectives, and priorities for State programs for adults with
				  intellectual and developmental disabilities as well mental illness and
				  substance abuse education, prevention and treatment.
2. "Department of Human Services" or "DHS"
				  means the State agency established under the provisions of R.I. Gen. Laws
				  Chapter 40-1 that is empowered to
				  administer certain human services. The DHS has been delegated the authority
				  through an interagency service agreement with the Executive Office of Health
				  and Human Services (EOHHS), the Medicaid Single State Agency, to determine
				  Medicaid eligibility in accordance with applicable State and Federal laws,
				  Rules and Regulations.
3.
				  "Developmental disability" means, for the purposes of the Rhode Island
				  Department of Behavioral Healthcare, Developmental Disabilities and Hospitals,
				  a condition that affects a person, eighteen (18) years or older, who is either
				  an intellectually developmentally disabled adult or a person with a severe,
				  chronic disability that:
a. Is attributable to
				  a mental or physical impairment or combination of mental and physical
				  impairments;
b. Manifests before
				  the person attains age twenty-two (22);
c. Is likely to continue
				  indefinitely;
d. Results in
				  substantial functional limitations in three (3) or more of the following areas
				  of major life activity:
(1) Personal
				  care
(2) Communication
(3) Mobility
(4) Learning
(5) Self-direction
(6) Capacity for independent living
(7) Economic self-sufficiency; and
(8) Reflects the person's need for a
				  combination and sequence of special, interdisciplinary, or generic care,
				  treatment or other services which are life-long or of extended duration and are
				  individually planned and coordinated.
4. "Eligibility date" means the first
				  (1st) day of the month in which a person is eligible
				  for Medicaid LTSS. It is based on the month the application or, for existing
				  beneficiaries, the request for LTSS is made and is otherwise unrelated to the
				  date a person entered an institution or began receiving LTSS, regardless of
				  payer. The eligibility date does not include periods of retroactive
				  eligibility.
5. "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
				  42-7.2 within the executive branch
				  of State government which serves as the principal agency for managing the
				  Departments of Children, Youth, and Families (DCYF); Health (RIDOH); Human
				  Services (DHS); and Behavioral Healthcare, Developmental Disabilities, and
				  Hospitals (BHDDH).
6. "Financial
				  eligibility" means the set of factors used to determine whether a person is
				  entitled to receive services based upon income and/or resource requirements, as
				  well as limitations related to the transfer of assets, which includes both
				  liquid resources and real property, prior to the application for Medicaid
				  LTSS.
7. "Functional disability"
				  means any long-term limitation resulting from an illness, health condition, or
				  impairment that affects a person's ability to perform certain activities of
				  daily living without substantial assistance or supervision.
8. "Home and Community-Based Services" or
				  "HCBS" means any Medicaid LTSS State Plan or Section 1115 waiver-authorized
				  services available to beneficiaries at home or in a community-based
				  setting.
9. "Institution" or
				  "Health institution" means a State-licensed health facility that provides
				  health and/or social services and supports on an in-patient basis. For the
				  purposes of this Rule, the term means long-term care hospitals and treatment
				  facilities (LTH), intermediate care facilities for persons with intellectual
				  disabilities (ICF/ID), and nursing facilities (NF).
10. "Integrated Health Care Coverage Groups"
				  or "IHCC" means any Medicaid coverage group consisting of adults who are
				  eligible based on receipt of Supplemental Security Income (SSI), SSI protected
				  status, the SSI income methodology and a related characteristic (age or
				  disability), or as a result of participation in another Federal or State
				  program, such as the Breast and Cervical Cancer Program. This group includes
				  beneficiaries eligible for community Medicaid (non-long-term care),
				  Medicaid-funded LTSS and the Medicare Premium Payment Program (MPPP).
11. "Integrated Health and Human Services
				  Eligibility System" or "IES" means the State's eligibility system that enables
				  applicants, through a single application, to be considered for multiple health
				  and human service programs simultaneously.
12. "Intermediate Care Facility for Persons
				  with Intellectual/Developmental Disabilities" or "ICF/ID" means a
				  State-licensed health care facility that provides long-term services and
				  supports to persons with intellectual/developmental disabilities.
13. "Katie Beckett eligibility" means an
				  eligibility category that allows certain children under age nineteen (19) who
				  have long-term disabilities or complex medical needs who require an
				  institutional level of care to obtain the Medicaid long-term services they need
				  at home. With Katie Beckett eligibility, only the child's income and resources
				  are considered when determining eligibility.
14. "Long-term services and supports" or
				  "LTSS" means a spectrum of services covered by the Medicaid program for persons
				  with clinical and functional impairments and/or chronic illness or diseases
				  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. The scope of these services and supports and
				  the choice of settings is determined by a comprehensive assessment of each
				  person's unique care needs.
15.
				  "LTSS living arrangement" means the institutional or home or community based
				  setting where a Medicaid LTSS beneficiary resides while receiving Medicaid
				  LTSS.
16. "LTSS specialist" means a
				  State agency representative responsible for conducting assessments, determining
				  eligibility for LTSS, authorizing services, and/or providing assistance to
				  people in navigating the Medicaid LTSS system.
17. "Medicaid Affordable Care Coverage
				  Groups" or "MACC" means a classification of persons eligible to receive
				  Medicaid who are subject to the Modified Adjusted Gross Income or "MAGI"
				  standard for determining income eligibility as outlined in the Medicaid Code of
				  Administrative Rules, Medicaid MAGI Financial Eligibility Determinations and
				  Verification (See Part
				  30-00-5 of this Title).
18. "MAGI standard" means the method for
				  evaluating Medicaid income eligibility using the modified adjusted gross income
				  (MAGI) standard established under the ACA. Persons who are or would be
				  income-eligible for the ACA expansion for adults may obtain Medicaid LTSS if
				  they meet the applicable clinical/functional eligibility criteria, are under
				  age sixty-five (65), and are not eligible for or enrolled in
				  Medicare.
19. "Medicaid single
				  state agency" means the State agency authorized under State law, Title XIX of
				  the U.S. Social Security Act (42 U.S.C. §
												1396a
et
				  seq
.) and the Medicaid State Plan as the entity legally responsible
				  for the program/fiscal management and administration of the Medicaid program.
				  The EOHHS is the designated single State agency in Rhode Island.
20. "Needs-based criteria" means the basis
				  for determining clinical/functional eligibility for Medicaid LTSS. The LTSS
				  needs-based criteria encompass medical, social, functional, and behavioral
				  factors, and the availability of family support and financial
				  resources.
21. "Preadmission
				  Screening and Resident Review" or "PASRR" means the process required by Federal
				  law that evaluates and ensures individuals who have a serious mental illness
				  (SMI) and/or intellectual disability are not inappropriately placed in nursing
				  facilities for long-term care. PASRR requires that those applicants for a
				  Medicaid-certified nursing facility are evaluated for
				  appropriateness.
22. "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
				  such as office visits, inpatient, home care, and day care.