Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 10 - Managed Care › Part 1 - Managed Care Service Delivery Arrangements › Section 210-RICR-40-10-1.2 - Definitions

Current through June 14, 2024
A. For the purpose of this Rule, the
				  following terms are defined as follows:
1.
				  "Appeal" means a request to review an "adverse benefit determination" based on
				  medical necessity, appropriateness, health care setting, and
				  effectiveness.
2. "Categorical
				  eligibility" means an applicant/beneficiary included in an IHCC group who is
				  eligible for Medicaid health coverage on the basis of income, resources, a
				  characteristic, and/or a level of need in a mandatory or optional coverage
				  group under the Medicaid State Plan, or who is treated as such, under the
				  State's Section 1115 demonstration waiver, in accordance with Title XIX. It
				  excludes persons who must spenddown to become eligible for Medicaid health
				  coverage as medically needy.
3.
				  "Elders and adults with disabilities" or "EAD" means the Medicaid IHCC group
				  established by R.I. Gen. Laws Chapter 40-8.5 for adults with an SSI
				  characteristic related to age (elders sixty-five (65) years of age or older) or
				  disability.
4. "Executive Office of
				  Health and Human Services" or "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.
5. "Full dual eligible" means a beneficiary
				  who is enrolled in Medicare Parts A and B and is eligible for Medicaid Health
				  Coverage through an IHCC or MACC group for elders and adults with disabilities
				  on the basis of income, resources and, when applicable, a characteristic or
				  need for LTSS.
6. "Grievance" means
				  an expression of dissatisfaction about any matter other than an action
				  associated with an adverse benefit determination and includes complaints about
				  the quality of care or services provided, and aspects of interpersonal
				  relations such as rudeness of a provider or an employee or a failure to respect
				  an enrollee's rights.
7.
				  "Integrated Health Care Coverage Group" or "IHCC" means any Medicaid coverage
				  group consisting of adults who are eligible on the basis of 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 (e.g., Breast and Cervical
				  Cancer). Includes beneficiaries eligible for community Medicaid (non-long-term
				  care), Medicaid-funded LTSS, and the Medicare Premium Payment Program
				  (MPP).
8. "Integrated Care
				  Initiative" or "ICI" means a Medicaid initiative that delivers integrated and
				  coordinated services to certain Medicaid and Medicare enrolled (MME)
				  beneficiaries through a managed care arrangement. The ICI includes services
				  from across the care continuum including primary, subacute, and long-term care.
				  The Medicare-Medicaid Plan (MMP) was established through ICI.
9. "Long-term services and supports" or
				  "LTSS" means a spectrum of services covered by the Rhode Island Medicaid
				  program that are required by individuals with functional impairments and/or
				  chronic illness, and includes skilled or custodial nursing facility care, as
				  well as various home and community-based services.
10. "Managed care arrangement" or "MCA" means
				  a system that may use capitated financing to deliver high quality services and
				  promote and optimize health 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. An MCA includes any arrangement under which an MCO or
				  contracted entity is granted some or all of the responsibility for providing
				  and/or paying for long-term care services and supports through a contractual
				  agreement with the Medicaid program.
11. "Managed care organization" or "MCO"
				  means an entity that provides health plan(s) that integrate an efficient
				  financing mechanism with quality service delivery, provides a "medical home" to
				  assure appropriate care and deter unnecessary services, and emphasizes
				  preventive and primary care.
12.
				  "Medicaid Affordable Care Coverage Groups" 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 as outlined in
				  Part 30-00-1 of this Title.
13.
				  "Medicaid and Medicare enrolled" or "MME" means full dual eligible or partial
				  dual eligible plus beneficiaries who are receiving Medicaid health coverage,
				  are enrolled in Medicare Part A, enrolled in Medicare Part B, and eligible to
				  enroll in Medicare Part D.
14.
				  "Medicaid health coverage" means the full scope of health care services and
				  supports authorized under the State's Medicaid State Plan and/or Section 1115
				  demonstration waiver provided through an authorized Medicaid delivery system.
				  The term encompasses the scope of health coverage available to categorically
				  and medically needy eligible beneficiaries as well as those who are treated as
				  such under the State's Section 1115 demonstration waiver. However, the term
				  does not apply to partial dual eligible persons who, under the provisions of
				  this section, qualify only for financial assistance through the MPPP to help
				  pay Medicare cost-sharing.
15.
				  "Medically necessary service" means a medical, surgical, or other service
				  required for the prevention, diagnosis, cure, or treatment of a health-related
				  condition including any such services that are necessary to prevent or slow a
				  decremental change in either medical or mental health status.
16. "Medically needy" means an IHCC group for
				  elders and persons with disabilities who have high medical expenses and income
				  that exceeds the maximum eligibility threshold for Medicaid. For non-LTSS
				  beneficiaries in this coverage group, Medicaid eligibility and coverage occur
				  when the amount they spend on medical expenses meets the medically needy income
				  limit established by the State. For LTSS beneficiaries, excess income must be
				  contributed toward the cost of care. Non-LTSS medically needy beneficiaries are
				  covered on a fee-for-service basis.
17. "Medicare-Medicaid Plan" or "MMP" is an
				  integrated managed care plan under contract with the Federal Centers for
				  Medicare and Medicaid Services (CMS) and EOHHS to provide fully integrated
				  Medicare and Medicaid benefits to eligible MME beneficiaries.
18. "Member" or "Enrollee" means a
				  Medicaid-eligible person receiving benefits through Rhody Health Partners, a
				  Medicare-Medicaid Plan, or the Program for All-Inclusive Care for the
				  Elderly.
19. "Partial dual
				  eligible" means a Medicare beneficiary who does not meet the requirements for
				  Medicaid Health Coverage, but who is eligible for the State's Medicare Premium
				  Payment Program (MPP).
20. "Partial
				  dual eligible plus" means a Medicare beneficiary who is eligible for Medicaid
				  health coverage as medically needy and the MPP.
21. "Person-centered planning" means an
				  individualized approach to planning that supports an individual to share his or
				  her desires and goals, to consider different options for support, and to learn
				  about the benefits and risks of each option. Person-centered planning places
				  the individual at the center of decision-making. It is designed to enable
				  people to direct their own services and supports to live a meaningful life that
				  maximizes independence and community participation. Person-centered planning is
				  a process that is directed by the individual, with impartial assistance and
				  supported decision-making when helpful. Person-centered planning teams may
				  include people who are close to the individual, as well as people who can help
				  to bring about needed change for the person and access to appropriate services.
				  However, at all times, the individual is empowered to decide who is part of the
				  planning team. Person-centered planning must meet the requirements of
				   42 C.F.R. §
												441.301(c)(1)  including, but
				  not limited to, ensuring that a person has sufficient and necessary information
				  in a form he/she can understand to make informed choices, enabling the person
				  to direct the process to the maximum extent possible, and conducting planning
				  meetings at times and in locations that are convenient to the
				  individual.
22. "Primary care"
				  means an array of primary, acute, and specialty services provided by licensed
				  health professionals that includes, but is 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, inpatient, care, home care, day care).
23. "Program of All Inclusive Care for the
				  Elderly" or "PACE" means a risk-based managed care service delivery option for
				  beneficiaries who have Medicare and/or Medicaid coverage and meet the financial
				  and clinical criteria for a nursing facility level of long-term services and
				  supports. Beneficiaries must be fifty-five (55) years or older to participate
				  in this option.
24. "Rhody Health
				  Options" or "RHO" means the capitated managed care delivery system operating
				  under contract with EOHHS to manage and coordinate Medicaid covered services
				  and supports, including LTSS, for eligible MNM and MME beneficiaries and to
				  coordinate Medicaid covered services with Medicare covered services for
				  eligible MME beneficiaries. RHO terminates as service delivery option on
				  September 30, 2018.
25. "Rhody
				  Health Partners" or "RHP" means the Medicaid managed care service delivery
				  option for adults in the IHCC groups that provides primary/acute and specialty
				  care through a medical home that focuses on prevention and promoting healthy
				  outcomes. The Rules for RHP for adults ages nineteen to sixty-four (19 - 64) in
				  the MACC groups are located in Part 30-05-2 of this Title.
26. "SSI income standard" means the basis for
				  determining Medicaid eligibility that uses the definitions and calculations for
				  evaluating income and resources established by the U.S. Social Security
				  Administration for the Supplemental Security Income (SSI) program.
27. "SSI protected status" means the class of
				  beneficiaries who retain categorical eligibility for Medicaid even though they
				  are no longer eligible for SSI due to certain changes in income or
				  resources.