reglab/statecodes huggingface dataset:
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 1 - Medicaid for Elders and Adults with Disabilities: Community Medicaid › Section 210-RICR-40-05-1.3 - Scope and Purpose

Current through June 14, 2024
This purpose of this Rule is to establish and describe the
					 Community Medicaid IHCC groups and the requirements for determining Medicaid
					 eligibility, effective on and after the effective date of this Rule. The
					 summary table below shows each of these groups and the agency authorized to
					 determine eligibility or the basis for eligibility:
Community Medicaid
								  Eligibility Pathways
IHCC
								  Group
Agency Responsible for
								  Determining Eligibility
Low-income Elders and Adults with Disabilities
								  (EAD)
EOHHS
SSI Recipients
Social Security Administration (SSA)
SSP Recipients
SSA and EOHHS
Pickle Amendment
EOHHS
§ 1619(a) Employed Adults with
								  Disabilities
SSA
§ 1619(b) Medicaid While
								  Working
SSA
Protected Surviving Spouses
EOHHS
Adult Children with Disabilities
EOHHS
Divorced/Surviving Spouses with
								  Disabilities
SSA
SSP Recipients, 12/73
EOHHS
Divorced/Surviving Spouses with Disabilities -
								  Actuarial Changes
SSA
Breast and Cervical Cancer Screening and
								  Treatment
Department of Health (DOH)
Refugee Medicaid Assistance (RMA)
EOHHS
Sherlock Plan
EOHHS
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 1 - Medicaid for Elders and Adults with Disabilities: Community Medicaid › Section 210-RICR-40-05-1.4 - Definitions

Current through June 14, 2024
A. For the purposes of this section, the
				  following definitions apply:
1. "Adult
				  dependent child" means an unmarried person eighteen (18) years of age or older
				  who has a disabling impairment that began before age twenty-two (22) that is
				  collecting disability related benefits from the U.S. Social Security
				  Administration (SSA).
2.
				  "Applicant" means the person seeking initial or continuing eligibility for
				  Medicaid.
3. "Community Medicaid
				  eligibility standards" means the income and resource standards used as the
				  basis for determining initial and continuing Medicaid eligibility for each
				  coverage group included in this section.
4. "Deemed income" means income attributed to
				  another person whether or not the income is actually available to the person to
				  whom it is deemed.
5. "Deemor"
				  means a person whose income and/or resources are subject to deeming. Such
				  individuals include non-applicant parents and spouses and sponsors of
				  non-citizens.
6. "Non-applicant" or
				  "NAPP" means a person whose finances are considered for deeming purposes
				  although is not seeking or is unqualified for Medicaid.
7. "Parent" means a natural or adoptive
				  father or mother living in the same household as the eligible child.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 1 - Medicaid for Elders and Adults with Disabilities: Community Medicaid › Section 210-RICR-40-05-1.5 - Eligibility for Elders and Adults with Disabilities

Current through June 14, 2024
1.5.1
Scope and Purpose
This section identifies the chief eligibility pathways for
					 persons sixty-five (65) and older and nineteen (19) to sixty-four (64) who are
					 living with a disabling impairment - adults with disabilities.
1.5.2
EAD Eligibility Pathway -
				  Low-income Elders and Adults with Disabilities
A. Under the Social Security Act,
				   42 U.S.C. §
												1396(a), States have the
				  option under the Medicaid State Plan of expanding eligibility to elders and
				  adults with disabilities up to and inclusive of one hundred percent (100%) of
				  the FPL. Rhode Island chose this option in 1999 and now refers to this
				  categorically eligible expansion group by the acronym "EAD." The EAD coverage
				  group has higher income and resource limits than the SSI program and serves,
				  therefore, as the State's chief general eligibility pathway for anyone with an
				  SSI characteristic who does not qualify for SSI benefits. Coverage group
				  features are as follows:
1. Eligibility
				  Criteria - To qualify for Medicaid coverage through the EAD eligibility
				  pathway, a person must meet the general eligibility requirements related to
				  residency, citizenship and cooperation set forth in §
												1.9   of this Part and the
				  following:
a. Characteristic Requirements. A
				  person must be without SSI and meet the characteristic requirements with
				  respect to:
(1) Age. Sixty-five (65) and
				  older; or
(2) Disability.
				  Determined by the State's Medicaid Assessment and Review Team (MART) to meet
				  the applicable SSI disability standards; or
(3) Blindness. Federal Regulations preclude
				  States that have expanded SSI-based eligibility to income above the SSI
				  standard (at or below seventy-five percent (75%)) to treat blindness as a
				  distinct eligibility characteristic. Accordingly, applicants who are blind and
				  are ineligible for SSI or an SSI Protected Status are subject to a MART
				  disability determination.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 1 - Medicaid for Elders and Adults with Disabilities: Community Medicaid › Section 210-RICR-40-05-1.6 - The Medicare Premium Payment Program (MPPP)

Current through June 14, 2024
1.6.1
Scope and Purpose
A. The Medicare Premium Payment Program
				  (MPPP) helps low-income elders sixty-five (65) and older and adults with
				  disabilities pay all or some of the costs of Medicare Part A and Part B
				  premiums, deductibles and co-payments.
1.
				  Basis of Eligibility - A person's income and resources, as calculated using the
				  SSI methodology, determine which type of Medicare premium assistance is
				  available. Members of this coverage group are known as "dual eligible," as they
				  qualify for both Medicare and Medicaid, as defined below:
a. Dual eligible beneficiaries who qualify
				  for the MPPP, but not full Medicaid health coverage are referred to as "partial
				  dual eligible" beneficiaries.
b.
				  Dual eligible beneficiaries who meet the all the eligibility requirements for
				  an IHCC or MACC group and are enrolled in Medicare Part A and Part B are known
				  as "full dual eligible beneficiaries."
c. Dual eligible beneficiaries who receive
				  Medicaid health coverage through the MN pathway, and meet the income
				  requirements for the MPPP, are referred to as "partial dual eligible plus
				  beneficiaries."
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 1 - Medicaid for Elders and Adults with Disabilities: Community Medicaid › Section 210-RICR-40-05-1.8 - Community Medicaid - LTSS Preventive Services

Current through June 14, 2024
1.8.1
Authority
Under the terms of the State's §1115 demonstration waiver,
					 Community Medicaid beneficiaries who do not yet need Medicaid LTSS but are at
					 risk for the nursing facility institutional level of care have access to LTSS
					 preventive services. Beneficiaries who meet the needs-based criteria for these
					 LTSS preventive services are eligible for a limited range of home and
					 community-based services and supports along with the full range of primary care
					 essential benefits they are entitled to receive. The goal of preventive
					 services is to delay or avert LTSS institutionalization or more extensive and
					 intensive home and community-based care.
1.8.2
Scope of Services
A. Depending on a beneficiary's needs, the
				  following LTSS preventive services may be available to Community Medicaid
				  beneficiaries:
1. Limited Certified Nursing
				  Assistant/Homemaker Services - These services include general household tasks
				  (e.g., meal preparation and routine household care) and are available when a
				  beneficiary can no longer perform them on their own and there is no other
				  person available to provide assistance. Limited personal care may also be
				  available.
a. Maximum hours available: Six (6)
				  hours per week for a single beneficiary or ten (10) hours per week for a
				  household with two (2) or more beneficiaries.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 1 - Medicaid for Elders and Adults with Disabilities: Community Medicaid › Section 210-RICR-40-05-1.9 - Community Medicaid General Eligibility Requirements

Current through June 14, 2024
1.9.1
Scope and Purpose
All applicants for Medicaid in the IHCC groups must meet
					 general eligibility requirements in addition to those related to income,
					 resources, and clinical need.
1.9.2
Characteristic
				  Requirements
A. Unless specifically
				  exempt, a person applying for Community Medicaid when eligibility is determined
				  by the State must establish their categorical relationship to SSI by qualifying
				  on the basis of one (1) of the following characteristics:
1. Age - A person qualifying on the basis of
				  age must be at least sixty-five (65) years of age in or before the month in
				  which eligibility begins.
a. Verification: An
				  applicant's age is verified electronically with information about date of birth
				  from the SSA and/or the Rhode Island Department of Health, Division of Vital
				  Statistics. If data matches are unsuccessful, an applicant is required to
				  provide paper documentation of date of birth to support a self-attestation of
				  age.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 2 - Community Medicaid: Medically Needy Eligibility › Section 210-RICR-40-05-2.1 - Scope and Purposes

Current through June 14, 2024
A. A medically needy
				  (MN) spenddown, previously referred to as the "Flexible Test of Income", is a
				  cost-sharing approach that provides a Medicaid eligibility pathway for certain
				  people who have income above the limit for their applicable coverage group if
				  they have high health expenses. Under the State's Medicaid State Plan, members
				  of these populations become eligible for Medicaid by "spending down" their
				  income to a limit established by the State - known as the medically needy
				  income limit or "MNIL" by deducting certain health care expenses. The following
				  populations may be medically needy eligible under this section:
1. Elders and adults with disabilities with
				  income above one hundred percent (100%) of the FPL;
2. Children with income above the MACC limit
				  of two hundred sixty-six percent (266%) of the FPL (includes the five percent
				  (5%) disregard);
3. Pregnant women
				  with income above the MACC limit of two hundred fifty-eight percent (258%) of
				  the FPL (includes the five percent (5%) disregard);
4. Parents/caretakers with income above the
				  MACC limit of one hundred thirty-eight percent (138%) of the FPL (includes the
				  five percent (5%) disregard);
5.
				  Non-qualified non-citizens seeking coverage for emergency Medicaid if
				  ineligible under all other pathways. (See § 1.7.5 of this Subchapter);
				  and
6. Certain refugees, as defined
				  in § 1.7.3 of this Subchapter, who do not otherwise qualify for Medicaid
				  health coverage or commercial insurance with financial help through
				  HSRI.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 2 - Community Medicaid: Medically Needy Eligibility › Section 210-RICR-40-05-2.3 - Spenddown Calculation

Current through June 14, 2024
A. For a person who
				  has income above the income standard across applicable eligibility pathways,
				  the spenddown standard for their eligibility coverage group is applied. For
				  example, the appropriate spenddown standard for parents/caretakers is one
				  hundred thirty-eight percent (138%) of the FPL (ceiling for MACC eligibility
				  when five percent (5%) disregard is applied) and two hundred sixty-six percent
				  (266%) of the FPL for children (MACC ceiling including disregard). The
				  appropriate spenddown standard for elders and adults with disabilities is the
				  medically needy income limit adjusted for household size.
1. Spenddown Amount - The spenddown amount is
				  calculated as follows:
a. The beneficiary's
				  anticipated monthly net income for each month of the eligibility period based
				  on the criteria appropriate for the specific coverage group using the SSI
				  methodology.
b. Net income for all
				  six (6) months.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 2 - Community Medicaid: Medically Needy Eligibility › Section 210-RICR-40-05-2.4 - Six-Month Spenddown Renewal

Current through June 14, 2024
Upon renewal, a six (6) month spenddown is calculated in
					 the same manner.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 2 - Community Medicaid: Medically Needy Eligibility › Section 210-RICR-40-05-2.5 - Allowable Expenses

Current through June 14, 2024
A. Allowable health
				  care expenses are those that are incurred by the beneficiary or other allowable
				  family member(s) that are not subject to payment by a third
				  (3rd) party and may be:
1. Paid or unpaid health care bills incurred
				  in the current eligibility period; and
2. Unpaid bills incurred prior to the current
				  eligibility period.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 2 - Community Medicaid: Medically Needy Eligibility › Section 210-RICR-40-05-2.6 - Expense Exceptions

Current through June 14, 2024
A. Certain health
				  care expenses are not allowed to be deducted from income. Such expenses
				  include, but are not limited to:
1. Premiums
				  paid by Medicaid or paid by the MPPP as a health care expense. Applicants and
				  beneficiaries should consider whether participation in the MPPP will adversely
				  affect their ability to maintain MN eligibility and
vice versa
with the assistance of an eligibility specialist.
2. Health care expenses incurred before the
				  first (1st) day of the six (6) month certification
				  period are not eligible for Medicaid payment; the beneficiary remains
				  responsible for those bills.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 3 - Retroactive Coverage (210-RICR-40-05-3) › Section 210-RICR-40-05-3.1 - Scope and Purpose

Current through June 14, 2024
Medicaid coverage may start retroactively for up to three
					 (3) months prior to the month of application for IHCC groups, unless explicitly
					 excluded. To qualify, a person must have met the criteria for Medicaid
					 eligibility during the retroactive period. Coverage generally stops at the end
					 of the month in which a person no longer meets the requirements for
					 eligibility. The provisions in this section do not apply to the MAGI-eligible
					 individuals and families in the Medicaid Affordable Care Coverage (MACC) groups
					 identified in the Medicaid Code of Administrative Rules, Affordable Care
					 Coverage Groups, except when a person who is ineligible for coverage in one of
					 these groups applies for MN IHCC in accordance with the provisions in Part 2 of
					 this Subchapter.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 05 - Community Medicaid › Part 3 - Retroactive Coverage (210-RICR-40-05-3) › Section 210-RICR-40-05-3.2 - General Provisions

Current through June 14, 2024
A. Medicaid
				  beneficiaries in the IHCC groups may request retroactive eligibility for up to
				  three months prior to the month of application.
1. Eligibility criteria - To obtain
				  retroactive coverage, applicants must meet all eligibility criteria related to
				  the applicable IHCC group during the retroactive period. Retroactive coverage
				  is also available to IV-E and non IV-E foster children and adoption subsidy
				  family-related coverage groups.
a. The
				  applicant must meet Medicaid eligibility requirements for each month in which
				  an unpaid medical bill was incurred. Thus, retroactive eligibility may be
				  determined for one, two, or three months of the retroactive period.
b. Only the income and resources available to
				  the applicant in the retroactive period are used to determine eligibility. No
				  deeming is required.
c. The
				  following chart details beneficiaries' eligible retroactive benefits:
Persons Eligible
Eligible for Retro
IV-E and non IV-E Foster Children
Y
Adoption Subsidy Children Coverage Groups
Y
IHCC group members, excluding partial dual
								  Qualified Medicare Beneficiaries (QMBs)
Y
Non-citizens who are eligible for emergency
								  Medicaid
Y
LTSS beneficiaries
Y
d.
				  At the time of application for Medicaid, if the applicant in one of these
				  categories indicates that an unpaid health medical bill was incurred in the
				  three-month period preceding the application, eligibility for retroactive
				  coverage must be determined.
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-40-10-1.1 - Overview of this Rule

Current through June 14, 2024
A. The purpose of
				  this Rule is describe the managed care service delivery options for Elders and
				  Adults with Disabilities and long-term care beneficiaries. The purpose is also
				  to set forth in clear language the respective roles and responsibilities of the
				  Executive Office of Health and Human Services (EOHHS), beneficiaries, health
				  plans, and other contractual entities related to managed care enrollment and
				  service delivery for Elders and Adults with Disabilities and long-term care
				  beneficiaries.
Program
Rhody Health
								  Partners
Medicare-Medicaid
								  Plan
PACE
Population
Elders and Adults with Disabilities who do not
								  have Medicare or other third-party coverage; Persons without Medicare who are
								  receiving LTSS in the home or community-based service setting, are enrolled in
								  RHP for essential primary care services only.
Elderly and non-elderly adults who have full
								  Medicare (Parts A, B, and D) coverage and Medicaid Health
								  Coverage
Medicaid beneficiaries age 55 and older who
								  qualify for a nursing home level of care
Mandatory/
Voluntary Enrollment
Mandatory
Voluntary
Voluntary
Covered Services
Medicaid
Medicaid and Medicare Parts A, B, and
								  D
Medicaid and Medicare Parts A, B, and D (if
								  eligible)
Participation Criteria
Age 21 and older; and
Eligible for Medicaid Health Coverage on the
								  basis of the SSI income standard (IHCC group)
Age 21 and older;
Eligible for Medicaid Health Coverage on the
								  basis of the SSI income standard (IHCC group) or the MAGI income standard (MACC
								  group); and
Enrolled in Medicare Part A, enrolled in
								  Medicare Part B, and eligible to enroll in Medicare Part D
Age 55 years and older;
Meet criteria for high or highest need for a
								  nursing facility level of care; and
Meet all other requirements for LTSS
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-40-10-1.3 - Rhody Health Partners (RHP)

Current through June 14, 2024
1.3.1
Authority and Scope
A. In 2005,
				  R.I. Gen. Laws §
											40-8.5-1.1 authorized the Medicaid agency to establish mandatory managed care delivery
				  systems for adults nineteen (19) years of age or older who are eligible on the
				  basis of participation in the Supplemental Security Income (SSI) program (see
				  §00-1.5 of this Chapter) or an SSI-related characteristic associated with
				  age or a disability and income. In Rhode Island, persons with SSI-related
				  characteristics are eligible under the Medicaid State Plan option for
				  low-income elders and adults living with disabilities (EAD) in accordance with
				  R.I. Gen. Laws Chapter 40-8.5. The requirements for adults in associated
				  special eligibility groups that have unique financial (e.g., SSI Protected
				  Status) or clinical criteria (e.g., breast and cervical cancer coverage group)
				  or limited benefits (e.g., partial dual eligible group and the Medicare Premium
				  Payment Program) are also located in §05-1.6 of this Chapter.
B. Beneficiaries eligible in these coverage
				  groups who do not require LTSS are sometimes referred to as "Community
				  Medicaid" and are members of the State's Integrated Health Care Coverage (IHCC)
				  groups. The provisions governing eligibility set forth in Subchapter 05 Part 1
				  of this Chapter and §00-3.1.2 of this Chapter and enrollment as
				  established herein will remain in effect unless or until replaced.
C. IHCC group beneficiaries who are eligible
				  on the basis of SSI income standard, do not require LTSS, and do not have third
				  (3rd) party coverage are subject to mandatory
				  enrollment in a Rhody Health Partners (RHP) Medicaid managed care plan.
				  Eligible beneficiaries have the choice of two (2) RHP-participating health
				  plans.
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-40-10-1.4 - RHP Benefit Package

Current through June 14, 2024
A. The IHCC groups
				  participating in RHP under this section receive the full scope of services
				  covered under the Medicaid State Plan and the State's Section 1115 waiver.
				  Covered services may be provided through the managed care plan or through the
				  fee-for-service delivery system if the service is "out-of-plan" - that is, not
				  included in the managed care plan but covered under Medicaid. Fee-for-service
				  benefits may be furnished either by the managed care provider or by any
				  participating provider.
1. Access to Benefits
				  - Each RHP member selects a primary care provider (PCP) who performs necessary
				  medical care and coordinates referrals to specialty care. The PCP orders
				  treatment determined to be medically necessary in accordance with the health
				  plan's policies. Prior authorization rules may apply, as required by the
				  Medicaid agency.
2. Delivery of
				  Benefits - In-plan services are paid for on a capitated basis.
3. Medical Necessity - The standard of
				  "medical necessity" is used as the basis for determining whether access to a
				  Medicaid covered service is required and appropriate. Medically necessary
				  services must be provided in the most cost-efficient and appropriate setting
				  and must not be provided solely for the convenience of the member or service
				  provider.
4. Medicaid Benefits -
				  The coverage provided through RHP is categorized as follows:
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-40-10-1.5 - Integrated Care Initiative (ICI)

Current through June 14, 2024
1.5.1
Authority and Overview
A. In
				  accordance with R.I. Gen. Laws Chapter 40-8.13, the State's Section 1115 W
				  aiver Demonstration, and other Federal waivers and authorities, EOHHS has
				  developed and implemented the ICI to expand access to comprehensive care
				  management and services through a managed care delivery system known as the
				  Medicare-Medicaid Plan (MMP).
B.
				  Under the authority of a special Federal Financial Alignment Demonstration, the
				  MMP integrates and coordinates Medicare and Medicaid covered services through a
				  managed care arrangement for MME beneficiaries. Enrollment is voluntary for
				  eligible beneficiaries. The operations of the MMP are bound by a three (3) way
				  agreement between EOHHS, the Federal Centers for Medicare and Medicaid Services
				  (CMS), and the participating MCO.
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-40-10-1.6 - Rhody Health Options (RHO)

Current through June 14, 2024
A. In accordance
				  with §
										7   of Pub. Laws 18-047 enacted
				  on June 22, 2018, Medicaid beneficiaries enrolled in RHO on and before October
				  1, 2018 will be placed in fee-for-service arrangements effective that date for
				  all Medicaid covered long-term services and supports. The RHO program
				  termination date is September 30, 2018.
B. Medicaid beneficiaries who were enrolled
				  in RHO on and before October 1, 2018 will continue to receive all medically
				  necessary services as contained in §
										1.4(A) (4)
				    of this Part. The standard of "medical necessity" is used as the basis for
				  determining whether access to a Medicaid covered service is required and
				  appropriate. Prior to the termination date of RHO for existing beneficiaries
				  and after for all new beneficiaries, any member who is dually eligible for
				  Medicaid and Medicare may be enrolled in a MMP while retaining the choice to
				  opt out and receive LTSS on a fee-for service basis. For Medicaid beneficiaries
				  who do not have Medicare, the transition is as follows:
1. Medicaid-only LTSS in a home and
				  community-based setting - Beneficiaries who are seeking or receiving LTSS in a
				  home and community-based setting as defined in Part 50-10-1 of this Title will
				  receive all essential primary care benefits through a Rhody Health Partners
				  managed care plan. Medicaid LTSS will be provided out-of-plan and paid for on a
				  fee-for-service basis after the first 30 days.
2. Medicaid-only LTSS in a health institution
				  --Persons seeking or receiving Medicaid in an institutional setting such as a
				  nursing facility or hospital in accordance with Part 50-05-1 of this Title will
				  be receive all Medicaid-covered services (primary care, subacute care,
				  long-term services and supports) on a fee-for-service basis.
1.6.1
RHO Appeals
The class of Medicaid beneficiaries who were enrolled in
					 RHO on and before October 1, 2018 do not have the right to appeal the
					 termination of their RHO coverage in accordance with
					  42 C.F.R. §
													431.220(b)  and
					 §
												10 -05-2.2 .1(A)(7)(a) of this Title. The right to appeal agency actions
					 unrelated to this change in law and policy that affect eligibility, or the
					 scope, amount, and or duration of Medicaid benefits is
					 preserved.
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-40-10-1.7 - Medicare-Medicaid Plan (MMP)

Current through June 14, 2024
1.7.1
Overview
Under the authority of a special Federal Financial
					 Alignment Demonstration, the MMP is designed to manage and coordinate the full
					 spectrum of both Medicaid and Medicare services for Medicare and Medicaid (MME)
					 adults. Enrollment is voluntary for eligible beneficiaries. A three (3) way
					 agreement between EOHHS, the MCO operating the MMP, and the Federal Centers for
					 Medicare and Medicaid Services (CMS) governs the organization, financing, and
					 delivery of Medicaid and Medicare services to MME beneficiaries who choose to
					 participate.
1.7.2
MMP
				  Participation Criteria
A. MME
				  beneficiaries are eligible for participation in the MMP if they are age
				  twenty-one (21) and older as follows:
1. MME
				  Enrollees - Medicare-Medicaid beneficiaries who are receiving Medicaid health
				  coverage, enrolled in Medicare Part A, enrolled in Medicare Part B, and
				  eligible to enroll in Medicare Part D. This cohort includes MME and other
				  Community Medicaid IHCC group beneficiaries as well as those who need LTSS.
				  Eligible MME beneficiaries include:
a. Members
				  of the IHCC groups receiving Community Medicaid, including persons with serious
				  and persistent mental illness, who do not need LTSS;
b. MAGI-eligible adults in the MACC group for
				  parents/caretakers;
c. LTSS
				  recipients residing in institutional or home and community-based settings
				  including those qualifying for the level of care provided in a nursing facility
				  and intermediate care facility for persons with intellectual disabilities
				  (ICF-ID) - such as nursing facility, assisted living and ID group home
				  residents as well as those residing in their own homes; and
d. Persons with End Stage Renal Disease
				  (ESRD) at the time of enrollment.
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-40-10-1.8 - Prescriptions: Generic Policy

Current through June 14, 2024
A. For RHP and MMP
				  enrolled members, Medicaid prescription benefits must be for generic drugs.
				  Exceptions for limited brand coverage for certain therapeutic classes may be
				  granted if approved by the Medicaid agency, or the MCO acting in compliance
				  with their contractual agreements with EOHHS, and in accordance with the
				  criteria described below:
1. Availability of
				  suitable within-class generic substitutes or out-of-class
				  alternatives.
2. Drugs with a
				  narrow therapeutic range that are regarded as the standard of care for treating
				  specific conditions.
3. Relative
				  disruptions in care that may be brought on by changing treatment from one drug
				  to another.
4. Relative medical
				  management concerns for drugs that can only be used to treat patients with
				  specific co-morbidities.
5.
				  Relative clinical advantages and disadvantages of drugs within a therapeutic
				  class.
6. Cost differentials
				  between brand and generic alternatives.
7. Drugs that are required under federal and
				  State regulations.
8. Demonstrated
				  medical necessity and lack of efficacy on a case by case basis.
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-40-10-1.9 - Non-Emergency Transportation Policy

Current through June 14, 2024
Responsibility for transportation services rests first with
					 the member. If the member's condition, place of residence, or the location of
					 the medical provider does not permit the use of bus transportation,
					 non-emergency transportation for the Medicaid enrollee may be arranged for by
					 EOHHS, or its agent, in accordance with the provisions established in Part
					 20-00-2 of this Title.
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-40-10-1.10 - Interpretation Services Policy

Current through June 14, 2024
EOHHS will notify the health plan when it knows of members
					 who do not speak English as a primary language who have either selected or been
					 assigned to the plan. If more than fifty (50) members speak a single language,
					 the RHP health plan must make available general written materials, such as its
					 member handbook, in that language. If more than five percent (5%) or fifty (50)
					 members, whichever is less, speak a single language, the MMP must make
					 available general written materials, such as its member handbook, in that
					 language. Interpreter services, including sign language interpreters, are
					 covered for any RHP or MMP member who speaks a non-English language as a
					 primary language or who is deaf or hard of hearing.
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-40-10-1.11 - Tracking, Follow-up, Outreach

Current through June 14, 2024
Tracking, follow-up, and outreach services are provided by
					 the health plan in association with an initial visit with the member's PCP,
					 preventive visits and prenatal visits, referrals that result from preventive
					 visits, and preventive dental visits. Outreach includes mail, phone, and home
					 outreach, if necessary, for members who miss preventive and follow-up visits,
					 and to resolve language, transportation, and other barriers to
					 care.
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-40-10-1.12 - Mainstreaming/Selective Contracting

Current through June 14, 2024
The mainstreaming of Medicaid beneficiaries into the
					 broader health delivery system is an important objective of RHP and MMP. The
					 MCO therefore must ensure that all of its network providers accept its members
					 for treatment. The MCO also shall accept responsibility for ensuring that
					 network providers do not intentionally segregate RHP and MMP members in any way
					 from other persons receiving services. MCOs may develop selective contracting
					 arrangements with certain providers for the purpose of cost containment but
					 shall adhere to the access standards as defined in the MCO
					 contracts.
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-40-10-1.13 - Program of All-Inclusive Care for the Elderly (PACE)

Current through June 14, 2024
1.13.1
Overview
PACE provides a managed plan of coordinated Medicare and
					 Medicaid covered services from across the care continuum to certain
					 beneficiaries age fifty-five (55) and older. The operations of PACE are bound
					 by a three (3) way agreement between EOHHS, CMS, and the PACE provider to
					 integrate the full range of Medicare (if eligible) and Medicaid services
					 (primary care, acute care, specialty care, behavioral health care, and LTSS)
					 for PACE participants.
1.13.2
EOHHS Responsibilities
EOHHS is responsible for the eligibility and enrollment
					 functions set forth in §1.13.4 of this Part, establishing PACE provider
					 standards, and oversight and monitoring of all aspects of the PACE
					 program.
1.13.3
PACE
				  Provider Responsibilities
A. The PACE
				  provider is responsible for:
1. Point of entry
				  identification;
2. Submitting all
				  necessary documentation for initial determinations and reevaluations of a level
				  of need and referral to EOHHS for a determination of financial
				  eligibility;
3. Verifying PACE
				  enrollment prior to service delivery;
4. Verifying and collecting required
				  beneficiary liability (cost-share amount);
5. Providing and coordinating all integrated
				  services;
6. Reporting changes to
				  the PACE-eligibility status of participants; and
7. Adhering to all PACE provider requirements
				  as outlined in the PACE Program Agreement between EOHHS and CMS, and to all
				  credentialing standards required by EOHHS including data submission.
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-40-10-1.14 - PACE Benefit Package

Current through June 14, 2024
A. CMS and EOHHS
				  approve PACE providers who are responsible for providing the full scope of
				  Medicare (if eligible) and Medicaid State Plan and waiver services, including
				  but not limited to:
1. Multidisciplinary
				  assessment and treatment planning;
2. Case Management services;
3. Personal Care;
4. Homemaking;
5. Rehabilitation;
6. Social Work;
7. Transportation;
8. Nutritional Counseling;
9. Recreational Therapy;
10. Minor Home Modifications; and
11. Specialized Medical Equipment and
				  Supplies.
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-40-10-1.15 - Federal Poverty Limits (FPLs) 2019

Current through June 14, 2024
Click
					 here to view
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 15 - Disabled Working Adults › Part 1 - Medicaid Code of Administrative Rules, Section 1373 Medicaid for Working People with Disabilities Program › Section 210-RICR-40-15-1.1 - Scope and Applicability

Current through June 14, 2024
A. One of the
				  principal objectives of health and human services policymakers is to support
				  Medicaid-eligible adults with disabilities who work by enabling them to obtain
				  or maintain the coverage they need to retain their independence and optimize
				  their health. Toward this end, an array of State and Federal laws and
				  Regulations have been adopted that establish special provisions for
				  disregarding all or a portion of the earned income of adults with disabilities
				  who work. The State also provides Medicaid coverage for an array of employment
				  services and supports to assist beneficiaries with disabilities who are
				  employed. In addition, the State has taken the option under Federal law to
				  create a unique eligibility pathway - known as the Sherlock Plan - which
				  enables working adults with disabilities who are otherwise Medicaid ineligible
				  or unable to obtain needed employment supports to buy into the program at a low
				  monthly cost.
B. To qualify for the
				  Medicaid special income provisions, a person must be determined to have a
				  disability by a Federal or State government entity or appropriately designated
				  contractual agent of the State in accordance with the standards set forth in
				  Subchapter 05 Part 1 of this Chapter. Such entities include the U.S. Social
				  Security Administration and the Medical Review Team (MART) and Office of
				  Medical Review (OMR) within the Executive Office of Health and Human Services
				  (EOHHS). Adults with disabilities who work and are seeking initial or
				  continuing eligibility for Medicaid long-term services and supports (LTSS) may
				  be subject to distinct "clinical/functional disability" criteria, as set forth
				  in §1.7.1 of this Part. A beneficiary who meets these disability criteria
				  and qualifies for these special income provisions is eligible for the full
				  range of Medicaid covered employment services and supports.
C. Employment services and supports may also
				  be available to adults with disabilities, over age nineteen (19), who are
				  eligible for Medicaid in accordance with the provisions of Part 30-00-1 of this
				  Title in one (1) of the Medicaid Affordable Care Coverage (MACC) groups based
				  on the modified adjusted gross income standard - MAGI. Although a disability
				  determination is not required, the scope of employment services and supports
				  available may not be as extensive as through the other eligibility pathways for
				  working adults with disabilities. Accordingly, seeking eligibility based on a
				  formal determination of disability is an option, as set forth in herein in the
				  following sections.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 15 - Disabled Working Adults › Part 1 - Medicaid Code of Administrative Rules, Section 1373 Medicaid for Working People with Disabilities Program › Section 210-RICR-40-15-1.2 - Legal Authority

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  -k, 1902(a)(10)(A)(ii)(XIII) and (XV);
				  1916(g), 1905(v)(1); 1929(b) [2],1382(h), and 1619(a) and (b);
2. Federal Regulations: These Regulations
				  hereby adopt and incorporate
				   42 C.F.R. §§
												435.120; 435.120(c)  (1990); 435.121(b) (2013); and 447.55(a) (2014) by reference, not including any
				  further editions or amendments thereof and only to the extent that the
				  provisions therein are not inconsistent with these Regulations and 20
				  C.F.R.§§416.260-269 and
				  416.976.
3. The Rhode Island Medicaid State Plan and
				  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 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 15 - Disabled Working Adults › Part 1 - Medicaid Code of Administrative Rules, Section 1373 Medicaid for Working People with Disabilities Program › Section 210-RICR-40-15-1.4 - SSI-Eligible Beneficiaries

Current through June 14, 2024
A. Rhode Island
				  provides Medicaid coverage to anyone who is eligible for and receiving SSI,
				  based on a determination by the Federal SSA. The State automatically enrolls
				  SSI beneficiaries in Medicaid upon receipt of electronic notification from the
				  SSA and must continue to provide coverage unless or until SSI status changes.
				  The SSA also determines whether working adults with disabilities receiving SSI
				  qualify for continuing Medicaid eligibility under two (2) special provisions in
				  §§1619(a) or (b) of Title XVI, the Federal law establishing the SSI
				  program.
B. Under
				  §§1619(a) and (b) of Title XVI, SSI beneficiaries who have increased
				  earned income from work are able to retain their Medicaid coverage. The amount
				  of the additional earned income affects whether §§1619(a) or (b)
				  provisions apply and, respectively, whether SSI cash assistance is reduced or
				  eliminated. However, Medicaid primary care essential benefit coverage and, as
				  applicable, LTSS continue without regard to changes in SSI status until the
				  State is notified otherwise by the SSA.
1.
				  1619(a) - "Special cash assistance" is available when an SSI beneficiary with a
				  disability has gross earned income for the month that exceeds the amount
				  ordinarily allowed to obtain or retain SSI eligibility. Both the special cash
				  payments and Medicaid coverage are authorized in this instance under
				  §1619(a) . Any beneficiary may qualify for 1619(a) as early as his or her
				  second (2nd) month on the SSI rolls. To qualify, a
				  person must:
a. Continue to have a disabling
				  impairment and meet all other non-disability requirements.
b. Have been eligible for and received a
				  regular SSI cash payment based on disability for a previous month within the
				  current period of eligibility. The prerequisite month does not necessarily have
				  to be the immediate prior month.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 15 - Disabled Working Adults › Part 1 - Medicaid Code of Administrative Rules, Section 1373 Medicaid for Working People with Disabilities Program › Section 210-RICR-40-15-1.8 - The Sherlock Plan

Current through June 14, 2024
A. The Sherlock
				  Plan for Working People with Disabilities is an SSI-related eligibility pathway
				  for working adults with disabilities established pursuant to the Balanced
				  Budget Act of 1997 (42 U.S.C. §
											1396a(a)(10)(ii)  (XIII)) and
				  R.I. Gen. Laws at §40-8.7-1.
				  The State law is based on the option under the Federal law to establish a
				  Medicaid eligibility pathway for adults with disabilities who are either unable
				  to afford or obtain health coverage and/or the services and supports they need
				  to work.
B. Adults with
				  disabilities eligible through the Sherlock pathway are entitled to the full
				  scope of Medicaid benefits and home and community-based services and supports
				  necessary to facilitate and/or maintain employment. This is the same scope of
				  coverage available to all Medicaid-eligible adults with disabilities who work,
				  without regard to eligibility pathway. The special provisions in the SSI method
				  established in Subchapter 00 Part 3 of this Title, and reiterated herein at
				  §
										1.4, of
				  this Part may apply. To ensure continuation of EOHHS' eligibility for enhanced
				  Federal funding, EOHHS will continue eligibility for individuals that may have
				  a change in employment status that occur during the Federal novel Coronavirus
				  Disease (COVID-19) declaration of emergency. Changes in employment after the
				  termination of the Federal novel coronavirus declaration of emergency will
				  follow the provisions in §1.8.5.
C. The Sherlock eligibility pathway is open
				  to adults with disabilities who are working and seeking:
1. Non-LTSS Medicaid primary care essential
				  benefit coverage with HCBS services including employment supports; or
2. Medicaid LTSS coverage including
				  integrated employment supports.
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-50-00-1.1 - Overview

Current through June 14, 2024
The provisions set forth herein pertain to the scope of
					 Medicaid long-term services and supports (LTSS) and the various pathways for
					 initial and continuing eligibility.