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-30-00-1.6 - MACC Group General Eligibility Requirements

Current through June 14, 2024
A. All applicants for MACC Group eligibility
				  must meet State residency requirements. Applicants for MACC Group eligibility
				  who are over the age of nineteen (19) must meet citizenship/immigration status
				  requirements. There are also certain cooperation requirements. Adults must
				  typically meet the cooperation requirements, whether applying for themselves or
				  on behalf of a dependent child. Verification of these requirements is an
				  automated process conducted through electronic data matches. Failure to meet
				  Medicaid general eligibility requirements or provide supporting documentation
				  upon request is considered non-cooperation and generally results in the denial
				  or discontinuation of eligibility. Children are exempt from sanctions due to
				  non-cooperation. The scope and application of each of these eligibility
				  requirements are as follows:
1. Age - "Age"
				  is one of the principal factors affecting eligibility for Medicaid and
				  assignment to the appropriate Medicaid service delivery system MACC
				  group.
2. MACC Group Age Limits -
				  The age requirements associated with each of the MACC groups are as follows:
MACC Coverage Groups
Age Requirements
Families and Parents/Caretakers
Parents/Caretakers of any age Dependent child up
								  to age eighteen (18) or nineteen (19) if enrolled in school
								  full-time
Pregnant People
Any age
Children and Young Adults
Up to age nineteen (19)
ACA Expansion Adults
Ages nineteen (19) to sixty-four (64)
a.
				  Verification - An applicant's self-attestation of age and identity is accepted
				  at the time of application. Post-eligibility electronic verification of date of
				  birth is conducted through the U.S. Social Security Administration (SSA) and/or
				  the Rhode Island Department of Health, Division of Vital Statistics. This
				  information is used to determine capitation rates for enrollees in Medicaid
				  managed care plans; these rates vary by age. If electronic verification is
				  unsuccessful, submission of paper documentation may be required for these
				  purposes. See Part 5 of this Subchapter for satisfactory forms of
				  documentation.
3. Social
				  Security Number - To support verification of age, income, and
				  citizenship/immigration status, individual applying for Medicaid who have been
				  assigned a Social Security Number (including children) shall provide their
				  Social Security Number (SSN) as a condition of eligibility for the program.
a. Only members of a household who are
				  applying for Medicaid coverage are required to provide an SSN. An SSN of a non-
				  applicant may be requested to electronically verify income. However,
				  unwillingness on the part of a non-applicant to provide an SSN upon request
				  shall not be used as the basis for denying eligibility to an applicant who has
				  provided an SSN. If an SSN is unavailable, other proof of income shall be
				  accepted.
b. Limits on Use -
				  Applicants shall also be informed that an SSN can be utilized only in the
				  administration of the Medicaid program, including for use in verifying age and
				  income eligibility.
c. Verification
				  - An SSN is verified through an electronic data-match with the SSA. Applicants
				  (not including children) must provide documentation of SSN if the data match
				  fails. Acceptable forms of documentation are identified in Part 5 of this
				  Subchapter.
4. State
				  Residency - Anyone who is applying for eligibility must be a resident of the
				  State. Any person living in the State voluntarily, who intends to reside in
				  Rhode Island for any reason is considered a resident of the State. Under
				  Federal Regulations a person does not need a fixed address in the State to be
				  considered a Rhode Island resident. Therefore, homelessness is not a bar to
				  eligibility.
a. For individuals who are
				  twenty-one (21) years of age or older,, or under the age of twenty-one (21) and
				  capable of expressing intent as an emancipated or married individual - If the
				  applicant is not living in an institution, the State of residence is the State
				  where the applicant is living voluntarily with the intention to reside; or
				  entered voluntarily with a job commitment or seeking employment, whether or not
				  currently employed.
b. For
				  individuals under the age twenty-one (21) who are not emancipated or married -
				  If the applicant is not living in an institution, the State of residence is the
				  State where the child/young adult resides or the State of the parent/care-taker
				  with whom the child lives. Under the requirements of this provision, the
				  residence of a pregnant person's unborn child is, the State in which the
				  pregnant person resides. A non-citizen pregnant person who lives in Rhode
				  Island is considered to be a resident, irrespective of whether the person's
				  immigration status indicates they are in the country permanently or for a
				  limited time (i.e., in the United States on a temporary visa of any
				  kind).
c. For individuals living in
				  institutions - Most Medicaid applicants living in institutional settings are
				  not included in the MACC groups.
d.
				  Disputes - If there is a dispute over residency for determining Medicaid
				  eligibility, the applicant is a resident of the State in which the applicant is
				  physically located. The MAGI standard of the State where the applicant is
				  physically located applies when determining eligibility.
e. Verification - Self-attestation of the
				  intent to remain in the State is accepted. Evidence that an applicant is
				  receiving public benefits in another State may result in a denial of
				  eligibility if paper documentation of residency is not provided.
5. Citizenship and Immigration
				  Status - The citizenship requirements for Medicaid eligibility for individuals
				  and families in MACC groups vary depending on the basis of eligibility. Some
				  non-citizens are not eligible for Medicaid; some are eligible for Medicaid only
				  after a five (5) year waiting period; and some are eligible without a waiting
				  period. Children up to the age of nineteen (19) are not subject to citizenship
				  requirements to be eligible for Medicaid, and pregnant people are not subject
				  to citizenship requirements under CHIP.
a.
				  Non-Citizens ineligible Except in Emergency Situations
(1) Non-qualified non-citizens. The
				  non-qualified category of non-citizens includes citizens of other nations who
				  are not considered to be immigrants under current Federal law, including those
				  in the United States on temporary or time- limited visa (such as visitors and
				  students) and those who are present in the country without proper documentation
				  (includes people with no or expired status).
(2) Non-qualified non-citizens who are adults
				  are not eligible for Medicaid, except in emergency situations (Part
				  10-00-3 of this Title).
				  Non-emergency services may be obtained through Federally Qualified Community
				  Health Centers. See Rhode Island Community Health Association at
www.richa.org
.
b. Non-Citizens barred from Medicaid During
				  Five (5) Year Waiting Period
(1) Qualified
				  non-citizens. The qualified non-citizens category includes persons who are
				  citizens of other nations who are lawfully present in the United States.
				  Qualified non-citizens are barred from Medicaid for a waiting period of five
				  (5) years under Federal law. Certain exemptions from the bar apply:
c. Non-Citizens Exempt from the
				  Five (5) Year Waiting Period
(1) Qualified
				  non-citizen children up to the age of nineteen (19) who are lawfully present in
				  the United States but who were born in another nation are eligible for Medicaid
				  as members of the MACC group for children and young adults. Children in this
				  subcategory of qualified non-citizens are eligible during the five (5) year bar
				  under an option contained in Title XXI, the Children's Health Insurance Program
				  (CHIP). Qualified non-citizen pregnant people are also eligible for Medicaid in
				  the MACC group, under an option in CHIP.
(2) There are several other subcategories of
				  non-citizens who are exempt from the five (5) year bar as specified in Part
				  10-00-3 of this Title. All
				  non-exempt qualified non-citizens are eligible to obtain coverage through State
				  and Federal health insurance marketplaces, such as HealthSource RI.com in Rhode
				  Island, and may be qualified for certain tax credits.
d. Non-qualified non-citizen pregnant people
				  in the applicable MACC group are eligible for Medicaid coverage. The pregnant
				  person's eligibility is tied to the eligibility of the baby they are carrying.
				  For the purposes of MACC group eligibility, the baby
in utero
is deemed to be a United States citizen and Rhode Island resident and remains
				  so as a newborn as long the birth occurs in Rhode Island.
e. Verification of citizenship/immigration
				  status - All members of a household applying for Medicaid coverage shall
				  provide their immigration and citizenship status. However, no adverse
				  eligibility determination shall be made regarding children up to the age of
				  nineteen (19) for whom citizenship/immigration status is not provided.
				  Non-applicants are exempt from this requirement. Any information provided by an
				  applicant or obtained through electronic verification under §
												1.6(A)(5)(e)
				    of this Part shall only be used to verify status. Under the ACA, citizenship
				  and immigration status are verified:
(1)
				  Electronically. The Medicaid agency shall use electronic verification through
				  the Federal hub (see Part 5 of this Subchapter) to the full extent feasible
				  through:
(AA) Social Security Administration
				  (SSA) or Rhode Island Department of Health, Division of Vital Statistics for
				  citizens.
(BB) U.S. Citizenship and
				  Immigration Services (USCIS) for non-U.S. adult citizens via the Systematic
				  Alien Verification for Entitlements (SAVE) database.
(2) Non-electronic. If unable to verify
				  immigration status electronically, enrollees have an opportunity to provide
				  other documents or to fix the records.
(3) Self-Attestation. An applicant's
				  attestation is accepted without electronic verification providing appropriate
				  paper documentation is provided to the Medicaid agency within ninety (90) days
				  of the eligibility determination. Failure to provide the required documentation
				  within that period results in a termination of Medicaid and the initiation of
				  the Medicaid recoupment process.
6. Relationship - The State evaluates the
				  relationship of household members applying for the MACC group for families and
				  parent/caretakers using the following:
a.
				  Caretaker Relative - For the purposes of MACC group eligibility,
				  parent/caretaker is any adult living with a Medicaid-eligible dependent child
				  who has assumed primary responsibility for that child. This definition
				  includes, but is not limited to:
(1) Father,
				  mother, grandfather, grandmother, brother, sister, stepfather, stepmother,
				  stepbrother, stepsister, uncle, aunt, first cousin, nephew or niece;
(2) The spouse of such parent or relative,
				  even after the marriage is terminated by death or divorce; or
(3) Another relative of the child based on
				  blood, adoption or marriage; domestic partner of parent or other caretaker
				  relative. If the parents are in the household, it is presumed that other
				  members in the household are not assuming primary responsibility for the
				  child's care.
(4) Dependent child -
				  For the purposes of determining eligibility the members of the MACC group for
				  families and parents/caretakers, a dependent child is a child under the age of
				  eighteen (18) or under the age of nineteen (19) if enrolled full-time in
				  school.
b. Verification
				  - Self-attestation on the application is accepted as verification of
				  relationship, except for deeming of newborns.