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-50-00-1.8 - Eligibility Determination Process

Current through June 14, 2024
A. There is a
				  multiphase process for determining eligibility and authorization for Medicaid
				  LTSS that includes the following steps:
1.
				  Information, Referral, Options Counseling - Prior to initiating the application
				  process and/or at any step during the eligibility determination sequence,
				  applicants and/or their family members or authorized representatives may seek
				  information, referral and/or options counseling to assist them in navigating
				  the LTSS system. Part 4 of this Subchapter sets forth role of this
				  service.
2. Person-centered
				  Planning - Upon making application for LTSS, the person-centered planning
				  process must begin for anyone seeking HCBS. The process is available, at the
				  applicant's option, for LTSS in a health care institution as well.
				  Person-centered planning is an individualized approach to planning that places
				  the applicant at the center of decisionmaking thereby enabling him/her to
				  direct his/her own services and supports in accordance with his/her own
				  desires, goals and preferences, with impartial assistance and supported
				  decision-making when helpful. Accordingly, the person-centered planning is an
				  on-going process that continues through the eligibility determination process
				  through to the authorization of services and thereafter. In accordance with
				  45 C.F.R. § 441.301(c)(1), the State
				  must ensure that throughout this process, the applicant has sufficient and
				  necessary information in a form he/she can understand to make informed choices
				  and direct the planning process to the maximum extent possible. See Part 4 of
				  this Subchapter for specific provisions.
3. Eligibility Determination Factors - To
				  gain access to LTSS, the information provided by applicants is evaluated across
				  the eligibility factors identified below, though not necessarily in a specific
				  order:
a. General eligibility factors. All
				  persons seeking initial or continuing Medicaid LTSS must meet the general
				  requirements for the program related to residency, citizenship and immigration
				  status, and Social Security Numbers and the like. The application form must be
				  completed and signed along with the authorizations necessary to conduct
				  electronic data matches to verify income and resources; and to request personal
				  health information to assess and review clinical/functional level of need.
				  General eligibility factors for MACC MAGI-based LTSS eligibility are located in
				  §30 -00-1.5(C) of this
				  Title and for SSI-based LTSS eligibility in Part 5 of this Subchapter. Existing
				  beneficiaries seeking LTSS must only update general eligibility information if
				  there have been changes since the point of their last renewal.
b. Clinical/functional eligibility factors.
				  An assessment of clinical and functional needs serves as the basis for a level
				  of care determination and is conducted for all persons seeking Medicaid LTSS,
				  without regard to eligibility pathway. This assessment is based on needs-based
				  criteria that evaluate clinical, functional, social and behavioral needs as
				  well as environmental factors. A Medicaid Assessment and Review Team (MART)
				  determination of disability status is not required unless the applicant is
				  seeking LTSS coverage while working through the Sherlock Plan or unless the
				  applicant has been deemed to have a disability by the Social Security
				  Administration. In response to the novel Coronavirus Disease (COVID-19), until
				  the end of the Federal declaration of the COVID-19 public health emergency,
				  EOHHS will temporarily conduct level of care determinations/redeterminations
				  for all LTSS eligibility pathways via phone and physician records. The
				  responsibilities for assessing need vary for each institutional level of care
				  as follows:
(1) Nursing Facility. The State
				  established clinical and functional disability criteria under the Section 1115
				  waiver which assess the scope of a beneficiary's need for a NF level of care.
				  The EOHHS is responsible for assessing the level of need of persons seeking
				  Medicaid coverage of LTSS typically provided in a NF and long-term hospital
				  care, including home and community-based alternatives. As indicated in Part 5
				  of this Subchapter, the scope of a person's clinical/functional need for a NF
				  level of care (high or highest) affects the type of LTSS available to the
				  person and thus the choice of setting (institutional and/or HCBS).
(2) Intermediate care facilities for persons
				  with intellectual disabilities. The BHDDH uses needs-based criteria to evaluate
				  clinical/functional eligibility for the ICF/ID level of care that incorporate
				  the requirements set forth in State law (R.I. Gen. Laws §
													40.1-22-6), the scope of
				  services and supports required, and the impact of familial, social, and
				  environmental factors that affect the choice of setting.
(3) Long-term Hospital Care. Each agency
				  serving beneficiaries who may require Medicaid LTSS in a hospital setting is
				  authorized under the State's 1115 waiver to tailor the clinical/functional
				  criteria to meet their population's general and unique needs within the
				  parameters of applicable Federal Regulations and laws. This applies to persons
				  seeking services through the EOHHS Habilitation Program that were authorized
				  prior to establishment of the Section 1115 demonstration in 2009 under the
				  State's Section 1915(c) Habilitation Waiver and the various programs
				  administered by the BHDDH. EOHHS determines clinical/functional eligibility for
				  applicants seeking an LTH level of care through the Medicaid Habilitation
				  program and certain persons referred by the BHDDH for admission to the State's
				  Eleanor Slater Hospital.
(4)
				  Children with Special Health Care Needs. Children with disabilities and/or
				  serious chronic and disabling conditions may require a NF, ICF/ID or LTH level
				  of care at home or in an institutional-setting. The process for assessing level
				  of need for children who are eligible based on the MAGI, SSI or custody of the
				  State's Department of Children, Youth and Families (DCYF) is conducted by
				  multiple entities under the auspices of the early, periodic, screening,
				  detection and treatment (EPSDT) in Part
				  30-00-1 of this Title. The
				  designated unit of EOHHS determines clinical/functional eligibility for
				  children who do not qualify for coverage through one (1) of these pathways and
				  are seeking coverage of LTSS in a home setting in accordance with the
				  provisions located in Subchapter 10 Part 3 of this Chapter. Continuing
				  eligibility for current beneficiaries is based on the method used to determine
				  initial eligibility and, if no basis for coverage is found, across the
				  remaining pathways.
c.
				  Financial Eligibility Factors. LTSS eligibility specialists in the Department
				  of Human Services (DHS) are responsible for determining financial eligibility
				  through the IES and related systems. The financial requirements pertain to an
				  array of factors including the calculation of countable income and resources
				  using the MAGI or SSI method and the allocation of resources and transfer of
				  asset requirements that are unique to the determination of LTSS eligibility.
				  Both of the following apply to new and existing beneficiaries seeking LTSS
				  without regard to basis of eligibility and are explained in greater detail in
				  Part 6 of this Subchapter.
(1) Allocation of
				  resources with spouses/dependents. The evaluation and allocation of resources
				  at the point the need for LTSS is established and/or at the time of application
				  is required for LTSS applicants who have spouses. This process, referred to as
				  the Community (Non-LTSS) Spouse Resource Allowance (SRA), allocates the joint
				  resources of couples in accordance with Federal standards to ensure a
				  sufficient amount is protected for the non-LTSS spouse's needs - that is,
				  unavailable to pay for the costs of care for the LTSS applicant/beneficiary.
				  The allocation of resources at this state of the eligibility process is
				  distinct from that which occurs when determining the amount of income a
				  beneficiary must pay toward the cost of care in the "posteligibility" treatment
				  of income. LTSS MAGI beneficiaries are subject to allocation of resource
				  requirements but are exempt from the post-eligibility treatment
				  process.
(2) Transfer of assets.
				  The determination of financial eligibility for Medicaid LTSS requires that the
				  State review whether an applicant made a "disqualifying" transfer of assets -
				  liquid resources and real property - in the sixty (60) month period before the
				  need for LTSS was established. A transfer is deemed to be disqualifying if the
				  asset was conveyed for less than fair market value. Under Federal law, such a
				  transfer is presumed to have been made to reduce assets for the expressed
				  purpose of gaining Medicaid LTSS eligibility. The State is required to impose a
				  penalty period, during which Medicaid coverage for LTSS is unavailable, that is
				  equal to the amount of the disqualifying transfer divided by the average cost
				  of care at the private pay rate.