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 2 - Long-term Services and Supports (LTSS) Medically Needy Eligibility Pathway › Section 210-RICR-50-00-2.5 - Medically Needy Eligibility Determination Process

Current through June 14, 2024
A. To be considered for the medically needy
				  pathway, an otherwise Medicaid eligible person must have income above the
				  Federal cap of three hundred percent (300%) of the SSI rate. The LTSS
				  eligibility requirements for Medicaid LTSS are outlined in §
										1.9     of this
				  Subchapter and are set forth in greater detail throughout this Part. All LTSS
				  applicants with countable income above the Federal cap are automatically
				  evaluated for the MN eligibility pathway. Total countable income must be at or
				  below the projected cost for the type of LTSS the person is seeking or
				  receiving, at the private pay rate, adjusted annually as set forth in §
										2.6     of this Part.
B. Eligibility is
				  determined in accordance with the following:
1. Excess income amount - The person's
				  countable income for the month is determined based on the provisions set forth
				  in Part  40-00-3 of this Title, pertaining to the SSI methodology. If income is
				  above the Federal cap after all required disregards and exclusions have been
				  applied, the medically needy income limit (MNIL) is deducted from remaining
				  income. This is the total amount of excess income that must be absorbed to
				  obtain MN eligibility for LTSS.
2.
				  Income and Institutional Cost Comparison - The projected cost of LTSS at the
				  private pay rate in the applicable health institution - nursing facility (NF),
				  intermediate care facility for intellectually/developmentally disabled
				  individuals (ICF/I-DD), or long-term hospital (LTH) - is deducted from the
				  excess income.
a. If excess income is absorbed
				  by the cost of LTSS, the person is MN eligible and the provisions related to
				  the post-eligibility treatment of income (PETI), set forth in Part 8 of this
				  Subchapter, are applied to determine the amount of the person's gross income
				  that is available to be applied toward the cost of care each month.
b. If excess income is not absorbed, the
				  remaining income provides the basis for determining the LTSS MN spenddown for
				  the projected budget period once the PETI Rules are applied. Allowable expenses
				  are deducted in accordance with §2.6.1(B)   of this Part below.
3. Spenddown - A MN LTSS spenddown
				  is based on the amount of excess income remaining after all required reductions
				  are taken in the PETI process. Income protected in the PETI process is
				  unavailable and therefore is excluded in the calculation of the spenddown. Once
				  protected income is subtracted, the total spenddown is the amount of allowable
				  expenses a person must incur to meet the MNIL.
a. Otherwise Medicaid eligible due to a
				  penalty. PETI does not apply when a person who is subject to penalty period for
				  LTSS coverage is otherwise eligible for Medicaid. Therefore, during such a
				  penalty period, in which Medicaid LTSS coverage is not available, all countable
				  income is available for spenddown purposes.
b. Verification. The State determines whether
				  the applicant/beneficiary has sufficient allowable expenses each month - both
				  incurred and projected - to meet this spenddown. Proof that incurred allowable
				  expenses meet the monthly spenddown may be required as indicated in §2.6.1   of this Part below.
4. Monthly projected spenddown period - The
				  State uses a one (1) month budget period to determine beneficiary liability and
				  therefore the amount of the spenddown required to maintain eligibility.
a. Start date. A one (1) month budget period
				  begins with the first (1st) calendar month during which the person receives
				  LTSS for any part of the month, applies for Medicaid coverage for that month,
				  and meets all other requirements for Medicaid eligibility.
b. End date. A one (1) month budget period
				  ends with the last calendar month during which the person received LTSS for any
				  part of the month and meets all other eligibility requirements.