reglab/statecodes huggingface dataset:
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.1 - Overview and Statutory Authority

Current through June 14, 2024
A. The goal of the
				  federal Affordable Care Act (ACA) of 2010 is to improve access to high quality
				  health insurance coverage for people of all ages and income levels. In keeping
				  with this purpose, the ACA established a presumptive eligibility program for
				  certain individuals and families in the newly reconfigured Medicaid Affordable
				  Care Coverage (MACC) groups. The MACC groups in Rhode Island are described in
				  "Medicaid Code of Administrative Rules, Section 1301, 'Medicaid Affordable Care
				  Coverage Groups'".
B. Federal
				  regulations governing the program at
				   42 C.F.R. §
											435.1110  authorize the states to provide
				  Medicaid for a limited period of time to individuals who are determined by a
				  "qualified hospital", on the basis of preliminary information, to be
				  presumptively eligible for Medicaid. This initial determination is made by the
				  hospital on the basis of the characteristics for MACC group eligibility. The
				  states have the discretion under these provisions to tailor presumptive
				  eligibility requirements program within certain parameters to meet their own
				  unique needs.
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.2 - Scope and Purpose of Hospital Presumptive Eligibility Program for Medicaid

Current through June 14, 2024
A. The State of
				  Rhode Island had determined that presumptive eligibility will be available to
				  individuals in the MACC groups who qualify for Medicaid-funded affordable
				  coverage. For all other individuals with MACC-like characteristics, presumptive
				  eligibility must be determined by a qualified hospital, licensed in Rhode
				  Island, and is only available in certain circumstances contingent upon
				  preliminary information supplied by the individual. Further, presumptive
				  eligibility is only available on a temporary basis - until the last day of the
				  month following the initial determination of presumptive eligibility or the
				  date full eligibility is determined, whichever comes first.
1. Exclusions: Individuals in the MACC groups
				  who are eligible for affordable coverage funded through the Children's Health
				  Insurance Program (CHIP) under Title XXI of the U.S. Social Security Act are
				  excluded from presumptive eligibility. CHIP-funded beneficiaries excluded from
				  HPE are as follows:
a. All lawfully present
				  non-citizen children while subject to the federal five (5) year ban;
b. Children up to age 19 with income from
				  133% to 261% of the FPL;
c. All
				  non-qualified non-citizen pregnant women with income up to 253% of the FPL;
				  and
d. Pregnant women with income
				  from 185% to 253% of the FPL.
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.3 - Definitions

Current through June 14, 2024
A. "Children's Health Insurance Program" or
				  "CHIP" means the program administered by the United States Department of Health
				  and Human Services that provides matching funds to states for health insurance
				  to families with children. The program was designed to cover uninsured children
				  in families with incomes that are modest but too high to qualify for
				  Medicaid.
B. "Executive Office of
				  Health and Human Services" or "EOHHS" means the designated "single state
				  agency", authorized under Title XIX of the U.S. Social Security Act (42 U.S.C. §
											1396a  et seq.), to be legally responsible for
				  the programmatic oversight, fiscal management, and administration of the
				  Medicaid program.
C. "Hospital
				  Presumptive Eligibility" or "HPE" means Medicaid eligibility granted on a
				  temporary basis to a person who meets certain criteria during a defined
				  period.
D. "Medicaid Affordable
				  Care Coverage Groups" or "MACC Groups" means a classification of persons
				  eligible to receive Medicaid based on similar characteristics who are subject
				  to the MAGI standard for determining income eligibility beginning January 1,
				  2014.
E. "Medicaid Code of
				  Administrative Rules" or "MCAR" means the compilation of rules governing the
				  Rhode Island Medicaid Program, promulgated in accordance with the State's
				  Administrative Procedures Act (R.I. Gen. Laws Chapter 42-35).
F. "Qualified Hospital" means any licensed
				  Rhode Island hospital participating in the Medicaid program that executes a
				  Notice of Intent to Participate in the HPE Program and a Memorandum of
				  Understanding with EOHHS to conduct presumptive eligibility determinations,
				  participates in training and certification sponsored by EOHHS, and remains in
				  good standing with EOHHS protocols.
G. "Self-Attestation" means the act of a
				  person affirming through an electronic or written signature that the statements
				  the person made when applying for Medicaid eligibility are truthful and
				  correct.
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.4 - Populations Eligible for HPE

Current through June 14, 2024
A. Qualified
				  hospitals participating in the HPE Program may complete presumptive eligibility
				  assessments for individuals who have the characteristics of members of the MACC
				  groups funded through Title XIX. HPE excludes individuals eligible for coverage
				  funded through CHIP and any individuals eligible for Medicaid on the basis of
				  age, blindness or disability and/or in need of Medicaid-funded long-term
				  services and supports.
B. Qualified
				  hospitals are authorized to make presumptive eligibility determinations for
				  individuals who demonstrate potential Medicaid eligibility in one of the
				  following MACC groups, but only as specified:
1. Families and Parents/Caretakers with
				  income up to 133% of the Federal Poverty Level (FPL) - Includes families and
				  parents/caretakers who live with and are responsible for dependent children
				  with income up to 133% of the FPL under the age of 18, or 19 if enrolled in
				  school full-time.
2. Pregnant women
				  with income up to 185% who are United States citizens or qualified
				  non-citizens. Members of this coverage group can be of any age. Pregnant women
				  are limited to one (1) HPE determination per pregnancy.
3. Children and Young Adults up to the age of
				  19 with income up to 133% of the FPL (CHIP exclusions apply).
4. Adults 19-64. This is the new Medicaid
				  State Plan expansion coverage group established in conjunction with
				  implementation of the ACA. The group consists of citizens and qualified
				  non-citizens with income up to 133% of the FPL who meet the age characteristic
				  and are not otherwise eligible for, or enrolled in, Medicaid under any other
				  state plan or Section 1115 waiver coverage group.
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.5 - Scope of Coverage

Current through June 14, 2024
A. Eligibility
				  Period. The hospital presumptive eligibility period begins, and includes, the
				  date the hospital makes the HPE determination. The hospital presumptive
				  eligibility period ends on the date that the Medicaid agency renders a
				  determination for full Medicaid eligibility; or the last day of the month
				  following the month in which the hospital made the HPE determination, whichever
				  comes first.
B. Covered Services.
				  Individuals determined eligible for HPE, receive the same scope of State Plan
				  and Section 1115 waiver services as members of a MACC group, except as follows:
1. All HPE beneficiaries -- No transportation
				  services.
2. Pregnant women --
				  Maternity services are limited to prenatal ambulatory care only. (Birthing
				  expenses are not covered.)
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.7 - Reporting

Current through June 14, 2024
The qualified hospital must submit monthly reports in a
					 standardized format as defined by EOHHS. These reports must be submitted
					 electronically by the fifth business day of the month following HPE
					 determinations. The reports must reflect accurate measurement of the
					 performance requirements described in §
										4.8   of this Part below. In
					 addition, the qualified hospital must prepare and submit any ad-hoc reports to
					 EOHHS upon request.
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.8 - Performance Requirements

Current through June 14, 2024
The EOHHS requires that a qualified hospital meet certain
					 performance standard to continue participation in the HPE. First, the qualified
					 hospital must submit full Medicaid applications for ninety-five percent (95%)
					 of the individuals granted HPE within five (5) calendar days from the date of
					 the initial determination of presumptive eligibility. Second the percentage of
					 these Medicaid applications that must be deemed fully complete by the EOHHS --
					 that is, contain no errors or otherwise require the State's intervention in
					 processing -- is set forth in contractual standards between the hospital and
					 the EOHHS. Last, the number of individuals qualifying for HPE who must be
					 determined to be eligible for full Medicaid, as determined by the EOHHS, is
					 also set forth in the Notice of Intent to Participate in the HPE Program and a
					 Memorandum of Understanding with EOHHS for the qualified hospital established
					 by EOHHS. In the event a qualified hospital does not meet acceptable
					 performance standards, participation in the HPE may be suspended or terminated
					 at the discretion of the EOHHS.
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.9 - Office of Program Integrity Agency Authority

Current through June 14, 2024
The EOHHS may undertake an array of actions to assess
					 whether qualified hospitals are meeting the performance standards for the
					 program. The EOHHS Office of Program Integrity (OPI) has been assigned
					 responsibility for performing routine audits and intensive reviews of the HPE
					 program, as appropriate. The OPI is also responsible for overseeing the
					 development and submission of any hospital Corrective Action Plans deemed
					 warranted. The OPI initial audits will commence within the first six (6) months
					 of the program's start-up date and then be performed annually thereafter or as
					 needed.
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.10 - Corrective Action

Current through June 14, 2024
A. In the event a
				  qualified hospital does not achieve proficiency on the performance requirements
				  outlined in §
										4.8   of this Part, the EOHHS
				  may require the development of Corrective Action Plan (CAP) indicating
				  interventions the hospital proposed to take to achieve compliance with these
				  and/or other contractual standards. The OPI is responsible for reviewing and
				  monitoring compliance with the CAP. HPE determinations may be suspended while
				  the CAP is being prepared or implemented, as appropriate.
B. EOHHS reserves the right to request
				  modifications to the CAP if the CAP is deemed ineffective to achieve
				  compliance;
C. The qualified
				  hospital must submit weekly CAP reports to EOHHS measuring the outcome of the
				  corrective actions the hospital has instituted;
D. HPE suspensions remain in full force and
				  effect until such time as the hospital demonstrates to EOHHS that it has
				  instituted corrective measures to bring the hospital into full compliance with
				  State and federal requirements.
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.11 - For Further Information or to Obtain Assistance

Current through June 14, 2024
For further information or to obtain assistance, please
					 contact: 1-855-697-4347.
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 4 - Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals (210-RICR-30-00-4) › Section 210-RICR-30-00-4.12 - Severability

Current through June 14, 2024
If any provisions of these Regulations or the application
					 thereof to any person or circumstance shall be held invalid, such invalidity
					 shall not affect the provisions or application of these Regulations which can
					 be given effect, and to this end the provisions of these Regulations are
					 declared to be severable.
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 5 - Medicaid MAGI Financial Eligibility Determinations and Verification › Section 210-RICR-30-00-5.1 - Scope and Legal Authority

Current through June 14, 2024
A. The purpose of
				  this rule is to describe the Modified Adjust Gross Income (MAGI) standard and
				  explain how it is applied; and establish the role and responsibilities of the
				  State and consumers when determining MAGI-related eligibility for the Medicaid
				  Affordable Care Coverage (MACC) groups identified in Part 1 of this
				  Subchapter.
B. This Part is
				  promulgated pursuant to:
1. Federal
				  authorities as follows:
a. Federal Laws -Title
				  IV, Title XIX, Title XXI of the U.S. Social Security Act and ACA (Pub. Law
				  111-148); Health Care and Education Reconciliation
				  Act of 2010 (Pub.
				  Law 111-115); Tax Cuts and Jobs Act of 2017, (Pub. Law
				  115-197), Title I, § 11051(c), 131 S tat.
				  2090.
b. Federal Regulations -
				   42 C.F.R.
				  §§
													435.603; 435.902-910;
				  435.916;
				  and
				  435.1005
c. The Medicaid State Plan and the
				  Title XIX, § 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 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 00 - Affordable Coverage Groups › Part 5 - Medicaid MAGI Financial Eligibility Determinations and Verification › Section 210-RICR-30-00-5.3 - MAGI Household Construction

Current through June 14, 2024
A. The principal
				  factor for determining MAGI-based eligibility is tax filing status and
				  household composition and size, based on the rules for household construction.
1. General rules of household construction -
				  For the purposes of calculating MAGI, a household consists of an applicant and
				  the people the applicant claims as a deduction for a personal exemption when
				  filing federal income taxes. Under IRS rules, the taxpayer may claim a personal
				  exemption deduction for him/herself, a spouse, and tax dependents. Non-family
				  members may be included as tax dependents under certain circumstances and are
				  treated as part of the tax household accordingly.
2. Special Medicaid rules of household
				  construction - The following rules for constructing a household are applied
				  when making MAGI-based Medicaid eligibility determinations:
a. "Relationship-based" rules are used when
				  an applicant is neither filing taxes nor being claimed as a tax dependent, and
				  under the exceptions outlined in §
												5.4   of this Part.
b. Medicaid household rules are "person
				  specific" within a family. Therefore, a Medicaid household must be constructed
				  for each person within a family.
c.
				  For married couples living together, each spouse must be included in the
				  household of the other spouse, regardless of whether they expect to file a
				  joint federal tax return or whether one (1) spouse expects to be claimed as a
				  tax dependent by the other spouse.
d. If a pregnant woman is applying for
				  coverage or is part of another applicant's household, the household size must
				  be adjusted to reflect the number of children that she is expecting.
				  Specifically, the pregnant woman is counted as one (1) plus the number of
				  children she expects to deliver. This pregnancy-adjusted household size is used
				  to determine the applicable FPL for the pregnant woman as well as for other
				  members of her household.
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 5 - Medicaid MAGI Financial Eligibility Determinations and Verification › Section 210-RICR-30-00-5.4 - Exceptions Requiring Application of Relationship Household Rules

Current through June 14, 2024
A. Relationship-based household composition
				  rules must be applied when an applicant meets the criteria for an exception
				  from the tax-based household rules. These alternative relationship-based rules
				  must be used to determine both household size and the income of the household
				  members included as part of total household income.
1. Relationship-based rules - The household
				  is determined based upon the family members who live with the applicant. The
				  rules vary slightly for children versus adults.
a. Adults. The relationship-based rules for
				  adults require that the household consist of the following persons:
(1) The adult applying for
				  coverage;
(2) The applicant's
				  spouse, if living with the applicant;
(3) The applicant's biological, adopted, and
				  step-children under age nineteen (19) years, if living with the
				  applicant.
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 5 - Medicaid MAGI Financial Eligibility Determinations and Verification › Section 210-RICR-30-00-5.6 - Verification of Income Using the MAGI Methodology

Current through June 14, 2024
A. To
				  achieve the ACA's goal of improving and streamlining access to all forms of
				  affordable coverage, including Medicaid, the federal government established a
				  data hub containing information related to various eligibility factors. The
				  federal data hub facilitates the electronic information exchange necessary to
				  verify eligibility both at the time of initial application and during annual
				  renewals thereafter. States have the flexibility to augment the electronic
				  verification process the federal data hub uses with any additional data bases
				  deemed appropriate. Rhode Island elected to use state level databases to verify
				  income first as they tend to be more correct, but still uses the federal data
				  hub, as appropriate.
B. The purpose
				  of §
										5.7   of this Part is to
				  identify the principal facets of the verification process, including the
				  electronic matches made through the federal data hub, and State-automated data
				  bases and alternatives. In addition, the provisions of this rule also set forth
				  the respective roles and responsibilities of the EOHHS, in its capacity as the
				  Single State Medicaid Agency and applicants in assuring this process functions
				  in the most secure, effective, and efficient manner possible.
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 5 - Medicaid MAGI Financial Eligibility Determinations and Verification › Section 210-RICR-30-00-5.7 - Verification Process

Current through June 14, 2024
A. As indicated in
				  Part 10-00-3 of this Title, attestations are accepted without verification for
				  residency, household composition, pregnancy and caretaker relative status. In
				  general, this verification process proceeds as follows:
1. Data matching - The State must assure that
				  an applicant's information is entered into the integrated eligibility system
				  (IES) and matched electronically to the full extent feasible through the
				  federal data hub and State data sources.
a.
				  Federal Data Hub. The federal data hub contains electronic information from
				  various agencies of the United States government, including the IRS, Social
				  Security Administration (SSA), HHS (Centers for Medicare and Medicaid Services
				  (CMS) and other agencies), Department of Homeland Security (USDHS), Department
				  of Veterans Affairs (VA), Department of Defense (DoD), Peace Corps, and Office
				  of Personnel Management (OPM). Various categories of data from these sources
				  are used to match on income, employment, health, entitlements, citizenship, and
				  criminal history. A full list of the data included in the federal hub and the
				  rules governing its use are located in
				   42 C.F.R. §§
													435.948 and  435.949.
b. State data sources. The State draws from
				  databases from an array of public agencies to verify income including the RI
				  Department of Labor and Training (DLT), Divisions of Revenue and Motor
				  Vehicles, and EOHHS agencies including Department of Human Services (DHS).
				  Specific databases include State Wage Information Collection Agency (SWICA) and
				  State unemployment compensation information (UI).
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 5 - Medicaid MAGI Financial Eligibility Determinations and Verification › Section 210-RICR-30-00-5.9 - Reasonable Explanations

Current through June 14, 2024
A. When attestation
				  and data sources are not reasonably compatible, the IES provides the applicant
				  with prompts for resolving any identified discrepancies. The applicant is asked
				  first to provide an explanation. Before an eligibility determination is made,
				  the applicant will be afforded an opportunity to explain any discrepancies
				  between their income attestation and the income source data.
B. The following chart is a list of
				  acceptable explanations when there is a discrepancy between an income
				  attestation and data sources. If the applicant provides any one (1) of these
				  explanations, eligibility will be based on their attestation and no further
				  verification is required. The State has only implemented reasonable explanation
				  options for income discrepancies.
______
Reasonable Explanations for Discrepancy in
								  Income
Lost job
Fluctuating income
Decrease in hours
Work on commissions
Multiple employers
Income from capital gains
Self-employed
Income from dividends
Do not file taxes
Income from royalties
Have not filed taxes yet
Seasonal worker
Homeless
Divorce or marriage
Victim of domestic violence
Death in family
Victim of natural disaster
Victim of identity theft
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 5 - Medicaid MAGI Financial Eligibility Determinations and Verification › Section 210-RICR-30-00-5.10 - Reconciliation Period

Current through June 14, 2024
If the applicant's data verification is not reasonably
					 compatible with the attested information and the applicant has been unable to
					 provide a reasonable explanation for discrepancies, applicants will be given a
					 thirty (30) day application period to submit satisfactory documentation.
					 Medicaid eligibility is only available during the reconciliation period as
					 specified §
										5.11   of this Part
					 below.
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 5 - Medicaid MAGI Financial Eligibility Determinations and Verification › Section 210-RICR-30-00-5.11 - Satisfactory Documentation and Alternative Forms of Verification

Current through June 14, 2024
A. During the reconciliation process,
				  applicants will be asked to submit satisfactory documentation to verify income
				  eligibility as indicated below:
Income Verification Sources
Pay stubs representative of the last four (4)
								  weeks of income Earnings Statement
Reports from Social Security, Veteran's
								  Administration, and other agencies
Employment Letter
When the applicant is unable to obtain the
								  information requested,
Book Keeping Records
Departmental forms (Wage Report, AP-50; Bank
								  Clearance, AP-91;
Property Unit Proof
Clearance with VA, AP-150 and AP-151) are
								  used.
Owner Occupied Proof
Monthly Rental Income Proof
Mortgage Breakdown Proof
Income Tax Returns
B.
				  The State may provide an alternate verification process. This alternative
				  process is available when one (1) or more of the following conditions apply:
1. The IRS's only tax data for the applicant
				  is over two (2) years old;
2. The
				  applicant attests that the family size or family members have changed since the
				  tax information being used for the determination was filed;
3. The applicant attests that a change in
				  circumstances has occurred or is reasonably expected to occur that may affect
				  eligibility;
4. The applicant
				  attests to a change in tax filing status that has or is reasonably expected to
				  change the tax filer's annual income; or
5. An applicant in the tax filer's family has
				  applied for unemployment benefits.
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 5 - Medicaid MAGI Financial Eligibility Determinations and Verification › Section 210-RICR-30-00-5.12 - Post-Eligibility Verification (PEV) by the Integrated Eligibility System (IES)

Current through June 14, 2024
A. The IES will conduct post-eligibility
				  verification of the beneficiary's information. The IES runs post-eligibility
				  verifications on the following beneficiary information:
1. Factors reviewed:
a. Incarceration status (Rhode Island
				  Department of Corrections data)
b.
				  Death data (Department of Health Vital Records data)
c. Current Income - Wages (Department of
				  Labor and Training - SWICA)
d.
				  Current Income - Unemployment Income (UI) (Department of Labor and
				  Training)
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.1 - RIte Care Overview

Current through June 14, 2024
A. RIte Care was
				  initially established as a statewide managed care demonstration project in 1994
				  under a waiver granted pursuant to §
										1115   of the Social Security Act,  42 U.S.C. §
											1315. The project's goal was to use a managed care delivery
				  system to increase access to primary and preventative care for certain
				  individuals and families who otherwise might not be able to afford or obtain
				  affordable coverage. Medicaid members participating in RIte Care are enrolled
				  in a managed care organization (MCO). EOHHS contracts with MCOs to provide
				  these health services to members at a capitated rate (fixed cost per enrollee
				  per month). RIte Care managed care plans serve the following MACC coverage
				  groups: families, children, parent caretakers, foster children (DCYF custody),
				  and pregnant women.
B. Individuals
				  and families who have access to employer-sponsored health insurance plans are
				  evaluated for participation in the RIte Share Premium Assistance Program in
				  accordance with provisions contained in "RIte Share Premium Assistance Program"
				  (Part 3 of this Subchapter). Adults in these families are required to enroll
				  any Medicaid-eligible family members in a RIte Share approved plan as a
				  condition of retaining Medicaid eligibility. Medicaid is provided on a
				  fee-for-service basis for certain beneficiaries in the populations RIte Care
				  plans serve.
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.2 - Scope and Purpose

Current through June 14, 2024
A. The purpose of
				  this Rule is to describe the RIte Care delivery system and the respective roles
				  and responsibilities of EOHHS and the individuals and families that are
				  receiving affordable coverage through a RIte Care MCO.
B. This Rule is consistent with the Federal
				  managed care Rules (42 C.F.R. Parts 431, 433, 438,
et seq
.,
				  Medicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid
				  Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third
				  Party Liability; Final Rule) published in March 2016 that contain, among other
				  provisions, certain mental health parity requirements added to the Public
				  Health Service Act (PHS Act) by the Paul Wellstone and Pete Domenici Mental
				  Health Parity and Addiction Equity Act of 2008 (MHPAEA) ((Pub. Law 110-343),
				  enacted on October 3, 2008). Such parity provisions (42 C.F.R. Parts 438, 440,
				  456, and 457) prohibit health plans from applying treatment limitations on
				  mental health and substance use disorders (SUDs) that would be more restrictive
				  than those applied to medical/surgical benefits.
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.3 - Program Management

Current through June 14, 2024
A. Title XIX of the
				  U.S. Social Security Act,  42 U.S.C. §§
											1396-1396w-7, provides the
				  legal authority for the Rhode Island Medicaid program. The RIte Care program
				  operates under a waiver granted by the Secretary of Health and Human Services
				  (HHS) pursuant to §
										1115   of the Social Security Act,  42 U.S.C. §
											1315. The RIte Care Managed Care Consumer Advisory Committee was established by
				  Executive Order in February 1994. The Committee is available to RIte Care
				  consumers to address suggestions, complaints, or related issues.
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.5 - Coverage Groups in RIte Care

Current through June 14, 2024
A. The RIte Care
				  population consists of members of: certain Medicaid affordable care coverage
				  (MACC) groups; coverage groups whose eligibility is NOT based on the MAGI
				  standard (non-MAGI) and several non-Medicaid coverage groups.
1. Medicaid Affordable Care Coverage (MACC)
				  Groups - RIte Care plans provides coverage for individuals and families in the
				  following MACC groups:
a. Families with income
				  up to one hundred sixteen percent (116 %) of the FPL and parents and caretaker
				  relatives with income between one hundred sixteen percent (116%) and one
				  hundred forty-one percent (141%) of the FPL who have dependent children up to
				  age eighteen (18) or, if attending school full-time, up to age nineteen
				  (19).
b. Pregnant women with family
				  income up to two hundred fifty-three percent (253%) of the FPL, including
				  non-citizen pregnant women.
c.
				  Children up to age nineteen (19) with family income up to two hundred sixty-one
				  percent (261%) of the FPL, including qualified non-citizen children.
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.6 - Excluded Medicaid Coverage Groups

Current through June 14, 2024
A. There are MACC
				  group beneficiaries who receive coverage on a fee-for-service basis rather than
				  through a RIte Care plan, as follows:
1.
				  Members of these coverage groups who are covered by employer-sponsored or other
				  third (3rd) party health insurance, may receive Medicaid on a fee-for-service
				  basis, rather than through enrollment in a RIte Care MCO:
a. IV-E foster children and children
				  receiving adoption subsidy (see §
												00-1.8(F)(3)   of this Chapter).
b. SSI recipients under age twenty-one (21)
				  (§
												00-1.6   of this Chapter).
c.
				  Children with disability - Katie Beckett Eligible under Part 50-10-3 of this
				  Title. Children under age nineteen (19) who: are living at home; require a
				  hospital, nursing home or ICF-ID level of care; and would qualify for Medicaid
				  if in a licensed health care institution.
d. SSI recipients over age twenty-one
				  (21).
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.7 - Retroactive Coverage

Current through June 14, 2024
A. Requests for
				  retroactive eligibility are evaluated at the time of application, but must not
				  delay a decision on prospective eligibility. Retroactive eligibility is not
				  available to MACC groups enrolled in RIte Care. Foster and adoption subsidy
				  children in Non-MAGI coverage groups are eligible for retroactive coverage if
				  eligible for SSI. Retroactive coverage is also available to SSI-related
				  eligible individuals and SSI-related medically needy flex-test cases. If
				  eligibility exists, retroactive payment for services is on a fee-for-service
				  basis and does not exceed a three-month time period.
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.8 - Overview of RIte Care Services

Current through June 14, 2024
A. Individual and
				  families enrolled in RIte Care receive the full scope of services covered under
				  the Medicaid State Plan and the State's Section  1115   waiver, unless otherwise
				  indicated. Covered services may be provided through the MCO or through the
				  fee-for-service delivery system if the service is "out-of-plan" - that is, not
				  included in the MCO but covered under Medicaid. Fee-for-service benefits may be
				  furnished by any participating provider. Rules of prior authorization apply to
				  any service required by EOHHS. Each RIte Care member selects a primary care
				  provider (PCP) who performs the necessary medical care and coordinates
				  referrals to specialty care. The primary care provider orders treatment
				  determined to be medically necessary in accordance with MCO policies.
				  Beneficiaries in the Extended Family Planning (EFP) coverage group do not
				  require a PCP. The extended family planning group is entitled only to family
				  planning services.
1. Access to Benefits -
				  Unless otherwise specified, members of all RIte Care coverage groups (MACC,
				  Non-MAGI) are entitled to a comprehensive benefit package that includes both
				  in-plan and specific out-of-plan services. Categories of eligibility for the
				  extended family planning benefit package are as follows:
a. Women otherwise Medicaid ineligible. The
				  package of services is available without the comprehensive benefit package.
				  Women who have given birth and are not eligible for Medicaid under another
				  coverage group lose the full scope of covered services twelve (12) months
				  postpartum or post-loss of pregnancy. Women in this category are eligible for
				  RIte Care for a period of up to twenty-four (24) months for the full family
				  planning benefit package. The benefit package includes interpreter services but
				  does not include transportation benefits. Renewal is required at twelve (12)
				  months.
b. Women who are otherwise
				  eligible for Medicaid. Women enrolled in RIte Care are eligible for family
				  planning services. Participation is voluntary. Members continue to be enrolled
				  with the same MCO they selected or were assigned to for comprehensive health
				  service delivery but for family planning services only for a twelve (12) month
				  period. Upon renewal at twelve (12) months, a participant may qualify for up to
				  an additional twelve (12) months. Services are covered on an outpatient basis
				  only. Non-prescription contraceptives are covered for members in this category
				  with a provider's order (i.e., prescription).
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.10 - Out-of-Plan Benefits

Current through June 14, 2024
A. Out-of-plan
				  benefits are not included in the capitated rate paid to the MCOs and are not
				  the responsibility of the MCO to provide. These services are provided by
				  existing Medicaid-approved providers who are reimbursed directly by EOHHS on a
				  fee-for-service basis. Out-of-plan benefits are provided to all Rite Care
				  enrollees with the following exceptions: Individuals eligible for Extended
				  Family Planning only; Pregnant women who are otherwise ineligible for Medicaid
				  and post-partum women with income above two hundred fifty-three percent (253%)
				  of FPL; and anyone enrolled in the guaranteed enrollment period but otherwise
				  ineligible for Medicaid. The covered benefits are as follows:
ELIGIBLE GROUP
BENEFIT(S) PROVIDED
								  OUT-OF-PLAN
All Rhody Health Partners, RIte Care and
								  Expansion members
Dental services
Court-ordered mental health and substance use
								  services ordered to a non-network facility or provider
Non-Emergency Transportation Services
								  (Non-Emergency transportation is coordinated by the contracted Health
								  Plans).
Nursing home services in excess of thirty (30)
								  consecutive days (RHP members only)
Residential services for MR/DD clients that are
								  paid by the State's BHDDH
Respite (Adult)
Neonatal intensive care Unit (NICU) Services at
								  Women's and Infants
Hospital. Except as specified in §
																2.9(C)   of
								  this Part
Special Education services as defined in the
								  child's Individual Education Plan (IEP) for children with special health needs
								  or developmental delays
Lead Program home assessment and non-medical case
								  management provided by Department of Health or Lead Centers for lead poisoned
								  children
Cedar Family Center Services
Centers of Excellence Programs
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.11 - Limits on Services

Current through June 14, 2024
A. The following
				  services are not covered under the RIte Care program:
1. Experimental procedures, except as
				  required by Rhode Island State law;
2. Private rooms in hospitals (unless
				  medically necessary);
3. Cosmetic
				  surgery;
4. Medications that treat
				  erectile dysfunction or other sexual disorders;
5. Infertility treatment services;
				  and
6. Any portion of services that
				  exceeds fifteen (15) days provided in an Institution for Mental Diseases (IMD)
				  for individuals between the ages of twenty-one (21) to sixty-four
				  (64).
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.12 - Scope of Provider Networks

Current through June 14, 2024
A. The MCO must
				  maintain provider networks in locations that are geographically accessible to
				  the populations to be served, comprised of hospitals, physicians, advanced
				  practice practitioners, mental health providers, substance use disorder
				  providers, pharmacies, transportation services, dentists, school based health
				  centers, etc. in sufficient numbers to make available all services in a timely
				  manner.
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.13 - Mainstreaming/Selective Contracting

Current through June 14, 2024
A. The
				  mainstreaming of Medicaid beneficiaries into the broader health delivery system
				  is an important objective of the Medicaid program. The MCO must ensure that all
				  of its network providers accept RIte Care members for treatment. The MCO also
				  must accept responsibility for ensuring that network providers do not
				  intentionally segregate RIte Care members in any way from other persons
				  receiving services.
B. Health plans
				  may develop selective contracting arrangements with certain providers for the
				  purpose of cost containment, but must still adhere to the access standards as
				  defined in the health plan contracts.
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.14 - Primary Care Providers (PCPs)

Current through June 14, 2024
A. The MCO has
				  written policies and procedures allowing every member to select a primary care
				  provider (PCP). If a member does not select a PCP during enrollment, the MCO
				  shall make an automatic assignment, taking into consideration such factors as
				  current provider relationships, language needs, and the relative proximity of
				  the PCP to the member's area of residence. The health plan must notify the
				  member in a timely manner of his/her PCP's name, location, and office telephone
				  number, and how to change PCPs, if desired. The PCP serves as the member's
				  initial and most important point of interaction with the MCO network. In
				  addition to performing primary care services, the PCP coordinates referrals and
				  specialty care. As such, PCP responsibilities include at a minimum:
1. Serving as the member's primary care
				  provider;
2. Ensuring that members
				  receive all recommended preventive and screening care appropriate for their age
				  group and risk factors;
3.
				  Referring for specialty care and other medically necessary services both in and
				  out-of-plan;
4. Maintaining a
				  current medical record for the member; and
5. Adhering to the EPSDT periodicity schedule
				  for members under age twenty-one (21).
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.15 - Service Accessibility Standards

Current through June 14, 2024
A. The service
				  accessibility standards which the health plan must meet are:
1. Twenty-four (24) hour coverage;
2. Travel time or distance;
3. Days to appointment for non-emergency
				  services.