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 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.3 - Definitions

Current through June 14, 2024
A. For the purposes of this section, the
				  following definitions apply:
1. "Applicant"
				  means a person seeking Medicaid coverage under this Part, in accordance with
				  the provisions established in Rhode Island General Laws and Public
				  Laws.
2. "Cost-effective" means
				  that the portion of the ESI that the State would subsidize, as well as
				  wrap-around costs, would, on average, cost less to the State than enrolling
				  that same individual/family in a Medicaid managed care plan.
3. "Cost-sharing" means any deductibles or
				  co-insurance associated with ESI.
4. "Employee premium" means the monthly
				  amount an individual or family is required to pay to the employer to obtain and
				  maintain ESI coverage.
5.
				  "Employer-Sponsored Insurance" or "ESI" means health insurance or a group
				  health plan offered to employees by an employer. This includes plans purchased
				  by small employers through HealthSource RI.
6. "Group health plan" means an employee
				  benefits plan as defined in Section
				   3(1)   of the
				  Employee Retirement Income Security Act of 1974 as qualified in R.I. Gen. Laws
				  §§
											27-50-3(T)(1) 
				  and
				   27-18.6-2(15).
7. "Health insurance coverage" or "Health
				  benefit plan" means a policy, contract, certificate or agreement offered by a
				  health insurance carrier to provide, deliver, arrange for, pay for, or
				  reimburse any of the costs of health care services as defined and qualified in
				  R.I. Gen. Laws §§
											27-18.5-2(7),
				   27-18.6-2(14) 
				  and
				   27-50-3(U)(1).
8. "Medicaid member" means a person who has
				  been determined to be eligible for Medicaid benefits.
9. "Modified Adjusted Gross Income" or "MAGI"
				  means income, adjusted by any amount excluded from gross income under section
				  911 of the IRS Code, and any interest accrued. Social Security benefits are not
				  included in gross income. The MAGI is the standard for determining income
				  eligibility for all Medicaid affordable care coverage groups (RICR Title 210,
				  Chapter 30 (Medicaid for Children, Families, and Affordable Care Act (ACA)
				  Adults).
10. "Policy holder" means
				  the employee with access to ESI.
11. "Rhode Island Works" or "RI Works" means
				  the State's Temporary Assistance for Needy Families (TANF) program that
				  provides assistance to low income needy families on the path to full employment
				  and financial independence. The program is administered by the Rhode Island
				  Department of Human Services, one of the four State agencies under the
				  Executive Office of Health and Human Services (EOHHS) umbrella.
12. "RIte Share-approved employer-sponsored
				  insurance" means an ESI plan that meets the coverage and cost-effectiveness
				  criteria for RIte Share.
13. "RIte
				  Share buy-in" means, in certain instances, individuals participating in RIte
				  Share are subject to a buy-in requirement. This requirement applies to a family
				  in which a Medicaid-eligible child is residing in a household with MAGI-based
				  income above 150% of the FPL and must enroll in the RIte Share-approved ESI
				  plan of a parent/caretaker - "the policy holder" - who is not eligible for
				  Medicaid.
14. "RIte Share Premium
				  Assistance Program" means the Rhode Island Medicaid premium assistance program
				  in which the State pays the eligible Medicaid member's share of the cost of
				  enrolling in a RIte Share-approved ESI plan. This allows the State to share the
				  cost of the health insurance coverage with the employer.
15. "RIte Share Unit" means the entity within
				  EOHHS responsible for assessing the cost-effectiveness of ESI, contacting
				  employers about ESI as appropriate, initiating the RIte Share enrollment and
				  disenrollment processes, handling member communications, and managing the
				  overall operations of the RIte Share program.
16. "Third party liability" or "TPL" means
				  other health insurance coverage. This insurance is in addition to Medicaid and
				  is usually provided through an employer. Since Medicaid is always payer of last
				  resort, the TPL is always the primary coverage.
17. "Wrap-around services or coverage" means
				  any health care services not included in the ESI plan that would have been
				  covered had the Medicaid member been enrolled in a Medicaid managed care plan
				  (Part 2 of this Subchapter). Coverage of deductibles and co-insurance is
				  included in the wrap. Co-payments to providers are not covered.