reglab/statecodes huggingface dataset:
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 1 - Medicaid Payments and Providers › Section 210-RICR-20-00-1.9 - Provider Eligibility - Suspension of Participation Pursuant to United States Department of Health and Human Services Order

Current through June 14, 2024
A. When a
				  provider is the subject of a notice by the United States Department of Health
				  and Human Services (HHS) requiring the provider's suspension or the denial,
				  termination, or refusal to renew a provider contract pursuant to §
										1902(a)(39)   of the Social Security Act,  42 U.S.C. §
											1396a(a)(39), or any
				  other section of the Social Security Act,  42 U.S.C. §§
											301-1397mm,
				  the provider's participation in the Rhode Island Medicaid program shall be
				  suspended or its provider contract shall be denied, terminated, or not renewed
				  in accordance with the HHS notice. The Rhode Island Medicaid program agency
				  shall not afford a hearing to the provider as to the correctness or validity of
				  the action taken by HHS.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 1 - Medicaid Payments and Providers › Section 210-RICR-20-00-1.11 - Notice of Violations and Sanctions

Current through June 14, 2024
A. When the
				  Medicaid agency intends to formally suspend or terminate a provider as a
				  consequence of a sanctionable violation, a notice of violation must be sent to
				  the provider by registered mail. The notice must include the following:
1. A plain statement of the facts or conduct
				  alleged to warrant the intended EOHHS action. If the Medicaid agency is unable
				  to state the matters in detail at the time the notice is served, the initial
				  notice may be limited to a statement of the issues involved and a detailed
				  statement shall be furnished as soon as is feasible.
2. A statement of the provider's right to a
				  hearing that indicates the provider must request the hearing within fifteen
				  (15) days of the receipt of the notice.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 1 - Medicaid Payments and Providers › Section 210-RICR-20-00-1.12 - Severability

Current through June 14, 2024
A. 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 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.1 - Legal Authority

Current through June 14, 2024
A. These rules and
				  regulations related to the Executive Office of Health and Human Services'
				  (EOHHS) Non-Emergency Medical Transportation (NEMT) Program are promulgated
				  pursuant to the authority conferred under:
1.
											42 C.F.R. §
												431.53"Assurance of
				  Transportation";
2.
											42 C.F.R. §
												440"Medicaid Program; State Option to Establish Non-Emergency Medical
				  Transportation Program";
3. Section
				  1902(a)(70) of the Social Security Act ("Deficit Reduction Act of
				  2005");
4. R.I. Gen. Laws §
											42-66-4(8)"Duties
				  of the Department";
5. R.I. Gen.
				  Laws §
											42-12-1.3"Transfer
				  of Functions from the Department of Elderly Affairs"; and
6. R.I. Gen. Laws §
											31-36-20(a)"Motor
				  Fuel Tax Disposition of Proceeds."
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.2 - Purpose and Overview

Current through June 14, 2024
The purpose of this regulation is to set forth methods and
					 requirements for the Non-Emergency Medical Transportation (NEMT) Program, the
					 Elderly Transportation Program (ETP), and the transportation for recipients of
					 Temporary Assistance to Needy Families (TANF).
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.4 - Transportation Services for Medicaid Beneficiaries

Current through June 14, 2024
A.
				  EOHHS recognizes that Medicaid beneficiaries need available and appropriate
				  transportation in order to access medical care, and assures the provision of
				  such transportation when required to obtain medically necessary services
				  covered by the Medicaid program.
B.
				  Transportation can be provided by any of the following modes, as appropriate to
				  the needs of the individual. Public transit (bus) is the preferred mode of NEMT
				  when both the beneficiary and the provider are within one-half (1/2) mile of an
				  established bus stop and the beneficiary is able to walk or transport
				  her/himself to the bus stop.
1. Public
				  transit (bus)
2. Taxi or Limited
				  Public Motor Vehicle (LPMV)
3. Ride
				  Share Program
4. Public Motor
				  Vehicles
5. Multi-Passenger
				  Van
6. Ambulance
7. Wheelchair Van.
8. Mileage Reimbursement.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.5 - Covered Services

Current through June 14, 2024
Covered Services - The Medicaid Program covers emergency
					 and NEMT. Ground transportation is covered and provided for when the individual
					 is a Medicaid beneficiary and is receiving a Medicaid-covered service.
2.5.1
Emergency Transportation
A. When medical services are obtained at a
				  hospital participating in the Medicaid program, it is the responsibility of the
				  hospital or emergency department staff to provide and pay for appropriate
				  transportation home if needed.
B.
				  For Medicaid managed care beneficiaries, emergency transportation is provided
				  by the managed care organization. Billing for this service is through the
				  managed care organization.
C. For
				  Medicaid fee-for-service beneficiaries, emergency transportation is provided by
				  the Medicaid fee-for-service program. Billing for this service is through the
				  Medicaid fee-for-service program.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.6 - Transportation Requests

Current through June 14, 2024
All NEMT requests must be scheduled through the State's
					 transportation management authority. Some requests may require a physician or
					 clinician's attestation and/or documentation. Information on how to contact the
					 State's transportation management authority is available at:
www.eohhs.ri.gov
.
2.6.1
Standing Order Requests
Regularly recurring appointments for which the beneficiary
					 requires NEMT transportation may be scheduled with the State's transportation
					 management authority. A licensed medical/behavioral health provider must
					 request or modify the standing order.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.7 - Service Models

Current through June 14, 2024
A.
				  Curb-to-curb
B.
				  Door-to-door
C. Wheelchair van: This
				  service is for beneficiaries who are permanently confined to a wheelchair and
				  cannot transfer out of it. Wheelchair-dependent beneficiaries must provide
				  their own wheelchair. A Hoyer Lift or two-person lift will be used to transfer
				  the beneficiary. Beneficiaries must request this service at the time of
				  reservation to the state's transportation management authority. Transportation
				  providers are not permitted to enter the beneficiary's residence or the
				  provider's office. Beneficiaries who will require additional assistance in
				  leaving their destination or upon arrival at their medical appointment may
				  bring an escort with them. Beneficiaries must inform the transportation
				  management authority when they reserve transportation that an escort will
				  accompany them.
D. Stretcher: A
				  beneficiary who is confined to a bed, cannot walk, and cannot sit in a
				  wheelchair may be transported by stretcher. The beneficiary must not require
				  medical assistance during transport. The driver must enter residence and a
				  clear, accessible path to the beneficiary must be available.
E. Basic Life Support (BLS) and Advanced Life
				  Support (ALS): Transportation of a beneficiary who is confined to a bed, cannot
				  walk, and cannot sit in a wheelchair requires medical assistance during
				  transport. The driver must enter residence and a clear, accessible path to the
				  beneficiary must be available.
F.
				  Mileage Reimbursement
1. Personal vehicle
				  mileage reimbursement is a payment to a friend, family member or volunteer who
				  transports the recipient in his/her own vehicle. The reimbursement must be
				  pre-approved by the State's transportation management authority and will be
				  paid at the approved reimbursement rate which is the federal transportation
				  mileage reimbursement rate.
2.
				  Personal vehicle mileage reimbursement is available to transport an eligible
				  Medicaid beneficiary to and from a Medicaid-covered service.
3. Trips will be validated by the State's
				  transportation management authority.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.8 - Passenger Cancellations

Current through June 14, 2024
A. Passengers must
				  make every effort to keep their scheduled trip appointments. If unable to keep
				  an appointment, notification must be provided to the State's transportation
				  management authority at least twenty-four (24) hours prior to the scheduled
				  trip.
B. If a medical appointment
				  is cancelled the same day, or there are other unforeseen circumstances, the
				  beneficiary should contact the State's transportation management authority as
				  soon as possible.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.9 - Passenger No-Shows

Current through June 14, 2024
A. Standing Orders
1. Passengers who frequently (more than three
				  (3) instances per month) do not cancel their regularly scheduled trip
				  appointment at least twenty-four (24) hours in advance may be required to
				  schedule each trip separately at least two (2) days in advance and will no
				  longer be eligible for "standing order" pick-ups.
2. After a sixty (60) day period, passengers
				  may request reinstatement of eligibility for standing order and scheduled ride
				  pick-ups without being required to confirm such trips in advance. Requests will
				  be subject to EOHHS approval.
3.
				  Passengers who frequently (more than three (3) instances per month) do not
				  cancel other scheduled trips, such as scheduled physician visits, at least
				  twenty-four (24) hours in advance may also be required to confirm scheduled
				  trips the morning of or twenty-four (24) hours in advance.
4. Passengers with a frequent pattern of
				  no-shows will receive written notice from the State's transportation management
				  authority that they will be subject to a change in their transportation
				  benefit. (See §
											2.18   of this Part,
				  "Complaint Process for Medicaid Beneficiaries and Persons Using the
				  Non-Medicaid Elderly Transportation Program and TANF
				  recipients").
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.10 - Physician's/Clinician's Attestation and/or Documentation

Current through June 14, 2024
All NEMT transportation requests that require an
					 attestation and/or written statement by the recommending physician/clinician
					 must include the specific reason/rationale why NEMT is required based upon a
					 client's functional ability and not only upon diagnosis.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.11 - Transportation Provider Participation Guidelines

Current through June 14, 2024
A. To
				  participate in the NEMT Program, a transportation provider must enter into a
				  signed agreement with the State's transportation management authority.
				  Providers must be in compliance with all applicable State and federal statutes
				  and regulations. All providers will be recruited and retained by the State's
				  transportation management authority. All required provider documents must be
				  submitted to the State's transportation management authority. All providers
				  must meet the requirements set forth by the State's transportation management
				  authority.
B. Drivers must treat
				  beneficiaries with courtesy and respect.
2.11.1
Ambulance Providers:
A. Must have a license issued through the
				  Rhode Island Department of Health (DOH);
B. License must be renewed
				  annually;
C. Must have proof of
				  insurance.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.12 - Recertification Process

Current through June 14, 2024
A. Ambulance
				  providers shall be recertified annually by the Rhode Island Department of
				  Health.
B. Taxi and Public Motor
				  Vehicle Carriers and providers shall be required to forward a copy of their
				  license or recertification with the DPUC to the State's transportation
				  management authority within thirty (30) days of renewal to avoid interruption
				  of program enrollment.
C. Ride
				  share companies must also provide a copy of their annual recertification permit
				  as a Transportation Network Company to the State's transportation management
				  authority to avoid interruption in program enrollment.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.13 - Claims Billing Guidelines

Current through June 14, 2024
A. NEMT: The
				  State's transportation management authority is responsible for claims and
				  billing for NEMT.
B. Emergency
				  Transportation: Providers will bill the health plans for emergency
				  transportation provided to Medicaid managed care beneficiaries. Providers will
				  bill the Medicaid fee-for-service program for emergency transportation provided
				  to Medicaid beneficiaries enrolled in the State's fee-for-service delivery
				  system.
2.13.1
Medicare/Medicaid Crossover Claims
A. Emergency Transportation
1. Medicare is the primary payer for
				  emergency transportation. The Medicaid FFS Program will not make any additional
				  payment on claims where the Medicare payment is equal to or more than the
				  Medicaid allowable amount.
2.
				  Payment of cross-over claims for Medicaid managed care recipients is handled
				  and directed by the managed care plans.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.14 - Non-Medicaid Elderly Transportation Program

Current through June 14, 2024
A. The
				  Non-Medicaid Elderly Transportation Program (ETP) is for individuals age 60
				  years and older who are not Medicaid eligible and who are not getting
				  transportation from the RIPTA RIde Program or from the Americans with
				  Disabilities Act (ADA) Program.
B.
				  Transportation funds available for this Program are specifically allocated for
				  services to be provided for Rhode Island residents sixty (60) years of age and
				  older.
C. The ETP provides
				  transportation to and from medical appointments, adult day care, meal sites,
				  dialysis/cancer treatment and the "INSIGHT Program."
D. The program requires a co-payment for each
				  trip segment. The co-payment amount is determined by EOHHS. The co-payment is
				  collected and retained by the transportation driver. Medicaid and "Costs Not
				  Otherwise Matchable" ("CNOM")-eligible individuals are exempt from this co-pay
				  for transportation in Priorities #1 - #4 in §
										2.15   of this Part
				  (below).
E. The ETP provides safe,
				  quality transportation services to qualified elderly individuals. Emphasis is
				  placed on priority categories of transportation services in relation to
				  existing state funding, vehicle and passenger safety and sensitivity to the
				  needs and concerns of elderly clients, and consistent assignment of preferred
				  transportation providers to the maximum extent possible.
F. Eligible participants must be legal
				  residents of the State of Rhode Island. As a condition of eligibility for
				  transportation services, participants must provide the information noted below
				  to the transportation management authority. This may include, but is not
				  limited to:
1. Date of birth;
2. Proof of residency, including but not
				  limited to, valid Rhode Island driver's license and/or Rhode Island state
				  identification card issued by the Rhode Island Division of Motor Vehicles;
				  voter identification card; current utility bill for a residence within Rhode
				  Island in the name of the individual requesting transportation
				  services;
3. Social Security
				  number;
4. Medical documentation as
				  requested by the State's transportation management authority.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.15 - Non-Medicaid Elderly Transportation Program - Specific Services

Current through June 14, 2024
The following transportation services may be provided to
					 Rhode Island elders by the State's transportation management authority based on
					 the following prioritization. Service provision is contingent upon available
					 state funding.
2.15.1
Special
				  Medical Care (Priority 1)
Special medical transportation includes transportation for
					 the purpose of kidney dialysis or cancer treatments. Names of clients to be
					 transported are to be provided to the State's transportation management
					 authority by the medical treatment facility, family, friends, or the client
					 themselves. The State reserves the right to limit special medical
					 transportation based on funding constraints or other programmatic
					 requirements.
2.15.2
Adult Day Care (Priority 2)
This category includes transport to and from adult day care
					 centers that are licensed by the Department of Health (DOH). Residences of
					 clients shall be verified by the adult day care center and provided to the
					 State's transportation management authority. The State reserves the right to
					 limit transportation to adult day care centers based on funding constraints or
					 other programmatic requirements.
2.15.3
General Medical Care (Priority
				  3)
This category includes transportation for any
					 medical/health services that are part of a total patient plan of care
					 supervised by a health care professional. Trips eligible under this service
					 category include visits to physicians' offices and dental offices as well as
					 all trips for tests and/or treatments ordered by a health care professional as
					 part of a treatment plan. The State reserves the right to limit general medical
					 transportation based on funding constraints or other programmatic
					 requirements.
2.15.4
INSIGHT (Priority 4)
A. This
				  category includes transport to and from INSIGHT, at their INSIGHT service
				  location(s). Riders must be sixty-five (65) years of age or over, have a sight
				  impaired condition and/or presently registered with the INSIGHT
				  agency.
B. Transportation shall be
				  at the discretion of the State and available during the same days and hours as
				  general medical trips. Trip requests must be forwarded to the State's
				  transportation management authority at least forty-eight (48) hours in advance.
				  The State reserves the right to limit transportation to INSIGHT based on
				  funding constraints or other programmatic requirements.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.16 - Non-Medicaid Elderly Transportation Program Service Provision Guidelines

Current through June 14, 2024
2.16.1
Limitation on
				  Transportation
Subject to state and federal law, EOHHS reserves the right
					 to limit, restrict, or terminate the availability of transportation due to
					 funding constraints, programmatic requirements, service availability, weather,
					 etc. (This provision applies to clients of the ETP only).
2.16.2
Service Models
A. Curb-to-curb
B. Door-to-door
C. Wheelchair van: Wheelchair dependent
				  beneficiaries must provide their own wheelchair. Beneficiaries must request
				  this service at the time of reservation to the State's transportation
				  management authority. Transportation providers are not permitted to enter the
				  client's residence or the provider's office. Beneficiaries who will require
				  additional assistance in leaving their destination or upon arrival at their
				  medical appointment may bring an escort with them. Beneficiaries must inform
				  the transportation management authority when they reserve transportation that
				  an escort will accompany them.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.17 - Transportation for Recipients of Temporary Assistance to Needy Families (TANF)

Current through June 14, 2024
A. Recipients of the State's Temporary
				  Assistance to Needy Families (TANF) Program are eligible to receive a monthly
				  bus pass. To obtain a monthly bus pass, TANF recipients must call the State's
				  transportation management authority to request a pass.
B. Bus passes will be mailed to the recipient
				  following the request.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.18 - Complaint Process for Medicaid Beneficiaries and Persons Using the Non-Medicaid Elderly Transportation Program and TANF Recipients

Current through June 14, 2024
A. Individuals may file a complaint as
				  follows:
1. Passengers or their family
				  members may submit a formal written or verbal complaint to the State's
				  transportation management authority. Contact information is available at
www.eohhs.ri.gov
.
2. The State's transportation management
				  authority will attempt to resolve the complaint with the individual and/or
				  his/her family.
3. In the event
				  transportation benefits are terminated or substantially altered, after due
				  notice, and the complainant wishes to pursue his/her concerns further, a
				  written complaint shall be forwarded to the State for a fair hearing. State
				  fair hearings shall be conducted in accordance with the provisions of Part
				  10-05-2 of this Title, Appeals Process and Procedures for EOHHS Agencies and
				  Programs, promulgated by EOHHS and available on the Secretary of State's
				  website.
4. In the event ETP
				  transportation benefits are terminated or altered due to a lack of Program
				  funding, formal appeal rights to a fair hearing shall not be
				  available.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.19 - 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 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 2 - Medicaid Payments and Providers: Transportation Services › Section 210-RICR-20-00-2.20 - Border Communities

Current through June 14, 2024
A. Border
				  Communities include cities and town that border Rhode Island and are considered
				  for the purpose of the Rhode Island Medical Assistance Program, instate
				  providers. Out-of-state service restrictions and prior authorization
				  requirements are not imposed on providers in the following communities:
Connecticut
Massachusetts
Danielson
Attleboro
Groton
Bellingham
Moosup
Blackstone
Mystic
Dartmouth
New London
Fall River
North Stonington
Foxboro
Pawcatuck
Milford
Putnam
New Bedford
Stonington
North Attleboro
Thompson
North Dartmouth
Waterford
Rehoboth
Seekonk
Somerset
South Attleboro
Swansea
Taunton
Uxbridge
Webster
Westport
Whitinsville
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 3 - Medicaid Payments for Out-of-State Care › Section 210-RICR-20-00-3.1 - Legal Authority and Purpose

Current through June 14, 2024
A. Title XIX of the
				  U.S. Social Security Act (42 U.S.C. §
											1396a
et seq
.) provides the
				  legal authority for the Rhode Island Medicaid Program. The Medicaid Program
				  also operates under a waiver granted by the Secretary of Health and Human
				  Services pursuant to §1115 of the Social Security Act (42 U.S.C. §
											1315). Additionally, R.I. Gen.
				  Laws Chapters 40-6, 40-8, and R.I. Gen. Laws §
										40-8-31 serve as the enabling statutes for this Regulation.
B. The purpose of this Rule is to describe
				  the respective roles and responsibilities of EOHHS and Medicaid beneficiaries
				  as it relates to receiving Medicaid services outside of Rhode Island.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 3 - Medicaid Payments for Out-of-State Care › Section 210-RICR-20-00-3.2 - Definitions

Current through June 14, 2024
A. As used herein, the following terms shall
				  be construed as follows:
1. "Executive Office
				  of Health and Human Services" or "EOHHS" means the State agency established in
				  2006 under the provisions of R.I. Gen. Laws Chapter 42-7.2 within the executive
				  branch of State government and serves as the principal agency for the purposes
				  of managing the Departments of Children, Youth, and Families (DCYF); Health
				  (DOH); Human Services (DHS); and Behavioral Healthcare, Developmental
				  Disabilities, and Hospitals (BHDDH). The EOHHS is designated as the "single
				  State agency," authorized under Title XIX of the U.S. Social Security Act
				  (42 U.S.C. §
												1396a
et seq
.) and, as such,
				  is legally responsible for the program/fiscal management and administration of
				  the Medicaid Program.
2.
				  "Temporarily absent" means time spent away from one's usual living
				  arrangements. The length of time an absence is considered temporary varies
				  based upon the reason for the absence, such as hospitalization, vacation, or
				  employment. During temporary absences, the responsibility to provide Medicaid
				  benefits does not transfer between States.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 3 - Medicaid Payments for Out-of-State Care › Section 210-RICR-20-00-3.3 - Requirement of Prior Authorization

Current through June 14, 2024
A. Payment for
				  out-of-State medical services that are provided to eligible Medicaid
				  beneficiaries living within Rhode Island requires prior authorization from the
				  Executive Office of Health and Human Services (EOHHS).
B. The following conditions must be met to
				  obtain prior authorization for out-of-State medical services:
1. If a Medicaid beneficiary requires
				  services from an out-of-State hospital or physician, the beneficiary's
				  attending physician must submit written medical justification to
				  EOHHS;
2. The medical services that
				  are required and being requested must not be available within Rhode
				  Island.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 3 - Medicaid Payments for Out-of-State Care › Section 210-RICR-20-00-3.4 - Exceptions to the Requirement for Prior Authorization

Current through June 14, 2024
A. The following provisions are exceptions to
				  the requirement for prior authorization:
1.
				  Emergency medical treatment and hospital services needed because the
				  beneficiary's health would be endangered if travel back to Rhode Island was
				  required;
2. Treatment was provided
				  by hospitals and practitioners located in one (1) of the border communities
				  listed in §
											3.6   of this Part where it is
				  the general practice for residents to use medical resources in these
				  communities;
3. Medical and
				  hospital treatment provided to foster children residing with families located
				  outside Rhode Island or in out-of-State residential treatment
				  centers.
4. In response to the
				  novel Coronavirus Disease (COVID-19), EOHHS will temporarily suspend most of
				  the prior authorization requirements. Effective October 1, 2021, prior
				  authorization requirements will be reinstated for all services except for
				  behavioral healthcare services. Effective January 1, 2022, prior authorizations
				  will be reinstated for behavioral healthcare services.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 3 - Medicaid Payments for Out-of-State Care › Section 210-RICR-20-00-3.5 - Services Rendered to Temporarily Absent Beneficiaries

Current through June 14, 2024
A. Payment for medical care provided to
				  eligible residents of Rhode Island who are temporarily absent from the State is
				  made under certain circumstances.
B. Temporarily absent includes visiting,
				  traveling or residing temporarily in another State without intending to become
				  a permanent resident of the alternate State. Medicaid payment is authorized
				  only in the following circumstances:
1. An
				  emergency arises from an accident or illness; or
2. The health of the individual would be
				  endangered if the care and services were postponed until the individual
				  returned to Rhode Island; or
3. The
				  health of the individual would be endangered if s/he undertook travel to return
				  to Rhode Island.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 3 - Medicaid Payments for Out-of-State Care › Section 210-RICR-20-00-3.6 - Border Communities

Current through June 14, 2024
A. Border
				  Communities include cities and town that border Rhode Island and are considered
				  for the purpose of the Rhode Island Medicaid Program, in State providers.
				  Out-of-State service restrictions and prior authorization requirements are not
				  imposed on providers in the following communities:
Connecticut
Massachusetts
Danielson
Attleboro
Groton
Bellingham
Moosup
Blackstone
Mystic
Dartmouth
New London
Fall River
North Stonington
Foxboro
Pawcatuck
Milford
Putnam
New Bedford
Stonington
North Attleboro
Thompson
North Dartmouth
Waterford
Rehoboth
Seekonk
Somerset
South Attleboro
Swansea
Taunton
Uxbridge
Webster
Westport
Whitinsville
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 3 - Medicaid Payments for Out-of-State Care › Section 210-RICR-20-00-3.7 - 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 1 - Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways › Section 210-RICR-30-00-1.1 - Overview

Current through June 14, 2024
A. The principal purpose of the Federal
				  Patient Protection and Affordable Care Act (ACA),
				  Pub. Law No.
				  111-148, was to increase access to health care by
				  leveraging resources, expanding choice, and removing the administrative,
				  financial, and legal barriers that have prevented people from obtaining the
				  coverage they need. Toward this end, the ACA:
1. Consolidated many of the existing Medicaid
				  coverage groups associated with the now defunct Federal Aid to Families with
				  Dependent Children Program (AFDC) into three (3) broad categories: children,
				  pregnant people and newborns, and parents/caretaker relatives;
2. Created an optional Medicaid coverage
				  group for adults between the ages of nineteen (19) and sixty-four (64) who
				  otherwise do not qualify for Medicaid and are not eligible for or enrolled in
				  Medicare;
3. Established a new
				  standard - Modified Adjusted Gross Income (MAGI) - for evaluating income
				  eligibility for Medicaid and other publicly supported forms of affordable
				  commercial coverage across these populations;
4. Eliminated distinctions in the financial
				  criteria and standardized the income eligibility requirements for the Medicaid
				  populations subject to the MAGI. This, in turn, made it possible for the States
				  to reorganize the MAGI- eligible populations with similar characteristics into
				  distinct, easily identifiable, Medicaid affordable care coverage (MACC)
				  groups;
5. Mandated that the States
				  automate the application and renewal process for populations subject to the
				  MAGI by building the capacity to determine eligibility on-line and conduct
				  electronic verifications through a variety of government approved data sources;
				  and
6. Applied these changes not
				  only to Medicaid, but also to the Children's Health Insurance Program (CHIP),
				  which is administered through the Medicaid program in Rhode Island, and
				  HealthSource RI (HSRI), the State's health insurance marketplace.
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-30-00-1.2 - Scope and Purpose

Current through June 14, 2024
A. The purpose of
				  this Rule is to establish the Medicaid Affordable Care Coverage (MACC) groups
				  and the eligibility pathways for individuals who share one (1) or more of their
				  characteristics and are exempt from MAGI and/or the provisions for the
				  Integrated Health Care Coverage (IHCC) groups under Chapter 40 of this
				  Title.
B. In Rhode Island, CHIP
				  eligibility is administered as an expansion through the Medicaid program rather
				  than through a separate State program as the principal distinction for most
				  eligibility pathways relates to claiming of Title XIX versus Title XXI Federal
				  financial participation rates. The exceptions, as indicated in this Rule, are
				  the CHIP-only eligibility pathways for lawfully present qualified non- citizen
				  children up to the age of nineteen (19) and qualified and non-qualified
				  pregnant women who meet the income limits set forth
				  herein.
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-30-00-1.3 - Legal Authority

Current through June 14, 2024
A. This Part is
				  promulgated pursuant to Federal authorities as follows:
1. Federal Law: §1115 of the Social
				  Security Act,  42 U.S.C. §
												1315; Title XIX of the U.S. Social
				  Security Act,  42 U.S.C.
				  §§
												1396a - 1396w - 7; Title XXI of
				  the Social Security Act,  42
				  U.S.C. §§
												1397aa - 1397mm;
				   42 U.S.C. §
												1396k; §
											1413(b)(1)(A)  of the Patient Protection and Affordable Care Act, Pub. Law No.
				  111-148.
2. Federal Regulations: 42 C.F.R. Parts 431,
				  435, 440, and 441.
3. The Medicaid
				  State Plan and the Section
				  1115 D emonstration
				  Waiver granted pursuant to §1115 of the Social
				  Security Act,  42 U.S.C. §
												1315.
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-30-00-1.7 - MACC and Non-MAGI Special Eligibility Categories

Current through June 14, 2024
A. Deemed Newborn Eligibility - Babies born
				  to Medicaid-eligible pregnant people who are residents of Rhode Island are
				  deemed eligible from the date of birth. Once deemed eligible as a newborn, the
				  infant remains eligible for one (1) year and, as such, is a non-MAGI
				  eligibility pathway. Accordingly, retroactive coverage is available for periods
				  prior to the application date if the newborn was otherwise deemed eligible. The
				  Medicaid-eligible parent of the newborn must comply with the following:
1. Enumeration - The parent/caretaker of a
				  newborn must obtain an SSN for a newborn. Failure to enumerate the child
				  results in a sanction against the parent/caretaker, not the child. The child
				  will remain eligible even if lacking an SSN because of parent/caretaker's
				  failure to cooperate. The sanction against the mother is loss of her
				  eligibility for failure to cooperate. This sanction will be removed once the
				  mother meets the enumeration requirements; or
2. Record of birth - If the newborn's SSN is
				  not provided at birth, Medicaid eligibility is provided under the mother' s SSN
				  if the hospital record of birth is submitted by the parents. The hospital
				  record of birth is a written document indicating that the newborn was
				  discharged in the mother's care and information related to date of birth and
				  verifying citizenship. The hospital record of birth must be signed by the
				  appropriate authorized representative of the hospital. If the infant was not
				  born in a hospital, proof of application for an SSN, self-attestation and
				  signed attestation of an attending health provider or birthing assistant may be
				  accepted as a record of birth.
3.
				  Verification - The birth may be reported by the parent/caretaker, or another
				  family member or friend, the parent/caretaker's Medicaid managed care plan, or
				  the hospital in which the child was born. See §
											1.7(A)(2)   of
				  this Part above for information pertaining to the hospital record of
				  birth.
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-30-00-1.9 - Information

Current through June 14, 2024
A. For Further Information or to Obtain
				  Assistance
1. Applications for affordable
				  coverage are available online on the following websites:
a.
www.eohhs.ri.gov
b.
www.dhs.ri.gov
c.
www.HealthSourceRI.com
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-30-00-1.10 - Severability

Current through June 14, 2024
A. 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 3 - Medicaid Application and Renewal Processes › Section 210-RICR-30-00-3.1 - Application Process for Medicaid Affordable Coverage: No Wrong Door

Current through June 14, 2024
3.1.1
Scope, Purpose, and Legal
				  Authority
A. One of the central goals
				  of the federal Affordable Coverage Act (hereinafter the ACA) of 2010 (Patient
				  Protection and Affordable Care Act,
				   42 U.S.C. §
												18001
et seq
.)
				  was to improve access to and the availability of affordable health coverage.
				  Toward this end, the ACA mandated that the States reform the Medicaid
				  application and renewal system to make it easier for consumers to navigate and
				  gain access to and retain affordable health care coverage.
B. The purpose of this Rule is to set forth
				  the application and renewal processes for members of the Medicaid Affordable
				  Care Coverage (MACC) groups subject to MAGI-based income eligibility
				  determinations. The Rule also sets forth the respective roles and
				  responsibilities of the EOHHS, its eligibility agents, and
				  applicants/beneficiaries. In addition, the Rule establishes the application and
				  renewal processes for children in the Integrated Health Care Coverage (IHCC)
				  groups who are exempt from MAGI determinations under Federal law and
				  Regulations and, therefore, the Medicaid State Plan because their eligibility
				  is tied to participation in other publicly funded programs including Federal
				  Supplemental Security Income (SSI), and the programs for children and youth
				  at-risk or in the custody of the Rhode Island Department of Children, Youth and
				  Families (DCYF).
C. This Part is
				  promulgated pursuant to:
1. Federal
				  authorities as follows:
a. Federal Laws -
				  Title IVE, Title XIX, and Title XXI of the U.S. Social Security Act and
				  ACA.
b. Federal Regulations -
				   42 C.F.R.
				  §§
														435.603; 435.902   through 910;
				  435.916;
				  and 435.1025
c. The Medicaid State
				  Plan and the Title XIX, Section 1115(a) Demonstration Waiver (11-W-00242/1),
				  effective through December 31, 2018.
2. State authorities - R.I. Gen. Laws
				  Chapters 40-6, 40-8, and 42-7.2.
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 3 - Medicaid Application and Renewal Processes › Section 210-RICR-30-00-3.3 - Information

Current through June 14, 2024
3.3.1
For Further Information or to
				  Obtain Assistance
A. Applications for
				  affordable coverage are available online on the following websites:
1.
www.eohhs.ri.gov
2.
www.dhs.ri.gov
3.
www.HealthSourceRI.com
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 3 - Medicaid Application and Renewal Processes › Section 210-RICR-30-00-3.4 - 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.