Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 1 - Medicaid Long-Term Services and Supports Overview and Eligibility Pathways › Section 210-RICR-50-00-1.7 - Qualifying for Medicaid LTSS

Current through June 14, 2024
A. Under Title XIX,
				  the federal Medicaid law, an applicant for LTSS must be either a current
				  beneficiary or possess an income, clinical/functional, or age-related
				  characteristic related to a MAGI eligible or SSI population AND have an
				  established need to qualify to apply. With the enactment of the Federal
				  Affordable Care Act of 2010, Federal law requires that Medicare, commercial
				  health insurers, and group health plans provide as part of the primary care
				  essential benefit package up to thirty (30) days of subacute and rehabilitative
				  care for persons who have had an acute care incident requiring services in a
				  health institution. Medicaid is also required to provide this benefit. Both
				  existing beneficiaries and new applicants must have established a continuing
				  need for LTSS - that is, for an institutional level of care - to qualify for
				  Medicaid LTSS once the thirty (30) days of essential benefit coverage is
				  exhausted. This need in previous Rhode Island Medicaid Rules was referred to as
				  "considered institutionalized" for the purposes of determining Medicaid LTSS
				  eligibility as indicated below:
1. Existing
				  beneficiaries - Under the Medicaid State Plan, all Medicaid beneficiaries are
				  eligible for up to thirty (30) days of LTSS coverage in addition to the
				  required thirty (30) day essential benefit period of acute and subacute care in
				  a health care institution as part of their non-LTSS primary essential benefit
				  coverage. A separate determination of eligibility or change in service delivery
				  is not required for this period of coverage. Therefore, an existing beneficiary
				  may qualify to apply for Medicaid LTSS without a change in eligibility or
				  service delivery options if they have received the required period of
				  continuous coverage is provided in this manner or, if seeking LTSS in the home
				  and community-based setting, they require or are receiving at least one (1)
				  Medicaid covered LTSS benefit to address a functional need that otherwise would
				  require care in an institutional setting. The Medicaid MCOs and DHS eligibility
				  specialists are available to provide assistance to existing beneficiaries
				  during this period.
2. New
				  applicants - New Applicants are considered to have such a need if they have met
				  one (1) of the following:
a. Received the
				  level of services typically provided in a NF, ICF-ID, or LTH setting for at
				  least thirty (30) consecutive days and are expected to have a continued need
				  for such services or have:
(1) Obtained acute
				  care services in a hospital or similar health facility for at least thirty (30)
				  consecutive days and are seeking LTSS;
(2) Received Medicaid preventive level
				  services while residing at home or in a community-based care setting for at
				  least thirty (30) consecutive days;
(3) Been determined to have needs that
				  require the level of services typically provided in a health care institution
				  for at least thirty (30) consecutive days or would require such services were
				  those in the home and community-based setting not provided.
b. Received or required at least
				  one (1) Medicaid covered LTSS benefit at home or in a community-based setting
				  to address a functional/clinical need that would otherwise necessitate the type
				  of LTSS typically provided in a health institution.