Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 40 - Medicaid for Elders and Adults with Disabilities › Subchapter 00 - Integrated Coverage Groups › Part 1 - Overview of Medicaid Integrated Care Coverage (210-RICR-40-00-1) › Section 210-RICR-40-00-1.8 - Medicaid Benefits

Current through June 14, 2024
A. The benefits
				  that members of the IHCC groups receive are dictated by the Medicaid State Plan
				  and the State's Section 1115 demonstration waiver. Medicaid benefits include
				  health care services and supports or, if a beneficiary has third party coverage
				  such as Medicare, wrap-around coverage and/or financial assistance in paying
				  premiums, co-pays, and cost-sharing.
1.
				  Premium Assistance/and Financial Help - Dual Medicare and Medicaid
				  beneficiaries, including those participating in the MPPP may receive full
				  Medicaid health coverage and/or financial help paying for Medicare. The scope
				  of benefits dual eligible beneficiaries receive depends on their income and
				  resources. Premium assistance is also available for some Community Medicaid
				  beneficiaries who have access to employer-sponsored insurance through the RIte
				  Share Premium Assistance Program as set forth in Medicaid Code of
				  Administrative Rules, Overview of the Affordable Care Coverage
				  Groups.
2. Health Care Services and
				  Supports - The scope of services and supports beneficiaries receive varies as
				  follows:
a. Community Medicaid. Beneficiaries
				  eligible for health coverage receive the full scope of primary care essential
				  benefits - including acute, subacute and rehabilitative services - as well as
				  thirty (30) days of LTSS and, based on need, a limited set of LTSS preventive
				  services. Subchapter 10 Part 1 of this Chapter identifies the scope of covered
				  services available through the managed care and fee-for-service delivery
				  options for IHCC group beneficiaries eligible for full Medicaid benefits. Note:
(1) The Medicaid benefits MPPP participants
				  are eligible to receive may be limited to premium payment assistance only,
				  depending on the basis of eligibility. See §05-1.6.1 of this Chapter.
(2) For the scope of services
				  covered under the Sherlock Plan, see Subchapter 15 Part 1 of this Chapter.
b. Medicaid LTSS.
				  Medicaid LTSS includes health supports, personal care, and social services in
				  an institutional or home and community-based setting. The scope of Medicaid
				  LTSS a beneficiary receives is based on need -- health status and functional
				  ability -- and personal health preferences and goals. Persons eligible for
				  Medicaid LTSS also receive the full scope of primary care essential benefits
				  authorized under the Medicaid State Plan. To be eligible for Medicaid LTSS, a
				  person must meet a specific set of financial and clinical criteria that do not
				  apply to applicants seeking coverage through other Medicaid eligibility
				  pathways.
3. Integrated
				  Care -- The State's Integrated Care Initiative (ICI) provides IHCC group
				  members who have Medicare and other forms of third-party coverage who qualify
				  for LTSS in accordance with the provisions set forth in the Medicaid Code of
				  Administrative Rules, Overview of Medicaid and SSI-Related Coverage Groups, to
				  obtain the coordinated services they need across the care continuum through a
				  single plan. Subchapter 10 Part 1 of this Chapter covers these options and the
				  process for plan selection and enrollment.
4. Retroactive Eligibility - Up to three (3)
				  months of Medicaid retroactive coverage is available for certain IHCC group
				  beneficiaries. To qualify, the State must determine that a person would have
				  met the applicable eligibility criteria for his or her coverage group if the
				  application was submitted during the retroactive period. The State provides
				  reimbursement to providers only for Medicaid covered services, however. The
				  provisions in Subchapter 5 Part 3 of this Chapter explain the process for
				  obtaining retroactive coverage in greater detail.