reglab/statecodes huggingface dataset:
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-50-00-1.2 - Legal Authority

Current through June 14, 2024
A. This Chapter of
				  Rules related to Medicaid LTSS is promulgated pursuant to Federal authorities
				  as follows:
1. Federal Law: Title XIX of the
				  U.S. Social Security Act  42
				  U.S.C. §§
												1396a, 1115,
				  1902,
				  1903,
				  1905,
				  1915;
				  1396k; and
				  1413(b)(1)(A) of
				  the Affordable Care Act.
2. Federal
				  Regulations: 42 C.F.R. Parts
				  431,
				  435,
				  440, and
				  441.
3. The Medicaid State Plan and the Title XIX,
				  Section 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 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-50-00-1.4 - Types of LTSS

Current through June 14, 2024
A. Under the terms
				  of Title XIX of the U.S. Social Security Act of 1964, Medicaid LTSS in an
				  institutional-setting is a State Plan service available to all otherwise
				  eligible Medicaid beneficiaries and new applicants, providing they meet certain
				  eligibility factors.
B.
				  "Institution" is the term used in Title XIX to refer to a hospital (H), an
				  intermediate care facility for persons with intellectual/developmental
				  disabilities (ICF/ID), and a nursing facility (NF). These institutions are
				  licensed in Rhode Island by the Department of Health (RIDOH) as health care
				  facilities under Chapter
				  23-17 of the R.I. Gen. Laws.
				  Although the term "institution" is not accurate in a licensure sense, under
				  Federal Regulations at  42 C.F.R. §
											440.40, the eligibility
				  criteria for Medicaid LTSS remain tied to these institutional settings and vary
				  in accordance with types of services each typically provides and the needs of
				  the population(s) they serve. As these services are now also available to
				  beneficiaries in a home and community-based setting, the Medicaid LTSS Rules
				  apply across settings, as follows:
1. Medicaid
				  LTSS in Health Care Institutions - Persons who meet the applicable eligibility
				  requirements may access LTSS in the following State-licensed health care
				  institutions/facilities
a. Nursing Facilities
				  (NF). A person is eligible to access Medicaid LTSS in a NF when it is
				  determined, based on a comprehensive assessment, that he or she has the highest
				  need for a NF level of care.
b.
				  Intermediate Care Facility for persons with Intellectual/Developmental
				  Disabilities (ICF/ID). To qualify, a person must meet the applicable statutory
				  standards set forth in R.I. Gen. Laws §
												40.1-22-6 pertaining to
				  developmental disabilities and:
(1) Have the
				  level of need for LTSS typically provided in an ICF-ID; or
(2) Would require an ICF/ID level of care if
				  were not for LTSS provided in a home or community based setting. As the State's
				  Section 1115 waiver provides the authority for the home and community-based
				  LTSS provided to members of this population with developmental disabilities,
				  the BHDDH is required to provide services in the least restrictive setting
				  appropriate to a person's level of care needs.
c. Long-term Hospital (LTH) - A person must
				  meet the needs-based criteria for long-term services in a hospital setting
				  established by BHDDH and/or the EOHHS. Medicaid LTSS may also be available to
				  children in State custody or with special health care needs receiving services
				  in residential treatment facilities and hospitals if they meet the applicable
				  level of care requirements.
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-50-00-1.5 - Applicability

Current through June 14, 2024
The provisions set forth herein apply to any person seeking
					 Medicaid LTSS coverage, including those who are uninsured, receiving non-LTSS
					 Medicaid under Part
					 40-00 - 3 of this Title or
					 "Medicaid Integrated Health Care Coverage, SSI Financial Eligibility
					 Determinations", or have third (3rd) party forms of
					 coverage through Medicare or a commercial insurer.
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-50-00-1.6 - Scope of LTSS Coverage

Current through June 14, 2024
A. Upon being
				  determined eligible for Medicaid LTSS, a beneficiary is entitled to Medicaid
				  State Plan and Section 1115 waiver services across the care continuum.
				  Subchapters 05 and 10 of this Chapter identify the LTSS covered services and
				  the various Medicaid LTSS programs that serve beneficiaries with specific types
				  of health needs, including the following:
1.
				  Primary care essential benefits. All LTSS Medicaid beneficiaries are entitled
				  to receive the primary care essential health benefits available to
				  beneficiaries in the MACC and IHCC groups, covered under the Medicaid State
				  Plan and Section 1115 demonstration waiver, including primary and preventive
				  care as well as acute and subacute services. If a beneficiary has third
				  (3rd) party insurance, such as Medicare or
				  commercial insurance that does not provide the full scope of Medicaid benefits,
				  Medicaid provides wrap-around coverage for any Medicaid services that are
				  unavailable.
2. Institutional and
				  home and community-based care. Medicaid LTSS beneficiaries are eligible for the
				  full scope of LTSS covered by the Medicaid State Plan and Section 1115 waiver.
				  As the State uses needs-based criteria to determine the scope of services a
				  beneficiary is authorized to receive, Medicaid LTSS coverage varies along with
				  a beneficiary's functional capacity and acuity needs, social environment,
				  access to family and other third (3rd) party
				  supports, and personal choices. The range of Medicaid LTSS extends from 24/7
				  comprehensive care in a health institution to a limited package of services in
				  a community-based setting, to one (1), a few, or a bundle of home and community
				  core and ancillary services in the home.
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-50-00-1.10 - Expedited Eligibility

Current through June 14, 2024
A. Expedited
				  eligibility is a special process authorized under the State's Section 1115
				  demonstration for adults age nineteen (19) and over seeking LTSS in a home and
				  community-based setting. The purpose of this special process is to provide a
				  limited package of HCBS for no more than ninety (90) days to applicants who
				  meet the need for LTSS in a home or community-based setting as specified in
				  §
										1.7(A)(2)(b)   of this Part and prefer to remain in or
				  transition to a home or community-based setting for a health institution while
				  a full determination of eligibility is being made.
1. Eligibility criteria - To be considered
				  for expedited eligibility, new applicants must submit a full and completed
				  application for Medicaid LTSS and self-attest to meeting the Medicaid LTSS
				  general and financial eligibility requirements for their appropriate coverage
				  group - that is, elder, adult with disability, MACC group adult and so forth.
				  Existing beneficiaries must notify an LTSS eligibility specialist and provide
				  any supplemental information required to initiate an expedited eligibility
				  review. The need for LTSS must be established in accordance with applicable
				  functional/clinical criteria established by EOHHS by a licensed treating
				  physician or appropriately qualified health practitioner or provider.
2. Applicable circumstances - Expedited
				  eligibility is the default eligibility for new applicants and existing non-LTSS
				  Medicaid beneficiaries who meet the requirements set forth in this Part in the
				  following circumstances:
a. Discharge from a
				  hospital. Discharge must be to a home or community-based setting from a
				  hospital or ancillary health institution after an acute care
				  admission.
b. Discharge from a from
				  a short-term health institution stay Discharge or transition to a home and
				  community-based setting from a nursing facility or subacute care facility for a
				  short-term stay or skilled rehabilitation if the services provided are not
				  covered as a Medicaid LTSS benefit and, as such, Medicaid reimbursement for the
				  stay is not required.
c. Expanded
				  need. A person seeking LTSS eligibility who is receiving preventive level
				  services authorized by EOHHS in accordance with Part
				  40-05-1 of this Title and has
				  expanded needs or is determined by a treating health practitioner to have the
				  need for in-home assistance to supplement skilled homecare or hospice services
				  currently in place; or to extend to the period after skilled services have
				  ended.
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-50-00-1.11 - Roles and Responsibilities

Current through June 14, 2024
A. Persons seeking
				  LTSS Medicaid eligibility must meet the general requirements that apply
				  program-wide related to residency, citizenship, and cooperation, among others.
1. Agency responsibilities - The EOHHS is
				  responsible for determining Medicaid LTSS eligibility, authorizing services,
				  the appropriate level of care planning and service coordination, as dictated by
				  setting, and enrollment in service delivery option of choice. Under the terms
				  of interagency agreements, the DHS and BHDDH have been authorized to determine
				  all or some aspects of LTSS eligibility as an agent of the EOHHS.
2. Applicant Responsibilities - Beneficiaries
				  determined eligible through this pathway must provide accurate and timely
				  information and the consent necessary for EOHHS, or its agent(s), to obtain the
				  health care information required for the clinical eligibility
				  determination.
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-50-00-1.12 - Severability

Current through June 14, 2024
If any provision in any section of this Rule or the
					 application thereof to any person or circumstances is held invalid, its
					 invalidity does not affect other provisions or applications of the Rule which
					 can be given effect without the invalid provision or application, and to this
					 end the provisions of this Rule are declared to be severable.
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 2 - Long-term Services and Supports (LTSS) Medically Needy Eligibility Pathway › Section 210-RICR-50-00-2.1 - Scope and Purpose

Current through June 14, 2024
A. Medically Needy
				  (MN) eligibility for Medicaid long-term services and supports (LTSS),
				  previously referred to as the "Flexible Test of Income", enables people with
				  income above the Federal benefit cap to obtain Medicaid LTSS coverage in
				  certain circumstances. The Federal benefit cap rate is three hundred percent
				  (300%) of the Supplemental Security Income (SSI) benefit rate and is the income
				  eligibility ceiling for both the "special income" and home and community-based
				  services (HCBS) LTSS pathways identified in Part 1 of this
				  Subchapter.
B. Under the Federal
				  law, the LTSS MN pathway is for LTSS beneficiaries only without regard to type
				  of care - institutional or HCBS settings. The provisions related to MN Non-LTSS
				  Community Medicaid are set forth in Part  40-05-2 of this Title. LTSS MN is
				  distinguished from MN Community Medicaid in that the spenddown is based on
				  monthly projected expenses rather than the costs that must be incurred over a
				  six (6) month budget period.
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 2 - Long-term Services and Supports (LTSS) Medically Needy Eligibility Pathway › Section 210-RICR-50-00-2.2 - Incorporated Materials

Current through June 14, 2024
A. These
				  Regulations hereby adopt and incorporate   42 C.F.R. §
											435.301
et
				  seq
. (2016) by reference, not including any further editions or
				  amendments thereof, and only to the extent that the provisions therein are not
				  inconsistent with these Regulations.
B. These Regulations hereby adopt and
				  incorporate   42 C.F.R. §
											435.831(3)(g)(1)  (2016) by reference, not
				  including any further editions or amendments thereof and only to the extent
				  that the provisions therein are not inconsistent with these
				  Regulations.
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 2 - Long-term Services and Supports (LTSS) Medically Needy Eligibility Pathway › Section 210-RICR-50-00-2.3 - Legal Authority

Current through June 14, 2024
A. Federal
				  Authorities
1. Federal Law: Title XIX, of the
				  Federal Social Security Act at:   42 U.S.C. §§
												1396a, 1396b, and 1396k;
2. Federal Regulations:   42 C.F.R. §
												435.301
et seq
. (2016).
3. The Rhode Island Medicaid State Plan and
				  the Title XIX, Section  1115(a)   Demonstration Waiver (11-W-00242/1), effective
				  through December 31, 2023.
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 2 - Long-term Services and Supports (LTSS) Medically Needy Eligibility Pathway › Section 210-RICR-50-00-2.4 - Definitions

Current through June 14, 2024
A. As used in this Part, the following terms
				  are defined as follows:
1. "Beneficiary
				  liability" means the LTSS beneficiary's financial obligation toward the
				  Medicaid LTSS cost of care, as determined monthly.
2. "Budget period" means the period of time
				  in which an applicant's income is measured for the purpose of determining
				  eligibility.
3. "Federal cap" means
				  three hundred percent (300%) of the Federal Supplemental Security Income (SSI)
				  Program monthly payment rate.
4.
				  "LTSS beneficiary" means a person who meets all the general,
				  clinical/functional, and financial eligibility requirements for LTSS, or a
				  person receiving Medicaid LTSS of any type regardless of living arrangement.
				  The LTSS beneficiary has been previously referred to as an "institutionalized"
				  individual.
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 2 - Long-term Services and Supports (LTSS) Medically Needy Eligibility Pathway › Section 210-RICR-50-00-2.7 - Health Institution and Income Cost Comparison

Current through June 14, 2024
A. The
				  following table sets forth the projected monthly private pay rates associated
				  with each institutional level of care that are used to determine whether a LTSS
				  applicant or beneficiary with excess countable income qualifies for LTSS MN
				  eligibility with or without a spenddown.
Rhode Island: Projected Monthly Private Pay
								  Costs by Institutional Level of Care - updated August 2023
Type of LTSS
Monthly/Daily Rate
Nursing facility (average
								  skilled)
$10,190.00 / $335.00
Intermediate Care Facility for I-DD
$22,350.00 / $735.00
Long-term hospital
$55,500.00 / $1,825.00
B.
				  The following table shows the State reimbursement for LTSS only. Incurred and
				  paid non-LTSS health care costs are excluded from the rates except in health
				  institutions (NF, ICF/I-DD, and LTH) and may be added toward the required
				  spenddown if allowable.
Rhode Island: State Medicaid LTSS-only
								  Monthly Reimbursement Rates by Service - updated May 2023 (Medical Services not
								  included)
Service
Monthly Rate
Nursing facility (average
								  custodial)
$7,500.00
Assisted Living
$2,500.00
Shared Living
$2,100.00
Home-Based Personal
								  Care
$3,000.00
Adult Day Services
								  Only
$1,600.00
Eleanor Slater -
								  Hospital
$55,500.00
Tavares
$22,350.00
Other Long-Term Care
								  Hospital
$25,850.00
DD at Home
$3,300.00
DD Shared living
$3,300.00
DD Group Home
								  (Private)
$9,200.00
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 3 - SSI-Related Coverage Groups (210-RICR-50-00-3) (Repealed) › Section 210-RICR-50-00-3.1 - Institutionalized SSI Beneficiaries. (Repealed)

Current through June 14, 2024
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 3 - SSI-Related Coverage Groups (210-RICR-50-00-3) (Repealed) › Section 210-RICR-50-00-3.2 - Non-Institutionalized SSI Beneficiaries. (Repealed)

Current through June 14, 2024
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 3 - SSI-Related Coverage Groups (210-RICR-50-00-3) (Repealed) › Section 210-RICR-50-00-3.3 - Residents of Long-Term Care Facilities. (Repealed)

Current through June 14, 2024
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 3 - SSI-Related Coverage Groups (210-RICR-50-00-3) (Repealed) › Section 210-RICR-50-00-3.4 - Short Inpatient Stays. (Repealed)

Current through June 14, 2024
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 3 - SSI-Related Coverage Groups (210-RICR-50-00-3) (Repealed) › Section 210-RICR-50-00-3.5 - Working Disabled. (Repealed)

Current through June 14, 2024
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 3 - SSI-Related Coverage Groups (210-RICR-50-00-3) (Repealed) › Section 210-RICR-50-00-3.6 - Cash Assistance Beneficiaries. (Repealed)

Current through June 14, 2024
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 4 - Long-Term Services and Supports Application and Renewal Process › Section 210-RICR-50-00-4.1 - Overview

Current through June 14, 2024
The purpose of this regulation is to set forth the
					 Long-Term Services and Supports (LTSS) application review and renewal process
					 in accordance with current State and federal laws and regulations.
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 4 - Long-Term Services and Supports Application and Renewal Process › Section 210-RICR-50-00-4.2 - Legal Authority

Current through June 14, 2024
A. Title XIX of the
				  U.S. Social Security Act provides the legal authority for the RI Medicaid
				  program. Additionally, legal authority related to long-term services and
				  supports is derived from the following sources:
1. State Law: R.I. Gen. Laws §
											40-8-6.1
2. Federal Law:
				   42 U.S.C. §
												1396a;  42 U.S.C. §
												1396  k; Section
				  1413(b)(1)(A) of the Affordable Care Act
3. Federal Regulations:
				  42 C.F.R.
				  §§ 435.905THROUGH 910;  42 C.F.R. §
												435.912(c)  (timelines).
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 4 - Long-Term Services and Supports Application and Renewal Process › Section 210-RICR-50-00-4.4 - Summary of LTSS Eligibility Determination Process

Current through June 14, 2024
A. Eligibility Factors. Evaluations of all
				  applications for Medicaid LTSS are based on eligibility requirements or factors
				  that fall into the following three categories:
1. General Eligibility Factors - Residency,
				  citizenship and immigration status, third-party health coverage, age, health
				  coverage, marital status, dependents (§40-05-1.9 of this Title).
2. Financial Eligibility Factors - Varies by
				  eligibility pathway and the method for determining income eligibility in
				  accordance with Part 40-00-3 of this Title.
3. Clinical/functional Eligibility - An
				  applicant's health care and functional health care needs are evaluated based on
				  information obtained from providers using pre-set needs-based criteria. The
				  needs-based criteria for the NF, ICF-ID, and LTHR vary in accordance with the
				  needs of the population served. Separate criteria related to disability status
				  and LOC are also used for children seeking Katie Beckett eligibility.
				  (Subchapter 10 Part 3 of this Chapter).
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 4 - Long-Term Services and Supports Application and Renewal Process › Section 210-RICR-50-00-4.5 - Starting the Application Process

Current through June 14, 2024
A. Applying for
				  LTSS. All persons seeking initial Medicaid LTSS must apply, including existing
				  Medicaid beneficiaries who are already covered through a non-LTSS pathway for
				  parents/caretakers and adults eligible under the federal Affordable Care Act
				  (ACA) expansion. Persons eligible for Community Medicaid (non-LTSS) are
				  evaluated on a set of general, financial and functional/ clinical eligibility
				  requirements in accordance with §40-05-1.5.2 of this Title and Rhode
				  Island's Medicaid Section 1115 waiver. The information existing beneficiaries
				  must provide when applying for LTSS is limited to only those eligibility
				  factors related to clinical / functional and financial eligibility not already
				  known to the agency.
B. Application
				  Points. The State is committed to pursuing a "No Wrong Door" policy that offers
				  consumers multiple application and renewal access points which all lead to the
				  State's IES. (§40-00-2.2 of this Title).
1. On-line, Self-Service - Persons seeking
				  initial or continuing eligibility have the option of accessing the eligibility
				  system on-line using a consumer self-service portal through links on the EOHHS
				  (www.eohhs.ri.gov) and DHS (
www.dhs.ri.gov
)
				  websites or directly through HSRI (HealthSourceRI.com). Supplemental forms and
				  required documentation may be uploaded directly on-line or faxed, emailed or
				  U.S. mailed. The information applicants provide on-line is entered directly
				  into the IES and processed electronically in real-time. The initial steps for
				  applying on-line are as follows:
a. Account
				  Creation. To initiate the application process, a person must create an account
				  in the eligibility system. This can be done through the self-service portal by
				  the applicant or with the help of an eligibility specialist or certified
				  assister.
(1) Identity proofing. The
				  applicant must provide personally identifiable information when creating an
				  on-line account as a form of identify proofing. Verification of this
				  information is automated.
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 4 - Long-Term Services and Supports Application and Renewal Process › Section 210-RICR-50-00-4.6 - Submitting the Application

Current through June 14, 2024
A. Completion of
				  Forms and Signature. All application forms must be complete and signed before
				  being submitted. To ensure equity between people who apply on-line versus
				  through the DHS-2, an application that is not completed and signed will not be
				  accepted and will be returned. The IES accepts electronic signatures.
B. Valid Information. Information provided on
				  the application must be validated in accordance with one or more of the
				  following methods to determine eligibility:
1. Attestation - Applicants must attest to
				  the truthfulness and accuracy of the information they provide by signing, under
				  penalty of perjury, the paper application and supplemental forms in ink, or if
				  applying on-line, through an electronic signature. An applicant's responses on
				  the signed application (so-called "attestations") are accepted as valid without
				  further verification or proof for a limited range of eligibility factors, such
				  as State residency and marital status or relationship.
2. Electronic Data Matches - Applicant
				  attestations related to income, immigration status, Medicare coverage, private
				  health insurance, and several other eligibility factors are verified
				  automatically through the IES using electronic matches with various federal and
				  State data sources. Applicants are asked to provide their consent for these
				  electronic data matches on the paper and on-line forms. If these matches fail
				  to validate applicant attestations, the applicant will receive a written
				  request for additional clarifying or supporting documentation before action is
				  taken on eligibility through an ADR.
3. Supporting Paper Documentation/Proof - In
				  instances in which eligibility factors cannot be electronically verified due to
				  a lack of data sources or an information discrepancy, an applicant must submit
				  additional documentation to prove the truthfulness and accuracy of attestations
				  or the full scope of information necessary to evaluate an eligibility factor.
				  The application forms for LTSS identify eligibility factors that require paper
				  documentation.
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 4 - Long-Term Services and Supports Application and Renewal Process › Section 210-RICR-50-00-4.7 - Application Cycle

Current through June 14, 2024
A. Application
				  Receipt and Filing date. The date a signed and completed application form is
				  manually or electronically date-stamped as received by the agency is the
				  application filing date. The application filing date is used to determine the
				  eligibility date for LTSS coverage. The eligibility date is the first day of
				  the month in which an application is filed. Retroactive coverage is available
				  if a person would have qualified for LTSS Medicaid for up to three (3) months
				  prior to the eligibility date. A signed, completed application form is
				  submitted by any of the following means:
1.
				  Electronically through the self-service portal;
2. A paper copy is date-stamped as received
				  by State agency staff;
3.
				  Electronically dated if uploaded, e-mailed, faxed, or scanned;
4. Delivered in-person and date-stamped by
				  State agency staff.
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 4 - Long-Term Services and Supports Application and Renewal Process › Section 210-RICR-50-00-4.8 - Application Completeness and Eligibility Determination Timelines

Current through June 14, 2024
A. Complete Application. Under State law, an
				  LTSS application is considered complete when the application form and
				  "attachments and supplemental information as necessary" provide the agency with
				  sufficient information to determine eligibility.
B. Scope of Information Required. The
				  information required for an application to be considered complete is not fixed.
				  An applicant's unique circumstances dictate which factors must be considered
				  when determining eligibility and, as such, when there is sufficient information
				  to determine eligibility. By signing the application, the applicant
				  self-attests to the truth of the information he or she provides on any required
				  forms submitted to the agency. To the full extent feasible, this information is
				  verified through electronic data sources. However, when no electronic sources
				  are available, the applicant must provide various types of documentation as
				  proof to support self-attestations.
C. The full range of information that may be
				  required for an application to be complete varies depending on the applicant's
				  situation and the type of verification/proof required. A list of eligibility
				  factors and types of acceptable documentation are located on the EOHHS website
				  at: http://www.eohhs.ri.gov/ProvidersPartners/FormsApplications.aspx and is
				  also available on paper by contacting the DHS-LTSS coverage line at (401) 415-
				  8455.
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 4 - Long-Term Services and Supports Application and Renewal Process › Section 210-RICR-50-00-4.10 - Applicant and Agency Responsibilities

Current through June 14, 2024
A. Applicant
				  responsibilities include:
1. Full responses
				  -- Responding to all questions related to LTSS eligibility on the application
				  and any required supplemental forms;
2. Providing any documentation requested to
				  verify the information on the form at the time the application is submitted and
				  at any point in which change reporting is due;
3. Promptly sending to health care providers
				  the signed clinical evaluation forms and associated releases and ensuring these
				  forms are returned in a timely manner.
4. Clinical status --Reporting any changes in
				  health status, such as trauma or marked decline in functional ability,
				  financial circumstances, such as sale of a home, asset loss or windfall, and/or
				  household composition, such as death or divorce of a spouse, that may affect
				  the determination of level of need after the initial application is submitted
				  during the time the application is pending action by the State.
5. Signature and truthfulness -- Signing the
				  form to provide consent for the determination of eligibility and the
				  verification of information through electronic sources and to attest to the
				  truthfulness of application responses. In the event of a death, the form may be
				  signed by an authorized representative or next of kin.
6. Duty to Report -- Applicants must report
				  changes in any information included on the application and supplemental forms
				  within ten (10) days from the date the change takes effect while the
				  application is open. Self-reports are permitted through the eligibility system
				  consumer self-service portal as well as in person, via fax, or mail. Failure to
				  report in a timely manner may result in the denial of an application based on
				  non-cooperation.
7.
				  Documentation/proof -- Applicants must provide any documentation or proof that
				  otherwise cannot be obtained related to any eligibility factors subject to
				  change upon written request. The information must be provided within the time
				  frame specified in the notice stating the basis for making the agency's
				  request. Failure to respond in a timely manner and/or to provide the
				  information requested without good cause is considered to be non-cooperation
				  and is grounds for denial.
8.
				  Financial resources -- Applicants must, as a condition of eligibility, take any
				  necessary steps to obtain annuities, pensions, retirement and disability
				  benefits along with any other forms of assistance available for support and
				  maintenance that may be identified by the agency, in writing, in accordance
				  with §40-00-2.5 of this Title. Good cause exceptions are considered when
				  requested in writing.
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 4 - Long-Term Services and Supports Application and Renewal Process › Section 210-RICR-50-00-4.11 - Renewal of Medicaid LTSS Eligibility

Current through June 14, 2024
A. LTSS
				  Medicaid financial and general eligibility must be re-evaluated at least once a
				  year. This annual review is now referred to as a renewal. Federal regulations [
				42 C.F.R. 435.916(b)]  require these
				  annual reviews to consider only those eligibility factors that are subject to
				  change and, to the full extent feasible, utilize electronic data sources for
				  verification purposes. Accordingly, LTSS Medicaid renewals require
				  beneficiaries to review information from the IES on key general and financial
				  eligibility factors that has been updated by internal and external data
				  sources, and report any inaccuracies or changes. The requirements for general
				  and financial eligibility renewals for Medicaid LTSS are conducted in
				  accordance with §40-00-2.7 of this Title.
B. Clinical and functional eligibility
				  re-evaluations are also required, but may be performed annually or less
				  frequently depending on the expected scope and duration of the need for LTSS.
				  The requirements for clinical and functional eligibility re-evaluations are
				  conducted in accordance with Part 5 of this Subchapter.
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 5 - "Medicaid Long-Term Services and Supports: Functional/Clinical Eligibility" (210-RICR-50-00-5) › Section 210-RICR-50-00-5.1 - Overview

Current through June 14, 2024
The process for determining function/clinical eligibility
					 for long-term services and supports (LTSS) centers on a comprehensive
					 evaluation that includes a functional assessment and consideration of each
					 applicant's unique medical, social, physical and behavioral health needs. The
					 results of this evaluation process are used to determine whether, and to what
					 extent, an applicant has the need for the level of care typically provided in a
					 nursing facility (NF), intermediate care facility for persons with intellectual
					 or developmental disabilities (ICF-I/DD), or long-term care hospital (LTH).
					 Under the terms of the Medicaid State Plan and the State's Title XIX, Section
					 1115 demonstration waiver, a person must have this level of need and meet both
					 the non-financial and financial eligibility requirements set forth in this Part
					 to qualify for Medicaid LTSS coverage in one of these institutions, at home, or
					 in a community-based service (HCBS) setting.
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 5 - "Medicaid Long-Term Services and Supports: Functional/Clinical Eligibility" (210-RICR-50-00-5) › Section 210-RICR-50-00-5.2 - Legal Authority

Current through June 14, 2024
A. This Part is
				  promulgated pursuant to the following federal and state authorities:
1. Federal Law -- Title XIX of the U.S.
				  Social Security Act
				   42 U.S.C. §
												1396a, Sections  1115, 1902, 1903, 1905, 1915,
				  1919.
2. Federal Regulations --  42
				  C.F.R. Part 440  including §§440.40, 440.70, 440.150, 440.155,
				  440.180, 440.181, 440.182.
3. The
				  RI Medicaid State Plan and the Title XIX, Section 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 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 5 - "Medicaid Long-Term Services and Supports: Functional/Clinical Eligibility" (210-RICR-50-00-5) › Section 210-RICR-50-00-5.6 - Nursing Facility (NF) Needs-based Level of Care Determinations

Current through June 14, 2024
5.6.1
Overview
Under Rhode Island law, any health care institution
					 licensed as a NF and certified for Medicare and Medicaid is authorized to
					 provide skilled nursing and custodial care. Many facilities in the State also
					 have the authority and capacity to offer subacute care, typically in the form
					 of rehabilitation services, limited skilled nursing, and/or hospice care.
5.6.2
NF Service
				  Classifications
A. The NF service
				  classifications are designed to provide service options that reflect the scope
				  and intensity of the beneficiary's need for the level of care typically
				  provided in a nursing facility.
1. Highest
				  need -- Beneficiaries in this classification have access to all the Medicaid
				  LTSS covered services they need at home, in the community, or in a nursing
				  facility, in accordance with their plan of care.
2. High need -- Beneficiaries in the high
				  classification have needs that can be met safely and effectively at home or in
				  a community-based Medicaid certified LTSS setting such as an assisted living or
				  shared living residence. Accordingly, these beneficiaries have access to the
				  full array of State Plan and Section 1115 demonstration waiver home and
				  community based services required to meet their needs as specified in the
				  person-centered individual plan of care.
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 5 - "Medicaid Long-Term Services and Supports: Functional/Clinical Eligibility" (210-RICR-50-00-5) › Section 210-RICR-50-00-5.7 - ICF/ID Needs-based Level of Care Determinations for Adults with Intellectual/Developmental Disabilities (IDD)

Current through June 14, 2024
5.7.1
Overview
A. In Rhode Island, the Medicaid ICF/I-DD
				  level of care is reserved for persons with developmental disabilities who meet
				  the criteria established in Part 40-00-1 of this Title. Although there are
				  licensed ICF/I-DD health institutions operating in Rhode Island, they are
				  limited in number and open only to new applicants who require intensive and
				  continuous skilled services in a highly restricted setting. Since the 1980s,
				  the State has implemented a "community first" approach for adults with
				  developmental disabilities who, were it not for access to HCBS, would require
				  the level of care typically provided in an ICF/I-DD.
B. In accordance with the principles
				  established in the Olmstead decision (Olmstead v. L.C., 527 U.S. 581), BHDDH
				  has developed service options that encourage independence and self-direction,
				  facilitate supportive employment, and provide the appropriate level of care.
				  The service classifications established by BHDDH are designed to ensure that
				  the service options available to beneficiaries meet their needs in the least
				  restrictive setting.
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 5 - "Medicaid Long-Term Services and Supports: Functional/Clinical Eligibility" (210-RICR-50-00-5) › Section 210-RICR-50-00-5.8 - Long-term Hospital Assessments and Level of Care Determinations

Current through June 14, 2024
A. Long-term hospitals and the related HCBS
				  alternatives serve people who may have one or more of a diverse set of clinical
				  and/or functional needs. In addition, the intervals for re-determining level of
				  care may differ depending on a beneficiary's acuity needs. Accordingly, both
				  the process and criteria for determining the LTH level of need vary across
				  agencies and populations as follows:
1. HCB
				  Habilitative Care [DOT] EOHHS LTSS specialists determine the level of need for
				  applicants and beneficiaries seeking home and community based habilitative
				  services. The NF needs-based criteria set forth in §5.6.3 of this Part
				  apply. Applicants and beneficiaries with the high and highest need have the
				  choice of obtaining Medicaid HCBS services in a community residential care
				  setting or at home.
2. Under 21
				  psychiatric care [DOT] Medicaid applicants and beneficiaries up to age
				  twenty-one (21) may obtain LTH services in a licensed psychiatric residential
				  treatment center or a hospital under the authority of the Early, Periodic,
				  Screening, Detection and Treatment (EPSDT) requirements of Title XIX and the
				  Medicaid State Plan. Assessments center on "medical necessity" and
				  clinical/functional need and are conducted by treating health practitioners,
				  the Medicaid managed care plans, and/or the DCYF, if the child or young adult
				  is participating in one of the department's programs.
3. Behavioral health services [DOT] The BHDDH
				  and the State's Community Mental Health Centers assess the clinical and
				  functional needs of applicants/beneficiaries with serious and persistent
				  behavioral health conditions and/or mental illnesses. This assessment is used
				  to determine:
a. Level of care. Whether the
				  person requires the services and supports typically provided in an LTH to meet
				  their clinical and functional needs;
b. Service classification. What the scope and
				  intensity of the person's need for the LTH level of care are; and
c. Service options. Whether the person's
				  needs can be met safely and effectively in the available HCBS alternatives, or
				  require the more intensive services, supports, and supervision that can be
				  accessed in a more restrictive health institution setting.
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 6 - Medicaid Long-Term Services and Supports: Financial Eligibility › Section 210-RICR-50-00-6.1 - Overview and Purpose

Current through June 14, 2024
A. Financial
				  eligibility for Medicaid LTSS is determined using a multi-faceted process that
				  considers countable income and resources at the time of application, the
				  allocation of joint spousal resources from the point the need for LTSS began,
				  and financial transactions over a look-back period of up to five (5) years. The
				  purpose of this process is not only to assess whether an applicant meets the
				  applicable income and resources limits, but also to ensure that Federal
				  requirements that both prohibit self-impoverishment and protect against spousal
				  impoverishment are met.
B. The LTSS
				  financial eligibility requirements differ somewhat depending on whether a
				  person is a current Medicaid beneficiary or a new applicant. The method
				  required by Federal Regulations for evaluating income and resources is linked
				  to the applicable category of Medicaid coverage: modified adjusted gross income
				  (MAGI) method for Affordable Care Act (ACA) expansion adults in Medicaid
				  Affordable Care Coverage (MACC) category or the Supplemental Security Income
				  (SSI) method for adults over age twenty-one (21) in the Integrated Health Care
				  Coverage (IHCC) category.
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 6 - Medicaid Long-Term Services and Supports: Financial Eligibility › Section 210-RICR-50-00-6.2 - Legal Authority

Current through June 14, 2024
A. This Part is
				  promulgated pursuant to the following Federal and State authorities:
1. Federal Law - Title XIX of the U.S. Social
				  Security Act,
				   42 U.S.C. §§
												1396a, Subsections 1902, 1903(i)(24), 1905, 1917(b) through (d), 1924(d) 03, 1905, 1915, 1919, 1929, 1934(a), and
				  1940.
2. Federal Regulations - 42
				  C.F.R. §§435.723(c)(2),
				  435.733(c)(2),
				  435.832(c)(2),
				  435.840
				  -
				  435.845,
				  435.602,
				  441.180,
				  441.300 to
				  441.310,
				  441.350 to
				  441.365,
				  430.25,
				  435.217,
				  440.180
				  and
				  460.92(b).
3. The Rhode Island Medicaid State Plan and
				  the Title XIX, Section 1115(a) Demonstration Waiver (11-W-00242/1), effective
				  through December 31, 2018.