reglab/statecodes huggingface dataset:
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.62 - Auto Re-Enrollment Following Resumption of Eligibility

Current through June 14, 2024
A. Members of families who receive Medicaid
				  and who are disenrolled from a dental plan due to loss of eligibility are
				  automatically re-enrolled, or assigned, into the same plan should they regain
				  eligibility within sixty (60) calendar days. If more than sixty (60) days has
				  elapsed, the family is permitted to select a plan from those open for
				  enrollment at that time.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.63 - Rite Smiles Lock-In

Current through June 14, 2024
A. After initial
				  enrollment into a RIte Smiles plan, enrollees are restricted to that dental
				  plan until the next open enrollment period, unless disenrolled under one (1) of
				  the conditions described below:
1. Loss of
				  Medicaid eligibility, including for non-payment of applicable premium shares
				  for RIte Care or RIte Share;
2.
				  Selection of another dental plan during open enrollment, if another plan
				  exists;
3. Death;
4. Relocation out-of-State;
5. Adjudicative actions;
6. Change of eligibility status;
7. Eligibility determination error;
8. As the result of a formal grievance filed
				  by the member against the dental plan or by the dental plan against the
				  member;
9. Just cause (as
				  determined by EOHHS).
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.64 - Open Enrollment

Current through June 14, 2024
A. During open
				  enrollment members have an opportunity to change RIte Smiles dental plans, if
				  more than one (1) dental plan is available.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.65 - Voluntary Disenrollment

Current through June 14, 2024
A. RIte Smiles
				  members seeking disenrollment during the lock-in period must first file a
				  formal appeal pursuant to appeal procedures with the dental plan (with the
				  exception that members are permitted to disenroll without cause during the
				  ninety (90) days following the effective date of the individual's initial
				  enrollment, if more than one (1) dental plan is available).
B. Disenrollment can only be ordered by EOHHS
				  after administrative review of the facts of the case. In order for
				  disenrollment to occur, EOHHS must first find in favor of the member, and then
				  determine that the appropriate resolution to the member's complaint is the
				  member's disenrollment.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.66 - Member Disenrollment

Current through June 14, 2024
A. Unless the
				  member's continued enrollment in the dental plan seriously impairs the dental
				  plan's ability to furnish services to either the particular member or other
				  members, a RIte Smiles dental plan may not request disenrollment of a member
				  because of:
1. An adverse change in the
				  member's health status;
2. The
				  member's utilization of medical/dental services; or
3. Uncooperative or disruptive behavior
				  resulting from the member's special needs. All disenrollments are subject to
				  approval by EOHHS.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.67 - Information and Referral

Current through June 14, 2024
A. For Further
				  Information or to Obtain Assistance:
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 05 - Service Delivery Options › Part 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.68 - 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 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.1 - Overview / Legal Authority

Current through June 14, 2024
Under the terms of Section 1906 of Title XIX of the U.S.
					 Social Security Act, states are permitted to pay an eligible individual's share
					 of the costs for enrolling in employer-sponsored health insurance coverage if
					 it is cost effective to do so. R.I. Gen. Laws §
										40-8.4-12 authorized the Medicaid agency to establish the RIte Share Premium Assistance
					 Program to subsidize the costs of enrolling Medicaid eligible individuals and
					 families in employer-sponsored health insurance (ESI) plans that have been
					 approved as meeting certain cost and coverage requirements (RIte
					 Share-approved). The Executive Office of Health and Human Services (EOHHS), the
					 Medicaid Single State Agency, uses cost-effective criteria to determine whether
					 ESI plans meet these requirements.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.2 - Scope and Purpose

Current through June 14, 2024
A. This Part applies
				  to individuals and families determined to be Medicaid eligible under RICR Title
				  210, Chapter 30 (Medicaid for Children, Families, and Affordable Care Act (ACA)
				  Adults). If these individuals or families have access to ESI, EOHHS must
				  conduct a review of the coverage to determine if the benefits are comparable to
				  Medicaid benefits and if the cost of the ESI is less expensive than Medicaid
				  managed care (in the aggregate). When ESI is found to be cost-effective, the
				  State will pay the employee's premium for that coverage.
B. The purpose of this rule is to set forth
				  the provisions governing participation in the RIte Share Program, the buy-in
				  requirement and the process for determining whether an ESI plan meets the
				  cost-effectiveness criteria established by EOHHS, the Medicaid agency. The rule
				  also identifies the respective roles and responsibilities of Medicaid-eligible
				  individuals and families and the Medicaid agency.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.4 - RIte Share Populations

Current through June 14, 2024
A. The income of
				  Medicaid members affects whether and in what manner they must participate in
				  RIte Share. Rite Share populations are determined pursuant to R.I. Gen. Laws
				  §
										40-8.4-12(c).
1. RIte Share includes: children, families,
				  parents and caretakers eligible for Medicaid, or the Children's Health
				  Insurance Program (CHIP), and childless adults between the ages of nineteen
				  (19) and sixty-four (64) who are not receiving or eligible to receive Medicare,
				  but are Medicaid eligible.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.5 - RIte Share Enrollment as a Condition of Eligibility

Current through June 14, 2024
A. Medicaid members over the age of nineteen
				  (19), who have access to RIte Share-approved ESI must enroll in that ESI as a
				  condition of continuing Medicaid eligibility. This requirement also applies to
				  any individuals who have, or previously had the option to waive ESI coverage to
				  receive financial compensation, including but not limited to, an increase in
				  hourly wage, an increase in weekly salary, and/or a lump sum payment. (An
				  increase in wages for waiving coverage is also known as "pay in lieu of
				  benefits.")
1. Exemptions - In certain
				  circumstances, Medicaid members with access to ESI are exempt from enrolling as
				  condition of maintaining eligibility:
a.
				  Under age 19. Medicaid-eligible children and young adults up to age nineteen
				  (19) are not required to enroll in a parent/caretaker relative's ESI as a
				  condition of maintaining Medicaid eligibility.
b. Enrolled in RI Works (TANF). There is a
				  limited six (6) month exemption from the mandatory enrollment requirement for
				  RI Works program participants. See §
												3.6   of this Part
				  below.
c. Pregnant women. Although
				  the State encourages enrollment, pregnant women will not be sanctioned if they
				  do not comply.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.6 - RI Works Participants

Current through June 14, 2024
A. RI Works
				  participants who are Medicaid-eligible are not required to enroll in a RIte
				  Share plan for their first six (6) months of employment. This six-month
				  exemption also applies to families losing eligibility for RI Works due to
				  employment. Specifically, to be subject to enrollment in a RIte Share approved
				  ESI plan, the RI Works participant must be:
1.
				  Age nineteen (19) or older; and
2.
				  Employed for a period of six (6) consecutive months or more by the same
				  employer.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.7 - RIte Share Premium Assistance

Current through June 14, 2024
A. Under the RIte
				  Share Premium Assistance Program, the State pays the employee's premium.
				  Medicaid members also receive wrap-around services.
1. Premium payments - EOHHS pays for ESI
				  premiums as follows:
a. EOHHS pays the
				  employee directly for their share of the ESI, or
b. EOHHS pays the employer directly for the
				  employee's share of the ESI.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.8 - RIte Share Buy-in Requirement

Current through June 14, 2024
A. In certain
				  instances, Medicaid beneficiaries participating in RIte Share are subject to a
				  buy-in requirement. This requirement applies to a household with MAGI-based
				  income above 150% of the FPL where only the child (children) is Medicaid
				  eligible, and the parent/caretaker has access to ESI that is RIte
				  Share-approved.
1. Buy-in amount - The
				  parent/caretaker is required to pay a monthly buy-in amount that varies with
				  income as follows:
Monthly Family Income
Monthly Buy-In Amount
Over 150% and not greater than 185% FPL
$ 61.00
Over 185% and not greater than 200% FPL
$ 77.00
Over 200% and not greater than 250% FPL
$ 92.00
2.
				  Notice - EOHHS must provide the adult in the family subject to the buy-in
				  requirement with timely notice. This may be done separately or in conjunction
				  with the notice of RIte Share participation. The notice must include the amount
				  of the buy-in, the process for making payments, the consequences for
				  non-payment and a statement of the right to appeal and request a
				  hearing.
3. Payment - Buy-in
				  amounts are not prorated. Therefore, a full monthly buy-in amount is due if
				  RIte Share enrollment is effective for any portion of a coverage
				  month.
4. Method of payment - The
				  parent/caretaker either pays the monthly RIte Share buy-in amount to EOHHS or,
				  if the member has direct deposit, EOHHS deducts the buy-in amount from their
				  ESI reimbursement.
5.
				  Non-compliance - If the parent/caretaker fails to pay the buy-in amount as
				  required, children and young adults in the family age nineteen (19) and under
				  who are eligible for Medicaid will be enrolled in a Medicaid managed care
				  plan.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.9 - Basis for Approving ESI Plans

Current through June 14, 2024
A. Only ESI or
				  group health plans that meet the cost-effectiveness and benefits criteria
				  specified in this Part are approved for the RIte Share Premium Assistance
				  Program.
1. Sources of information for
				  determining cost-effectiveness - Determinations of ESI cost-effectiveness are
				  based on information gathered from the following sources:
a. Application materials. When applying for
				  Medicaid, applicants must indicate: current health insurance coverage status;
				  relationship to policy holder; plan name; policy number; eligibility for and
				  type of coverage and individuals covered by the plan. Subchapter 00 Part 3 of
				  this Chapter explains the process for applying for Medicaid through the State's
				  affordable care eligibility system and the manner in which this information is
				  collected and maintained.
b. The
				  RIte Share Unit. This EOHHS Unit collects employer data about ESI plans for
				  Medicaid-eligible individuals/households. Information from employers includes
				  data necessary to determine whether the employer's ESI offerings meet EOHHS's
				  cost-effectiveness and benefits criteria.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.10 - Methodology for Determining Cost-Effectiveness

Current through June 14, 2024
A. The
				  RIte Share Unit uses the information about the ESI plan to compare the cost of
				  the employee's share, for the ESI to the cost of enrollment in Medicaid managed
				  care. An ESI plan is determined to be cost-effective when, on the aggregate,
				  the total cost of medical coverage through RIte Share is less than the cost of
				  coverage if enrolled in a Medicaid managed care plan. RIte Share participants
				  receive coverage comparable in scope, amount, and duration to coverage provided
				  in a Medicaid managed care plan.
1.
				  Cost-effectiveness test - To be cost-effective, the policy holder's monthly ESI
				  premium share, deductibles, co-insurance plus any Medicaid covered services not
				  covered by the ESI plan (such as services covered under the RIte Care Health
				  Plan contract but not under the ESI plan) must be less than the average
				  capitation payment for an average individual/family enrolled in a Medicaid
				  managed care plan. These average costs must be actuarially determined at such
				  intervals as deemed appropriate by EOHHS.
2. There are three cost effectiveness
				  determinations for each employer plan:
a.
				  Family coverage where all family members are Medicaid eligible (income less
				  than or equal to one hundred thirty six percent (136%) of the federal poverty
				  guidelines (FPL));
b. Family
				  coverage where only children and/or pregnant women in the family are Medicaid
				  eligible (for families, income greater than one hundred and thirty-six percent
				  (136%) and less than or equal to, two hundred and sixty one percent (261%); for
				  pregnant women, income greater than one hundred and thirty six percent (136%),
				  and less than or equal to two hundred fifty three percent (253%) of FPL);
				  and
c. Individual coverage where
				  only the employee is Medicaid eligible (133% FPL) (Medicaid
				  Expansion).
d. All the above listed
				  FPL guidelines are not inclusive of the five percent (5%) income disregard to
				  allow for minor fluctuation in income.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.11 - Scope and Consequence of Approving an ESI Plan

Current through June 14, 2024
RIte Share-approved ESI plans are reevaluated on an annual
					 basis to ensure that all Medicaid beneficiaries who are enrolled receive
					 coverage comparable in scope, amount, and duration to that provided in a
					 Medicaid managed care plan. From the date an ESI plan is approved until the
					 date it is reevaluated, any Medicaid beneficiaries who work for that employer,
					 and their Medicaid-eligible dependents, must enroll in the ESI through RIte
					 Share.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.12 - Enrollment Process

Current through June 14, 2024
A. Medicaid
				  beneficiaries who are required to participate in RIte Share must enroll in the
				  ESI plan as directed by EOHHS. Enrollment into RIte Share may occur upon
				  initial determination or at the time of Medicaid annual renewal, or as deemed
				  appropriate by EOHHS. Enrollment in RIte Share is deemed to be a "qualifying
				  event" and may occur at any time, including outside the open enrollment period.
1. Eligibility determination and RIte Share
				  referral - The referral for RIte Share participation is based on information
				  provided by the Medicaid beneficiary in conjunction with an initial Medicaid
				  application or annual Medicaid renewal; and documented in the EOHHS database as
				  to whether an employer offers RIte Share-approved coverage.
2. Notice RIte Share participation required -
				  A notice must be sent by EOHHS indicating that participation in RIte Share is a
				  condition of retaining Medicaid eligibility as follows:
a. Fourteen days' notice. Upon determining
				  that a Medicaid member is qualified for coverage through RIte Share, EOHHS
				  provides a written "Notification of Eligibility for Enrollment" stating the
				  employee must select a RIte Share-approved ESI plan through their employer's
				  personnel or human resources office within fourteen (14) calendar
				  days.
b. Thirty days' notice.
				  Written notice will be sent to the Medicaid beneficiary approximately thirty
				  (30) days prior to the date that enrollment in RIte Share is required, but only
				  in instances when approval of the ESI plan is the impetus for the requirement
				  to enroll rather than a determination/renewal of Medicaid eligibility
3. Prior agreement - In certain
				  circumstances, EOHHS may have a prior agreement with the employer which permits
				  the RIte Share Unit to enroll an eligible individual/family in the ESI plan
				  upon receipt of an acknowledgment or written consent from the policy holder.
				  The notification of enrollment sent from the RIte Share Unit to the
				  Medicaid-ineligible policy holder as well as to any Medicaid recipients in such
				  cases shall explain any such prior arrangements and any additional appeal and
				  hearing rights that follow therefrom.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.13 - Access to ESI

Current through June 14, 2024
A. All Medicaid
				  applicants and beneficiaries are required to provide information about access
				  to ESI. For the purposes of RIte Share, "access" to ESI is as follows:
1. A Medicaid-eligible individual, age
				  nineteen (19) or older who is, or has the option to be enrolled in an
				  employer-sponsored health insurance or group health benefit plan;
2. A Medicaid-eligible individual who is, or
				  has the option to be, enrolled in an employer-sponsored health insurance or
				  group health benefit plan as the spouse, dependent, or family member of a
				  Medicaid-ineligible policy holder.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.15 - Continuing Eligibility - Medicaid Renewals

Current through June 14, 2024
A. For
				  Medicaid beneficiaries renewing eligibility, EOHHS must assess as part of the
				  redetermination process whether anyone in the household is a RIte Share
				  participant and if there has been any change in access to ESI.
1. Notice of renewal - Medicaid beneficiaries
				  must be provided with a notice at the time of renewal specifying the terms for
				  continuing eligibility. The terms for continuing coverage vary as follows:
a. Medicaid managed care enrollees without
				  access to ESI continue enrollment in the Medicaid managed care plan that
				  provided coverage in the previous period of eligibility in accordance with Part
				  2 of this Subchapter.
b. Medicaid
				  managed care enrollees who have gained access to a RIte Share-approved ESI plan
				  continue to be enrolled in the Medicaid managed care plan that provided
				  coverage in the previous period of eligibility pending review by the RIte Share
				  Unit. In such cases, EOHHS sends a notice stating that eligibility is continued
				  and that coverage in a Medicaid managed care plan continues pending action on
				  the ESI plan by the RIte Share Unit. A referral to the RIte Share Unit is made
				  accordingly.
c. RIte Share
				  participants who retain access to the RIte Share-approved ESI plan that
				  provided coverage during the during the previous period of eligibility,
				  continue to be enrolled in the ESI plan pending review by the RIte Share Unit
				  of any changes that might result in withdrawal of approval of the ESI plan,
				  disenrollment, and subsequent enrollment in a Medicaid managed care
				  plan.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.16 - Renewal of RI Works Participants

Current through June 14, 2024
A. At the time
				  eligibility renewals are completed, EOHHS is responsible for assessing whether
				  RI Works participants are subject to enroll in a RIte Share-approved plan as a
				  condition of continuing Medicaid eligibility.
1. Employed under six (6) months - Only those
				  RI Works participants, age nineteen (19) or older, who have access to ESI and
				  have been steadily employed for a period of six (6) consecutive months or more,
				  shall be subject to enrollment in RIte Share. All other RI Works participants
				  continue enrollment in the Medicaid managed care plan which provided coverage
				  until the next scheduled redetermination of eligibility.
2. Employed six (6) months or over - If the
				  RI Works participant has been employed for over six (6) months, the notice of
				  renewal sent by EOHHS must state that enrollment in the Medicaid managed care
				  plan that provided coverage during the previous period of eligibility is
				  continued, pending review of the ESI plan by the RIte Share Unit. If enrollment
				  in an approved ESI plan is a condition of retaining continuing eligibility,
				  Medicaid beneficiaries shall receive notice from the RIte Share Unit at least
				  fourteen (14) days prior to enrollment in an ESI plan.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.17 - RIte Share Premium Assistance Payment

Current through June 14, 2024
A. It
				  is the responsibility of EOHHS to establish the appropriate mechanism for
				  transferring payment for the RIte Share-approved ESI plan premiums.
1. The payment options include:
a. Enrollment costs are paid directly by the
				  employer without any wage withholding from the policy holder. The RIte Share
				  Unit or its agent either mails a check or electronically transfers payment to
				  the employer's bank or account, on a monthly basis, to cover the enrollment
				  costs for any individuals/families on the ESI as a result of RIte Share
				  enrollment. These are called "participating" employers.
b. Enrollment costs are paid by the employer
				  after wage withholding from the policy holder. The RIte Share Unit or its agent
				  mails a check or electronically transfers payment to the policy holder, on a
				  monthly basis, to cover the enrollment costs for any individuals/families on
				  ESI as a result of RIte Share enrollment.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.18 - Role of RIte Share Unit

Current through June 14, 2024
A. The RIte Share
				  Unit is responsible for overseeing the operations of the program as follows:
1. Eliciting information from employers about
				  the health plans they offer to workers on an ongoing basis;
2. Evaluating health plans for RIte Share
				  approval;
3. Maintaining a database
				  of RIte Share-approved ESI plans; and
4. Contacting employers to make RIte Share
				  enrollment decisions.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.19 - ESI Enrollment Verification

Current through June 14, 2024
A. Verification of
				  enrollment in a RIte Share-approved ESI plan is required.
1. Participating employer - For Medicaid
				  beneficiaries working for a RIte Share approved employer, the employer is
				  required to submit verification to the RIte Share Unit that initial enrollment
				  in the ESI has been made in the manner prescribed by EOHHS.
2. Approved plan - For individuals working
				  for a RIte Share-approved employer, the individual must provide verification of
				  enrollment by completing the appropriate form, which requires the signature of
				  a representative of the employer, or by submitting a copy of the official ESI
				  enrollment receipt. Once this verification has been received, EOHHS will
				  initiate premium payment.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.20 - Failure to Enroll

Current through June 14, 2024
A. Failure to enroll
				  in the ESI plan is grounds for termination of Medicaid eligibility for the
				  non-pregnant parent(s) or caretaker over the age of nineteen (19) in the
				  household.
1. Discontinuation - EOHHS sends a
				  "Notice of Discontinuation", stating that Medicaid eligibility has been
				  terminated for adults in the household due to the failure to enroll in the RIte
				  Share-approved plan. Anyone in the household subject to the notice may reapply
				  (for inactive cases) or request reinstatement (for active Medicaid cases) if
				  they choose to comply with RIte Share, if an exemption from participation is
				  granted, or if the individual no longer has access to the ESI. Please refer to
				  §
											3.5   of
				  this Part.
2. Disqualification -
				  Procedures for handling cases in which the policy holder is not eligible for
				  Medicaid are the same as for an eligible policy holder, with one exception: The
				  Medicaid agency sends a "Notice of Disqualification" to the policy holder
				  indicating that ESI costs will not be paid by EOHHS. Please refer to §
											3.5   of this Part.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.21 - Disenrollment from RIte Share-Approved Plan

Current through June 14, 2024
A. RIte Share
				  beneficiaries who are voluntarily or involuntarily disenrolled from an approved
				  ESI plan must report the change in enrollment status to EOHHS in no more than
				  ten (10) days from the date the disenrollment action occurs. The type of
				  disenrollment determines EOHHS's response as follows:
1. Voluntary disenrollment -
				  Medicaid-eligible RIte Share beneficiaries age nineteen (19) or older who
				  voluntarily disenroll from an approved ESI will be terminated for coverage
				  based on the failure to meet the non-financial cooperation requirements set
				  forth in this Part. Voluntary disenrollment includes, but is not limited to,
				  instances in which a RIte Share beneficiary:
a. Requests that the employer drop coverage
				  or cease enrollment for the entire family or a Medicaid-eligible individual in
				  the family;
b. Fails to meet the
				  requirements established by the employer to maintain enrollment in the approved
				  plan such as, submit required documentation or forms.
c. Engages in unlawful or fraudulent acts,
				  such as submitting false claims that violate the terms for continuing
				  enrollment in the ESI plan. Please refer to §
												3.5   of this Part.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.22 - Cooperation Requirements

Current through June 14, 2024
A. All Medicaid
				  applicants and beneficiaries must cooperate with the non-financial requirements
				  for eligibility as follows:
1. Information -
				  All individuals and families are required to provide information about other
				  health coverage (TPL) and/or access to ESI when applying for initial or
				  continuing eligibility. The required information relating specifically to
				  access to ESI includes, but is not limited to:
a. The names of any family members in the
				  household currently covered by, or with access to, ESI;
b. The name of the policy holder and the
				  employer offering the ESI; and
c.
				  Verification of monthly enrollment costs via a paycheck stub if the policy
				  holder is currently enrolled or, if available, enrollment information provided
				  by the employer indicating the policy holder's monthly premium for the
				  appropriate family composition.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.23 - Good Cause

Current through June 14, 2024
A. EOHHS is
				  responsible for determining whether good cause exists for an exception to the
				  non-financial cooperation requirements for Medicaid eligibility contained in
				  Subchapter 00 Part 1 of this Chapter and, more specifically, for participation
				  in RIte Share, except as noted below:
1.
				  Extraordinary circumstances - EOHHS must exempt a Medicaid beneficiary from
				  RIte Share participation only when there are extraordinary circumstances which
				  preclude the individual from receiving medically necessary care through the
				  RIte Share-approved plan. For purposes of this exemption, "extraordinary
				  circumstances" may include but not be limited to:
a. The existence of an unusual and
				  life-threatening medical condition which requires medical treatment that cannot
				  be provided or arranged by the RIte Share plan whether it is provided through
				  the custodial or non-custodial parent;
b. The existence of a chronic, severe medical
				  condition for which the Medicaid beneficiary has a long-standing treatment
				  relationship for that condition with a provider who does not participate in the
				  RIte Share plan and/or refuses to enroll as a Medicaid participating
				  provider.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.24 - Notice and Appeal Rights

Current through June 14, 2024
Medicaid applicants and recipients shall receive timely
					 notification of eligibility and enrollment determinations and the right to
					 appeal. EOHHS shall also provide timely notification, including appeal rights,
					 of any adverse decisions that reduce or terminate benefits. See Part 10-05-2 of
					 this Title for full statement of these rights.
Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults › Subchapter 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.25 - 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.
http://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 05 - Service Delivery Options › Part 3 - RIte Share Premium Assistance Program › Section 210-RICR-30-05-3.26 - 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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.1 - Overview and legal authority

Current through June 14, 2024
R.I. Gen. Laws §
										40-8.12-3 mandated the Executive Office of Health and Human Services (EOHHS) to establish
					 a fund to ensure insurance coverage through HealthSource RI is affordable for
					 parents and caretakers of Medicaid-eligible children in households with incomes
					 below 175% of the Federal Poverty Level (FPL). The fund is available to assist
					 caretakers who are not otherwise eligible for Medicaid through the RI
					 Affordable Health Care Coverage Assistance Program (AHCCA).
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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.2 - Scope and Purpose

Current through June 14, 2024
A. Caretakers of
				  Medicaid-eligible children in households with incomes below 175% FPL who are
				  not Medicaid eligible themselves can apply for financial assistance for paying
				  for health insurance coverage accessed through HealthSource RI.
B. The purpose of this rule is to set forth
				  the provisions governing this financial assistance. The rule describes the
				  scope of the Affordable Health Care Coverage Assistance (AHCCA) Program, the
				  basis for determining eligibility, and the respective responsibilities of the
				  State and the individuals seeking assistance through the Program.
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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.3 - Definitions

Current through June 14, 2024
A. For the purposes of this rule, the
				  following definitions apply:
1. "Affordable
				  Care Act" or "ACA" means the federal Patient Protection and Affordable Care Act
				  of 2010. The law is also sometimes referred to as "Obamacare" and federal
				  health reform.
2. "APTC/CSR
				  eligibility" means the application of the IRS-based measure of income known as
				  "Modified Adjusted Gross Income" (MAGI) for determining eligibility for
				  affordable health care through health insurance exchanges/marketplaces
				  established under the ACA. Also, "APTC" means advanced premium tax credits and
				  "CSR" means cost-sharing reductions.
3. "Caretaker" means any adult over age
				  nineteen (19) living with a Medicaid-eligible dependent child who has assumed
				  primary responsibility for that child as defined in MCAR section 1305.13,
				  "Eligibility Requirements." This term includes relatives and
				  non-relatives.
4. "HealthSource RI"
				  means the state-based health insurance marketplace (also referred to as a
				  "benefit exchange") established in conjunction with implementation of the
				  federal Affordable Care Act of 2010.
5. "Qualified Health Plan" means a health
				  plan certified by HealthSource RI that provides essential benefits and meets
				  all other related ACA requirements to be offered through the State's health
				  benefits exchange.
6. "Silver Plan"
				  means a Qualified Health Plan offered through HealthSource RI that covers
				  approximately 70% of an enrollee's medical costs. There are federal subsidies
				  for certain Silver Plan enrollees to help cover co-payments and other
				  out-of-pocket expenses.
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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.4 - Eligibility Requirements

Current through June 14, 2024
A. Caretakers must
				  meet certain requirements related to income, health coverage, and relationship
				  to be eligible to participate in the AHCCA Program. Coverage through
				  HealthSource RI is also a condition of eligibility.
1. Eligibility - The requirements are as
				  follows:
a. Income. Household income at or
				  under 175% of the FPL.
b. Health
				  coverage. Caretakers must not be otherwise eligible for Medicaid.
c. Relationship. Caretakers need to have
				  primary responsibility for a Medicaid-eligible child who is under the age of
				  nineteen (19).
d. Must pay their
				  monthly Silver Plan premium on-time.
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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.5 - Application Process

Current through June 14, 2024
A. Caretakers must
				  submit an application for AHCCA through EOHHS.
1. Application forms will be available at the
				  HealthSource RI Contact Center located at: 401 Wampanoag Trail, Riverside, RI
				  02915 or at EOHHS, Virks Building, 3 West Road, Cranston, RI 02920 or at
				  www.eohhs.ri.gov or
www.HealthSourceRI.com
. Applicants must
				  also provide basic demographic information and information regarding enrollment
				  in a Qualified Health Plan through HealthSource RI.
2. State's Responsibilities - EOHHS must
				  review and determine eligibility for financial assistance within sixty (60)
				  days. If additional information is needed by EOHHS, a new review period will
				  begin once the additional information has been received.
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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.6 - Eligibility Approval - Premium Amount

Current through June 14, 2024
A. If a caretaker
				  is approved, EOHHS calculates the AHCCA subsidy amount in accordance with the
				  following chart:
Rhode Island Affordable Health Care Coverage
								  Assistance Program Assistance
Total Family Size
138 % FPL to 150% FPL
151% FPL to 175 % FPL
2
$39
$28
3
$49
$43
4
$59
$58
5
$69
$73
6
$79
$88
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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.7 - Notice

Current through June 14, 2024
EOHHS, or its agent, must send a notice to the caretaker
					 with an eligibility determination for AHCCA. All notices must include a
					 statement of the rights of the caretaker applying.
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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.8 - Payment of Subsidies

Current through June 14, 2024
The payment option for the AHCCA subsidy includes the
					 following: The caretaker pays the premium due to the insurer to HealthSource
					 RI. EOHHS or its agent mails a check to the caretaker
					 monthly.
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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.9 - Duration and Continuing Eligibility

Current through June 14, 2024
A. Period of
				  eligibility - Eligibility for the AHCCA subsidy is on a month-to-month basis.
				  The subsidy may be curtailed sooner if there is a change in any eligibility
				  factor that affects household or enrollment in the Qualified Health Plan
				  selected by the caretaker. Continuation of the subsidy must be reconsidered if
				  such a change occurs, if eligibility under §
										1.4   of this Part still
				  applies, AHCCA financial assistance continues.
B. Notice - EOHHS must provide notice to the
				  eligible caretaker sixty (60) days prior to termination. The notice must
				  include guidance on how to apply for continued financial assistance as well as
				  the right to appeal EOHHS actions as indicated in §
										1.10   of this Part.
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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.10 - Termination or Denial of Participation

Current through June 14, 2024
Eligibility for the AHCCA must be denied or terminated, as
					 appropriate, upon determining that an applicant has provided false information
					 on an application for assistance or has not provided timely notification of
					 changes that would affect the eligibility factors set forth in §
										1.4   of this
					 Part.
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 10 - Premium Assistance › Part 1 - Rhode Island Affordable Health Care Coverage Assistance Program (210-RICR-30-10-1) › Section 210-RICR-30-10-1.11 - Hearing and the Right to Appeal

Current through June 14, 2024
A. EOHHS must
				  provide applicants and recipients of AHCCA subsidies with notice of the right
				  to appeal and request a hearing with regard to the following agency actions:
1. A determination that an applicant
				  disapproved for AHCCA participation and the basis for the decision of
				  ineligibility;
2. The amount of
				  assistance determined;
3.
				  Termination of eligibility to participate in the AHCCA. (See regulations
				  contained in Part 10-05-2 of this Title).