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-30-05-2.24 - RHP In-Plan Capitated Benefits

Current through June 14, 2024
A. The benefits
				  which the MCO provides within the capitated (fixed cost per enrollee per month)
				  benefit.
B. RHP comprehensive
				  benefit package - The following benefits are included in the capitated rate on
				  an annual basis, based on medical necessity:
SERVICE
SCOPE OF BENEFIT (ANNUAL)
Including but not limited
								  to:
Inpatient Hospital
								  Care
As medically necessary. EOHHS shall be
								  responsible for inpatient admissions or authorizations while Member was in
								  Medicaid fee-for-service, prior to Member's enrollment in Health Plan.
								  Contractor shall be responsible for inpatient admissions or authorizations,
								  even after the Member has been disenrolled from Contractor's Health Plan and
								  enrolled in another MCO or re-enrolled into Medicaid fee-for-service, until the
								  management of the Member's care is formally transferred to the care of another
								  MCO, another program option, or fee-for-service Medicaid.
Outpatient Hospital
								  Services
Covered as needed, based on medical
								  necessity.
Includes physical therapy, occupational therapy,
								  speech therapy, language therapy, hearing therapy, respiratory therapy, and
								  other Medicaid covered services delivered in an outpatient hospital
								  setting.
Therapies
Covered as medically necessary, includes physical
								  therapy, occupational therapy, speech therapy, hearing therapy, respiratory
								  therapy and other related therapies.
Physician/Provider
								  Services
Covered as needed, based on medical necessity,
								  including primary care, specialty care, obstetric and newborn care.
Family Planning
								  Services
Enrolled female members have freedom of choice of
								  providers for family planning services.
Prescription Drugs
Covered when prescribed by an MCO
								  physician/provider. Generic substitution only unless provided for otherwise as
								  described in the Managed Care Pharmacy Benefit Plan Protocols.
Non-Prescription Drugs
Covered when prescribed by a Health Plan
								  physician/provider/APP. Limited to non-prescription drugs, as described in the
								  Medicaid Managed Care Pharmacy Benefit Plan Protocols. Includes nicotine
								  cessation supplies ordered by an MCO physician or APP. Includes medically
								  necessary nutritional supplements ordered by an MCO physician or
								  APP.
Laboratory Services
Covered when ordered by a Health Plan
								  physician/provider including urine drug screens.
Radiology Services
Covered when ordered by a Health Plan
								  physician/provider.
Diagnostic Services
Covered when ordered by a Health Plan
								  physician/provider.
Mental Health and Substance Use -
								  Outpatient & Inpatient
Covered as needed for all members, including
								  residential substance use treatment for youth. Covered services include a full
								  continuum of mental health and substance use disorder treatment, including but
								  not limited to, community-based narcotic treatment, methadone, and community
								  detox. Covered residential treatment includes therapeutic services but does not
								  include room and board, except in a facility accredited by the Joint Commission
								  on Accreditation of Healthcare Organizations ("JCAHO"). Also includes, DCYF
								  ordered administratively necessary days, or hospital-based detox, MH/SUD
								  residential treatment (including minimum six (6) month SSTAR birth residential
								  services), Mental Health Psychiatric Rehabilitative Residence (MHPRR),
								  psychiatric rehabilitation day programs, Community Psychiatric Supportive
								  Treatment (CPST),Crisis Intervention for individuals with severe and persistent
								  mental illness (SPMI) enrolled in the Community Support Program (CSP), Opioid
								  Treatment Program Health Homes (OTP), Assertive Community Treatment (ACT),
								  Integrated Health Home (IHH), and services for individuals at
								  CMHCs.
Home Health Services
Covered services include those services provided
								  under a written plan of care authorized by a physician/provider including
								  full-time, part-time, or intermittent skilled nursing care and certified
								  nursing assistant services as well as physical therapy, occupational therapy,
								  respiratory therapy and speech-language pathology, as ordered by an MCO
								  physician. This service also includes medical social services, durable medical
								  equipment and medical supplies for use at home. Home health services do not
								  include respite care, relief care or day care.
Home Care Services
Covered services include those provided under a
								  written plan of care authorized by a physician/provider including full-time,
								  part-time or intermittent care by a licensed nurse or certified nursing
								  assistant as well as; physical therapy, occupational therapy, respiratory
								  therapy and speech therapy. Home care services include laboratory services and
								  private duty nursing for a patient whose medical condition requires more
								  skilled nursing than intermittent visiting nursing care. Home care services
								  include personal care services, such as assisting the client with personal
								  hygiene, dressing, feeding, transfer and ambulatory needs. Home care services
								  also include homemaking services that are incidental to the client's health
								  needs such as making the client's bed, cleaning the client's living areas such
								  as bedroom and bathroom, and doing the client's laundry and shopping. Home care
								  services do not include respite care, relief care or day care.
Preventive Services
Covered when ordered by a health plan
								  physician/provider. Services include homemaker services, minor environmental
								  modifications, physical therapy evaluation and services, and personal care
								  services.
EPSDT Services
Provided to all children and young adults up to
								  age twenty-one (21). Includes tracking, follow-up and outreach to children for
								  initial visits, preventive visits, and follow-up visits. Includes
								  inter-periodic screens as medically indicated. Includes multi-disciplinary
								  evaluations and treatment, including, PT/OT/ST, for children with significant
								  disabilities or developmental delays.
Emergency Room Service and Emergency
								  Transportation Services
Covered both in- and out-of-State, for Emergency
								  Services or when authorized by an MCO Provider, or in order to assess whether a
								  condition warrants treatment as an emergency service.
Nursing Home Care and Skilled Nursing
								  Facility Care
Covered when ordered by a Health Plan
								  physician/provider. For Rhody Health Partners/Expansion members, the Contractor
								  payments are limited to thirty (30) consecutive days. Please refer to the
								  Nursing Home Status Form Policy. All skilled and custodial care covered.
								  Contractor is responsible for notifying the State to begin dis-enrollment
								  process. For RIte Care members, please refer to stop-loss
								  provisions.
School-Based Clinic
								  Services
Covered for RIte Care members as Medically
								  Necessary at all designate sites.
Services of Other
								  Practitioners
Covered if referred by an MCO physician.
								  Practitioners certified and licensed by the State of Rhode Island including
								  nurse practitioners, physicians' assistants, social workers, licensed
								  dietitians, psychologists and licensed nurse midwives.
Court-ordered mental health and substance
								  use services - criminal court
Covered for all members. Treatment must be
								  provided in totality, as directed by the Court or other State official or body,
								  such as a Probation Officer, the Rhode Island State Parole Board. If the length
								  of stay is not prescribed on the court order, the MCOs may conduct Utilization
								  Review on the length of stay. The MCOs must offer appropriate transitional care
								  management to persons upon discharge and coordinate and/or arrange for in-plan
								  medically necessary services to be in place after a court order expires. The
								  following are examples of Criminal Court Ordered Benefits that must be provided
								  in totality as an inplan benefit:
Bail Ordered: Treatment is prescribed as a
								  condition of bail/bond by the court.
Condition of Parole: Treatment is prescribed as a
								  condition of parole by the Parole Board.
Condition of Probation: Treatment is prescribed
								  as a condition of probation.
Recommendation by a Probation State Official:
								  Treatment is recommended by a State official (Probation Officer, Clinical
								  social worker, etc.).
Condition of Medical Parole: Person is released
								  to treatment as a condition of their parole, by the Parole Board.
Court-ordered mental health and substance
								  use treatment - civil court
All Civil Mental Health Court Ordered Treatment
								  must be provided in totality as an in-plan benefit. All Regulations in the R.I.
								  Gen. Laws §
																40.1-5-5 must be followed. If the length of stay is not
								  prescribed on the court order, the MCOs may conduct Utilization Review on the
								  length of stay. The MCOs must offer appropriate transitional care management to
								  persons upon discharge and coordinate and/or arrange for in-plan medically
								  necessary services to be in place after a court order expires. Note the
								  following are facilities where treatment may be ordered: The Eleanor Slater
								  Hospital, Our Lady of Fatima Hospital, Rhode Island Hospital (including
								  Hasbro), Landmark Medical Center, Newport Hospital, Roger Williams Medical
								  Center, Butler Hospital (including the Kent Unit), Bradley Hospital, Community
								  Mental Health Centers, Riverwood, and Fellowship. Any persons ordered to
								  Eleanor Slater Hospital for more than seven (7) calendar days, will be
								  dis-enrolled from the MCO at the end of the month, and be re-assigned into
								  Medicaid FFS. Civil Court Ordered Treatment can be from the result of:
a) Voluntary Admission
b) Emergency Certification
c) Civil Court Certification
Court-ordered treatment that is not an in-plan
								  benefit or to a non-network provider, is not the responsibility of the
								  Contractor. Court ordered treatment is exempt from the fourteen (14) day prior
								  authorization requirement for residential treatment.
Podiatry Services
Covered as ordered by Health Plan
								  physician/provider.
Optometry Services
For children under twenty-one (21):
Covered as medically necessary with no other
								  limits.
For adults twenty-one (21) and older:
Benefit is limited to examinations that include
								  refractions and provision of eyeglasses if needed once every two (2) years.
								  Eyeglass lenses are covered more than once in two (2) years only if medically
								  necessary. Eyeglass frames are covered only every two (2) years. Annual eye
								  exams are covered for members who have diabetes. Other medically necessary
								  treatment visits for illness or injury to the eye are covered.
Oral Health
Inpatient:
Contractor is responsible for operating room
								  charges and anesthesia services related to dental treatment received by a
								  Medicaid beneficiary in an inpatient setting.
Outpatient:
Contractor is responsible for operating room
								  charges and anesthesia services related to dental treatment received by a
								  Medicaid beneficiary in an outpatient hospital setting.
Oral Surgery:
Treatment covered as medically necessary. As
								  detailed in the Schedule of In-Plan Oral Health Benefits updated January
								  2017.
Hospice Services
Covered as ordered by an MCO
								  physician/provider.
Services limited to those covered by
								  Medicare.
Durable Medical Equipment
Covered as ordered by an MCO physician/provider
								  as medically necessary.
Adult Day Health
Day programs for frail seniors and other adults
								  who need supervision and health services during the daytime. Adult Day Health
								  programs offer nursing care, therapies, personal care assistance, social and
								  recreational activities, meals, and other services in a community group
								  setting. Adult Day Health programs are for adults who return to their homes and
								  caregivers at the end of the day.
Children's Evaluations
Covered as needed, child sexual abuse evaluations
								  (victim and perpetrator); parent child evaluations; fire setter evaluations;
								  PANDA clinic evaluations; and other evaluations deemed medically
								  necessary.
Nutrition Services
Covered as delivered by a registered or licensed
								  dietitian for certain medical conditions and as referred by an MCO
								  physician.
Group/Individual Education
								  Programs
Including childbirth education classes, parenting
								  classes, wellness/weight loss and tobacco cessation programs and
								  services.
Interpreter Services
Covered as needed.
Transplant Services
Covered when ordered by an MCO
								  physician.
HIV/AIDS Non-Medical Targeted
								  Case
This program may be provided for people living
								  with HIV/AIDS and for those at high risk for acquiring HIV (see provider manual
								  for distinct eligibility criteria for
Management for People Living with HIV/AIDS
								  (PLWH/As) and those at High Risk for acquiring HIV
beneficiaries to qualify for this service). These
								  services provide a series of consistent and required "steps" such that all
								  clients are provided with and Intake, Assessment, Care Plan. All providers must
								  utilize an acuity index to monitor beneficiary severity. Case management
								  services are specifically defined as services furnished to assist individuals
								  who reside in a community setting or are transitioning to a community setting
								  to gain access to needed medical, social, educational and other services, such
								  as housing and transportation. Targeted case management can be furnished
								  without regard to Medicaid's state-wideness or comparability requirements. This
								  means that case management services may be limited to a specific group of
								  individuals, such as HIV/AIDS, by age or health/mental health condition, or a
								  specific area of the state. (Under EPSDT, of course, all children who require
								  case management are entitled to receive it.) May include:
Benefits/entitlement counseling and referral
								  activities to assist eligible beneficiaries to obtain access to public and
								  private programs for which they may be eligible
All types of case management encounters and
								  communications (face-to-face, telephone contact, other)
Categorical populations designated as high risk,
								  such as, transitional case management for incarcerated persons as they prepare
								  to exit the correctional system; adolescents who have a behavioral health
								  condition; sex workers; etc.
A series of metrics and quality performance
								  measures for both HIV case management for PLWH/s and those at high risk for HIV
								  will be collected by providers and are required outcomes for delivering this
								  service.
Does not involve coordination and follow up of
								  medical treatments.
AIDS Medical Case
								  Management
Medical Case Management services (including
								  treatment adherence) are a range of beneficiary-centered services that link
								  beneficiaries with health care, psychosocial, and other services. The
								  coordination and follow-up of medical treatments are components of medical case
								  management. These services ensure timely and coordinated access to medically
								  appropriate levels of health and support services and continuity of care,
								  through ongoing assessment of the client's and other key family members' needs
								  and personal support systems. Medical case management includes the provision of
								  treatment adherence counseling to ensure readiness for, and adherence to,
								  complex HIVIAIDS treatments. Key activities include
1) Initial assessment of service needs;
2) Development of a comprehensive, individualized
								  service plan;
3) Coordination of services required to implement
								  the plan;
4) Monitoring the care;
5) Periodic re-evaluation and adaptation of the
								  plan as necessary over the time beneficiary is enrolled in services.
It includes beneficiary-specific advocacy and/or
								  review of utilization of services. This includes all types of case management
								  including face-to-face, phone contact, and any other form of
								  communication.
Treatment for Gender
								  Dysphoria
Comprehensive benefit package.
Rehabilitation
								  Services
Physical, Occupational and Speech therapy
								  services may be provided with physician orders by RI DOH licensed outpatient
								  Rehabilitation Centers. These services supplement home health and outpatient
								  hospital clinical rehabilitation services when the individual requires
								  specialized rehabilitation services not available from a home health or
								  outpatient hospital provider. See also EPSDT.
In Lieu of Service
All services as provided in §
																2.9(C)   of this
								  Part can be utilized as an in Lieu of Service if alternative service or setting
								  is a medically appropriate and cost-effective substitute for the covered
								  service or setting.
Value Add Services
Services/equipment which are not in the State
								  Plan but are cost effective, improve health and clinically
								  appropriate.
C.
				  EOHHS policy affects the access to and/or the scope and amount of several
				  benefits as follows:
1. Prescriptions: Generic
				  Policy. For RHP enrolled members, prescription benefits must be for generic
				  drugs. Exceptions for limited brand coverage for certain therapeutic classes
				  may be granted if approved by EOHHS, or the MCO acting in compliance with their
				  contractual agreements with EOHHS, and in accordance with the criteria
				  described below:
a. Availability of suitable
				  within-class generic substitutes or out-of class alternatives.
b. Drugs with a narrow therapeutic range that
				  are regarded as the standard of care for treating specific
				  conditions.
c. Relative disruptions
				  in care that may be brought on by changing treatment from one drug to
				  another.
d. Relative medical
				  management concerns for drugs that can only be used to treat patients with
				  specific co-morbidities.
e.
				  Relative clinical advantages and disadvantages of drugs within a therapeutic
				  class.
f. Cost differentials
				  between brand and generic alternatives.
g. Drugs that are required under Federal and
				  State Regulations.
h. Demonstrated
				  medical necessity and lack of efficacy on a case by case basis.