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-50-00-5.4 - Assessments for Needs-Based Level of Care Determinations

Current through June 14, 2024
A. The scope of services accessible to a
				  beneficiary varies in accordance with a person's needs, including his or her
				  goals and preferences, the range of services and supports available under the
				  State's Medicaid State Plan and Section 1115 demonstration waiver, as well as
				  federal and State regulations, rules or laws. The range of available authorized
				  service options varies with each type of health institution (NF, ICF/I-DD,
				  LTH), as the populations they serve have a range of service and support needs
				  that also vary. As indicated in the following sections, the service options
				  available to a person who meets the functional/clinical eligibility
				  requirements for LTSS associated with one of these institutions is tied to the
				  scope of his or her service needs at the time of application and in subsequent
				  reassessments of need.
B. The
				  functional/clinical eligibility determination process uses needs-based criteria
				  drawn from a variety of sources. The process is initiated when the information
				  necessary to evaluate an applicant's current health status and functional
				  service needs become available to the State through one or more of the
				  following sources:
1. Health care
				  practitioner evaluation --The application includes a clinical evaluation form
				  that must be completed by a treating, licensed health care practitioner with
				  first-hand knowledge about the health status and functional needs of an
				  applicant. The signed and completed form, and any required associated
				  documentation, provide the baseline for determining an applicant's needs
				  level.
2. Health records and
				  documentation -- Applicants must provide the State with the authorization to
				  obtain health records and other forms of clinical documentation from health
				  care providers and practitioners who have or are providing care to the
				  applicant.
3. Health institution
				  care/service plans -- Agency representatives from across the EOHHS agencies
				  obtain information from health providers who assess and/or develop care/service
				  plans for applicants who have or are receiving services or are about to be
				  discharged.
4. HCBS functional
				  assessment -- The State requires in-depth functional assessments of applicants
				  seeking home and community-based services to ensure they can obtain the
				  appropriate services safely and effectively in the setting of choice. The
				  results of the assessments also assist in care planning and guide the
				  authorization of services. As the State pursues a "no wrong door" approach,
				  these assessments may be conducted by agency representative working for the
				  State or various community entities using assessment tools that, although
				  sometimes variable, focus on the same set of functional abilities and
				  limitations.
a. NF level of care- HCBS.
				  Responsibilities for HCBS functional assessments are shared across the EOHHS
				  agencies.
b. ICF/I-DD level of care
				  -HCBS -- Agency representatives in the Department of Behavioral Healthcare,
				  Developmental Disabilities and Hospitals (BHDDH) conduct assessments of all
				  applicants seeking the ICF/I-DD level of care without regard to
				  setting.
c. LT Hospital level of
				  care -HCBS. The EOHHS agency representative that determine the NF level of care
				  assess applicants for the HCBS Habilitation Program that serves people with
				  severe disabilities that occur in adulthood. BHDDH agency representatives
				  conduct assessments of persons with serious and persistent behavioral health
				  needs seeking Medicaid LTSS in a community-based congregate
				  setting.