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-30-05-2.16 - Mandatory Participation in Managed Care

Current through June 14, 2024
A.
				  Participation in managed care is mandatory for the members of the MACC,
				  non-MAGI and non-Medicaid funded coverage groups identified in §
										2.1   of
				  this Part except as specified in §
										2.34   of this Part. Medicaid members in
				  these coverage groups with third (3rd) party medical coverage or insurance may
				  be exempt from this mandate only as indicated in §
										2.38   of this Part at
				  the discretion of the 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-30-05-2.17 - Enrollment Procedures, Rights and Responsibilities

Current through June 14, 2024
A. The enrollment process for MACC groups is
				  set forth in §
										2.34   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 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.18 - Rhody Health Partners - Program Overview

Current through June 14, 2024
A. Rhody
				  Health Partners (RHP) is a managed care delivery system for adult Medicaid
				  beneficiaries ages nineteen (19) to sixty-four (64) eligible under the ACA
				  expansion as well as adults with disabilities eligible under Part 40-00-1 of
				  this Title.
B. As with RIte Care,
				  beneficiaries under this Rule who have access to a Medicaid approved
				  employer-sponsored health insurance plans are evaluated for participation in
				  the RIte Share Premium Assistance Program and are required to enroll in an
				  employer plan approved by EOHHS as a condition of retaining Medicaid
				  eligibility.
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-30-05-2.19 - Scope and Purpose

Current through June 14, 2024
A. Eligible members
				  of the MACC group for adults ages nineteen (19) to sixty-four (64) and must not
				  be eligible for or enrolled in Medicare will be enrolled in a RHP health plan
				  or, as applicable, RIte Share. The purpose of this section is to describe the
				  RHP delivery system for members of this MACC coverage group and the respective
				  roles and responsibilities of EOHHS and the individuals receiving affordable
				  coverage through RHP.
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-30-05-2.20 - Applicability

Current through June 14, 2024
A. The provisions governing RHP for persons
				  who are eligible for Medicaid on the basis of being aged, blind, or with a
				  disability are located in Part 40-10-1 of this Title.
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-30-05-2.21 - MACC Group in Rhody Health Partners

Current through June 14, 2024
A. The MACC
				  group participating in RHP is adults, ages nineteen (19) to sixty-four (64),
				  who are not: pregnant, entitled to received Medicare Part A or B, or otherwise
				  eligible for or enrolled in a Medicaid State Plan mandatory coverage group.
				  See: Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways
				  (Subchapter 00 Part 1 of this Chapter).
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-30-05-2.22 - Overview of RHP

Current through June 14, 2024
A. Individuals
				  enrolled in RHP receive the full scope of services covered under the Medicaid
				  State Plan and the State's Section  1115   waiver, unless otherwise indicated.
				  Covered services may be provided through the MCO or through the fee-for-service
				  delivery system if the service is "out-of-plan" - that is, not included in the
				  MCO but covered under Medicaid. Fee-for-service benefits may be furnished
				  either by the managed care provider or by any participating provider. Rules of
				  prior authorization apply to any service required by EOHHS. In response to the
				  novel Coronavirus Disease (COVID-19), EOHHS will temporarily suspend most prior
				  authorization requirements. Effective October 1, 2021, prior authorization
				  requirements will be reinstated for all services except for behavioral
				  healthcare services. Effective January 1, 2022, prior authorizations will be
				  reinstated for behavioral healthcare services. Each RHP member selects a
				  primary care provider (PCP) who performs the necessary medical care and
				  coordinates referrals to specialty care. The primary care provider orders
				  treatment determined to be medically necessary in accordance with MCO
				  policies.
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-30-05-2.23 - Access to Benefits

Current through June 14, 2024
A. Unless otherwise
				  specified, MACC group adults coverage groups entitled to a comprehensive
				  benefit package that includes both in-plan and out-of-plan services. In-plan
				  services are paid for on a capitated basis. The State may, at its discretion,
				  identify other services paid for on a fee-for-service basis rather than at a
				  capitated rate.
B. Delivery of
				  Benefits - The coverage provided through the RHP is categorized as follows:
1. In-Plan Benefits
2. Out-of-Plan Benefits
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-30-05-2.25 - SPMI Modifications

Current through June 14, 2024
A. SPMI adults have
				  access to a comprehensive benefit package. All elements of the comprehensive
				  benefit package are the responsibility of the MCO when a beneficiary is
				  enrolled in the Rhody Health Partners delivery system.
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-30-05-2.26 - Out-of-Plan Benefits

Current through June 14, 2024
A. Out-of-plan
				  benefits are not included in the managed care contracts and are not the
				  responsibility of the MCO to provide. These services are provided by existing
				  Medicaid-approved providers who are reimbursed directly by EOHHS on a
				  fee-for-service basis. Out-of-plan benefits are provided to all RHP enrollees
				  with the following exceptions: anyone enrolled in the guaranteed enrollment
				  period but otherwise ineligible for Medicaid. The covered benefits are as
				  follows:
ELIGIBLE GROUP
BENEFIT(S) PROVIDED
								  OUT-OF-PLAN
All Rhody Health Partners and Expansion
								  members
Dental services
Court-ordered mental health and substance use
								  services ordered to a non-network facility or provider
Non-Emergency Transportation Services
								  (Non-Emergency transportation is coordinated by the contracted Health
								  Plans)
Nursing home services in excess of thirty (30)
								  consecutive days
Residential services for MR/DD clients that are
								  paid by the State's BHDDH
Respite (Adult)
Neonatal intensive care Unit (NICU) Services at
								  Women's and Infants
Hospital. Except as specified in §
																2.9(C)   of
								  this Part
Special Education services as defined in the
								  child's Individual Education Plan (IEP) for children with special health needs
								  or developmental delays
Lead Program home assessment and non-medical case
								  management provided by Department of Health or Lead Centers for lead poisoned
								  children
Cedar Family Center Services (RIte Care)
Centers of Excellence Programs
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-30-05-2.27 - Services that are Not Covered by Medicaid

Current through June 14, 2024
A. Non-covered
				  services - The following services are not covered under the Medicaid program:
1. Experimental procedures, except as
				  required by Rhode Island State law;
2. Private rooms in hospitals (unless
				  medically necessary);
3. Cosmetic
				  surgery;
4. Medications that treat
				  erectile dysfunction or other sexual disorders;
5. Infertility treatment services;
				  and
6. Any portion of services that
				  exceeds fifteen (15) days provided in an Institution for Mental Diseases (IMD)
				  for individuals between the ages of twenty-one (21) to sixty-four (64). RHP
				  managed care enrollees may access IMDs.
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-30-05-2.28 - Scope of Provider Networks

Current through June 14, 2024
A. The MCO must
				  maintain provider networks in locations that are geographically accessible to
				  the populations to be served, comprised of hospitals, physicians, advanced
				  practice practitioners, mental health providers, substance use disorder
				  providers, pharmacies, transportation services, dentists, school based health
				  centers, etc. in sufficient numbers to make available all services in a timely
				  manner.
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-30-05-2.29 - Mainstreaming/Selective Contracting

Current through June 14, 2024
A. The
				  mainstreaming of Medicaid beneficiaries into the broader health delivery system
				  is an important objective of EOHHS. The MCO must ensure that all of its network
				  providers accept RHP members for treatment. The MCO also must accept
				  responsibility for ensuring that network providers do not intentionally
				  segregate RHP members in any way from other persons receiving
				  services.
B. Health plans may
				  develop selective contracting arrangements with certain providers for the
				  purpose of cost containment, but must still adhere to the access standards as
				  defined in the health plan contracts.
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-30-05-2.30 - Primary Care Providers (PCPs)

Current through June 14, 2024
A. The MCO has
				  written policies and procedures allowing every member to select a primary care
				  provider (PCP). If a member does not select a PCP during enrollment, the MCO
				  shall make an automatic assignment, taking into consideration such factors as
				  current provider relationships, language needs, and the relative proximity of
				  the PCP to the member's area of residence. The MCO must notify the member in a
				  timely manner of his/her PCP's name, location, and office telephone number, and
				  how to change PCPs, if desired. The PCP serves as the member's initial and most
				  important point of interaction with the health plan network. In addition to
				  performing primary care services, the PCP coordinates referrals and specialty
				  care. As such, PCP responsibilities include at a minimum:
1. Serving as the member's primary care
				  provider;
2. Ensuring that members
				  receive all recommended preventive and screening care appropriate for their age
				  group and risk factors;
3.
				  Referring for specialty care and other medically necessary services both in and
				  out-of-plan;
4. Maintaining a
				  current medical record for the member; and
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-30-05-2.31 - Service Accessibility Standards

Current through June 14, 2024
A. The service
				  accessibility standards which the MCO must meet are:
1. Twenty-four (24) hour coverage;
2. Travel time or distance;
3. Days to appointment for non-emergency
				  services.
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-30-05-2.32 - Mandatory Participation in Managed Care

Current through June 14, 2024
A.
				  Participation in managed care is mandatory for the members of the MACC,
				  non-MAGI and non-Medicaid funded coverage groups identified in §
										2.1   of
				  this Part except as specified in §
										2.34   of this Part. Medicaid members in
				  these coverage groups with third (3rd) party medical coverage or insurance may
				  be exempt from this mandate only as indicated in §
										2.38   of this Part, at
				  the discretion of the 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-30-05-2.33 - Enrollment Procedures, Rights, and Responsibilities

Current through June 14, 2024
A. The enrollment process for MACC groups
				  using the RHP delivery system is set forth in §
										2.34   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 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.34 - Enrollment Processes for RIte Care and Rhody Health Partners Managed Care Plans Overview

Current through June 14, 2024
A. With the
				  approval of the State's Section  1115   waiver in 2009, enrollment in an MCO
				  became mandatory for all individuals and families covered in the Rhode Island
				  Medicaid program who do not require long term services and supports. The
				  State's goal in implementing this policy is to assure that all Rhode Islanders
				  enrolled in Medicaid have access to an organized system of high quality
				  services that provides a medical home focusing on primary care and prevention
				  services.
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-30-05-2.35 - Scope and Purpose

Current through June 14, 2024
A. The Medicaid
				  eligible Medicaid Affordable Care Coverage (MACC) groups identified in the
				  "Affordable Care Coverage Groups" (Subchapter 00 Part 1 of this Chapter) must
				  enroll for coverage in a RIte Care (families, parent/caretaker, children and
				  pregnant women) or Rhody Health Partners (adults nineteen (19) to sixty-four
				  (64) without children) managed care plan, as described above. There are other
				  Medicaid coverage groups enrolled in both service delivery systems.
B. This Rule applies to all RIte Care
				  coverage groups identified in §
										2.1   of this Part. It does not apply to
				  adults eligible on the basis of age, blindness, or disability subject to the
				  provisions for RIte Care unless the beneficiary qualifies for and chooses the
				  eligibility pathway for parents/caretakers. See Part 40-10-1 of this Title for
				  a description of these groups.
C.
				  EOHHS must ensure that enrollment in RIte Care and Rhody Health Partner (RHP)
				  MCOs function in a timely and efficient manner that respects the rights of
				  Medicaid eligible individuals and families and the State's interest in assuring
				  that they have ready access to an organized system of high quality health
				  care.
D. The provisions of this
				  rule also apply to any applicants in these coverage groups who have access to
				  employer-sponsored (ESI) health plans who may be qualified for the RIte Share
				  premium assistance program, as specified in Part 3 of this Subchapter, until
				  further notice from the 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-30-05-2.36 - Initiating Enrollment: No Wrong Door

Current through June 14, 2024
A. The enrollment
				  process begins at the point in which an eligibility determination has been made
				  and the applicant is notified. Once determined eligible, a Medicaid member must
				  select an MCO at the time a determination is made if applying online through
				  the web-portal either alone or with assistance. Notice of eligibility provided
				  by EOHHS, whether electronically or on paper, must inform the Medicaid member
				  of whether enrollment in a RIte Care versus Rhody Health Partners plan is
				  required. The Medicaid coverage group that is the basis of eligibility for an
				  individual or family determines the delivery system - RIte Care or RHP - in
				  which a person must enroll (see Subchapter 00 Part 1 of this Chapter).
1. Enrollment channels - Once determined
				  eligible, a Medicaid eligible person may enroll in a RIte Care or Rhody Health
				  Partners Plan, as appropriate:
a. Online
				  through the eligibility portal independently or with a navigator's
				  assistance;
b. Over the phone with
				  a Contact Center representative; or
c. In-person at the Contact Center or a DHS
				  office. (Contact information located in §
												2.67   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 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.37 - Enrollment of Newborns and Adopted Children

Current through June 14, 2024
A. RHP members
				  remain enrolled in their current plan until the time of renewal or the birth of
				  the child or the end of the pregnancy, whichever comes first.
1. Newborns - Infants born to mothers with
				  income up to two hundred fifty-three percent (253%) of FPL who are enrolled in
				  an MCO on the date of their baby's birth are automatically enrolled into a RIte
				  Care MCO. If the newborn's mother is enrolled in a RIte Care MCO, the child is
				  automatically enrolled in the mother's MCO. If the newborn's mother is enrolled
				  in a RHP MCO, the baby and the mother will be enrolled in a RIte Care MCO,
				  effective on the date of birth, once certification of the birth has been
				  received. If the newborn's mother is enrolled in an ESI or other qualified
				  health plan (QHP) with a Medicaid wrap, the baby is enrolled in RIte Care or
				  RIte Share if the plan meets the cost-effectiveness test set forth in Part 3 of
				  this Subchapter. §
											00-1.8(A)   of this Chapter for newborn deeming
				  provisions.
2. Adopted children -
				  Enrollment of adopted children who are eligible on their own or as part of a
				  Medicaid eligible family also varies depending on the basis of Medicaid
				  coverage. Legally adopted children are enrolled as of the date the adoption
				  becomes final. This date cannot be prior to the date Medicaid eligibility is
				  established. The applicable provisions on eligibility and enrollment of child
				  participating the State's adoption subsidy program are located in, Medicaid
				  Affordable Care Coverage Groups Overview and Eligibility Pathways (Subchapter
				  00 Part 1 of this Chapter). A parent, caretaker or guardian must notify EOHHS
				  when a newborn deemed eligible is adopted.
3. Other Infants and Children - All infants
				  and children with income up to the two hundred sixty-one percent (261%) of the
				  FPL level are Medicaid eligible under the MACC group for children and young
				  adults, irrespective of the eligibility of a parent, caretaker or pregnant
				  mother as indicated in the provisions in, Medicaid Affordable Care Coverage
				  Groups Overview and Eligibility Pathways (Subchapter 00 Part 1 of this
				  Chapter). Any infants and children determined eligible on this basis are
				  enrolled in a RIte Care or, as applicable, RIte Share-approved ESI health plan
				  in accordance with the provisions of this rule applicable to all other Medicaid
				  members.
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-30-05-2.38 - Medicaid Members Exempt from Enrollment Managed Care

Current through June 14, 2024
A. Certain Medicaid members who would
				  otherwise receive care through the RIte Care or RHP delivery systems may be
				  granted exemptions from mandatory enrollment in an MCO for good cause in narrow
				  range of "extraordinary circumstances" upon approval of EOHHS. An extraordinary
				  circumstance, as defined for these purposes, is a situation, factor or set of
				  factors that preclude a Medicaid member from obtaining the appropriate level of
				  medically necessary care through the managed care delivery system - RIte Care
				  or RHP - designated for the Medicaid member's coverage group.
1. Types of extraordinary circumstances -
				  Such a situation, factor or set of factors may include the existence of a
				  chronic, severe medical condition for which the member has a longstanding
				  treatment relationship with a licensed health care practitioner who does not
				  participate in any of the Medicaid MCOs in the delivery system designated to
				  provide care to the member.
2.
				  Limits - A Medicaid member's preference to continue a treatment relationship
				  with a particular physician or other health care practitioner who does not
				  participate with an MCO in the member's designated delivery system does not
				  constitute an "extraordinary circumstance" in and of itself.
3. Exemption requests - Requests for
				  exemption to mandatory enrollment in managed care due to extraordinary
				  circumstances must be made in writing, include appropriate documentation
				  (letter from physician, medical records, or other as indicated), and signed.
				  Exemption requests should be routed to EOHHS.
4. Agency actions and duration of exemption -
				  EOHHS makes enrollment exemption determinations based on a consideration of the
				  circumstances of each member's individual request. Once exempted, an individual
				  can be exempt for as long as the extraordinary circumstance exists. Nonexempt
				  Medicaid members in a household must follow the regular Medicaid MCO enrollment
				  process.
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-30-05-2.39 - MCO Lock-In

Current through June 14, 2024
A. Following
				  initial enrollment into an MCO, Medicaid members are restricted to that MCO
				  until the next open enrollment period. During this health plan lock-in, a
				  Medicaid member may request to be reassigned to another MCO only under one of a
				  set of specific allowed conditions.
1. Allowed
				  conditions for reassignment requests - Members may request to be reassigned to
				  another MCO for any of the following reasons:
a. Substandard or poor quality
				  care;
b. Inadequate access to
				  necessary specialty services;
c.
				  Lack of access to services covered under the contract, or lack of access to
				  providers experienced in dealing with the enrollee's care needs;
d. The MCO does not, because of moral or
				  religious objections, cover the services the enrollee seeks;
e. The enrollee needs related services to be
				  performed at the same time; not all related services are available within the
				  provider network; and the enrollee's primary care provider or another provider
				  determines that receiving the services separately would subject the enrollee to
				  unnecessary risk;
f. Insufficient
				  transportation;
g.
				  Discrimination;
h. Member
				  relocation;
i. Good cause as
				  defined in §
												2.48(A)(4)   of this Part.
j. Without cause during the ninety (90) days
				  following the effective date of the Medicaid member's initial enrollment with
				  the MCO.
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-30-05-2.40 - Open Enrollment

Current through June 14, 2024
A. During an open
				  enrollment period, Medicaid members have an opportunity to change MCOs. Open
				  enrollment extends to all RHP enrollees and RIte Care enrollees, with the
				  exception of members in the Extended Family Planning coverage group and foster
				  care children who are receiving foster care or adoption subsidy assistance
				  (Title IV-E), are in foster care, or are otherwise in an out-of-home
				  placement.
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-30-05-2.41 - Membership Handbook

Current through June 14, 2024
A. The Medicaid MCO
				  must provide a Medicaid enrollee with a membership handbook and information on
				  how to select a primary care provider member. This information must be sent by
				  mail within ten (10) days of the date of enrollment for all members excluding
				  foster children.
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-30-05-2.42 - Identification Cards

Current through June 14, 2024
A. Medicaid members
				  are issued two identification cards - permanent MCO cards and permanent Rhode
				  Island Medicaid cards.
1. MCO permanent cards
				  - Medicaid MCOs must issue permanent identification cards to all Medicaid
				  members within ten (10) days of the date the enrollment was received by the
				  MCO. The card identifies the MCO name and a twenty-four (24) hour, toll-free
				  telephone number for the Medicaid member to call in the event of an urgent or
				  emergent health care problem. The card also includes the telephone number for
				  the MCO's membership services division and may include the name and telephone
				  number of the recipient's primary care provider.
2. Medicaid cards - A Rhode Island Medicaid
				  identification card is also issued to Medicaid members who are eligible for
				  out-of-plan benefits through the State's Medicaid Management Information System
				  (MMIS).
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-30-05-2.43 - Interim Fee-for-Service Coverage

Current through June 14, 2024
A. For RIte Care
				  members only, there is a seven (7) day period between Medicaid MCO assignment
				  and MCO enrollment in which services provided to a Medicaid member may be paid
				  for on a fee-for-service basis. The services must be delivered to the Medicaid
				  member by a health provider or practitioner certified to participate in the
				  Rhode Island Medicaid program to qualify for the fee-for service payment.
				  Services delivered prior to MCO enrollment to a pregnant woman who is otherwise
				  ineligible for Medicaid with income above two hundred fifty-three percent
				  (253%) of the FPL are not covered.
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-30-05-2.44 - Verification of Eligibility/Enrollment

Current through June 14, 2024
A. Medicaid MCO
				  have the opportunity to contact EOHHS, a DHS office, the automated enrollment
				  mailbox utilized by the health plans, or the automated eligibility verification
				  system as necessary and appropriate to verify eligibility and plan enrollment
				  if a Medicaid member requires immediate services.
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-30-05-2.45 - Responsibility of Medicaid Members to Report Change in Status

Current through June 14, 2024
A. Medicaid members are responsible for
				  reporting certain changes in status including any related to family size,
				  residence, income, employment, third (3rd) party coverage, and child support.
				  Such information must be filed with EOHHS, the Contact Center or a DHS field
				  office within ten (10) days of the date the change occurs. In addition, EOHHS
				  conducts periodic reviews to determine whether any changes in status have
				  occurred that affect eligibility or health plan enrollment. Medicaid MCOs must
				  also report to EOHHS any changes in the status of Medicaid members once they
				  become known.
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-30-05-2.46 - Transitioning Members between MCOs and Delivery Systems

Current through June 14, 2024
A. It may be necessary to transition a
				  Medicaid member between MCOs or from one (1) delivery system - RHP to RIte Care
				  or vice versa - for a variety of reasons:
1.
				  Change in MCOs within a delivery system - The transition between Medicaid MCOs
				  may occur as a result of change in MCO during open enrollment or a change that
				  is ordered as part of a grievance resolution. The MCOs have written policies
				  and procedures for transferring relevant patient information, including medical
				  records and other pertinent materials, when transitioning a member to or from
				  another MCO. The MCO must transfer this information at no cost to the
				  member.
2. Change in delivery
				  systems - Medicaid members may be transitioned from one managed care delivery
				  system into another as a result of changes in eligibility status. Adults
				  enrolled in RIte Care who are between the ages of nineteen (19) and sixty-four
				  (64) may be eligible under the MACC group for adults when their dependent
				  children age out of MACC group for children and young adults. Once a RHP member
				  has given birth, both newborn and/or parents may be transitioned to RIte Care
				  if income is within the eligibility thresholds set forth in Medicaid Affordable
				  Care Coverage Groups Overview and Eligibility Pathways (Subchapter 00 Part 1 of
				  this Chapter). Enrollment in MCOs during such transitions will strive to
				  preserve the continuity of care to the full extent feasible. Accordingly,
				  Medicaid members enrolled in a particular MCO subject to a delivery system
				  transition will be enrolled in the same health plan, if participating, in the
				  new delivery system.
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-30-05-2.47 - Grievances, Appeals, and Hearings

Current through June 14, 2024
A. The State
				  provides a grievance and appeals process that MCO providers and Medicaid
				  enrollees must use when seeking redress against health plans. This is the same
				  process that the MCOs must use when seeking to disenroll members who are
				  habitually non-compliant or who pose a threat to plan employees or other
				  members. See Part 10-05-2 of this Title, Appeals Process and Procedures for
				  EOHHS Agencies and Programs, for additional information.
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-30-05-2.49 - EOHHS Authority

Current through June 14, 2024
A. EOHHS has sole
				  authority as the Medicaid Single State Agency for disenrolling Medicaid members
				  from an MCO. Requests for disenrollment, either as the result of a formal
				  grievance filed by the Medicaid member against the MCO, or by the MCO against
				  the Medicaid member, is subject to an administrative review process 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-30-05-2.50 - Reasons for Disenrollment

Current through June 14, 2024
A. EOHHS may
				  disenroll Medicaid eligible MCO members for a variety of reasons including, but
				  not limited to, any of the following:
1.
				  Death;
2. Loss of
				  eligibility;
3. Selection of
				  another MCO during open enrollment;
4. Change of residence outside of the MCO's
				  service area;
5. Non-payment of
				  premium share;
6.
				  Incarceration;
7. Permanent
				  placement in Eleanor Slater Hospital;
8. Long-term placement in a nursing facility
				  for more than thirty (30) days (does not apply to RIte Care members);
9. Disenrollment as the result of a formal
				  grievance filed by the member against the MCO; or
10. Disenrollment as the result of a formal
				  grievance filed by the MCO against the member.
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-30-05-2.51 - Disenrollment Effective Dates

Current through June 14, 2024
A. Member
				  disenrollments outside of the open enrollment process become effective on the
				  date specified by EOHHS, but not fewer than six (6) days after the MCO has been
				  notified, unless the MCO waives this condition. The MCOs have written policies
				  and procedures for complying with EOHHS disenrollment orders.
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-30-05-2.52 - Right to Appeal

Current through June 14, 2024
A. All
				  notifications of disenrollment must include information regarding the Medicaid
				  member's right to appeal the decision and the procedures for requesting an
				  EOHHS administrative fair hearing.
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-30-05-2.53 - Medicaid Member Rights and Protections

Current through June 14, 2024
A. All Medicaid
				  members are guaranteed access to quality health care delivered in a timely and
				  respectful manner. To ensure this goal is met, the following rights and
				  protections must be clearly stipulated by both EOHHS and the MCO.
1. Enrollment - EOHHS will make every effort
				  to provide the following:
a. Multilingual
				  services to all people who do not speak English;
b. Written enrollment information will be
				  provided in a clear and easy-to-understand format;
c. Enrollment information provided by the MCO
				  must include detailed information on how to obtain transportation services,
				  second opinions, interpreter services, referrals, emergency services and
				  out-of-State services unavailable in Rhode Island. Information must also be
				  provided regarding switching primary care providers, disenrollment for good
				  cause, the in-plan grievance process and the EOHHS appeals process;
d. The State will conduct a special
				  enrollment outreach effort for beneficiaries who are homeless or who live in
				  transitional housing;
e. Once a
				  Medicaid member is enrolled, the MCO will conduct a special enrollment outreach
				  effort for any enrollees who are homeless or who live in transitional
				  housing;
f. The MCO is prohibited
				  from engaging in any door-to-door or telemarketing or any other similar unfair
				  marketing practices;
g. Enrollees
				  will be provided with counseling assistance in the selection process for their
				  primary care providers;
h. Medicaid
				  members who receive on-going care from a primary care provider or specialist
				  will be advised by the non-biased enrollment counselor which providers are
				  participating in each MCO option so as to promote continuity of care;
i. If a Medicaid member is auto-assigned to
				  an MCO, the member, within ninety (90) days, may dispute that assignment
				  through the right to rebuttal. A decision by EOHHS must be rendered within ten
				  (10) days of the filing of the rebuttal and is subject to appeal.
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-30-05-2.54 - Pharmacy Home Program

Current through June 14, 2024
A. The objective of
				  the Pharmacy Home Program is to prevent members from obtaining excessive
				  quantities of prescribed medications through visits to multiple prescribers and
				  pharmacies and improving health outcomes. Participants enrolled in the program
				  are required to obtain all medications from a specific pharmacy location
				  otherwise known as a "Pharmacy Home" for a period of two (2) years.
B. The EOHHS, or its contracted MCO, will
				  establish criteria to identify members for inclusion in the Pharmacy Home
				  Program. Members will be notified at least thirty (30) days prior to enrollment
				  in the program.
C. Select provider
				  referrals are available as part of the Pharmacy Home Program. The EOHHS, or its
				  contracted MCO, will ensure that members with complex medical and/or behavioral
				  health needs are connected with high quality select providers to meet those
				  needs. Members who use multiple providers and have one or more complex medical
				  conditions and chronic diseases shall be referred as needed to a select
				  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 2 - Medicaid Managed Care Delivery Options › Section 210-RICR-30-05-2.55 - Rite Smiles Dental Plan Overview

Current through June 14, 2024
A. The RIte Smiles
				  Program is a statewide dental benefits managed care delivery system established
				  under a Federal waiver. The program's goal is to improve access to oral health
				  services for Rhode Island children who receive Medicaid. Emphasis is placed on
				  preventive and primary care dental services and education.
B. Children born on or after May 1, 2000 who
				  are receiving dental benefits through Medicaid are enrolled in a RIte Smiles
				  dental plan. EOHHS contracts with one (1) or more dental plans to provide oral
				  health services to these Medicaid-eligible children.
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-30-05-2.56 - Legal Authority

Current through June 14, 2024
A. Title XIX of the
				  Social Security Act,  42 U.S.C. §§
											1396-1396w-7, provides the legal
				  authority for the Medicaid Program. The RIte Smiles Program operates under the
				  State's Section  1115   waiver.
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-30-05-2.57 - Coverage Groups

Current through June 14, 2024
A. Participation in
				  the RIte Smiles Program is mandatory for all children in the following
				  populations who were born on or after May 1, 2000 and who are receiving
				  Medicaid:
1. Section 1931 children and related
				  populations (including poverty level groups and RI Works cash
				  recipients);
2. Blind and/or
				  disabled children;
3. Foster care
				  children who are receiving foster care or adoption subsidy assistance (Title
				  IV-E), are in foster care, or are otherwise in an out-of-home
				  placement;
4. Section 1115 Waiver
				  Children.
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-30-05-2.58 - Excluded Coverage Groups

Current through June 14, 2024
A. The following
				  groups are excluded from participation in the RIte Smiles Program:
1. Children born on or before April 30,
				  2000;
2. Children who have access
				  to third (3rd) party dental benefits;
3. Children who reside in nursing facilities
				  or Intermediate Care Facilities for Individuals with Intellectual Disabilities
				  (ICF/ID).
4. Children who reside
				  outside of the State of Rhode Island. Those children who are not eligible to
				  participate in the RIte Smiles Program receive dental benefit coverage under
				  the fee-for-service system.
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-30-05-2.59 - Retroactive Eligibility

Current through June 14, 2024
A. If a member is
				  eligible for retroactive eligibility, the dental plan does not provide coverage
				  to Medicaid beneficiaries during the period of retroactive
				  eligibility.
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-30-05-2.60 - Enrollment Process

Current through June 14, 2024
A. All children
				  determined eligible for Medicaid who were born on or after May 1, 2000 must
				  enroll in a RIte Smiles Program dental plan. The parent(s) or guardian(s) of
				  the eligible children may have a choice of dental plans, if more than one (1)
				  plan is available, in which to enroll.
B. The enrollment process ensures that
				  applicants/beneficiaries are provided with sufficient information (if a choice
				  of dental plan is available) in order to make an informed choice when deciding
				  upon which RIte Smiles plan to choose.
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-30-05-2.61 - Voluntary Selection of a Dental Plan

Current through June 14, 2024
A. Newly eligible
				  children for RIte Care, RIte Share, or fee-for service Medicaid will be given a
				  choice of RIte Smiles plans on their Medicaid application.