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-30-05-2.4 - Definitions

Current through June 14, 2024
A. For the purposes of this Rule, the
				  following definitions apply:
1. "Advance
				  practice provider" or "APP" means and includes physician assistants, certified
				  nurse practitioners, psychiatric clinical nurse specialists, and certified
				  nurse midwives. These individuals must maintain compliance with all applicable
				  statutes and regulations and not exceed their scopes of practice.
2. "Appeal" means a formal request by a
				  covered person or provider for reconsideration of a decision, such as a
				  utilization review recommendation, a benefit payment, or administrative
				  action.
3. "Applicant" means a
				  person seeking Medicaid coverage under this Part, in accordance with the
				  provisions established in Rhode Island General Laws and Public Laws.
4. "Care manager" means a nurse or social
				  worker with specialized training in providing care management
				  services.
5. "Complementary
				  alternative medicine" or "CAM" means treatment from a chiropractor,
				  acupuncturist, and/or massage therapist.
6. "Days" means calendar days.
7. "Employer sponsored insurance" or "ESI"
				  means health insurance or a group health plan offered to employees by an
				  employer. This includes plans purchased by small employers through
				  HealthSourceRI.
8. "Enrollee" means
				  a Medicaid member or "beneficiary" who is enrolled in a Medicaid managed care
				  plan.
9. "Executive Office of
				  Health and Human Services" or "EOHHS" means the State agency established in
				  2006 under the provisions of R.I. Gen. Laws Chapter 42-7.2 within the executive
				  branch of State government and serves as the principal agency for the purposes
				  of managing the Departments of Children, Youth, and Families (DCYF); Health
				  (DOH); Human Services (DHS); and Behavioral Healthcare, Developmental
				  Disabilities, and Hospitals (BHDDH). The EOHHS is designated as the "single
				  state agency," authorized under Title XIX of the U.S. Social Security Act,  42 U.S.C. §§
												1396-1396w-7, and, as such, is legally responsible for the
				  program/fiscal management and administration of the Medicaid Program.
10. "Grievance" means an expression of
				  dissatisfaction about any matter other than an adverse benefit determination.
				  Grievances may include, but are not limited to:
a. Quality of care or services
				  provided;
b. Aspects of
				  interpersonal relationships such as rudeness of a provider or
				  employee;
c. Failure to respect the
				  member's rights regardless of whether remedial action is requested;
d. Right to dispute an extension of time
				  proposed by the MCO to make an authorization decision.
11. "In lieu of services" means cost
				  effective alternative services/equipment, even where those services/equipment
				  are not identified as an in-plan benefit, when the use of such alternative
				  services/equipment are medically appropriate and cost effective, such as the
				  purchase of an air conditioner, where clinically appropriate, which helps a
				  beneficiary avoid hospitalization.
12. "Limited English proficiency" or "LEP"
				  means that enrollees do not speak English as their primary language and may
				  have a limited ability to read, write, speak, or understand English and may be
				  eligible to receive language assistance for a particular type of service,
				  benefit, or encounter.
13. "Managed
				  care organization" or "MCO" means a health plan system that integrates an
				  efficient financing mechanism with quality service delivery, provides a
				  "medical home" to assure appropriate care and deter unnecessary services, and
				  emphasizes preventive and primary care.
14. "Medicaid affordable care coverage group"
				  or "MACC" means a classification of persons eligible to receive Medicaid based
				  on similar characteristics who are subject to the MAGI standard for determining
				  income eligibility as follows:
a. Families and
				  Parents/Caretakers with income up to one hundred forty-one percent (141%) of
				  the Federal Poverty Level (FPL) - Includes families and parents/caretakers who
				  live with and are responsible for dependent children under the age of eighteen
				  (18) or nineteen (19) if enrolled in school full-time. It also includes
				  families eligible for time-limited transitional Medicaid.
b. Pregnant women. Members of this coverage
				  group can be of any age. The pregnant woman and each expected child are counted
				  separately when constructing the household and determining family size.
				  Eligibility extends for the duration of the pregnancy and two (2) months
				  post-partum. The coverage group includes all pregnant women with income up to
				  two hundred fifty-three percent (253%) of the FPL, regardless of whether the
				  legal basis of eligibility is Medicaid or CHIP, including pregnant women who
				  are non-citizen residents of the State. The unborn child's citizenship and
				  residence is the basis for eligibility.
c. Children and Young Adults. Age is the
				  defining characteristic of members of this MACC group. This coverage group
				  includes: infants under age one (1), children from age one (1) to age nineteen
				  (19) with income up to two hundred sixty-one percent (261%) of the FPL; and
				  qualified and legally present non-citizen infants and children up to the age of
				  nineteen (19), who have income up to two hundred sixty-one percent (261%) of
				  the FPL.
d. Adults 19-64. This is
				  the new Medicaid State Plan expansion coverage group established in conjunction
				  with implementation of the ACA. The group consists of citizens and qualified
				  non-citizens with income up to one hundred thirty-three percent (133%) of the
				  FPL who meet the age characteristic and are not otherwise eligible for, or
				  enrolled in, Medicaid under any other State plan or Section  1115   waiver
				  coverage group. Adults found eligible for Social Security benefits are also
				  eligible under this coverage group during the two (2) year waiting
				  period.
15. "Medically
				  needy" means a classification of persons eligible to receive Medicaid based
				  upon similar characteristics who are subject to the MAGI standard for
				  determining income eligibility.
16.
				  "Navigator" means a person working for a State-contracted organization with
				  certified assisters who have expertise in Medicaid eligibility and
				  enrollment.
17. "Non-MAGI coverage
				  group" means a Medicaid coverage group that is not subject to the modified
				  adjusted gross income eligibility determination. Includes Medicaid for persons
				  who are aged, blind or living with disabilities and persons in need of
				  long-term services and supports as well as individuals who qualify for Medicaid
				  based on their eligibility for another publicly-funded program, including
				  children in foster care, anyone receiving Supplemental Security Income (SSI) or
				  eligible for or enrolled in the Medicare Premium Assistance Program.
18. "Peer navigator" means paraprofessionals
				  with specialized training who are community resource specialists employed and
				  supervised by peer advocacy organizations.
19. "Prospective Medicaid enrollee" means a
				  Medicaid beneficiary or family who has not enrolled in an MCO.
20. "Prudent layperson standard" means the
				  standard used to determine the need for an emergency room visit. An "emergency"
				  is defined as a condition that a prudent layperson "who possesses an average
				  knowledge of health and medicine" expects may result in:
a. Placing a patient in serious
				  jeopardy;
b. Serious impairment of
				  bodily function; or
c. Serious
				  dysfunction of any bodily organs.
21. "Rhody health partners" means the
				  Medicaid managed care program that delivers affordable health coverage to
				  eligible adults without dependent children, ages nineteen (19) to sixty-four
				  (64), under §
											2.18   of this Part and adults with disabilities eligible
				  under Part 40-10-1 of this Title.
22. "RIte care" means the Medicaid managed
				  care delivery system for eligible families, pregnant women, children up to age
				  nineteen (19), young adults older than age nineteen (19), and foster children
				  (DCYF custody) (see §
											2.1   of this Part).
23. "RIte share" means the Medicaid premium
				  assistance program for eligible individuals and families who have access to
				  cost-effective commercial coverage.
24. "Section  1115   Waiver" means the waiver
				  authorized pursuant to §
											1115   of the Social Security Act,  42 U.S.C. §
												1315.
25. "Section  1931" or "§
											1931" means §
											1931   of the Social Security Act,  42 U.S.C. §
												1396u-1.
26. "Title IV-E" means
				  Title IV-E of the Social Security Act,  42 U.S.C. §§
												670-679c.
27. "Title XIX" means
				  Title XIX of the Social Security Act,  42 U.S.C. §§
												1396-1396w-7
28. "Urgent medical
				  problem" means a medical, physical, or mental condition manifesting itself by
				  acute symptoms of sufficient severity (including severe pain) such that the
				  absence of medical attention within twenty-four (24) hours could reasonably be
				  expected to result in:
a. Placing the
				  patient's health in serious jeopardy;
b. Serious impairment to bodily function;
				  or
c. Serious dysfunction of any
				  bodily organ or part.