A. Title XIX of the U.S. Social Security Act (42 U.S.C. § 1396a et seq.) provides the legal authority for the Rhode Island Medicaid Program. The Medicaid Program also operates under a waiver granted by the Secretary of Health and Human Services pursuant to Section 1115 of the Social Security Act (42 U.S.C. § 1315). Additionally, R.I. Gen. Laws Chapters 40-6, 40-8, and R.I. Gen. Laws § 40-8-31 serve as the enabling statutes for this regulation.

B. The purpose of this rule is to describe the respective roles and responsibilities of EOHHS and Medicaid beneficiaries as it relates to receiving Medicaid services outside of Rhode Island.

A. As used herein, the following terms shall be construed as follows:

1. “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. § 1396a et seq.) and, as such, is legally responsible for the program / fiscal management and administration of the Medicaid Program.

2. “Temporarily absent” means time spent away from one’s usual living arrangements. The length of time an absence is considered temporary varies based upon the reason for the absence, such as hospitalization, vacation, or employment. During temporary absences, the responsibility to provide Medicaid benefits does not transfer between states.

A. Payment for out-of-state medical services that are provided to eligible Medicaid beneficiaries living within Rhode Island requires prior authorization from the Executive Office of Health and Human Services (EOHHS).

B. The following conditions must be met to obtain prior authorization for out-of-state medical services:

1. If a Medicaid beneficiary requires services from an out-of-state hospital or physician, the beneficiary’s attending physician must submit written medical justification to EOHHS;

2. The medical services that are required and being requested must not be available within Rhode Island.

C. Out-of-state medical services require prior authorization. Only those services that are contained within the Rhode Island Medicaid scope of services will be reimbursed.

A. The following provisions are exceptions to the requirement for prior authorization:

1. Emergency medical treatment and hospital services needed because the beneficiary’s health would be endangered if travel back to Rhode Island was required;

2. Treatment was provided by hospitals and practitioners located in one of the border communities listed in § 3.6 of this Part where it is the general practice for residents to use medical resources in these communities;

3. Medical and hospital treatment provided to foster children residing with families located outside Rhode Island or in out-of-state residential treatment centers.

A. Payment for medical care provided to eligible residents of Rhode Island who are temporarily absent from the state is made under certain circumstances.

B. Temporarily absent includes visiting, traveling or residing temporarily in another state without intending to become a permanent resident of the alternate state. Medicaid payment is authorized only in the following circumstances:

1. An emergency arises from an accident or illness; or

2. The health of the individual would be endangered if the care and services were postponed until the individual returned to Rhode Island; or

3. The health of the individual would be endangered if s/he undertook travel to return to Rhode Island.

C. When EOHHS receives a claim for out-of-state medical care not authorized in advance that was rendered to a Medicaid beneficiary temporarily absent from the state, the EOHHS contacts the Medicaid beneficiary to determine residency plans.

1. If the Medicaid beneficiary indicates s/he is planning to return to the state, written notification of this is required to be sent to EOHHS;

2. If the Medicaid beneficiary indicates in writing that s/he plans to reside permanently outside Rhode Island, Medicaid benefits are terminated at the end of the month following the month in which the notification of intent to reside outside Rhode Island is received.

A. Border Communities include cities and town that border Rhode Island and are considered for the purpose of the Rhode Island Medicaid Program, in-state providers. Out-of-state service restrictions and prior authorization requirements are not imposed on providers in the following communities:

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.