Overview of Medicaid Integrated Care Coverage (210-RICR-40-00-1)

A.This Chapter establishes the Medicaid Integrated Health Care Coverage (IHCC) groups for elders, adults with disabilities, and certain individuals who qualify as medically needy (MN) due to high health care expenses. In addition, sections of this Chapter set forth the basic tenets of the Supplemental Security Income (SSI) methodology for determining Medicaid eligibility in general and, specifically, for those applicants and beneficiaries seeking coverage through an IHCC Community Medicaid eligibility pathway.

B.The term Community Medicaid refers hereinafter to anyone applying for or renewing eligibility for non-LTSS Medicaid health coverage as MN or through a pathway for elders and adults with disabilities on the basis of SSI, an SSI-related characteristic (that is, age, blindness or disability), or special requirements related to a particular characteristic, condition or circumstances. Community Medicaid also encompasses Medicare beneficiaries seeking financial assistance through the State’s Medicare Premium Payment Program (MPPP).

C.Although all the IHCC groups for MN and elders and adults with disabilities are described in this Chapter – both Community Medicaid and LTSS – there are separate sections, as indicated below, that provide more in-depth provisions related to IHCC groups, as follows:

1.The Sherlock Plan and Ticket to Work Plan provide eligibility pathways for adults with disabilities who are working. Although referenced in this Section as two of the IHCC groups subject to the SSI methodology, the Sherlock Plan and Ticket to Work Plan are covered in detail in a separate section (Subchapter 15, Part 1 of this Chapter) along with other eligibility opportunities for persons with disabilities who are working.

2.An overview of the LTSS coverage groups subject to the SSI methodology is included in this Chapter to show areas of overlap in the application process and determination of financial eligibility. However, LTSS eligibility and services are covered in detail in Chapter 50 of this Title.

3.Children and families in the IHCC category who are eligible on the basis of their participation in other programs – e.g., children in foster care or SSI-eligible – are addressed in Part 30-00-1 of this Title.

A.This Part is promulgated pursuant to Federal authorities as follows:

1.Federal Law: Title XIX of the U.S. Social Security Act, 42 U.S.C. §§ 1396-1396w-7; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148; and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-115.

2.The Medicaid State Plan and the Section 1115 Waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315.

B.Applicable State authority is derived from R.I. Gen. Laws Title 40 and R.I. Gen. Laws Chapter 42-7.2. 

A.This Part provides an overview of the IHCC groups included in this Chapter. The rules governing the IHCC groups have been amended and revised as set forth herein to reflect programmatic changes resulting from the following State and federal Medicaid initiatives:

1.Section 1115 Waiver – The rules in this Chapter implement Section 1115 Waiver authorities that streamline and refine SSI-based eligibility determinations, enhance the availability of cost-effective primary care, and improve the integration of services and a wider range of supports across the care continuum.

2.ACA Implementation – The federal Patient Protection and Affordable Care Act (ACA), Pub. L. No. 111-148, mandated changes in the way states organize Medicaid coverage groups, the standards they use for determining income-based eligibility, and the application and renewal processes for all eligible populations. This Chapter establishes administrative rules that implement ACA reforms related to eligibility and the application and renewal process for the IHCC groups to ensure they match those already in effect for MACC groups.

3.Integrated Eligibility System – RI Bridges is the State’s integrated health and human services eligibility system (IES). The State’s IES provides the State with the system capacity to implement all programmatic changes required by the ACA and authorized under the Section 1115 Waiver. In addition to automating most facets of the application, eligibility determination and enrollment processes, the State’s IES also conducts a multi-tiered evaluation of eligibility that makes it possible to consider applicants for most forms of publicly financed health coverage and various other State-administered health and human services through a single application process.

A.For the purposes of this Chapter, the following definitions apply:

1.“Affordable Care Act” or “ACA” means the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, and the Three Percent Withholding Repeal and Job Creation Act, Pub. L. No. 112-56.

2.“Applicant” means the person in the household who, if determined eligible, would qualify for Medicaid in one of the Integrated Health Care Coverage groups on the basis of the provisions set forth herein.

3.“Calendar quarter” means a period of three (3) full calendar months beginning with January, April, July, or October.

4.“Community Medicaid” means the term used to refer to IHCC groups that are provided with Medicaid health coverage for essential primary care and limited preventive services in some circumstances, but does not include more than thirty (30) days of continuous LTSS.

5.“Executive Office of Health and Human Services” or “EOHHS” means the state agency established under the provisions of R.I. Gen. Laws Chapter 42-7.2 designated as the single State agency for the Medicaid program.

6.“Dual Eligible Beneficiary” means a person who is enrolled in Medicaid and Medicare. The term includes elders and adults with disabilities who are enrolled in Medicare and receive Medicaid health coverage and/or financial assistance through the State’s Medicare Premium Payment Program (MPPP).

7.“Income Standard” or “Income Limit” means the maximum amount of countable income a person can have to qualify for Medicaid health coverage through an eligibility pathway or coverage group after all required exclusions, disregards, and deductions.

8.“Long-Term Services and Supports” or “LTSS" means a spectrum of services covered by the Rhode Island Medicaid program for persons with clinical and functional impairments and/or chronic illness that require the level of care typically provided in a health care institution. Medicaid LTSS includes skilled or custodial nursing facility care, therapeutic day services, and personal care as well as various home and community-based services. Medicaid beneficiaries eligible for LTSS are also provided with primary care essential benefits.

10.“Medicaid Affordable Care Coverage (MACC) Groups” means the populations whose income eligibility for Medicaid is determined on the basis of the Modified Adjusted Gross Income (MAGI) standard. This includes children up to age nineteen (19), parents/caretakers, pregnant people, and otherwise ineligible adults age nineteen (19) to sixty-four (64) in accordance with the provisions established in Part 30-00-1 of this Title.

12.“Primary Care Essential Benefits” means non-LTSS Medicaid health coverage, and includes an array of acute, subacute, and specialty essential benefits, as identified under the Medicaid State Plan and Section 1115 Waiver, provided by licensed health professionals. These essential benefits include, but are not limited to: health promotion, disease prevention, health maintenance, counseling, patient education, various specialty services, and diagnosis and treatment of acute and chronic medical and behavioral health illnesses and conditions in a variety of health care settings (e.g., office visits, inpatient, home care, day care, etc.).

13.“Primary Care Provider” means a health care practitioner who is licensed as:

a.a physician with a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine and is responsible for monitoring a beneficiary’s overall health; or

b.a nurse practitioner, clinical nurse specialist, or physician assistant and, to the extent licensure allows, is responsible for, or collaborates with a physician, monitoring a beneficiary’s overall health.

14.“Resource Standard” or “Resource Limit” means the maximum amount of resources a person can have to qualify for Medicaid health coverage through an eligibility pathway or coverage group after all required exclusions.

15."Section 1115 Waiver" means the waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315.

16.“Title XIX” means Title XIX of the U.S. Social Security Act, 42 U.S.C. §§ 1396-1396w-7, that established the Medicaid program and provides the legal basis for providing services and benefits to certain populations in each IHCC group.

17.“Wrap-around Coverage” means the Medicaid benefits provided to a beneficiary who has another form of health insurance – e.g., Medicare or a commercial plan – that serves as the principal payer for their health care, but that does not cover those benefits.

A.The provisions of this Chapter govern the following eligibility pathways that use the SSI methodology in whole or in part to determine eligibility for Medicaid benefits:

1.Elders and Adults with Disabilities (EAD) – Low-income elders who are sixty-five (65) and older and adults living with disabilities who have income at or below one hundred percent (100%) of the Federal Poverty Level (FPL) and resources at or under $4,000 for an individual or $6,000 for a couple.

2.Medically Needy (MN) – Elders, adults with disabilities, children, parents and caretakers of Medicaid-eligible children, and pregnant people who do not qualify for eligibility on the basis of income but have high health expenses and must spend or contribute income and/or resources above the applicable income standard to obtain or retain Medicaid eligibility. Subchapter 05 Part 2 of this Chapter pertains to the MN eligibility pathway for Community Medicaid.

3.Supplemental Security Income (SSI) Recipients – All persons receiving SSI cash assistance based on age or as an adult with a disability, as determined by the federal Social Security Administration (SSA). SSI recipients are automatically eligible for Medicaid on this basis and are not required to apply for Medicaid health coverage through the State. Program-specific provisions for SSI recipients twenty-one (21) and older are included in this Chapter. The relevant provisions for Medicaid beneficiaries under twenty-one (21) are located in the sections pertaining to coverage for children and families.

4.State Supplement Payment (SSP) – Persons who qualify to receive the optional state-funded supplemental payment under 218-RICR-20-00-5 are automatically eligible for Medicaid health coverage under the Medicaid State Plan.

5.SSI Protected Status Beneficiaries – This group, sometimes referred to as “SSI-lookalikes,” includes persons who meet the age or disability criteria for SSI, but are ineligible for full SSI cash benefits or qualify for special treatment. To protect Medicaid health coverage for members of these coverage groups, federal law requires the application of special rules that confer or preserve Medicaid eligibility.

6.Medicaid Premium Payment Program (MPPP) for Medicare beneficiaries with income at or below one hundred thirty-five percent (135%) of the FPL. The MPPP provides financial help through Medicaid to assist in paying Medicare costs including premiums, deductibles, and coinsurance in amounts that vary depending on income and resources.

7.Sherlock Plan for Working Adults with Disabilities – The State’s program for working adults with disabilities age sixty-five (65) and older. The Sherlock Plan provides Medicaid health coverage and/or LTSS to persons with disabilities who are working. As set forth in greater detail in Subchapter 15, Part 1 of this Title, Sherlock beneficiaries age sixty-five (65) or older in this group may have countable income at or below two-hundred fifty percent (250%) of the FPL and resources less than or equal to $10,000 for an individual and $20,000 for a couple.

8.Ticket to Work Plan for Working Adults with Disabilities – The State’s program for working adults with disabilities ages sixteen (16) to sixty-four (64). The Ticket to Work Plan provides Medicaid health coverage and/or LTSS to persons with disabilities who are working. As set forth in greater detail in Subchapter 15, Part 1 of this Title, Ticket to Work beneficiaries are not required to meet an income or resource standard in order to qualify for coverage.

9.IHCC Medicaid LTSS -- Consists of new applicants seeking Medicaid-funded LTSS and current IHCC group beneficiaries who develop a continuous need for the level of care typically provided in an institution (hospital, nursing facility, or intermediate care facility for person with intellectual disabilities). Beneficiaries eligible in the MACC groups who require LTSS are not subject to the SSI methodology; LTSS eligibility based on the SSI methodology and more generally is located in Chapter 50 of this Title.

A.The IHCC category also includes members of the special coverage groups below who are subject to unique eligibility requirements waiving some or all facets of the SSI methodology due to specific conditions, circumstances, or characteristics.

1.Low-income, uninsured people with breast or cervical cancer – Medicaid coverage group for uninsured people under age sixty-five (65) who are screened under the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program and are found to need treatment for breast or cervical cancer or for precancerous conditions of the breast or cervix.

2.Refugee Medicaid Assistance (RMA) – Federally mandated coverage group for individuals and families operating under the auspices of the U.S. Department of Health and Human Services, Office of Refugee Resettlement. Refugees who qualify for this program receive eight (8) months of Medicaid health coverage or commercial coverage with financial help through HealthSource RI (HSRI), depending on income. Eligibility is evaluated first using the MAGI methodology set forth Part 30-00-1 of this Title, and the SSI standards for Community Medicaid in Part 40-05-1 of this Chapter. Only persons in this group who are ineligible for Medicaid or commercial plan with financial help and have income at or below two hundred percent (200%) of the FPL may qualify for MN coverage under this pathway.

3.Emergency Medicaid – Medicaid health coverage available to non-citizens who have emergency health care needs who meet all the general and income requirements for coverage with the exception of immigration status.

A.With the implementation of the State’s IES, all IHCC group members have the option of applying online, using a self-service portal, submitting a completed paper application, or in-person by visiting one of the field offices of the RI Department of Human Services (DHS). The IES also allows for the following important changes to the application and eligibility determination process:

1.Coverage Group Options – To maximize choice and ease of access, the State’s IES evaluates all applicants for Medicaid health coverage using multiple eligibility pathways, within and across the major coverage group categories.

2.Streamlined Document Submission and Verification – The State’s IES created the capacity for applicants and beneficiaries to upload important documents and verification materials online as well through more traditional means. The system also has capacity to access to a broader array of electronic data sources for verifying and updating critical eligibility information related to income and assets.

3.Modified Passive Eligibility Renewal – The eligibility renewal process for IHCC group members has been reformed to ease the burden on beneficiaries. The State’s passive renewal process requires beneficiaries to review the eligibility information in their accounts, including updates through electronic data sources, and notify the agency within a specified time period of any changes or discrepancies that may affect the continuation of coverage. The renewal process and variations across coverage groups are set forth in Part 2 of this Subchapter.

A.The benefits that members of the IHCC groups receive are dictated by the Medicaid State Plan and the State’s Section 1115 Waiver. Medicaid benefits include health care services and supports or, if a beneficiary has third party coverage such as Medicare, wrap-around coverage and/or financial assistance in paying premiums, co-pays, and cost-sharing.

1.Premium Assistance/and Financial Help – Dual eligible beneficiaries, including those participating in the MPPP, may receive full Medicaid health coverage and/or financial help paying for Medicare. The scope of benefits dual eligible beneficiaries receive depends on their income and resources as set forth in Subchapter 05 Part 1 of this Chapter. Premium assistance is also available for some Community Medicaid beneficiaries who have access to employer-sponsored insurance through the RIte Share Premium Assistance Program as set forth in Part 30-05-3 of this Title.

2.Health Care Services and Supports – The scope of services and supports beneficiaries receive varies as follows:

a.Community Medicaid. Beneficiaries eligible for health coverage receive the full scope of medically necessary primary care essential benefits – including acute, subacute and rehabilitative services – as well as thirty (30) days of LTSS and, based on need, a limited set of LTSS preventive services. Subchapter 10 Part 1 of this Chapter identifies the scope of covered services available through the managed care and fee-for-service delivery options for IHCC group beneficiaries eligible for full Medicaid benefits. Note:

(1)The Medicaid benefits MPPP participants are eligible to receive may be limited to premium payment assistance only, depending on the basis of eligibility. See Subchapter 05 Part 1 of this Chapter.

(2)For the scope of services covered under the Sherlock and Ticket to Work Plans, see Subchapter 15 Part 1 of this Chapter.

b.Medicaid LTSS. Medicaid LTSS includes health supports, personal care, and social services in an institutional or home and community-based setting. The scope of Medicaid LTSS a beneficiary receives is based on need -- health status and functional ability -- and personal health preferences and goals. Persons eligible for Medicaid LTSS also receive the full scope of medically necessary primary care essential benefits. To be eligible for Medicaid LTSS, a person must meet a specific set of financial and clinical criteria that do not apply to applicants seeking coverage through other Medicaid eligibility pathways.

3.Integrated Care -- The State’s Integrated Care Initiative (ICI) provides IHCC group members who have Medicare and other forms of third-party coverage who qualify for LTSS to obtain the coordinated services they need across the care continuum through a single plan. Subchapter 10 Part 1 of this Chapter covers these options and the process for managed care plan selection and enrollment.

4.Retroactive Eligibility – Up to three (3) months of Medicaid retroactive coverage is available for certain IHCC group beneficiaries. To qualify, the State must determine that a person would have met the applicable eligibility criteria for their coverage group if the application was submitted during the retroactive period. The State provides reimbursement to providers only for Medicaid covered services, however. The provisions in Subchapter 05 Part 3 of this Chapter explain the process for obtaining retroactive coverage in greater detail.

A.The service delivery options for IHCC group members are dictated in large part by type of Medicaid health coverage and eligibility pathway.

B.