3.1Overview / Legal Authority
Under the terms of Section 1906 of Title XIX of the U.S. Social Security Act, states are permitted to pay an eligible individual's share of the costs for enrolling in employer-sponsored health insurance coverage if it is cost effective to do so. R.I. Gen. Laws § 40-8.4-12 authorized the Medicaid agency to establish the RIte Share Premium Assistance Program to subsidize the costs of enrolling Medicaid eligible individuals and families in employer-sponsored health insurance (ESI) plans that have been approved as meeting certain cost and coverage requirements (RIte Share-approved). The Executive Office of Health and Human Services (EOHHS), the Medicaid Single State Agency, uses cost-effective criteria to determine whether ESI plans meet these requirements.
3.2Scope and Purpose
A.This Part applies to individuals and families determined to be Medicaid eligible under RICR Title 210, Chapter 30 (Medicaid for Children, Families, and Affordable Care Act (ACA) Adults). If these individuals or families have access to ESI, EOHHS must conduct a review of the coverage to determine if the benefits are comparable to Medicaid benefits and if the cost of the ESI is less expensive than Medicaid managed care (in the aggregate). When ESI is found to be cost-effective, the State will pay the employee’s premium for that coverage.
B.The purpose of this rule is to set forth the provisions governing participation in the RIte Share Program, the buy-in requirement and the process for determining whether an ESI plan meets the cost-effectiveness criteria established by EOHHS, the Medicaid agency. The rule also identifies the respective roles and responsibilities of Medicaid-eligible individuals and families and the Medicaid agency.
3.3Definitions
A.For the purposes of this section, the following definitions apply:
1.“Applicant” means a person seeking Medicaid coverage under this Part, in accordance with the provisions established in Rhode Island General Laws and Public Laws.
2.“Cost-effective” means that the portion of the ESI that the State would subsidize, as well as wrap-around costs, would, on average, cost less to the State than enrolling that same individual/family in a Medicaid managed care plan.
3.“Cost-sharing” means any deductibles or co-insurance associated with ESI.
4.“Employee premium” means the monthly amount an individual or family is required to pay to the employer to obtain and maintain ESI coverage.
5.“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 HealthSource RI.
6.“Group health plan” means an employee benefits plan as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974 as qualified in R.I. Gen. Laws §§ 27-50-3(T)(1) and 27-18.6-2(15).
7.“Health insurance coverage” or “Health benefit plan” means a policy, contract, certificate or agreement offered by a health insurance carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services as defined and qualified in R.I. Gen. Laws §§ 27-18.5-2(7), 27-18.6-2(14) and 27-50-3(U)(1).
8.“Medicaid member” means a person who has been determined to be eligible for Medicaid benefits.
9.“Modified Adjusted Gross Income” or “MAGI” means income, adjusted by any amount excluded from gross income under section 911 of the IRS Code, and any interest accrued. Social Security benefits are not included in gross income. The MAGI is the standard for determining income eligibility for all Medicaid affordable care coverage groups (RICR Title 210, Chapter 30 (Medicaid for Children, Families, and Affordable Care Act (ACA) Adults).
10.“Policy holder” means the employee with access to ESI.
11.“Rhode Island Works” or “RI Works” means the State’s Temporary Assistance for Needy Families (TANF) program that provides assistance to low income needy families on the path to full employment and financial independence. The program is administered by the Rhode Island Department of Human Services, one of the four State agencies under the Executive Office of Health and Human Services (EOHHS) umbrella.
12.“RIte Share-approved employer-sponsored insurance” means an ESI plan that meets the coverage and cost-effectiveness criteria for RIte Share.
13.“RIte Share buy-in” means, in certain instances, individuals participating in RIte Share are subject to a buy-in requirement. This requirement applies to a family in which a Medicaid-eligible child is residing in a household with MAGI-based income above 150% of the FPL and must enroll in the RIte Share-approved ESI plan of a parent/caretaker – “the policy holder” – who is not eligible for Medicaid.
14.“RIte Share Premium Assistance Program” means the Rhode Island Medicaid premium assistance program in which the State pays the eligible Medicaid member’s share of the cost of enrolling in a RIte Share-approved ESI plan. This allows the State to share the cost of the health insurance coverage with the employer.
15.“RIte Share Unit” means the entity within EOHHS responsible for assessing the cost-effectiveness of ESI, contacting employers about ESI as appropriate, initiating the RIte Share enrollment and disenrollment processes, handling member communications, and managing the overall operations of the RIte Share program.
16.“Third party liability” or “TPL” means other health insurance coverage. This insurance is in addition to Medicaid and is usually provided through an employer. Since Medicaid is always payer of last resort, the TPL is always the primary coverage.
17.“Wrap-around services or coverage” means any health care services not included in the ESI plan that would have been covered had the Medicaid member been enrolled in a Medicaid managed care plan (Part 2 of this Subchapter). Coverage of deductibles and co-insurance is included in the wrap. Co-payments to providers are not covered.
3.4RIte Share Populations
A.The income of Medicaid members affects whether and in what manner they must participate in RIte Share. Rite Share populations are determined pursuant to R.I. Gen. Laws § 40-8.4-12(c).
1.RIte Share includes: children, families, parents and caretakers eligible for Medicaid, or the Children’s Health Insurance Program (CHIP), and childless adults between the ages of nineteen (19) and sixty-four (64) who are not receiving or eligible to receive Medicare, but are Medicaid eligible.
3.5RIte Share Enrollment as a Condition of Eligibility
A.Medicaid members over the age of nineteen (19), who have access to RIte Share-approved ESI must enroll in that ESI as a condition of continuing Medicaid eligibility. This requirement also applies to any individuals who have, or previously had the option to waive ESI coverage to receive financial compensation, including but not limited to, an increase in hourly wage, an increase in weekly salary, and/or a lump sum payment. (An increase in wages for waiving coverage is also known as "pay in lieu of benefits.")
1.Exemptions – In certain circumstances, Medicaid members with access to ESI are exempt from enrolling as condition of maintaining eligibility:
a.Under age 19. Medicaid-eligible children and young adults up to age nineteen (19) are not required to enroll in a parent/caretaker relative’s ESI as a condition of maintaining Medicaid eligibility.
b.Enrolled in RI Works (TANF). There is a limited six (6) month exemption from the mandatory enrollment requirement for RI Works program participants. See § 3.6 of this Part below.
c.Pregnant women. Although the State encourages enrollment, pregnant women will not be sanctioned if they do not comply.
2.Mandatory ESI Enrollment – Once it has been determined by EOHHS that the ESI offered by a particular employer is RIte Share-approved, all eligible Medicaid members with access to that ESI are required to participate in RIte Share.
3.Non-compliance – Failure to meet the mandatory enrollment requirement results in the termination of the Medicaid eligibility of the policy holder and other Medicaid members nineteen (19) or older in the household that would have been covered under the ESI until the policy holder complies with the RIte Share participation and enrollment procedures established by EOHHS in this rule. (See § 3.20 of this Part).
4.Reinstatement – The period of ineligibility may be shortened and Medicaid eligibility reinstated if
a.the policy holder complies with RIte Share’s request to enroll in ESI,
b.if the employer’s plan is no longer RIte Share-approved,
c.if the policy holder no longer has access to that ESI (e.g., decrease in work hours).
3.6RI Works Participants
A.RI Works participants who are Medicaid-eligible are not required to enroll in a RIte Share plan for their first six (6) months of employment. This six-month exemption also applies to families losing eligibility for RI Works due to employment. Specifically, to be subject to enrollment in a RIte Share approved ESI plan, the RI Works participant must be:
1.Age nineteen (19) or older; and
2.Employed for a period of six (6) consecutive months or more by the same employer.
B.RI Works participants who do not meet both of these criteria at the time Medicaid eligibility is renewed in accordance with § 3.16 of this Part are exempt from participating in RIte Share.
3.7RIte Share Premium Assistance
A.Under the RIte Share Premium Assistance Program, the State pays the employee’s premium. Medicaid members also receive wrap-around services.
1.Premium payments – EOHHS pays for ESI premiums as follows:
a.EOHHS pays the employee directly for their share of the ESI, or
b.EOHHS pays the employer directly for the employee’s share of the ESI.
2.Cost-sharing – Medicaid beneficiaries enrolled in ESI are not obligated to pay any cost-sharing that is not otherwise applicable to Medicaid. For RIte Share enrollees, EOHHS pays for any ESI co-insurance and deductibles. (Co-pays are not covered by EOHHS, but as long as the RIte Share enrollee seeks services from a participating Medicaid provider, the RIte Share enrollee cannot be billed for copayments by that provider.) RIte Share Enrollees are notified of the cost sharing policy through their initial enrollment notice.
3.Wrap-around coverage – Services and benefits that are covered by Medicaid, but are not offered through the ESI plan, are made available through the Medicaid program. Wrap-around services/coverage ensures that RIte Share enrollees receive health coverage comparable in scope, amount and duration to Medicaid members enrolled in Medicaid managed care. Medicaid covers these services for Medicaid members participating in RIte Share when using Medicaid providers.
4.Repayment and recoupment – EOHHS has the authority to recover Medicaid benefit overpayment claims and cost-share arrearages through offset of the individual State income tax refund in accordance with R.I. Gen. Laws §§ 44-30.1-1, 44-30.1-3, 44-30.1-4 and 44-30.1-8 in R.I. Gen. Laws Chapter 44-30.1 entitled ‘Setoff of Refund of Personal Income Tax.’
3.8RIte Share Buy-in Requirement
A.In certain instances, Medicaid beneficiaries participating in RIte Share are subject to a buy-in requirement. This requirement applies to a household with MAGI-based income above 150% of the FPL where only the child (children) is Medicaid eligible, and the parent/caretaker has access to ESI that is RIte Share-approved.
1.Buy-in amount – The parent/caretaker is required to pay a monthly buy-in amount that varies with income as follows:
Monthly Family Income | Monthly Buy-In Amount |
Over 150% and not greater than 185% FPL | $ 61.00 |
Over 185% and not greater than 200% FPL | $ 77.00 |
Over 200% and not greater than 250% FPL | $ 92.00 |
2.Notice – EOHHS must provide the adult in the family subject to the buy-in requirement with timely notice. This may be done separately or in conjunction with the notice of RIte Share participation. The notice must include the amount of the buy-in, the process for making payments, the consequences for non-payment and a statement of the right to appeal and request a hearing.
3.Payment – Buy-in amounts are not prorated. Therefore, a full monthly buy-in amount is due if RIte Share enrollment is effective for any portion of a coverage month.
4.Method of payment – The parent/caretaker either pays the monthly RIte Share buy-in amount to EOHHS or, if the member has direct deposit, EOHHS deducts the buy-in amount from their ESI reimbursement.
5.Non-compliance – If the parent/caretaker fails to pay the buy-in amount as required, children and young adults in the family age nineteen (19) and under who are eligible for Medicaid will be enrolled in a Medicaid managed care plan.
3.9Basis for Approving ESI Plans
A.Only ESI or group health plans that meet the cost-effectiveness and benefits criteria specified in this Part are approved for the RIte Share Premium Assistance Program.
1.Sources of information for determining cost-effectiveness – Determinations of ESI cost-effectiveness are based on information gathered from the following sources:
a.Application materials. When applying for Medicaid, applicants must indicate: current health insurance coverage status; relationship to policy holder; plan name; policy number; eligibility for and type of coverage and individuals covered by the plan. Subchapter 00 Part 3 of this Chapter explains the process for applying for Medicaid through the State’s affordable care eligibility system and the manner in which this information is collected and maintained.
b.The RIte Share Unit. This EOHHS Unit collects employer data about ESI plans for Medicaid-eligible individuals/households. Information from employers includes data necessary to determine whether the employer’s ESI offerings meet EOHHS’s cost-effectiveness and benefits criteria.
2.EOHHS reserves the right to request additional information about the ESI plan from the Medicaid beneficiary, the policy holder (even if not an eligible Medicaid member), and, where appropriate and necessary, the employer or insurance carrier.
3.10Methodology for Determining Cost-Effectiveness
A.The RIte Share Unit uses the information about the ESI plan to compare the cost of the employee's share, for the ESI to the cost of enrollment in Medicaid managed care. An ESI plan is determined to be cost-effective when, on the aggregate, the total cost of medical coverage through RIte Share is less than the cost of coverage if enrolled in a Medicaid managed care plan. RIte Share participants receive coverage comparable in scope, amount, and duration to coverage provided in a Medicaid managed care plan.
1.Cost-effectiveness test – To be cost-effective, the policy holder’s monthly ESI premium share, deductibles, co-insurance plus any Medicaid covered services not covered by the ESI plan (such as services covered under the RIte Care Health Plan contract but not under the ESI plan) must be less than the average capitation payment for an average individual/family enrolled in a Medicaid managed care plan. These average costs must be actuarially determined at such intervals as deemed appropriate by EOHHS.
2.There are three cost effectiveness determinations for each employer plan:
a.Family coverage where all family members are Medicaid eligible (income less than or equal to one hundred thirty six percent (136%) of the federal poverty guidelines (FPL));
b.Family coverage where only children and/or pregnant women in the family are Medicaid eligible (for families, income greater than one hundred and thirty-six percent (136%) and less than or equal to, two hundred and sixty one percent (261%); for pregnant women, income greater than one hundred and thirty six percent (136%), and less than or equal to two hundred fifty three percent (253%) of FPL); and
c.Individual coverage where only the employee is Medicaid eligible (133% FPL) (Medicaid Expansion).
d.All the above listed FPL guidelines are not inclusive of the five percent (5%) income disregard to allow for minor fluctuation in income.
B.The figures used as the basis for assessing cost-effectiveness shall be made available, upon request, by EOHHS.
3.11Scope and Consequence of Approving an ESI Plan
RIte Share-approved ESI plans are reevaluated on an annual basis to ensure that all Medicaid beneficiaries who are enrolled receive coverage comparable in scope, amount, and duration to that provided in a Medicaid managed care plan. From the date an ESI plan is approved until the date it is reevaluated, any Medicaid beneficiaries who work for that employer, and their Medicaid-eligible dependents, must enroll in the ESI through RIte Share.
3.12Enrollment Process
A.Medicaid beneficiaries who are required to participate in RIte Share must enroll in the ESI plan as directed by EOHHS. Enrollment into RIte Share may occur upon initial determination or at the time of Medicaid annual renewal, or as deemed appropriate by EOHHS. Enrollment in RIte Share is deemed to be a “qualifying event” and may occur at any time, including outside the open enrollment period.
1.Eligibility determination and RIte Share referral – The referral for RIte Share participation is based on information provided by the Medicaid beneficiary in conjunction with an initial Medicaid application or annual Medicaid renewal; and documented in the EOHHS database as to whether an employer offers RIte Share-approved coverage.
2.Notice RIte Share participation required – A notice must be sent by EOHHS indicating that participation in RIte Share is a condition of retaining Medicaid eligibility as follows:
a.Fourteen days’ notice. Upon determining that a Medicaid member is qualified for coverage through RIte Share, EOHHS provides a written “Notification of Eligibility for Enrollment” stating the employee must select a RIte Share-approved ESI plan through their employer's personnel or human resources office within fourteen (14) calendar days.
b.Thirty days’ notice. Written notice will be sent to the Medicaid beneficiary approximately thirty (30) days prior to the date that enrollment in RIte Share is required, but only in instances when approval of the ESI plan is the impetus for the requirement to enroll rather than a determination/renewal of Medicaid eligibility
3.Prior agreement – In certain circumstances, EOHHS may have a prior agreement with the employer which permits the RIte Share Unit to enroll an eligible individual/family in the ESI plan upon receipt of an acknowledgment or written consent from the policy holder. The notification of enrollment sent from the RIte Share Unit to the Medicaid-ineligible policy holder as well as to any Medicaid recipients in such cases shall explain any such prior arrangements and any additional appeal and hearing rights that follow therefrom.
3.13Access to ESI
A.All Medicaid applicants and beneficiaries are required to provide information about access to ESI. For the purposes of RIte Share, “access” to ESI is as follows:
1.A Medicaid-eligible individual, age nineteen (19) or older who is, or has the option to be enrolled in an employer-sponsored health insurance or group health benefit plan;
2.A Medicaid-eligible individual who is, or has the option to be, enrolled in an employer-sponsored health insurance or group health benefit plan as the spouse, dependent, or family member of a Medicaid-ineligible policy holder.
B.Failure to provide this information as required may lead to the termination of Medicaid eligibility, unless there is good cause for non-compliance as specified in § 3.23 of this Part.
3.14Non-custodial Parents with TPL
A.Medicaid is always the payer of last resort. Accordingly, EOHHS considers all other health insurance or coverage provided to a Medicaid-eligible individual as third-party liability (TPL) coverage. EOHHS reserves the right to disenroll Medicaid beneficiaries with TPL from Medicaid managed care and enroll them in RIte Share. This is called RIte Share Zero Premium.
1.TPL coverage through the non-custodial parent – Children who are enrolled in both Medicaid managed care and also have access to coverage through a non-custodial parent (NCP), will be transitioned into RIte Share Zero Premium unless the custodial parent shows good cause for not making the transition. The child will retain access to all applicable Medicaid covered services the entire time that they are in RIte Share Zero Premium. Should the NCP lose their ESI, the RIte Share Unit must be notified at least ten (10) days prior to the child’s disenrollment to meet established reporting requirements and assure the child is transitioned back into Medicaid managed care without coverage gaps.
2.Custodial parent non-compliance – If the custodial parent refuses to allow the child to be enrolled in the NCP’s coverage, the custodial parent’s Medicaid eligibility is terminated until the custodial parent complies with the RIte Share participation requirement. Good cause exemptions to RIte Share are permitted under § 3.23 of this Part.
3.Notice and enrollment – Medicaid beneficiaries must be provided with notice from EOHHS explaining their rights and responsibilities including:
a.RIte Share participation. The requirement to participate in RIte Share is a condition of continuing Medicaid eligibility for adults in the household. The Medicaid member with TPL must receive the notice fourteen (14) or thirty (30) days, as appropriate (see § 3.12 of this Part), prior to the required transition from a Medicaid managed care plan.
b.Grace period. Parents/caretakers are given a fourteen (14) day grace period to report any changes in the NCP’s coverage and/or report any difficulties with using the NCP’s coverage.
c.Failure to respond. If the parent/caretaker does not respond, the Medicaid beneficiaries who are covered under the NCP's policy will be transitioned from Medicaid managed care to RIte Share, and sent appropriate documentation. Those household members who are not covered under the NCP's coverage (such as a custodial mom, children not related to the NCP, etc.) will remain in Medicaid managed care.
d.Cost-sharing. The notification must indicate clearly that EOHHS is not responsible for coinsurance, cost sharing obligations, or wrap-around coverage for the NCP or any other Medicaid-ineligible family members
3.15Continuing Eligibility – Medicaid Renewals
A.For Medicaid beneficiaries renewing eligibility, EOHHS must assess as part of the redetermination process whether anyone in the household is a RIte Share participant and if there has been any change in access to ESI.
1.Notice of renewal – Medicaid beneficiaries must be provided with a notice at the time of renewal specifying the terms for continuing eligibility. The terms for continuing coverage vary as follows:
a.Medicaid managed care enrollees without access to ESI continue enrollment in the Medicaid managed care plan that provided coverage in the previous period of eligibility in accordance with Part 2 of this Subchapter.
b.Medicaid managed care enrollees who have gained access to a RIte Share-approved ESI plan continue to be enrolled in the Medicaid managed care plan that provided coverage in the previous period of eligibility pending review by the RIte Share Unit. In such cases, EOHHS sends a notice stating that eligibility is continued and that coverage in a Medicaid managed care plan continues pending action on the ESI plan by the RIte Share Unit. A referral to the RIte Share Unit is made accordingly.
c.RIte Share participants who retain access to the RIte Share-approved ESI plan that provided coverage during the during the previous period of eligibility, continue to be enrolled in the ESI plan pending review by the RIte Share Unit of any changes that might result in withdrawal of approval of the ESI plan, disenrollment, and subsequent enrollment in a Medicaid managed care plan.
2.Loss of ESI – RIte Share participants who involuntarily lose access to an approved ESI plan that provided coverage during the previous period of eligibility for any of the reasons stated in § 3.21 of this Part receive coverage as follows:
a.Any Medicaid-eligible individuals in the family will receive coverage through fee-for-service pending either enrollment in a Medicaid managed care plan, or if the Medicaid members have gained access to another ESI plan, approval of that plan by the RIte Share Unit.
3.Notice of renewal – In all such cases, the notice of renewal for continuing eligibility sent by EOHHS to the Medicaid beneficiaries shall include a statement of the applicable terms for continuing eligibility including any buy-in requirement, the reason(s) for establishing the terms, and the right to appeal and request a hearing with respect to either (See Part 10-05-2 of this Title), as well as all other information required in this section. The enrollment referral transmitted to the RIte Share Unit shall also indicate which terms apply and shall be sent at the time the redetermination is made.
3.16Renewal of RI Works Participants
A.At the time eligibility renewals are completed, EOHHS is responsible for assessing whether RI Works participants are subject to enroll in a RIte Share-approved plan as a condition of continuing Medicaid eligibility.
1.Employed under six (6) months – Only those RI Works participants, age nineteen (19) or older, who have access to ESI and have been steadily employed for a period of six (6) consecutive months or more, shall be subject to enrollment in RIte Share. All other RI Works participants continue enrollment in the Medicaid managed care plan which provided coverage until the next scheduled redetermination of eligibility.
2.Employed six (6) months or over – If the RI Works participant has been employed for over six (6) months, the notice of renewal sent by EOHHS must state that enrollment in the Medicaid managed care plan that provided coverage during the previous period of eligibility is continued, pending review of the ESI plan by the RIte Share Unit. If enrollment in an approved ESI plan is a condition of retaining continuing eligibility, Medicaid beneficiaries shall receive notice from the RIte Share Unit at least fourteen (14) days prior to enrollment in an ESI plan.
3.17RIte Share Premium Assistance Payment
A.It is the responsibility of EOHHS to establish the appropriate mechanism for transferring payment for the RIte Share-approved ESI plan premiums.
1.The payment options include:
a.Enrollment costs are paid directly by the employer without any wage withholding from the policy holder. The RIte Share Unit or its agent either mails a check or electronically transfers payment to the employer's bank or account, on a monthly basis, to cover the enrollment costs for any individuals/families on the ESI as a result of RIte Share enrollment. These are called “participating” employers.
b.Enrollment costs are paid by the employer after wage withholding from the policy holder. The RIte Share Unit or its agent mails a check or electronically transfers payment to the policy holder, on a monthly basis, to cover the enrollment costs for any individuals/families on ESI as a result of RIte Share enrollment.
2.Notice of payment method –The notification of RIte Share participation sent to the beneficiaries shall clearly specify the method for paying enrollment costs.
3.18Role of RIte Share Unit
A.The RIte Share Unit is responsible for overseeing the operations of the program as follows:
1.Eliciting information from employers about the health plans they offer to workers on an ongoing basis;
2.Evaluating health plans for RIte Share approval;
3.Maintaining a database of RIte Share-approved ESI plans; and
4.Contacting employers to make RIte Share enrollment decisions.
B.Upon receipt of beneficiary referral information, the RIte Share Unit verifies employment and access to a RIte Share-approved ESI plan. Based on this review, the RIte Share Unit determines:
1.Whether the Medicaid beneficiary is approved for RIte Share; and
2.The date that individual or family must enroll in the ESI in order to maintain Medicaid eligibility.
C.The specific procedures for making such determinations vary depending on the enrollment status of the Medicaid beneficiary and the employer’s customary enrollment process.
3.19ESI Enrollment Verification
A.Verification of enrollment in a RIte Share-approved ESI plan is required.
1.Participating employer – For Medicaid beneficiaries working for a RIte Share approved employer, the employer is required to submit verification to the RIte Share Unit that initial enrollment in the ESI has been made in the manner prescribed by EOHHS.
2.Approved plan – For individuals working for a RIte Share-approved employer, the individual must provide verification of enrollment by completing the appropriate form, which requires the signature of a representative of the employer, or by submitting a copy of the official ESI enrollment receipt. Once this verification has been received, EOHHS will initiate premium payment.
3.20Failure to Enroll
A.Failure to enroll in the ESI plan is grounds for termination of Medicaid eligibility for the non-pregnant parent(s) or caretaker over the age of nineteen (19) in the household.
1.Discontinuation – EOHHS sends a “Notice of Discontinuation”, stating that Medicaid eligibility has been terminated for adults in the household due to the failure to enroll in the RIte Share-approved plan. Anyone in the household subject to the notice may reapply (for inactive cases) or request reinstatement (for active Medicaid cases) if they choose to comply with RIte Share, if an exemption from participation is granted, or if the individual no longer has access to the ESI. Please refer to § 3.5 of this Part.
2.Disqualification – Procedures for handling cases in which the policy holder is not eligible for Medicaid are the same as for an eligible policy holder, with one exception: The Medicaid agency sends a “Notice of Disqualification” to the policy holder indicating that ESI costs will not be paid by EOHHS. Please refer to § 3.5 of this Part.
B.Both the “Notice of Discontinuation” and the “Notice of Disqualification” shall include a statement indicating that any affected Medicaid-eligible individuals in the household have the right to appeal and to request a hearing to contest the change in eligibility and the enrollment decision.
3.21Disenrollment from RIte Share-Approved Plan
A.RIte Share beneficiaries who are voluntarily or involuntarily disenrolled from an approved ESI plan must report the change in enrollment status to EOHHS in no more than ten (10) days from the date the disenrollment action occurs. The type of disenrollment determines EOHHS’s response as follows:
1.Voluntary disenrollment – Medicaid-eligible RIte Share beneficiaries age nineteen (19) or older who voluntarily disenroll from an approved ESI will be terminated for coverage based on the failure to meet the non-financial cooperation requirements set forth in this Part. Voluntary disenrollment includes, but is not limited to, instances in which a RIte Share beneficiary:
a.Requests that the employer drop coverage or cease enrollment for the entire family or a Medicaid-eligible individual in the family;
b.Fails to meet the requirements established by the employer to maintain enrollment in the approved plan such as, submit required documentation or forms.
c.Engages in unlawful or fraudulent acts, such as submitting false claims that violate the terms for continuing enrollment in the ESI plan. Please refer to § 3.5 of this Part.
2.Involuntary disenrollment – Involuntary disenrollment includes the loss of access to ESI as a result of change in employment, termination of coverage by the employer for an entire class of workers, death, separation, divorce, disability of the policy holder, or any other factors that could be reasonably construed as involuntary disenrollment as defined in this Part.
3.RIte Share Unit responsibilities – Upon receiving a report from the employer, the ESI plan insurance provider, or Medicaid beneficiary indicating that disenrollment has occurred, the RIte Share Unit verifies the accuracy of the report and assesses whether it is voluntary or involuntary in nature.
a.Voluntary Disenrollment – Notice of Discontinuation. Once the report has been verified and it is determined to be voluntary disenrollment, EOHHS sends a “Notice of Discontinuance” noting termination of the Medicaid eligibility of the policy holder, parent(s) or caretaker relative in the applicant’s household until the individual demonstrates compliance with enrollment procedures established by EOHHS. The “Notice of Discontinuance” must also include any remedies for shortening the period of ineligibility as well as the right to request a hearing and appeal the decision:
(1)Medicaid-ineligible individuals are provided with a notice from EOHHS stating they are disqualified from RIte Share.
(2)All Medicaid-eligible pregnant women and children must be automatically enrolled in a Medicaid managed care plan.
(3)This period of Medicaid ineligibility may be shortened and Medicaid eligibility established if such individual becomes exempt from RIte Share enrollment or no longer has access to ESI for reasons such as a change in employment. (See § 3.21 of this Part).
b.Involuntary disenrollment – There is no adverse action taken against Medicaid beneficiaries required to participate in RIte Share if disenrollment from an approved ESI plan is involuntary.
3.22Cooperation Requirements
A.All Medicaid applicants and beneficiaries must cooperate with the non-financial requirements for eligibility as follows:
1.Information – All individuals and families are required to provide information about other health coverage (TPL) and/or access to ESI when applying for initial or continuing eligibility. The required information relating specifically to access to ESI includes, but is not limited to:
a.The names of any family members in the household currently covered by, or with access to, ESI;
b.The name of the policy holder and the employer offering the ESI; and
c.Verification of monthly enrollment costs via a paycheck stub if the policy holder is currently enrolled or, if available, enrollment information provided by the employer indicating the policy holder's monthly premium for the appropriate family composition.
2.RIte Share participation – Medicaid beneficiaries required to enroll in the ESI must cooperate as follows:
a.Enroll in the ESI in the manner, and within the timelines, established by EOHHS. Failure to do so will result in the termination of Medicaid for any eligible parents/caretaker age nineteen (19) and older in the family. The eligibility of any other Medicaid beneficiaries in a family must not be terminated as the result of the refusal of an otherwise ineligible policy holder to enroll in the ESI. See § 3.20 of this Part.
b.Submit verification of enrollment in accordance with § 3.19 of this Part when the employer does not participate in RIte Share.
c.Provide reports to EOHHS indicating any changes in enrollment status of Medicaid-eligible family members, enrollment costs, household composition, employment, income, residence, and access to ESI within ten (10) days from the date the change occurs.
d.Pay buy-in amounts – Individuals subject to the buy-in requirements must cooperate in making monthly buy-in payments in accordance with § 3.7 of this Part to remain enrolled in ESI. Failure to make a required premium payment, without good cause, as specified in § 3.23 of this Part, results in disenrollment from the RIte Share Premium Assistance Program and loss of ESI premium coverage.
3.23Good Cause
A.EOHHS is responsible for determining whether good cause exists for an exception to the non-financial cooperation requirements for Medicaid eligibility contained in Subchapter 00 Part 1 of this Chapter and, more specifically, for participation in RIte Share, except as noted below:
1.Extraordinary circumstances – EOHHS must exempt a Medicaid beneficiary from RIte Share participation only when there are extraordinary circumstances which preclude the individual from receiving medically necessary care through the RIte Share-approved plan. For purposes of this exemption, "extraordinary circumstances" may include but not be limited to:
a.The existence of an unusual and life-threatening medical condition which requires medical treatment that cannot be provided or arranged by the RIte Share plan whether it is provided through the custodial or non-custodial parent;
b.The existence of a chronic, severe medical condition for which the Medicaid beneficiary has a long-standing treatment relationship for that condition with a provider who does not participate in the RIte Share plan and/or refuses to enroll as a Medicaid participating provider.
2.Non-Custodial Parent (NCP) –
a. EOHHS must exempt a Medicaid beneficiary from RIte Share participation if enrollment in the health plan of the non-custodial parent could result in reasonably anticipated physical and/or emotional harm to the child, custodial parent, or other relative with whom the child is living. Claims of physical and/or emotional harm must be determined by EOHHS to be of a genuine and serious nature. The emotional harm to the custodial parent or other relative with whom the child lives must be of such a serious nature that the capacity to care for the child adequately would be reduced.
b. EOHHS may exempt a Medicaid beneficiary from RIte Share participation if the NCP’s coverage has a limited Rhode Island provider network which would negatively impact access to care for the child.
c.Corroborative evidence – Such evidence supporting a determination of good cause must be supplied to EOHHS. Corroborative evidence may include: court, medical, criminal, child protective services, Family Violence Option Program, social services, psychological, or law enforcement records which indicate that the non-custodial parent might inflict physical and or emotional harm on the child, custodial parent, or other relative with whom the child lives.
3.Other programs – If good cause has been granted for any other benefit program administered by EOHHS or DHS, the good cause exemption will be honored by the RIte Share Program.
4.Nature of request – Enrollment exemptions requested due to extraordinary circumstances must be in writing, with appropriate documentation (letter from physician, medical records, restraining orders, or others as indicated), and signed by the Medicaid beneficiary, parent/caretaker or person designated to make the request on their behalf.
5.Basis of the determination – EOHHS makes RIte Share participation exemption determinations on a case by case basis after considering all required documentation and any other relevant information pertaining to the request. An exemption may be granted for any length of time during the period in which the extraordinary circumstances exist. When an exemption is granted, Medicaid beneficiaries are enrolled in the appropriate Medicaid managed care plan in accordance with Part 2 of this Subchapter.
6.Limits – An individual's preference to continue a treatment relationship with a doctor or other health care provider who does not participate in the RIte Share plan or Medicaid program does not in and of itself constitute an "extraordinary circumstance."
3.24Notice and Appeal Rights
Medicaid applicants and recipients shall receive timely notification of eligibility and enrollment determinations and the right to appeal. EOHHS shall also provide timely notification, including appeal rights, of any adverse decisions that reduce or terminate benefits. See Part 10-05-2 of this Title for full statement of these rights.
3.25Information
3.26Severability
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.
