1.1Overview and legal authority
R.I. Gen. Laws § 40-8.12-3 mandated the Executive Office of Health and Human Services (EOHHS) to establish a fund to ensure insurance coverage through HealthSource RI is affordable for parents and caretakers of Medicaid-eligible children in households with incomes below 175% of the Federal Poverty Level (FPL). The fund is available to assist caretakers who are not otherwise eligible for Medicaid through the RI Affordable Health Care Coverage Assistance Program (AHCCA).
1.2Scope and Purpose
A.Caretakers of Medicaid-eligible children in households with incomes below 175% FPL who are not Medicaid eligible themselves can apply for financial assistance for paying for health insurance coverage accessed through HealthSource RI.
B.The purpose of this rule is to set forth the provisions governing this financial assistance. The rule describes the scope of the Affordable Health Care Coverage Assistance (AHCCA) Program, the basis for determining eligibility, and the respective responsibilities of the State and the individuals seeking assistance through the Program.
1.3Definitions
A.For the purposes of this rule, the following definitions apply:
1.“Affordable Care Act” or “ACA” means the federal Patient Protection and Affordable Care Act of 2010. The law is also sometimes referred to as “Obamacare” and federal health reform.
2.“APTC/CSR eligibility” means the application of the IRS-based measure of income known as “Modified Adjusted Gross Income” (MAGI) for determining eligibility for affordable health care through health insurance exchanges/marketplaces established under the ACA. Also, “APTC” means advanced premium tax credits and “CSR” means cost-sharing reductions.
3.“Caretaker” means any adult over age nineteen (19) living with a Medicaid-eligible dependent child who has assumed primary responsibility for that child as defined in MCAR section 1305.13, “Eligibility Requirements.” This term includes relatives and non-relatives.
4.“HealthSource RI” means the state-based health insurance marketplace (also referred to as a “benefit exchange”) established in conjunction with implementation of the federal Affordable Care Act of 2010.
5.“Qualified Health Plan” means a health plan certified by HealthSource RI that provides essential benefits and meets all other related ACA requirements to be offered through the State’s health benefits exchange.
6.“Silver Plan” means a Qualified Health Plan offered through HealthSource RI that covers approximately 70% of an enrollee’s medical costs. There are federal subsidies for certain Silver Plan enrollees to help cover co-payments and other out-of-pocket expenses.
1.4Eligibility Requirements
A.Caretakers must meet certain requirements related to income, health coverage, and relationship to be eligible to participate in the AHCCA Program. Coverage through HealthSource RI is also a condition of eligibility.
1.Eligibility – The requirements are as follows:
a.Income. Household income at or under 175% of the FPL.
b.Health coverage. Caretakers must not be otherwise eligible for Medicaid.
c.Relationship. Caretakers need to have primary responsibility for a Medicaid-eligible child who is under the age of nineteen (19).
d.Must pay their monthly Silver Plan premium on-time.
2.Plan enrollment – AHCCA financial assistance will be available only if the applicant has enrolled in a Silver Plan through HealthSource RI.
1.5Application Process
A.Caretakers must submit an application for AHCCA through EOHHS.
1.Application forms will be available at the HealthSource RI Contact Center located at: 401 Wampanoag Trail, Riverside, RI 02915 or at EOHHS, Virks Building, 3 West Road, Cranston, RI 02920 or at www.eohhs.ri.gov or www.HealthSourceRI.com. Applicants must also provide basic demographic information and information regarding enrollment in a Qualified Health Plan through HealthSource RI.
2.State’s Responsibilities – EOHHS must review and determine eligibility for financial assistance within sixty (60) days. If additional information is needed by EOHHS, a new review period will begin once the additional information has been received.
1.6Eligibility Approval – Premium Amount
A.If a caretaker is approved, EOHHS calculates the AHCCA subsidy amount in accordance with the following chart:
Rhode Island Affordable Health Care Coverage Assistance Program Assistance |
Total Family Size | 138 % FPL to 150% FPL | 151% FPL to 175 % FPL |
2 | $39 | $28 |
3 | $49 | $43 |
4 | $59 | $58 |
5 | $69 | $73 |
6 | $79 | $88 |
1.7Notice
EOHHS, or its agent, must send a notice to the caretaker with an eligibility determination for AHCCA. All notices must include a statement of the rights of the caretaker applying.
1.8Payment of Subsidies
The payment option for the AHCCA subsidy includes the following: The caretaker pays the premium due to the insurer to HealthSource RI. EOHHS or its agent mails a check to the caretaker monthly.
1.9Duration and Continuing Eligibility
A.Period of eligibility – Eligibility for the AHCCA subsidy is on a month-to-month basis. The subsidy may be curtailed sooner if there is a change in any eligibility factor that affects household or enrollment in the Qualified Health Plan selected by the caretaker. Continuation of the subsidy must be reconsidered if such a change occurs, if eligibility under § 1.4 of this Part still applies, AHCCA financial assistance continues.
B.Notice – EOHHS must provide notice to the eligible caretaker sixty (60) days prior to termination. The notice must include guidance on how to apply for continued financial assistance as well as the right to appeal EOHHS actions as indicated in § 1.10 of this Part.
1.10Termination or Denial of Participation
Eligibility for the AHCCA must be denied or terminated, as appropriate, upon determining that an applicant has provided false information on an application for assistance or has not provided timely notification of changes that would affect the eligibility factors set forth in § 1.4 of this Part.
1.11Hearing and the Right to Appeal
A.EOHHS must provide applicants and recipients of AHCCA subsidies with notice of the right to appeal and request a hearing with regard to the following agency actions:
1.A determination that an applicant disapproved for AHCCA participation and the basis for the decision of ineligibility;
2.The amount of assistance determined;
3.Termination of eligibility to participate in the AHCCA. (See regulations contained in Part 10-05-2 of this Title).
1.12For Further Information or to Obtain Assistance
A.See the following websites:
1.www.eohhs.ri.gov
2.www.HealthSourceRI.com
B.For assistance finding a place to apply or for assistance completing the application, please call: 1-855-609-3304 or 1-855-840-HSRI (4774) or the Premium Assistance Program at 401-462-0311.
1.13Severability
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.
