210-RICR-30-00-1
210-RICR-30-00-1. Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways (version Amendment, 09/27/2022 to 01/25/2023)
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210-RICR-30-00-1
o TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND
HUMAN SERVICES
o CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND
AFFORDABLE CARE ACT (ACA) ADULTS
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SUBCHAPTER 00 - AFFORDABLE COVERAGE GROUPS
o Part 1 - Medicaid Affordable Care Coverage Groups Overview and
Eligibility Pathways
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1.1
Overview
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A.
The principal purpose of the federal Affordable Care Act of 2010 was to
increase access to health care by leveraging resources, expanding choice, and
removing the administrative, financial, and legal barriers that have prevented
people from obtaining the coverage they need. Toward this end, the ACA:
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1.
Consolidated many of the existing Medicaid coverage groups
associated with the now defunct federal Aid to Families with Dependent
Children Program (AFDC) into three broad categories: children, pregnant
peoplewomen and newborns, and parents/caretaker relatives;
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2.
Created an optional Medicaid coverage group for adults between
the ages of nineteen (19) and sixty-four (64) who otherwise do not qualify
for Medicaid and are not eligible for or enrolled in Medicare;
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3.
Established a new standard - Modified Adjusted Gross Income
(MAGI) -- for evaluating income eligibility for Medicaid and other publicly
supported forms of affordable commercial coverage across these
populations;
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4.
Eliminated distinctions in the financial criteria and standardized the
income eligibility requirements for the Medicaid populations subject to the
MAGI. This, in turn, made it possible for the states to reorganize the
MAGI-eligible populations with similar characteristics into distinct, easily
identifiable, Medicaid affordable care coverage (MACC) groups;
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5.
Mandated that the states automate the application and renewal
process for populations subject to the MAGI by building the capacity to
determine eligibility on-line and conduct electronic verifications through a
variety of government approved data sources; and
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6.
Applied these changes not only to Medicaid, but also to the
Children’s Health Insurance Program (CHIP), which is administered
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through the Medicaid program in Rhode Island, and HealthSource RI
(HSRI), the State’s health insurance marketplace.
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1.2
Scope and Purpose
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A.
The purpose of this rule is to establish the Medicaid Affordable Care
Coverage (MACC) groups and the eligibility pathways for individuals who share
one or more of their characteristics and are exempt from MAGI and/or the
provisions for the Integrated Health Care Coverage (IHCC) groups under
Chapter 40 of this Title.
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B.
In Rhode Island, CHIP eligibility is administered as an expansion through
the Medicaid program rather than through a separate state program as the
principal distinction for most eligibility pathways relates to claiming of Title XIX
versus Title XXI federal financial participation rates. The exceptions, as indicated
in this rule, are the CHIP-only eligibility pathways for lawfully present qualified
non-citizen children up to the age of nineteen (19) and qualified and non-qualified
pregnant women who meet the income limits set forth herein.
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1.3
Legal Authority
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A.
This Part is promulgated pursuant to federal authorities as follows:
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1.
Federal Law: Title XIX of the U.S. Social Security Act; 42 U.S.C. §
1396a, Sections 1115, 1902, 1903, 1905, 1925,1931, 1937, 2107; Title
XXI of the Social Security Act, 42 U.S.C. §§ 1397aa through 1397mm; 42
U.S.C. § 1396k; Section 1413(b)(1)(A) of the Affordable Care Act.
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2.
Federal Regulations: 42 C.F.R. §§ 431,435, 440, and 441.
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3.
The Medicaid State Plan and the Title XIX, Section 1115 (a)
Demonstration Waiver (11-W-00242/1), effective through December 31,
2018.
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B.
Applicable State authority is derived from R.I. Gen. Laws, Chapters 40-8,
42-12.3, and §§ 40-8.4 and 40-8.12.
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C.
The rules in this Part supersede the Medicaid Code of Administrative
Rules (MCAR), Sections 1301,1305, and 0342 unless otherwise indicated,
pertaining to Medicaid MACC and non-MAGI eligibility for children and families
and authorized services.
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1.4
Definitions
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A.
For the purposes of Medicaid MACC and non-MAGI eligibility groups
covered under this Part, the following definitions apply:
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1.
“ACA expansion adults” means the eligibility pathway established
by the federal Affordable Care Act (ACA) of 2010 and by R.I. Gen. Laws §
40-8.12, for persons between the ages of nineteen (19) and sixty-four (64)
who are not eligible for or enrolled in Medicare and do not qualify for
Medicaid in any other eligibility group.
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2.
“Dependent child” means a child under the age of eighteen (18) or
under the age of nineteen (19), if enrolled full-time in school.
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3.
“Hospital presumptive eligibility” means the temporary and time-
limited Medicaid eligibility pathway for persons who meet certain
requirements and are receiving care in a hospital pending submission of a
complete application.
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4.
“Managed care organization” or “MCO” means a health plan system
that integrates an efficient financing mechanism with quality service
delivery and a "medical home" to assure appropriate preventive care and
deter unnecessary services.
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5.
“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.
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6.
“Rhode Island Code of Regulations” or “RICR” means the
compilation of rules governing the Rhode Island Medicaid program
promulgated in accordance with the State’s Administrative Procedures Act
(R.I. Gen. Laws Chapter 42-35).
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7.
“Medicaid member” means a Medicaid beneficiary enrolled in a
managed care plan.
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8.
“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.
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9.
“Navigator” means a person working for a State-contracted
organization that provides certified assisters who have expertise in
Medicaid eligibility and enrollment.
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10.
“Non-citizen” means anyone who is not a U.S. citizen at the time of
application including lawfully present immigrants and persons born in
other countries who are present in the U.S. without documentation.
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11.
“Non-MAGI coverage group” means a Medicaid coverage group
that is not subject to the modified adjusted gross income eligibility
determination. For the purposes of this Part, it includes Medicaid for
persons who qualify for Medicaid based on their eligibility for another
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publicly funded program, including children in the substitute care under the
auspices of the DCYF such as current, and some instances, former foster
care recipients and anyone receiving Supplemental Security Income (SSI).
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12.
“Qualified non-citizen” means a person legally present in the United
States based on immigration status who, if otherwise eligible for Medicaid,
is prohibited or “barred” under federal law from receiving Medicaid
coverage for a period of five (5) years from the date the immigration status
was secured from the United States Citizenship and Immigration services
(USCIS)U.S. Immigration and Naturalization Service (INS). Certain
qualified non-citizens are exempt from the five (5) year Medicaid p banrn.
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13.
“Rhody Health Partners” means the Medicaid managed care
delivery system for ACA expansion adults (see Part 05-2 of this Chapter)
and adults with disabilities (See Chapter 40 of this Title).
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14.
“RIte Care” means the Medicaid managed care delivery system for
eligible families, pregnant womenpeople, children up to age 19, and young
adults older than age 19 (see Part 05-2 of this Chapter).
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15.
“RIte Share” means the Medicaid premium assistance program for
eligible individuals and families who have access to cost-effective
commercial health insurance plans coverage.
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16.
“Self-attestation” means the act of a person affirming through an
electronic or written signature that the statements the person made when
applying for Medicaid eligibility are truthful and correct.
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17.
“Title XIX” means the section of the U.S. Social Security Act that
established the Medicaid program and provides the legal basis for
providing services and benefits to certain populations in each MACC
group.
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18.
“Title XXI” means the section of the U.S. Social Security Act that
established the Children’s Health Insurance Program (CHIP) and provides
the legal basis for providing services and benefits to certain targeted low-
income children and pregnant women through Medicaid.
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1.5
Eligibility Pathways for MACC and Non-MAGI Groups
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A.
Rhode Island’s Medicaid MACC groups are comprised of individuals and
families who share an eligibility characteristic, such as age or relationship as
follows, unless otherwise indicated below. MACC group members do not have
access to retroactive coverage under the terms and conditions of the State’s
Section 1115 Demonstration Waiver.
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1.
Families and Parents (caretaker relatives). The defining
characteristic of this coverage group is a relationship with a child up to the
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age of eighteen (18), or the age of nineteen (19) if enrolled in school full-
time, who is eligible for Medicaid. Parent/caretaker eligibility is a function
of how the eligible child is claimed for tax purposes as a dependent when
constructing a MAGI household. This coverage group includes:
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a.
Families with income up to 116% of the Federal Poverty
Level (FPL) who are eligible under the Medicaid State Plan through
the authority provided by Section 1931 of Title XIX.
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b.
Parents/caretaker relatives with income from 116% to 141%
of the FPL who are eligible under the State’s Section 1115
demonstration waiver.
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c.
Parents/caretakers with income from 138% to 175% of the
FPL who would have been eligible for Medicaid on December 31,
2013, may qualify for the Rhode Island Affordable Health Care
Coverage Assistance Program. Parents/caretakers eligible for this
program may obtain a State subsidized “silver” commercial plan
through the Rhode Island’s health insurance marketplace as
specified in Part 10-1 of this Chapter. The State’s integrated
eligibility system automatically evaluates the parents/caretakers of
Medicaid-eligible children for this Program if they do not qualify for
coverage under this Part.
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d.
Pregnant womenpeople. Members of this coverage group
can be of any age. The pregnant woman person and each
expected child are counted separately when constructing the
household and determining family size. Eligibility extends for the
duration of the pregnancy and, as of October 1, 2002, two twelve
(12) months post-partum. The coverage group includes all pregnant
women people with income up to 253% of the FPL. Pregnant
people with income under 190% of the FPL who meet Medicaid
requirements for citizenship/immigration status are eligible for
medical coverage through Medicaid. Pregnant people with income
above 190% of the FPL up to 253% of the FPL who meet Medicaid
requirements for citizenship/immigration status and pregnant
people with income up to 253% of the FPL who do not meet
Medicaid requirements for citizenship/immigration status are
eligible for medical coverage through CHIP, regardless of whether
the legal basis of eligibility is Medicaid or CHIP. CHIP medical
coverage for those pregnant people who do not meet Medicaid
requirements for citizenship/immigration status is based on the
eligibility status of the unborn child. The CHIP eligibility pathway
includes two populations: is for 1) pregnant women people with
income above 190% FPL and 2) children from conception to birth
who are exempt from citizenship and immigration status eligibility
requirements. who are non-citizen residents of the State. In the
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case of CHIP, the unborn child’s citizenship and residence is the
basis for eligibility. Retroactive medical coverage is available for up
to ninety (90) days prior to the eligibility date for otherwise eligible
pregnant womenpeople.
(1) As of October 1, 2022, tTwelve (12) month post-partum
coverage shall be extended to people who:
(a) Are not eligible for Medicaid under another
Medicaid eligibility category; or
(b) Do not have qualified non-citizen status for
Medicaid, whose births are financed by Medicaid
through coverage of the child and who, before
October 1, 2022, were only eligible to receive state-
only extended family planning benefits postpartum, as
outlined in 210-RICR-30-05-2.6(A)3.
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e.
Children and Young Adults. Age is the defining characteristic
of members of this MACC group. This coverage group includes:
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(1)
Infants under age one (1) unless a deemed newborn
(see § 1.7(A) of this Part) up to age nineteen (19) who have
family income up to 261% of the FPL; and
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(2)
All Children, including all non-citizen children not
legally present, Qualified and legally present non-citizen
children up to the age of nineteen (19), who have income up
to 261% of the FPL.
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f.
ACA Expansion Adults - The group consists of citizens and
qualified non-citizens with income up to 133% of the FPL who meet
the age characteristic and are not otherwise eligible for, or enrolled
in, Medicare or Medicaid under any other state plan or Section
1115 waiver coverage group. Adults found eligible awaiting a
determination for Supplemental Security Income (SSI) or the
receipt of Social Security benefits are also eligible under this
coverage group during the two (2) year application pending and
benefit waiting periods.
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B.
MACC Group Income Eligibility - The income thresholds and ceilings for
the MACC groups eligible through these pathways are summarized as follows:
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o MACC
Group
o Income
Threshold
- As
percent of
the FPL
o Income
Ceiling
with the
5 percent
disregard
- As a
percent
of the
FPL
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a. Families
o 116%
o 121%
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b.
Parents/Caretakers
o 116%
o 141%
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c. Pregnant
WomenPeople
o 253%
o 258%
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d. Children/Young
Adults
o 261%
o 266%
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e. ACA Expansion
Adults
o 133%
o 138%
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C.
There are currently multiple Medicaid coverage groups that are not subject
to the MAGI. Eligibility for adults who are nineteen (19) years of age and older
who are not subject to the MAGI standard is set forth as follows:
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1.
Persons twenty-one (21) years of age and older eligible for
Medicaid based on receipt of Supplemental Security Income (SSI),
Optional State Supplemental Payments (SSP), and/or SSI-protected
status - § 210-RICR-40-00-1.5(A)(3) of this Title;
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2.
Low income elders who are sixty-five (65) and older, and adults
with disabilities (EAD) between the ages of nineteen (19) and sixty-four
(64) with income up to 100 percent of the FPL to who do not qualify for
SSI and are eligible for or enrolled in in Medicare - § 210-RICR-40-00-
1.5(A)(1) of this Title;
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3.
Full or partial Medicare-Medicaid dual eligible beneficiaries
participating in the Medicare Premium Payment Program - § 210-RICR-
40-00-1.5(A)(6) of this Title;
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4.
Women People eligible for Medicaid through the Breast and
Cervical Cancer Treatment Program (BCCTP) - § 210-RICR-40-00-
1.6(A)(1) of this Title;
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5.
Adults seeking initial or continuing eligibility for Medicaid long-term
services and supports (LTSS) who are eligible for or enrolled in Medicare
or are age sixty-five (65) and older with service needs requiring the level
of care typically provided in health institutions - § 210-RICR-50-00-
1.9(A)(3) of this Title;
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6.
Otherwise ineligible children with serious disabilities up to age
eighteen (18) who qualify under Katie Beckett process because they are
receiving the level of care at home that is typically provided in a health
institution -- 210-RICR-Part 50-10-3 of this Title;
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7.
Medically needy eligible persons who become eligible for Medicaid
by spending down excess income on allowable health expenses - §210-
RICR -40-00-1.5(A)(2) of this Title.
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D.
Children and families exempt from the MAGI with eligibility covered under
this Part are as set forth below:
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1.
No income determination required – Individuals and families up to
age twenty-one (21) whose eligibility does not require an income
determination for Medicaid, including those eligible on the basis of:
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a.
Supplemental Security Income (SSI). Children and young
adults with disabilities determined by the federal Social Security
Administration (SSA) to be eligible for SSI benefits who are up to
age nineteen (19) or in the custody of the State, up to age twenty-
one (21), including those residing in health institutions; and
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b.
DCYF programs. Children and youth eligible on the basis of
their participation in a DCYF foster care, kinship or guardian
program whether in a home-based, residential or institutional
setting, including young adults aging out of foster care in Rhode
Island, up to age twenty-six (26) who are eligible under the federal
Foster Care Independence Act of 1999 (Chafee Act).
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2.
Deemed eligibility -- Infants born to Medicaid-eligible pregnant
woman people are deemed eligible from date of birth to age one (1)
without regard to changes in income or other factors as long as they
remain residents of the State.
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3.
Transitional/extended Medicaid – Families with income above 116
percent of the FPL who no longer qualify for Medicaid coverage under
Title XIX, Section 1931 due to earnings from work, including recipients of
the RI Works Program administered by the RI Department of Human
Services may qualify for continued coverage through this pathway.
Eligibility for extended Medicaid is for six (6) months, renewable up to a
year as long as gross income is at or below 175 percent of the FPL.
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1.6
MACC Group General Eligibility Requirements
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A.
Applicants for MACC Group eligibility must meet state residency
requirements. Applicants for MACC Group eligibility who are over the age of
nineteen (19) must meet citizenship/immigration status and residency
requirements. These two (2) requirements do not apply to all non-citizen
Medicaid applicants under the age of nineteen.. There are also certain
cooperation requirements. Adults must typically meet the cooperation
requirements, whether applying for themselves or on behalf of a dependent child.
Verification of these requirements is an automated process conducted through
electronic data matches. Failure to meet Medicaid general eligibility requirements
or provide supporting documentation upon request is considered non-
cooperation and generally results in the denial or discontinuation of eligibility.
Children are exempt from sanctions due to non-cooperation. The scope and
application of each of these eligibility requirements are as follows:
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1.
Age - “Age” is one of the principal factors affecting eligibility for
Medicaid and assignment to the appropriate Medicaid service delivery
system MACC group.
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2.
MACC Group Age Limits - The age requirements associated with
each of the MACC groups are as follows:
o MACC
Coverage
Groups
o Age
Requirement
s
o Families and
Parents/Care
takers
o Parents/Care
takers of any
age
o Dependent
child up to
age 18 or 19
if enrolled in
school full-
time
o Pregnant
WomenPeopl
e
o Any age
o Children and
Young Adults
o Up to age 19
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o ACA
Expansion
Adults
o Ages 19 to
64
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a.
Verification – An applicant’s self-attestation of age and
identity is accepted at the time of application. Post-eligibility
electronic verification of date of birth is conducted through the U.S.
Social Security Administration (SSA) and/or the RI Department of
Health, Division of Vital Statistics. This information is used to
determine capitation rates for enrollees in Medicaid managed care
plans; these rates vary by age. If electronic verification is
unsuccessful, submission of paper documentation may be required
for these purposes. See Part 5 of this Subchapter for satisfactory
forms of documentation.
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3.
Social Security Number - To support verification of age, income,
and citizenship/immigration status, Eeach individuals applying for
Medicaid who have been assigned s a Social Security Number (not
including children) and who is applying for Medicaid shallmust have
provide their a Social Security Number (SSN) as a condition of eligibility
for the program.
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a.
Condition of Eligibility - Applicants who are required to submit a
SSN shall must be notified prior to or while completing the application that
furnishing an SSN is a condition of eligibility. Only members of a
household who are applying for Medicaid coverage are required to provide
a SSN. A SSN of a non-applicant may be requested to electronically verify
income. However, unwillingness on the part of a non-applicant to provide
a SSN upon request shall notcannot be used as thea basis for denying
eligibility to an applicant who has provided a SSN. If a SSN is unavailable,
other proof of income shallmust be accepted.
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(1) Children up to the age of nineteen (19) are not required to furnish an
SSN as a condition of eligibility.
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b.
Limits on Use - Applicants shallmust also be informed that a SSN
canwill be utilized only in the administration of the Medicaid program,
including for use in verifying age and income eligibility.
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c.
Verification - A SSN is verified through an electronic data-match
with the SSA. Applicants (not including children) must provide
documentation of SSN if the data match fails. Acceptable forms of
documentation are identified in 210-RICR-30-00-5 Part 5 of this
Subchapter..
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4.
State Residency - Anyone who is applying for eligibility must be a
resident of the State. Any person living in the State voluntarily, who
intends to reside in Rhode Island for any reason is considered a resident
of the State. Under federal regulations a person does not need a fixed
address in the State to be considered a Rhode Island resident. Therefore,
homelessness is not a bar to eligibility.
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a.
For individuals who are twenty-one (21) years of age or
older,over the age of twenty-one (21), or under the age of twenty-
one (21) and capable of expressing intent as an emancipated or
married individual - If the applicant is not living in an institution, the
state of residence is the state where the applicant is living
voluntarily with the intention to reside; or entered voluntarily with a
job commitment or seeking employment, whether or not currently
employed.
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b.
For individuals under the age of twenty-one (21) who are not
emancipated or married – If the applicant is not living in an
institution, the state of residence is the state where the child/young
adult resides or the state of the parent/care-taker with whom the
child lives. Under the requirements of this provision, tThe
residence of a pregnant women’s person's unborn child is, under
the terms of this provision, the state in which the pregnant women
person resides. A non-citizen pregnant woman person who lives in
Rhode Island is considered to be a resident, irrespective of whether
the woman’s person's immigration status indicates she they areis in
the country permanently or for a limited time (i.e., in the United
States on a temporary visa of any kind).
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c.
For individuals living in institutions - Most Medicaid
applicants living in institutional settings are not included in the
MACC groups.
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d.
Disputes - If there is a dispute over residency for determining
Medicaid eligibility, the applicant is a resident of the state in which
the applicant is physically located. The MAGI standard of the state
where the applicant is physically located applies when determining
eligibility.
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e.
Verification - Self-attestation of the intent to remain in the
State is accepted. Evidence that an applicant is receiving public
benefits in another state may result in a denial of eligibility if paper
documentation of residency is not provided.
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5.
Citizenship and Immigration Status - The citizenship requirements
for Medicaid eligibility for individuals and families in MACC groups vary
depending on the basis of eligibility. Some non-citizens are not eligible for
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Medicaid; some are eligible for Medicaid only after a five (5)- year waiting
period; and some are eligible without a waiting period. Children up to the
age of nineteen (19) are not subject to citizenship requirements to be
eligible for Medicaid, and pregnant people are not subject to citizenship
requirements under CHIP. All applicants, except children, shall must
provide information about citizenship, whether U.S. citizens or lawfully
presentqualified non-citizens., except in the case of children. Under
federal law, non-citizens are categorized into two (2) groups – qualified
and non-qualified non-citizens.
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a.
Non-Citizens Ineligible Except in Emergency Situations
Non-qualified non-citizens. The non-qualified category of
non-citizens includes citizens of other nations who are not
considered to be immigrants under current federal law,
including those in the United States on temporary or time-
limited visa (such as visitors and students) and those who
are present in the country without proper documentation
(includes people with no or expired status).
e.
Non-qualified non-citizens who are adults are not
eligible for Medicaid, except in emergency situations (Part
10-00-3 of this Title). Non-emergency services may be
obtained through Federally Qualified Community Health
Centers. See Rhode Island Community Health Association
at www.richa.org.
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b. Non-Citizens Barred from Medicaid During Five (5)- Year Waiting
Period
Qualified non-citizens. The qualified non-citizens category
includes persons who are citizens of other nations who are
lawfully present in the United States. Qualified non-citizens
are barred from Medicaid for a waiting period of five (5)
years under federal law. Certain exemptions from the bar
apply:
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bc.
Non-Citizens Exempt from the Five (5)- Year Waiting Period
Qualified non-citizen children up to the age of nineteen (19)
who are lawfully present in the United States but who were
born in another nation are eligible for Medicaid as members
of the MACC group for children and young adults. Children
in this subcategory of qualified non-citizens are eligible
during the five (5) year bar under an option contained in Title
XXI, the Children’s Health Insurance Program (CHIP).
Qualified non-citizen pregnant women people are also
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eligible for Medicaid in the MACC group, under an option in
CHIP.
c.
There are several other subcategories of non-citizens
who are exempt from the five (5) year waiting periodbar as
specified in Part 10-00-3 of this Title. All non-exempt
qualified non-citizens are eligible to obtain coverage through
state and federal health insurance marketplaces, such as
HealthSource RI.com in Rhode Island, and may be qualified
for certain tax credits.
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cd.
Non-qualified non-citizens. The non-qualified category of
non-citizens includes citizens of other nations who are not
considered to be immigrants under current federal law, including
those in the United States on temporary or time-limited visa (such
as visitors and students) and those who are present in the country
without proper documentation (includes people with no or expired
status).
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e.
Non-qualified non-citizens who are adults are not eligible for
Medicaid, except in emergency situations (Part 10-00-3 of this
Title). Non-emergency services may be obtained through Federally
Qualified Community Health Centers. See Rhode Island
Community Health Association at www.richa.org.
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df.
Non-qualified non-citizen pregnant women people in the
applicable MACC group are eligible for Medicaid coverage. The
pregnant woman’s person's eligibility is tied to the eligibility of the
baby she they areis carrying. For the purposes of MACC group
eligibility, the baby in utero is deemed to be a United States citizen
and a Rhode Island resident and remains so as a newborn as long
the birth occurs in Rhode Island.
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ge.
Verification of citizenship/immigration status — Adultllny
members of a household who are applying for Medicaid coverage
must shall provide their immigration and citizenship status.
However, , except that no adverse eligibility determination shallwill
be made regardingagainst children up to the age of nineteen ( 19)
for whom citizenship/immigration status is not provided. Non-
applicants are exempt from thise requirement. Any information
provided by an applicant or obtained through electronic verification
under (h) electronically shall onlymust be used only for to verifying
statestatus. Under the ACA, citizenship and immigration status are
verified:
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h.
Electronically. The Medicaid agency shallmust use electronic
verification through the federal hub (see 210-RICR-30-00-5Part 5 of
this Subchapter) to the full extent feasible through:
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(1)
Social Security Administration (SSA) or RI
Department of Health, Division of Vital Statistics for citizens.
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(2)
U.S. Citizenship and Immigration Services (USCIS)
for non–U.S. adult citizens via the Systematic Alien
Verification for Entitlements (SAVE) database.
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i.
Non-electronic. If unable to verify immigration status
electronically, enrollees have an opportunity to provide other
documents or to fix the records.
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j.
Self-Attestation. An applicant’s attestation is accepted
without electronic verification providing appropriate paper
documentation is provided to the Medicaid agency within ninety
(90) days of the eligibility determination. Failure to provide the
required documentation within that period results in a termination of
Medicaid and the initiation of the Medicaid recoupment process.
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6.
Relationship - The State evaluates the relationship of household
members applying for the MACC group for families and parent/caretakers
using the following:
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a.
Caretaker Relative - For the purposes of MACC group
eligibility, parent/caretaker is any adult living with a Medicaid-
eligible dependent child who has assumed primary responsibility for
that child. This definition includes, but is not limited to:
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(1)
Parent, grandparent, sibling, stepparent, stepsibling,
Father, mother, grandfather, grandmother, brother, sister,
stepfather, stepmother, stepbrother, stepsister, uncle, aunt,
first cousin, nephew or niece;
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(2)
The spouse of such parent or relative, even after the
marriage is terminated by death or divorce; or
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(3)
Another relative of the child based on blood, adoption
or marriage; domestic partner of parent or other caretaker
relative. If the parents are in the household, it is presumed
that other members in the household are not assuming
primary responsibility for the child’s care.
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(4)
Dependent child - For the purposes of determining
eligibility the members of the MACC group for families and
parents/caretakers, a dependent child is a child under the
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age of eighteen (18) or under the age of nineteen (19) if
enrolled full-time in school.
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b.
Verification - Self-attestation on the application is accepted
as verification of relationship, except for deeming of newborns.
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1.7
MACC and Non-MAGI Special Eligibility Categories
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A.
Deemed Newborn Eligibility - Babies born to Medicaid-eligible pregnant
women people who are residents of Rhode Island are deemed eligible from the
date of birth. Once deemed eligible as a newborn, the infant remains eligible for
one (1) year and, as such, is a non-MAGI eligibility pathway. Accordingly,
retroactive coverage is available for periods prior to the application date, ifdate if
the newborn was otherwise deemed eligible. The Medicaid-eligible parent of the
newborn must comply with the following:
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1.
Enumeration - The parent/caretakerparents of a newborn must
obtain a SSN for a newborn. Failure to enumerate the child results in a
sanction against the parent/caretaker mother, not the child. The child will
remain eligible even if lacking an SSN because of parent/caretaker
mother's failure to cooperate. The sanction against the parent/caretaker
mother is loss of theirher eligibility for failure to cooperate. This sanction
will be removed once the parent/caretaker mother meets the enumeration
requirements; or
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2.
Record of birth - If the newborn’s SSN is not provided at birth,
Medicaid eligibility is provided under the parent/caretaker mother’s SSN if
the hospital record of birth is submitted by the parent/caretakers. The
hospital record of birth is a written document indicating that the newborn
was discharged in the mother's parent/caretaker's care and information
related to date of birth and verifying citizenship. The hospital record of
birth must be signed by the appropriate authorized representative of the
hospital. If the infant was not born in a hospital, proof of application for an
SSN, self-attestation and signed attestation of an attending health provider
or birthing assistant may be accepted as a record of birth.
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3.
Verification - The birth may be reported by the
parent/caretakermother, or another family member or friend, the
parent/caretaker mother’s Medicaid managed care plan, or the hospital in
which the child was born. See § 1.7(A)(2) of this Part above for
information pertaining to the hospital record of birth.
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B.
Federal law and regulations prohibit the use of federal matching funds for
health care provided on the premises of correctional facilities to otherwise
MACC-eligible persons while incarcerated. Accordingly, full Medicaid health
coverage of such persons is suspended during periods of incarceration. While
the suspension remains in effect, the State is responsible for reimbursing costs
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related to acute care hospital stays of twenty-four (24) or more hours, but only
when the otherwise Medicaid-eligible incarcerated person receives that care off
the premises of the correctional facility.
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1.
Reinstatement upon Release. Medicaid health coverage that has
been suspended due to incarceration must be reinstated promptly by the
Medicaid agency upon the person’s release from a correctional facility.
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2.
Residency. Suspension of Medicaid health coverage is limited to
Rhode Island residents while incarcerated in correctional facilities.
Medicaid health coverage for Rhode Islanders incarcerated in the
correctional facilities of other states or in a federal penitentiary is
terminated in accordance with the residency requirements set forth herein.
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C.
Infants. An infant born to an incarcerated pregnant woman person with
suspended eligibility is treated as a deemed newborn in accordance with Subpart
A above and is qualified to receive Medicaid health coverage until the end of the
month of the infant’s first birthday.
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D.
Hospital Presumptive Eligibility - Under the implementing regulations for
the federal Affordable Care Act at 42 C.F.R.§ 435.1110, states must offer
Medicaid coverage to individuals who are not already Medicaid members for a
limited period. This form of “presumptive eligibility” is only available in certain
circumstances when a qualified hospital determines, on the basis of preliminary
information, that an individual has the characteristics for Medicaid eligibility. Such
individuals are “presumed eligible” for Medicaid until the end of the following
month or the date full eligibility is determined, whichever comes first. The State
makes presumptive eligibility available to persons who have been determined by
a qualified hospital to meet the characteristics of one of the MACC groups
eligible for Title XIX coverage. Persons eligible under CHIP are excluded. See
“Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals”
promulgated by EOHHS for additional detail on the provisions governing hospital
presumptive eligibility determinations in Rhode Island.
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E.
Section 1931 Extended/ Transitional Medicaid – Families eligible for
Medicaid under section 1931 of Title XIX, the federal Medicaid law, may be
eligible for an extension of Medicaid (referred hereinafter to “extended” Medicaid)
for up to twelve (12) months when their family income exceeds the Section 1931
family eligibility ceiling. Although extended Medicaid is considered a non-MAGI
pathway, families eligible under Section 1931 are a MACC coverage group. As
such, their initial eligibility is determined using the MAGI standard and they are
renewed on that basis until their income increases to the family limit of 116
percent of the FPL. Extended Medicaid is only one of several Medicaid coverage
options available to members of a household that no longer meets Section 1931
income requirements. There are MACC group and, some instances, IHCC group
and commercial insurance alternatives through HealthSource RI that may be
more beneficial and/or appropriate for family members losing Section 1931
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coverage. However, all these beneficiaries are evaluated for extended Medicaid
along with these other alternatives before Sections 1931 coverage is terminated.
Requirements for extended Medicaid are as follows:
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1.
Initial Eligibility Criteria - At the time a family becomes ineligible for
Section 1931 Medicaid benefits, the State must verify and confirm,
whether:
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2.
The family has a child living in the home who is under the age of
eighteen (18) or between the age of eighteen (18) and nineteen (19) if the
child is a full-time student in a secondary school, or at the equivalent level
of vocational or technical training, and is reasonably expected to complete
the program before or in the month of his/her nineteenth (19th) birthday. A
student attending summer school full time, as defined by school
authorities, is considered a full-time student for these purposes; and
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3.
Eligibility for Section 1931 Medicaid coverage was discontinued
because of earned income of a parent /caretaker or other member of the
family due to: employment; increased hours of employment; or an
increase in wages.
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4.
Extended Medicaid is not provided to any beneficiary who has been
legally determined to be ineligible for cash assistance because of fraud at
any time during the last prior six months in which the family received
benefits.
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5.
Notice Requirements - A notice is sent informing the family of the
right to extended Medicaid for up to the maximum of twelve (12) months.
The notice also sets forth the following beneficiary responsibilities. The
family must:
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a.
Submit a report which includes an accounting of the family's
earned income and the "necessary child care" expenses;
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b.
Enroll in an employer's health plan (whether individual or
family coverage) if it is offered at no cost to the parent / caretaker in
accordance with the provisions related to the Rite Share Premium
Assistance Program set forth in Part 30-05-3 of this Title; and
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c.
Report circumstances which could result in the
discontinuance of extended benefits (e.g., no age appropriate child
in the family or a move out-of-state).
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6.
Loss of Benefits Due to Employment - To receive extended
Medicaid is employment of a parent / caretaker or other member(s) of the
family whose earned income contributes to the family's loss of eligibility for
Section 1931 Medicaid. Often employment linked with other changes,
such as a parent returning to the home or a child turning eighteen, may
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combine to cause the loss of eligibility. While there must be a relationship
between earned income and the loss of eligibility for Section 1931
Medicaid to qualify for extended Medicaid, the advent or increase in
earned income need not be the only factor causing the loss.
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7.
Beneficiaries Eligible for Extended Medicaid - The first month of
extended Medicaid is the first full or partial month in which the family loses
eligibility for Medicaid health care coverage under Section 1931, but only
in those instances in which eligibility under any other Medicaid coverage
group is unavailable. If the family is eligible for Medicaid State Plan or
waiver coverage, extended Medicaid will be denied.
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8.
Extended Medicaid is provided to those beneficiaries who:
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a.
Are living in the household, and whose needs and income
were included in determining Section 1931 eligibility of the
assistance unit at the time such benefits were discontinued;
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b.
Have needs and income would be taken into account in
determining Section 1931 Medicaid eligibility using the MAGI
standard if the family were applying for either of these programs in
the current month. A child born after Section 1931 benefits are
discontinued, or a child, parent or step-parent who returns home
after Section 1931 benefits are discontinued, is included as a
member of the family for purposes of providing extended Medicaid.
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9.
Receipt of Extended Medicaid - Extended Medicaid continues
throughout the first seven (7) months following the loss of Section 1931
Medicaid eligibility unless:
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a.
No age-appropriate child is living in the family; or
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b.
The parent / caretaker refuses to apply for health coverage
offered by the employer.
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10.
When it is determined that a family no longer has a child who meets
the age requirements living in the home, Medicaid for all family members
ends the last day of the month in which the family no longer includes such
child.
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11.
Continuation of Extended Medicaid - To continue to receive the
remaining months of extended Medicaid, up to the limit of the full twelve
months of the transitional medical program, families must:
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a.
Include a child who meets the age requirement living in the
household; and
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b.
Timely file the earned income report when due in the
seventh (7th) month; and
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c.
Pass the 175 percent of the FPL earned income test; and
pass the parent / caretaker employment test.
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12.
Failure to Meet Continuation Requirements - If the family fails to
pass the income test, the Medicaid agency discontinues extended
Medicaid benefits on the last day of a reporting month.
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13.
Limits - The maximum amount of time under the extended Medicaid
program is limited to twelve (12) months. The Medicaid agency must
provide a notice of closing if eligibility is discontinued prior to the receipt of
the maximum time allowed under the program's twelve (12) month time-
limited benefits. Eligibility is always discontinued on the last day of a
month.
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14.
Good Cause - A family may have reason to claim good cause for
failure to comply with required action. Good cause may exist for any of
the following which may lead to the termination of extended Medicaid:
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a.
Failure to timely submit an earned income report;
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b.
Failure of the parent / caretaker to be employed;
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c.
Failure to comply with any extended Medicaid requirements
other than the above;
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d.
Failure to submit the earned income report or to include
appropriate verifications, may exist if circumstances beyond the
recipient's control prevent the requirement from being met when
due.
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e.
Good cause includes circumstances beyond the
beneficiary’s control, such as, but not limited to: involuntary loss of
employment; illness or incapacity; unanticipated household
emergency; work demands or conditions that render continued
employment unreasonable, such as working without being paid on
schedule.
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15.
Discontinuing Extended Medicaid - Notice from the State is
required if a family becomes ineligible for Section 1931 Medicaid for
reasons related to employment.
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16.
Prior to termination of extended Medicaid, each member of the
family is evaluated for Medicaid coverage in every other possible MACC
and IHCC group category as well as for commercial coverage subsidized
by the federal and/or State government offered through HealthSource RI,
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the State’s health insurance market. Notice to the beneficiary indicates
the alternative forms of coverage available and how to enroll or if
additional information is required to determine whether eligibility for these
other cover options exists.
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F.
Children with Special Circumstances
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1.
This category includes children and youth who are or were in the
care and custody of the RI Department of Children, Youth and Family and,
by virtue of that status, are automatically eligible for Medicaid without a
MAGI-based income determination. They are included in this rule as they
share the characteristics of the MACC group coverage group for children
and youth though eligible through a non-MAGI pathway. However,
members of these groups may be eligible for up to ninety (90) days of
retroactive coverage prior to the eligibility date.
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2.
The DCFY is responsible for certifying the eligibility of children and
youth in the coverage group and in making the referral for Medicaid to the
appropriate unit of the designated State agency and for notifying the
agency when there is a change in circumstances that may affect a child’s
Medicaid eligibility, coverage, or service delivery options. The change in
circumstance could be related to placement, the child’s financial status, or
a return to the family and/or termination of participation in the applicable
programs. Prior to any change that may result in the end of Medicaid
eligibility, the DCYF must ensure that the beneficiary and/or his/her family
or guardians are aware that alternative forms of Medicaid are available
and provide assistance as appropriate.
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3.
Adoption Subsidy/IV-E Foster Children - This non-MAGI coverage
group is the eligibility pathway for children in DCYF substitute care under
the authority of Title IV-E of the U.S. Social Security Act. The coverage
group includes foster children, children in kinship guardianship care and
adopted children whose Medicaid eligibility is based on participation in the
following DCYF administered, Title IV-E programs:
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a.
The Foster Care Maintenance Program - This Program
provides federally funded foster care payments on behalf of the
following children: Children previously eligible under the federal
Title IV-A Foster Care Maintenance Program; Certain children
voluntarily placed or involuntarily removed from their homes; and
Children in public non-detention type facilities housing no more
than twenty-five (25) children. Children for whom a cash payment is
made under the foster care program are deemed eligible for
Medicaid. Medicaid eligibility for children in the Foster Care
Maintenance program exists as long as the Title IV-E payment
continues to be made for them or up to the age of twenty-one (21) if
still in foster care.
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b.
The Adoption Assistance Program - The Title IV-E
authorized and funded adoption assistance program provides
federal funding for continuing payments for hard-to-place children
with special needs. Children in this Program must be SSI
beneficiaries at the time of adoption. An adoption subsidy cash
payment is not a necessary condition of Medicaid eligibility for
these adoption assistance children. They continue to be eligible for
Medicaid as long as a Title IV-E adoption assistance agreement is
in effect. An interlocutory order or final decree also need not exist.
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c.
Residency requirements - Title IV-E adoption assistance
children, kinship guardianship assistance children, and Title IV-E
foster care children are eligible for Medicaid in their states of
residence. Accordingly, Rhode Island is required to provide
Medicaid coverage to children eligible under this pathway as long
as they remain residents of the State and under the care and
custody of DCYF, even if services are being provided in a
jurisdiction of another state.
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4.
Non IV-E Foster Child Under 18 - This coverage group includesis
children under the age of eighteen (18), or if a child is eighteen (18) years
old 18, the child will complete high school before their his/her nineteenth
(19th) birthday, who are in foster family care or in a kinship guardianship
care and are not eligible for Title IV-E.
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5.
Non IV-E, State Adoption Assistance - This coverage group is hard-
to-place children for whom the state provides adoption/guardianship
assistance and who are not eligible for Title IV-E. The basis of eligibility
for Medicaid is deprivation of parental support occasioned by the child's
separation from his/her family.
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6.
The determination of financial need. When a child is not living in a
home maintained by the child's parents, the State considers only the
child's own income and resources.
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7.
Age Limit. Medicaid under this coverage group may be provided
until the child reaches the age of twenty-one (21).
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8.
Post Foster Care Medicaid Eligibility - The Foster Care
Independence Act of 1999 established the John H. Chafee Foster Care
Independence Program (42 U.S.C. § 1396a(a)(10)). This Medicaid
eligibility pathway is open to youth who were in foster care in Rhode Island
on their eighteenth (18th) birthday. Medicaid eligibility for youth qualifying
for this coverage continues until the age of twenty-six (26) years old as
long as the individualsy remain residents of the State.
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a.
Living arrangement. A post foster care adolescent may be
residing independently or with others (including family members).
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b.
Renewal. A renewal of Medicaid eligibility is completed once
in a twelve (12) month period to ensure that the beneficiary eligible
in this group is a resident of Rhode Island.
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c.
Limits. Under the terms of the Chafee Act, young adults may
only qualify for Medicaid under this group if not otherwise eligible
through SSI or as aged, blind or disabled and/or in need of long
term services and supports. In addition, although eligible for the full
scope of Medicaid State Plan and Section 1115 waiver services
available to all adults, the EPSDT benefit for children continues up
to the age of twenty-one (21) only.
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1.8
Cooperation Requirements
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A.
All applicants and beneficiaries subject to this Part must cooperate with an
array of requirements as a condition of obtaining or retaining (post-eligibility)
eligibility. Specific requirements related to application and renewal are located in
Part 3 of this Subchapter and for the purposes of evaluating and verifying income
are set forth in Part 5 of this Subchapter.
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B.
Cooperation requirements applicable across populations are as follows:
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1.
Third Party Liability (TPL) - Third Party Liability refers to any
individual, entity (e.g., insurance company) or program (e.g., Medicare)
that may be liable for all or part of a Medicaid applicant’s coverage. Under
Section 1902(a)(25) of the Social Security Act, the State is required to
take all reasonable measures to identify legally liable third parties and
treat verified TPL as a resource of the Medicaid beneficiary once
determined eligible. Applicants/beneficiaries must furnish information
about all sources of TPL. The State and Medicaid managed care
organizations, under contractual agreements with the State, are
responsible for identifying and pursuing TPL for beneficiaries covered by
employer-sponsored health insurance plans through the RIte Share
program. Failure to cooperate with the TPL requirement or to enroll in a
RIte Share plan as required in Part 30-05-3 of this Title results in the
ineligibility of the parent.
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2.
Referral to Office of Child Support Services (OCSS) - All applicants
reporting an absent parent are referred to the Office of Child Support
Services within the Department of Human Services, once they have been
determined eligible for Medicaid and received appropriate notice.
Compliance with the OCSS requirement is a condition of retaining
eligibility. As a condition of eligibility, an applicant who can legally assign
rights for a dependent child born out of wedlock is required to do so and
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cooperate in establishing the paternity parentage of that child for the
purposes of obtaining medical care support and medical care payments
for both the applicant and the child. Failure to cooperate in assigning
rights results in a determination of ineligibility for the parent, unless a good
cause exemption has been granted by the State. In instances when
domestic violence may be the basis for an exemption to the cooperation
requirement, referral to the Family Violence Option Project may be made
to assist the parent seeking an exemption.
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3.
RIte Share Premium Assistance Program - Individuals and families
determined to have access to cost-effective employer-sponsored health
insurance (ESI) are required to enroll in the ESI plan if so directed by the
State. Members of the MACC groups with access to ESI who are eligible
for Medicaid will be permitted to enroll in a Medicaid managed care plan,
as appropriate. The Medicaid agency will conduct a post-enrollment
review of those members with access to ESI to determine whether
participation in RIte Share is required. The provisions governing the RIte
Share program are located in Part 30-05-3 of this Title.
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C.
Duty to Report - All Medicaid applicants and beneficiaries have a duty to
report changes in income, family size, address, and access to ESI within ten (10)
days of the date the change takes effect. Failure to make timely reports may
result in the denial or discontinuation of Medicaid eligibility.
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D.
A Medicaid applicant or member must have the opportunity to claim good
cause for refusing to cooperate. Good cause may be claimed by contacting a
DHS or EOHHS agency representative. To claim good cause, a person must
state the basis of the claim in writing and present corroborative evidence within
twenty (20) days of the claim; provide sufficient information to enable the
investigation of the existence of the circumstance that is alleged as the cause for
non-cooperation; or, provide sworn statements from other individuals supporting
the claim.
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E.
Basis for Claim. A determination of good cause is based on the evidence
establishing or supporting the claim and/or an investigation by Medicaid agency
staff of the circumstances used as justification for the claim of good cause for
non-cooperation.
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F.
State Requirements. The determination as to whether good cause exists
must be made within thirty (30) days of the date the claim was made unless the
agency needs additional time because the information required to verify the claim
cannot be obtained within the time standard. The person making the claim must
be notified accordingly, provided with the reason for the decision, and the right to
appeal through the EOHHS Administrative Fair Hearing Process specified in Part
10-05-2 of this Title.
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G.
A Medicaid beneficiary may terminate Medicaid eligibility at any time.
Such requests must be made in writing and submitted to a state agency or HSRI
representative in-person, via U.S. Mail, fax, on-line via the beneficiary’s secure
account, or made by telephone to HSRI when telephonic recording capabilities
exist. The Medicaid agency is responsible for providing the Medicaid beneficiary
with a formal notice of the voluntary termination of Medicaid eligibility that
indicates the effective date, the impact of terminating eligibility for each member
of the household, and the right of the beneficiary to reapply for Medicaid health
coverage at any time.
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1.9
Information
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A.
For Further Information or to Obtain Assistance
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1.
Applications for affordable coverage are available online on the
following websites:
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a.
www.eohhs.ri.gov
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b.
www.dhs.ri.gov
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c.
www.HealthSourceRI.com
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2.
Applicants may also apply in person at one of the Department of
Human Services offices or by U.S. Mail. Request an application by calling
1-855-697-4347 and TTY 1-888-657-3173.3. For assistance finding a
place to apply or for assistance completing the application, please call: 1-
855-840-HSRI (4774).
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1.10 Severability
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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.
210-RICR-30-00-1
TITLE 210 - EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES
CHAPTER 30 - MEDICAID FOR CHILDREN, FAMILIES, AND AFFORDABLE CARE
ACT (ACA) ADULTS
SUBCHAPTER 00 - AFFORDABLE COVERAGE GROUPS
PART 1 - MEDICAID AFFORDABLE CARE COVERAGE GROUPS OVERVIEW AND
ELIGIBILITY PATHWAYS (210-RICR-30-00-1)
Type of Filing: Amendment
Agency Signature
_________________________________________________________________
Agency Head Signature
Agency Signing Date
Governor's Signature
____________________________
Signed By
_________________________________________________________________
Governor or Designee
Governor Signing Date
Department of State
____________________________
Regulation Effective Date
_________________________________________________________________
Department of State Initials
Department of State Date
09/27/2022
Eileen Cheng
September 27, 2022
E-SIGNED by Ana Novais
on 2022-09-27 16:11:16 EDT
September 27, 2022
E-SIGNED by Office of the Governor
on 2022-09-27 16:43:23 EDT
September 28, 2022
E-SIGNED by Department of State
on 2022-09-28 08:52:54 EDT