210-RICR-30-10-1. Rhode Island Affordable Health Care Coverage Assistance Program (version Adoption, 12/31/2013 to 02/01/2018)

State of Rhode Island and Providence Plantations Executive Office of Health & Human Services Access to Medicaid Coverage Under the Affordable Care Act Section 1315: Rhode Island Affordable Health Care Coverage Assistance Program December 2013 i Rhode Island Executive Office of Health and Human Services Access to Medicaid Coverage Under the Affordable Care Act Rules and Regulations Section 1315: Rhode Island Affordable Health Care Coverage Assistance Program TABLE OF CONTENTS Section Number Section Name 1315: Rhode Island Affordable Health Care Coverage Assistance Program Page Number 1315.01 Overview 1 1315.02 Scope and Purpose 1 1315.03 Definitions 1 1315.04 Eligibility Requirements 2 1315.05 Application Process 2 1315.06 Eligibility Approval – Premium Amount 3 1315.07 Notice 3 1315.08 Payment of Subsidies 3 1315.09 Duration and Continuing Eligibility 3 1315.10 Termination or Denial of Participation 4 1315.11 Hearing and the Right to Appeal 4 1315.12 For Further Information/Assistance 4 1315.13 Severability 4 ii Introduction These rules related to Access to Medicaid Coverage Under the Affordable Care Act, Section 1315 of the Medicaid Code of Administrative Rules entitled, “Rhode Island Affordable Health Care Coverage Assistance Program” are promulgated pursuant to the authority set forth in Rhode Island General Laws Chapter 40-8 (Medical Assistance), including Public Law 13-144; Title XIX of the Social Security Act; Patient Protection and Affordable Care Act (ACA) of 2010 (U.S. Public Law 111-148); Health Care and Education Reconciliation Act of 2010 (U.S. Public Law 111- 15); Rhode Island Executive Order 11-09; and the Code of Federal Regulations 42 CFR Parts 431, 435, 436 et. seq. Pursuant to the provisions of §42-35-3(a)(3) and §42-35.1-4 of the General Laws of Rhode Island, as amended, consideration was given to: (1) alternative approaches to the regulations; (2) duplication or overlap with other state regulations; and (3) significant economic impact on small business. Based on the available information, no known alternative approach, duplication or overlap was identified and these regulations are promulgated in the best interest of the health, safety, and welfare of the public. 1 1315 Rhode Island Affordable Health Care Coverage Assistance Program 1315.01 Overview RIGL §40-8.12-3 (as contained in Public Law 13-144) 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 parents/caretakers who are not otherwise eligible for Medicaid through the newly established RI Affordable Health Care Coverage Assistance Program (AHCCA). 1315.02 Scope and Purpose Effective January 1, 2014, parents/caretakers of Medicaid-eligible children in households with incomes below 175% FPL who are not Medicaid eligible themselves can apply for financial assistance paying for health insurance coverage accessed through HealthSource RI. 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. 1315.03 Definitions For the purposes of this rule, the following definitions apply: “Affordable Care Act (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. “APTC/CSR eligibility” APTC/CRS eligibility means the application of the IRS-based measure of income known as “Modified Adjusted Gross Income” 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. “HealthSourceRI” 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. “Parent or Caretaker or Caretaker relative” means any adult over age nineteen (19) living with a Medicaid-eligible dependent child that has assumed primary responsibility for that child as defined in MCAR section 1305.13. 2 “Qualified Health Plan” means a health plan certified by HealthSourceRI that provides essential benefits and meets all other related ACA requirements to be offered through the State’s health benefits exchange. “Silver Plan” means a qualified health plan offered through HealthSourceRI that covers about 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. 1315.04 Eligibility Requirements Parents/caretaker relatives must meet certain requirements related to income, health coverage, and relationship to be eligible to participate in the Affordable Health Care Coverage Assistance program. Coverage through HealthSourceRI is also a condition of eligibility. 01. Eligibility -- The requirements are as follows: (01) Income. Household income at or under 175% of the FPL. (02) Health Coverage. Parents/Caretakers must not be otherwise eligible for Medicaid. (03) Relationship. Parents/Caretakers need to have primary responsibility for a Medicaid- eligible child. 02. Plan enrollment – AHCCA financial assistance will be available only if the applicant has enrolled in a Silver Plan through HealthSoureRI. 1315.05 Application Process Parents/caretakers must make application for the AHCCA through the EOHHS. 01. Applicant’s Responsibilities – To obtain assistance, applicants must submit a request to EOHHS. Application forms will be available at the HealthSourceRI Contact Center located at: 70 Royal Little Drive Providence, RI 02904 or at www.eohhs.ri.gov or www.healthsourceri.com. Applicants must also provide demographic information and information regarding enrollment in a Qualified Health Plan through HealthSource RI. 02. State’s Responsibilities -- The Medicaid agency must review and determine eligibility for financial assistance within sixty (60) days. If additional information is needed by the Medicaid agency, a new review period will begin once the additional information has been received. 3 1315.06 Eligibility Approval – Premium Amount If a parent/caretaker is approved, the Medicaid agency calculates the amount of AHCCA financial assistance in accordance with the following chart: Rhode Island Affordable Health Care Coverage Assistance Program Assistance after January 2014 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 1315.07 Notice The EOHHS must send a notice to the parent/caregiver relative with an eligibility determination for AHCCA. If eligibility exists, the notification must include the amount of the subsidy. Notice of denial must state the reasons for the disapproval of the application. All notices must include a statement of the rights of the parent/caregiver applicant. 1315.08 Payment of Subsidies The payment options for the AHCCA subsidy include the following: • Option 1 -- The parent/caretaker pays the premium due to the insurer. EOHHS or its agent either mails a check or electronically transfers payment to the bank or account of parent/caretaker relative on a monthly basis. • Option 2 – The AHCCA payment is made to the insurer and is deducted from the amount the parent/caretaker is required to pay to the insurer. 1315.09 Duration and Continuing Eligibility 01. Period of eligibility -- Eligibility for the AHCCA subsidy is for a twelve (12) month period. 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 parent/caretaker. Continuation of the subsidy must be reconsidered if such a change occurs, if eligibility under section 1315.04 still applies, AHCCA financial assistance continues. 4 02. Notice – The EOHHS must provide notice to the eligible parent/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 1315.10. 1315.10 Termination 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 section 1315.04. 1315.11 Hearing and the Right to Appeal The 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: • A determination that an applicant disapproved for AHCCA participation and the basis for the decision of ineligibility; • The amount of assistance determined; • Termination of eligibility to participate in the AHCCA. 1315.12 For Further Information or to Obtain Assistance See the following websites: • www.eohhs.ri.gov • www.HealthSourceRI.com 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). 1315.13. Severability 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.