210 R.I. Code R. 210-RICR-10-00-1.3

Current through December 3, 2024

Section 210-RICR-10-00-1.3 - Purposes and Scope of the Medicaid Program

A. The Rhode Island Medicaid program is the joint federal/state health care program that provides publicly funded health coverage to low-income individuals and families, adults without dependent children age nineteen (19) to sixty-four (64), elders, and persons with disabilities who otherwise cannot afford or obtain the services and supports they need to live safe and healthy lives.

B. Eligibility -- Coverage Groups. A coverage group is a classification of individuals eligible to receive Medicaid benefits based on a shared characteristic such as age, income, health status, and level of need criteria. Pursuant to the authority provided under the Medicaid and CHIP State Plans and the State's Section 1115 demonstration waiver, health coverage, services, and supports are available to individuals and families who meet the eligibility requirements for the following coverage groups:

1. Medicaid Affordable Care Coverage (MACC) Groups - A single income standard - Modified Adjusted Gross Income or "MAGI" - must be used to determine the eligibility of all applicants under the Medicaid affordable care coverage groups, which are as follows:

a. Families with children and young adults, pregnant women, infants and parents/caretakers with income up to the levels sets forth in Part 30-00-3 of this Title;

b. Adults between the ages of nineteen (19) and sixty-four (64) without dependent children who meet the income limits set forth in the Part 30-00-3 of this Title, including any persons in this age group who are awaiting a determination of eligibility for Medicaid on the basis of age, blindness, or disability pursuant to Part 40-05-1 of this Title or receipt of Supplemental Security Income (SSI) pursuant to Part 40-00-3 of this Title;

2. Integrated Health Care Coverage (IHCC) Groups - All applicants for Medicaid who must meet both clinical and financial eligibility requirements or who are eligible based on their participation in another needs-based, federally funded health and human services program are not subject to the MAGI. The State has reclassified these categorically and medically needy populations into coverage groups based on shared eligibility characteristics, level of need, and/or access to integrated care options as follows:

a. Adults between the ages the ages of nineteen (19) and sixty-four (64) who are blind or disabled and elders age sixty-five (65) and older who meet the financial and clinical eligibility for Medicaid-funded coverage established pursuant Part 40-05-1 of this Title;

b. Persons of any age who require long-term services and supports in an institutional or home and community-based setting who meet the financial and clinical criteria established pursuant to the Parts 50-00-6 and 50-00-5 of this Title, respectively, or in the case of children eligible under the Katie Beckett provision, who meet the criteria in the Part 50-10-3 of this Title;

c. Individuals eligible for Medicaid-funded health coverage on the basis of their participation in another publicly funded program including children and young adults receiving services authorized by the Department of Children, Youth and Families and persons of any age who are eligible on the basis of receipt of SSI benefits.

d. Medically needy individuals who meet all the eligibility criteria for coverage except for excess income. Individuals in this coverage group achieve eligibility by applying a flexible test of income which applies excess income to certain allowable medical expenses thereby enabling the individual to "spend down" to within a medically needy income limit (MNIL) established by the Medicaid agency.

e. Low-income elders and persons with disabilities who qualify for the Medicare Premium Payment Program (MPP) authorized by the Title XIX. Medicaid pays the Medicare Part A and/or Part B premiums for MPP beneficiaries.

C. Benefits. Medicaid beneficiaries are eligible for the full scope of services and supports authorized by the Medicaid State Plan and the Section 1115 demonstration waiver.

1. General scope of coverage. Although there is variation in benefits by coverage group, in general Medicaid health coverage includes the following:

Doctor's office visits	Home health care
Immunizations	Skilled nursing care
Prescription and over-the-counter medications	Nutrition services Interpreter services
Lab tests	Childbirth education programs
Residential treatment	Prenatal and post-partum care
Behavioral health services	Parenting classes
Drug or alcohol treatment	Smoking cessation programs
Early and Periodic, Screening, Detection and Treatment (EPSDT)	Transportation services Dental care
Referral to specialists	Expedited LTSS
Hospital care	Organ transplants
Emergency care	Durable Medical Equipment
Urgent Care
Long-term Services and Supports (LTSS) in home and community-based and health care institutional settings such as nursing homes

2. EPSDT. Title XIX authorizes Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for all Medicaid beneficiaries who are under age twenty-one (21) for the purposes of identifying and treating behavioral health illnesses and conditions. Medically necessary EPSDT services must be provided irrespective of whether they are within the scope of Medicaid State Plan covered services.

3. Limits. Certain benefits covered by the Medicaid State Plan or the State's Section 1115 waiver are subject to limits under federal and/or State law. Program-wide benefit limits are set forth in § 1.5 of this Part. Limits and restrictions applicable to specific coverage groups are located in the rules describing the coverage group and service delivery.

210 R.I. Code R. 210-RICR-10-00-1.3

Amended effective 3/17/2024