Section 210-RICR-10-00-1.4 - Program AdministrationA. Applications and Eligibility. EOHHS implements a "no wrong door" policy to ensure persons seeking eligibility for Medicaid health care coverage have the option to apply at multiple locations throughout the State and in a manner that is best suited to their needs including, but not limited to, in-person, on-line, by telephone, or by U.S. mail. Application and eligibility information for the MACC groups is located in the Part 30-00-3 of this Title. An overview of the application process for the IHCC groups is located in Part 40-00-1 of this Title. 1. Determinations. EOHHS must make timely and efficient eligibility, enrollment, and renewal decisions. Accordingly, EOHHS or an entity designated by the Secretary for such purposes must review and make eligibility and renewal determinations for Medicaid health care coverage in accordance with applicable State and federal laws, rules, and regulations.2. Timeliness. In general, determinations must be made in no more than thirty (30) days from the date a completed application is received by EOHHS or its designee unless clinical eligibility factors must be considered. In instances in which both clinical and financial eligibility factors are material to the application process, as for eligibility for Medicaid-funded LTSS or coverage for persons with disabilities, determinations must be made in ninety (90) days. Applicable time-limits and other eligibility requirements are set forth in the Rhode Island Code of Regulations, Title 210, in the chapters related to each population Medicaid serves by eligibility coverage groups.3. Cooperation. As a condition of eligibility, the Medicaid applicant/beneficiary must meet certain cooperation requirements, such as providing the information needed for an eligibility determination, taking reasonable action to make income or resources available for support, assigning of rights to medical support or other third-party payments for medical care, or pursuing eligibility for other benefits. Failure to cooperate may result in a denial or termination of eligibility.B. Eligibility Agent -- DHS. The Medicaid State Agency is authorized under Title XIX and federal implementing regulations to enter into agreements with other State agencies for the purposes of determining Medicaid eligibility. EOHHS has entered into a cooperative agreement with the Rhode Island Department of Human Services (DHS) that authorizes the DHS to conduct certain eligibility functions. In accordance with 42 C.F.R. § 431.10(e)(3), the DHS has agreed to carry out these functions in accordance with the Medicaid State Plan, the State's Section 1115 demonstration waiver, and the rules promulgated by EOHHS.C. Written Notice. EOHHS is responsible for notifying an applicant, in writing, of an eligibility determination. If eligibility has been denied, the notice to the applicant sets forth the reasons for the denial along with the applicable legal citations and the right to appeal and request a fair hearing. The Appeals Process and Procedures for EOHHS Agencies and Programs (Subchapter 05 Part 2 of this Chapter) regulations describe in greater detail the appeal and hearing process.D. Mandatory Managed Care Service Delivery. To ensure that all Medicaid beneficiaries have access to quality and affordable health care, EOHHS is authorized to implement mandatory managed care delivery systems. Managed care is a health care delivery system that integrates an efficient financing mechanism with quality service delivery, provides a medical home to assure appropriate care and deter unnecessary services, and places emphasis on preventive and primary care. Managed care systems also include a primary care case management model in which ancillary services are provided under the direction of a physician in a practice that meets standards established by the Medicaid agency. Managed care systems include the Medicaid program's integrated care options such as long-term services and supports and primary care health coverage for eligible beneficiaries. The managed care options for Medicaid beneficiaries vary on the basis of eligibility as follows: 1. Families with children eligible under the Part 30-00-1 of this Title are enrolled in a RIte Care managed care plan in accordance with the Part 30-05-2 of this Title or, as applicable, an employer health plan approved by EOHHS for the RIte Share Premium Assistance Program in accordance with the Part 30-05-3 of this Title unless specifically exempted;2. Adults ages nineteen (19) to sixty-four (64) eligible in accordance with the Part 30-00-1 of this Title are enrolled in a Rhody Health Partners managed care plan in accordance with the Part 30-05-2 of this Title or, as applicable, an employer health plan approved by EOHHS for the RIte Share premium assistance program in accordance with the Part 30-05-3 of this Title unless specifically exempted;3. Elders and adults who are blind or living with a disability and between the ages of nineteen (19) and sixty-four (64) eligible pursuant to Part 40-05-1 of this Title are enrolled in a Rhody Health Partners plan or Connect Care Choice primary care case management practices in accordance with Part 40-10-1 of this Title.4. Persons eligible for Medicaid-funded long-term services and supports in accordance with the Part 50-00-1 of this Title have the choice of self-directed care, fee-for-service, or enrolling for services in PACE, Rhody Health Options, or Connect Care Choice Community Partners in accordance with Part 40-10-1 of this Title.5. Persons eligible as medically needy or as a result of participation in another publicly funded health and human services program may be enrolled in fee-for-service or a managed care plan depending on the basis of eligibility. See exemptions in the Part 30-05-2 of this Title "RIte Care Program" Parts 30-05-2 and 40-10-1 of this Title related to coverage group.E. Waiver eligibility and services. Until 2009, the Medicaid program utilized authorities provided through its RIte Care Section 1115 and multiple Title 1915(c) waivers to expand eligibility and access to benefits beyond the scope provided for in the Medicaid State Plan. At that time, the State received approval from the Secretary of the U.S. Department of Health and Human Services (DHHS) to operate the Rhode Island Medicaid program under a single Section 1115 demonstration waiver. All Medicaid existing Section 1115 and Section 1915(c) waiver authorities have been incorporated into the Medicaid program-wide Section 1115 demonstration waiver, as it has been renewed and extended, since it was initially approved in 2009.210 R.I. Code R. 210-RICR-10-00-1.4
Amended effective 3/17/2024