210 R.I. Code R. 210-RICR-10-00-3.10

Current through December 3, 2024

Section 210-RICR-10-00-3.10 - Cooperation Requirements

A. As a condition of eligibility, all Medicaid applicants and beneficiaries must meet certain cooperation requirements which enable to State to meet Federal laws, Rules and Regulations related to obtaining and retaining Federal matching funds for the program.

1. General cooperation requirements - Applicants and beneficiaries must:

a. Application information. Provide any information requested by the State that is necessary to determine eligibility for Medicaid;

b. Assignment of rights. Medical support or other third-party payments for health care services must be assigned to the State. An applicant must also assign to the EOHHS any third-party payments for any other household members eligible under the Medicaid and CHIP State Plan and/or Section 1115 demonstration waiver for whom he or she has the legal authority under State law to make such an assignment. This assignment obligation takes effect under State law upon an applicant's filing for Medicaid;

c. Child support. Cooperate in establishing paternity and obtaining support, except when an exemption exists, with the State's Office of Child Care Enforcement. Exemptions exist for pregnant women with no other children until the birth of the child, parent/caretakers in child-only application cases, and children in general. The State does not deny initial eligibility to an adult applying for Medicaid pending cooperation with the child support requirement. However, termination of eligibility is initiated if an adult applicant or beneficiary does not cooperate by the time of the first periodic electronic verification;

d. Enrollment in RIte Share. An applicant with access to cost-effective employer-sponsored insurance (ESI) must enroll in the plan as a condition of eligibility. Medicaid-eligible children are not denied eligibility or subject to the loss of coverage, if their parent/caretakers with access to coverage do not cooperate and enroll in the approved plan. Specific provisions governing the RIte Share program are located in Part 30-05-3 of this Title;

e. Alternative sources of support and assistance. Take all reasonable actions to make income/resources available to meet needs. A reasonable action is one that will likely result in more financial benefit accruing to a household than the cost of Medicaid coverage. In addition, for eligibility to continue to exist, a beneficiary who claimed that income or resources owned by or owed to him or her are unavailable must show a good faith effort to continue to take reasonable actions unless the State approves a good cause exemption made in writing. Reasonable actions include, but are not limited to:

(1) Filing applications for other benefits to which an applicant/beneficiary may be entitled including, but not limited to, State and federally-funded health care and cash assistance programs and income tax credits and private or public retirement benefits, food assistance, or supplemental insurance;

(2) Making formal requests to other joint owners to sell or otherwise liquidate jointly held property;

(3) Requesting guardians, trustees, and other legally authorized representatives to make resources or income available from estates, trusts, settlements, and other financial instruments;

(4) Retain counsel to petition a court to adjudicate any monetary or property claim which the client may have against any person; and

(5) Report to the State at the time of renewal or more frequently upon request progress being made toward making the resource or income available for use.

f. Quality Assurance. Assist the State by providing full cooperation in any quality assurance and/or program integrity activities.

2. Third-party liability - All applicants and beneficiaries must identify and provide information about third-party payers liable for Medicaid covered services and supports and, as required in § 3.10(A)(1) of this Part above, assign rights to payments. Beyond cooperating in this manner, the State generally pursues third-party liability without further assistance from the beneficiary. However, the State may require a beneficiary to:

a. Appear at a designated State or local office to provide information or evidence relevant to the case;

b. Serve as a witness at a court or other proceeding;

c. Provide information, or attest to lack of information, under penalty of perjury;

d. Pay to the State any support or medical care funds received that are covered by the assignment of rights; and

e. Take any other reasonable steps to assist in establishing paternity and securing medical support and payments and in identifying and providing information to assist the State in pursuing any liable third party.

B. Non-cooperation with any requirement that is a condition of eligibility may result in the denial or termination of Medicaid eligibility for applicants and beneficiaries nineteen (19) years of age or older unless specifically exempt in Federal or State laws or the Rules and/or Regulations established under this Title. Such exemptions are identified, as appropriate, in the Chapters of this Title pertaining to each coverage category as indicated in § 3.6(B)(1) of this Part above.

210 R.I. Code R. 210-RICR-10-00-3.10

Adopted effective 12/29/2022