Section 210-RICR-10-05-2.1 - Purpose, Scope and Applicability2.1.1LEGAL AUTHORITYA. The Rhode Island Executive Office of Health and Human Services (EOHHS) was established in 2006 within the executive branch of state government and serves as the principal agency of the executive branch for the purposes of managing the Departments of Children, Youth, and Families (DCYF); Health (RIDOH); Human Services (DHS); and Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH). The EOHHS is designated as the "single state agency," authorized under Title XIX of the U.S. Social Security Act (42 U.S.C. § 1396a et. seq.) and, as such, is legally responsible for the program / fiscal management and administration of the Medicaid Program.B. Although the four (4) state agencies under EOHHS (DCYF, RIDOH, DHS, and BHDDH) maintain the authority to execute their respective administrative powers and duties in accordance with state law, R.I. Gen. Laws § 42-7.2-6.1(2) transferred to the EOHHS the principal responsibility for "legal services including applying and interpreting the law, oversight of the rule making process, and administrative duties and any related functions and duties deemed necessary by the secretary" for all publicly funded health and human services. It is in this capacity that the EOHHS is authorized and designated by state law to be the entity responsible for appeals and hearings related to the publicly-funded health and human services programs identified in § 2.1.3 of this Part below. EOHHS has been authorized as the designated exchange appeals entity pursuant to the Rules and Regulations Pertaining to Health Source RI, 220-RICR- 90-00-1.2.1.2PURPOSEThe purpose of this rule is to set forth the respective roles and responsibilities of the EOHHS and beneficiaries pertaining to the exercise and protection of the right to dispute certain agency actions by filing an appeal to request an administrative fair hearing.
2.1.3SCOPE AND APPLICABILITYA. In accordance with R.I. Gen. Laws § 42-7.2-6.1, the provisions of this rule apply to both applicants for and beneficiaries of publicly funded health and human services programs administered by the agencies operating under the EOHHS umbrella as well as to providers and other interested parties who may be affected by any actions they take. 1. Scope. The EOHHS is authorized by law, regulation, or directive of the Secretary to manage the appeals and hearing process for the agencies under its jurisdiction and such agencies as delegated to EOHHS. The EOHHS is also authorized to act as the appeal entity for transfers and discharges from licensed nursing facilities and assisted living residences for all payers. The rule covers both the appeal and hearing processes. The rule is organized as follows: a. Section 2.1 - Purpose, Scope, and Applicability. In addition to establishing the legal basis for the rule and its purpose, scope, and application, this part also sets forth the definitions for key terms and processes used throughout the rule.b. Section 2.2 - Appeals Process. General provisions for the appeals process, including appeal filing requirements and procedures, appellant and agency responsibilities, and informal options for resolving an appeal.c. Section 2.3 - Administrative Fair Hearings and Appeal Decisions. This section sets forth the provisions governing the administrative fair hearing process and the disposition of appeals.d. Section 2.4 - Agency/Program Special Provisions. The rule sets forth any agency/program-specific provisions required under applicable federal and/or state laws and regulations. These agency/program specific requirements are noted within the general provisions where applicable unless of such significant scope and effect that it was necessary and appropriate to include them in a separate section of this Part.2. Applicability. The provisions set forth in this rule apply on a statewide basis to the following agencies and programs: a. Rhode Island Works (RIWorks) (See Rhode Island Department of Human Services (DHS) Rules and Regulations)b. Child Care Assistance Program (CCAP) (See DHS Child Care Assistance Program Rules and Regulations, 218-RICR- 20-00-4 )c. Supplemental Nutrition Assistance Program (SNAP), formerly "Food Stamps" (See DHS Rules and Regulations, 218-RICR- 20-00-1)d. Supplemental Security Income and State Supplemental Payment Program, (218-RICR- 20-00-5)e. Office of Child Support Services (OCSS) (See Rhode DHS Rules and Regulations, 218-RICR- 30-00-1). To the extent the OCSS administers a case in Family court, those matters are not governed by or otherwise subject to this rule.f. General Public Assistance Program (GPA) (See DHS "General Public Assistance Program Sections 0600-0626 of the DHS Manual")g. Long-term Ombudsman, Community-Based Services, and Security Housing for the Elderly, Rhode Island Division of Elderly Affairs (DEA) of the DHS, programs and services (R.I. Gen. Laws Chapter 42-66 and DEA Rules, Regulations and Standards Governing the Home and Community Care Services to the Elderly Program (218-RICR- 40-00-4); Rules, Regulations, and Standards for Certification of Case Management Agencies (218-RICR- 40-00-5); Rules and Regulations Governing the Long Term Care Ombudsperson Program (218-RICR- 40-00-1); Rules and Regulations Governing the Prescription Drug Discount Program for the Uninsured (218-RICR- 40-00-6); Rules, Regulations, and Standards Governing the Pharmaceutical Assistance to the Elderly Program (218-RICR- 40-00-2); and Rules, Regulations, and Standards Governing Security for Housing for the Elderly (218-RICR- 40-00-3)h. Vocational Rehabilitation (VR) Program and Services for the Blind and Visually Impaired Program (SBVI), Office of Rehabilitation Services' (ORS) of the Department of Human Services (See DHS "Vocational Rehabilitation Program Regulations," (218-RICR- 50-00-1); "Services for the Blind and Visually Impaired - Social Service/Independent Living Units," (218-RICR- 50-00-2); and "Business Enterprises Program Regulations," (218-RICR- 50-00-3)).i. The RI Veteran's Home, RI Veterans Cemetery, and State Veterans Office of Veterans' Affairs (VA) (See R.I. Gen. Laws Chapter 30-17.1 and Rhode Island Veterans Home: Administrative Procedures for the Billing and Collection of Maintenance Fees (180-RICR- 10-00-2); RI Veterans Memorial Cemetery (180-RICR- 20-00-1); and "Rhode Island Veterans Home: General Rules of the Rhode Island Veterans Home" (180-RICR- 10-00-1))j. Medicaid, including eligibility for and the scope, amount, and duration of any Medicaid-funded health coverage, services, and/or supports authorized by the state's Medicaid State Plan or Title XIX, Section 1115 research and demonstration waiver (See the Executive Office of Health and Human Services (EOHHS), R.I. Gen. Laws § 42-7.2, Rhode Island Medicaid Code of Administrative Rules or MCAR)k. Eligibility appeals, other than Large Employer Appeals, for HealthSource RI, the state's health benefits exchange, pursuant to R.I. Gen. Laws Chapter 42-157.l. Programs and services offered through the Department of Behavioral Healthcare, Development Disabilities, and Hospitals to include individuals with behavioral health care needs and persons with developmental disabilities and any related institutional and home and community-based services as contained in R.I. Gen. Laws Title 40.1, "Rules and Regulations Licensing Procedure and Process for Facilities and Programs Licensed by the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals"; "Rules & Regulations Relating to the Definition of Developmentally Disabled Adult and The Determination of Eligibility as a Developmentally Disabled Adult"; "Rules and Regulations for the Licensing of Behavioral Healthcare Organizations."m. Child protective and behavioral health services, child care, and foster care licensure and any related residential and community-based services. Department of Children, Youth, and Families (DCYF) programs and services as contained in R.I. Gen. Laws Chapter 42-72 and DCYF rules, standards, program policy and procedures. Family and juvenile court matters are not governed by this rule.n. Assisted living residences and nursing facility transfers or discharges for all residents, both Medicaid and non-Medicaid.2.1.4DEFINITIONSA. For the purposes of this rule, the following terms are defined as follows: 1. "Administrative hearing officer" means an impartial official authorized to preside over and decide a hearing involving a contested agency action, without regard to whether the official is an administrative law judge, a hearing officer or examiner, or other person designated by the Secretary to serve in this capacity.2. "Administrative fair hearing" means a formal adjudication of a contested agency action in which an appellant can assert the right to a benefit, service, form of assistance, or good and to secure, in an administrative proceeding before an impartial hearing officer, equity of treatment under federal and state laws, rules, regulations, policies and procedures.3. "Advance notice period" means the period of time prior to the effective date of most types of adverse agency actions. If a person appeals an agency action during this period, benefits or assistance continue or are reinstated until the appeal is resolved. This continuation or reinstatement is sometimes referred to as "aid pending."4. "Adverse action" means a final agency action subject to appeal, including but not limited to: any decision resulting in a change, limitation, termination, or denial of eligibility, the scope, amount, duration or delivery of assistance, the ability to practice or to provide a service, an adverse decision by a managed care entity (after exhausting internal appeals), a decision related to the Pre-Admission Screening Resident Review ("PASRR") Program as contained in 42 C.F.R § 431.201 (2016) or a decision that affects service planning or placement, or any other provision as set forth in §2.1.3(A)(2) of this Part.5. "Affected party" means the person or entity who is applying for or receiving benefits/services/assistance whether referred to as a beneficiary, recipient, enrollee, client, consumer, small employer, employer or member, as well as any person acting as the designated representative or "agent" (navigator, broker, etc.) of such a person or entity.6. "Agency representative" is a person authorized by the state to take agency actions and, therefore, to be designated or assigned to represent the agency's rules, policies, and positions in the appeal process.7. "Agency/appeal response" means the explanation and rationale for the agency action subject to dispute. The agency/appeal response is prepared by an agency representative and cites the rule, policy, and/or statute that provides the legal justification for the action in dispute.8. "Appeal process" means a proceeding that includes various forms of informal and formal dispute resolution. The intent of the appeal process is to ensure that agency actions are consistent with established federal and state laws, rules, regulations, policies, and procedures.9. "Appeal record" means the appeal decision, all papers, documents, exhibits, and requests filed in the proceeding and, if a hearing was held, the transcript or recording of hearing testimony or an official report containing the substance of what happened at the hearing.10. "Appeal request" means a request by a person affected by an agency action to review and resolve a dispute of an agency action in an administrative fair hearing; or a desire to challenge agency delay or failure to act. An appeal request may also be filed to request a hearing to dispute one or more general issues related but not limited to, agency policies, standards, practices, notice requirements, and/or performance.11. "Appellant" means the affected party who is requesting an appeal. An appellant may be: c. an individual who is an authorized representative of the appellant, either a legal guardian or an individual designated in writing by the person to represent their interests in an appeal ord. a person or entity making an appeal on the behalf of an individual or class of individuals affected by an agency action.12. "Assistance" means any cash payments, benefit, service or support, or benefit card, plan or package of services provided directly or by an authorized agent or contractor of a program administered by the health and human services agencies operating under the umbrella of the EOHHS. For the purpose of this rule, assistance has the same meaning as benefit(s), service(s), and support(s) irrespective of how provided or delivered.13. "Complaint" has the same meaning as "grievance."14. " De novo review" means a review of an appeal without deference to prior decisions in the matter.15. "Dispute" means the subject of disagreement or dissatisfaction with a final agency action that serves as the basis for an appeal.16. "EHO" means the Executive Office of Health and Human Services Hearing Office which has been designated by law and the Secretary to serve as the appeals entity for programs administered by the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, the Department of Children, Youth and Families, the Department of Human Services, the EOHHS and which may also have been designated under Rules and Regulations Pertaining to HealthSource RI (220-RICR- 90-00-1) as the appeals entity for programs administered by HealthSource RI.17. " Ex parte communication" means a written or oral communication about a matter on appeal that occurs between the members or employees of an agency assigned to render an order or to make findings of fact and conclusions of law in a contested case and any person or party to an appeal, or in connection with any issue of law, with any party or his or her representative, except upon notice and opportunity for all parties to participate. But any agency member may communicate with other members of the agency and may have the aid and advice of one or more personal assistants. a. Ex parte communications are prohibited except that communications with the hearing officer for the purpose of scheduling and other administrative functions are not considered to be ex parte.18. "Formal dispute resolution" means a proceeding, such as an administrative fair hearing, before a qualified hearing officer, or a pre-hearing settlement conference in which both parties make a final effort to resolve the matter in dispute prior to the formal hearing.19. "Grievance" means any complaint or dispute (other than a final agency decision or action) expressing dissatisfaction with any aspect of the operations, activities, or behavior of a provider, regardless of whether remedial action is requested. A grievance is not an appeal request.20. "HealthSource RI" or "HSRI" means the state's benefit exchange (also referred to as an "Exchange") established under R.I. Gen. Laws Chapter 42-157 and which meets the applicable standards of 45 C.F.R Part 155 (2012) and, as such, is authorized to make qualified health plans (QHPs) available to individuals and employers/employees who meet certain eligibility requirements. Unless otherwise identified, "HSRI" includes the individual market for qualified individuals and the Small Business Health Options Program (SHOP) serving the state's small group market for qualified employers /employees. The "Exchange" and "HSRI" have the same meaning for the purposes of this Part.21. "Informal dispute resolution" means a discussion about the matter in dispute between an appellant and an agency representative. The informal dispute resolution process occurs while a contested agency action hearing is pending and excludes any involvement by the administrative hearing officer assigned to the case.22. "Integrated Care Initiative" or "ICI" means a Medicaid initiative that delivers integrated and coordinated services to certain Medicaid and Medicaid and Medicare dual eligible beneficiaries through a managed care arrangement. Includes services from across the care continuum including primary, subacute, and long-term care.23. "Involuntary discharges and transfers" means the relocation of a resident initiated by a licensed nursing facility or assisted living residence to another health care facility, residence, or non-institutional setting. The EHO is the designated appeal entity for such discharges and transfers without respect to payer.24. "Modified Adjusted Gross Income" or "MAGI" means income used to determine eligibility for premium tax credits and other savings for marketplace health insurance plans and for Medicaid and the Children's Health Insurance Program (CHIP).25. "Medicare-Medicaid Plan" or "MMP" is an integrated managed care plan under contract with the federal Centers for Medicare and Medicaid Services (CMS), EOHHS, and a managed care organization to provide fully integrated Medicare and Medicaid benefits to Medicare/Medicaid eligible (MME) beneficiaries.26. "Pre-hearing settlement conference" means the formal dispute resolution option that takes the form of meeting, held prior to an administrative fair hearing, in which the affected party and a representative of the agency make a final effort to settle the appeal matters without having a formal adjudication. Not all agencies offer the option for a pre-hearing settlement conference in all situations.27. "Recoupment" means the process in which an agency seeks to recover the cost for assistance provided to an affected party either in error or during the aid pending period if an adverse action is upheld in the disposition of an appeal.28. "Small Business Health Options Program" or "SHOP" means a program operated by an Exchange pursuant to the ACA, 42 U.S.C. § 1311 and 45 C.F.R § 155.700 et seq. (2012). 45 C.F.R § 155.700 et seq. provides that a qualified employer may provide its employees and their dependents with access to one (1) or more QHP.29. "Timely and adequate notice" means the formal notice sent by an agency to a person providing: a statement of an intended agency action that affects eligibility, the scope, amount, and/or duration of assistance; reasons and a legal citation for the action; the date the action will take effect, and an explanation of appeal rights and the process for requesting a hearing and, for some programs, obtaining legal representation. The notice must also identify the advance notice period when an adverse action is to be taken and the circumstances in which benefits/services/assistance may continue if a hearing is requested.30. "Vacate" means to set aside a previous action.210 R.I. Code R. 210-RICR-10-05-2.1
Amended effective 7/22/2020