210 R.I. Code R. 210-RICR-20-00-1.3

Current through December 3, 2024

Section 210-RICR-20-00-1.3 - Definitions

A. As used in this Rule, the following terms and phrases have the following meanings:

1. "Conviction" means as assigned in R.I. Gen. Laws §§ 42-7.2-18.2 and 42-7.2-18.4.

2. "Disqualifying conviction" means a conviction, federal or state, for any of the crimes listed in R.I. Gen. Laws §§ 42-7.2-18.2 and 42-7.2-18.4.

3. "High-risk provider" means a provider that poses a high risk of fraud, waste or abuse. These providers are:

a. Designated by the Centers for Medicare and Medicaid Services as high categorical risk according to 42 C.F.R. § 424.518 (2021);

b. Individual personal care attendants and homemakers providing direct care to individuals under Chapter 50-10-2 of this Title; and

c. Shared living caregivers providing direct care to individuals under Chapter 50-10-1 of this Title.

4. "Limited-risk provider" means a provider that is neither a moderate-risk provider nor a high-risk provider.

5. "Moderate-risk provider" means a provider that poses a moderate risk of fraud, waste or abuse. These providers are:

a. Providers designated by the Centers for Medicare and Medicaid Services as moderate categorical risk according to 42 C.F.R. § 424.518 (2021);

b. Severely disabled nursing home care providers;

c. Providers employing personal care attendants and homemakers; and

d. RIte Share co-pay providers.

6. "Provider" means an individual or entity including physicians, nurse practitioners, physician assistants, and others who are engaged in the delivery of medical/behavioral health care services, or ordering or referring for those services, and is legally authorized to do so by the State in which the provider delivers the services. This includes fee-for-service and managed care providers.

7. "Rhode Island Medicaid program" means a combined State and Federally funded program established on July 1,1966, under the provisions of 42 U.S.C. §§ 1396-1396w-7. The enabling State legislation is to be found at R.I. Gen. Laws Chapter 40-8, as amended.

8. "Secretary" means the Rhode Island Secretary of the Executive Office of Health and Human Services (EOHHS) who is responsible for the oversight, coordination, and cohesive direction of State-administered health and human services, including the Medicaid agency, and for ensuring all applicable laws are executed.

9. "State agency" means the Rhode Island Executive Office of Health and Human Services (EOHHS) which is designated under the Medicaid State Plan as the Single State Agency responsible for the administration of the Medicaid Program.

210 R.I. Code R. 210-RICR-20-00-1.3

Amended effective 3/17/2022
Amended effective 7/17/2023
Amended effective 3/17/2024