210 R.I. Code R. 210-RICR-30-00-1.5

Current through December 3, 2024

Section 210-RICR-30-00-1.5 - Eligibility Pathways for MACC and Non-MAGI Groups

A. Rhode Island's Medicaid MACC groups are comprised of individuals and families who share an eligibility characteristic, such as age or relationship as follows, unless otherwise indicated below. MACC group members do not have access to retroactive coverage under the terms and conditions of the State's Section 1115 W aiver.

1. Families and Parents (caretaker relatives). The defining characteristic of this coverage group is a relationship with a child up to the age of eighteen (18), or the age of nineteen (19) if enrolled in school full-time, who is eligible for Medicaid. Parent/caretaker eligibility is a function of how the eligible child is claimed for tax purposes as a dependent when constructing a MAGI household. This coverage group includes:

a. Families with income up to one hundred sixteen percent (116%) of the Federal Poverty Level (FPL) who are eligible under the Medicaid State Plan through the authority provided by §1931.

b. Parents/caretaker relatives with income from one hundred sixteen percent (116%) to one hundred forty-one percent (141%) of the FPL who are eligible under the State's Section 1115 waiver.

c. Parents/caretakers with income from one hundred thirty-eight percent (138%) to one hundred seventy-five percent (175%) of the FPL who would have been eligible for Medicaid on December 31, 2013, may qualify for the Rhode Island Affordable Health Care Coverage Assistance Program. Parents/caretakers eligible for this program may obtain a State subsidized "silver" commercial plan through the Rhode Island's health insurance marketplace as specified in Subchapter 10 Part 1 of this Chapter. The State's integrated eligibility system automatically evaluates the parents/caretakers of Medicaid-eligible children for this Program if they do not qualify for coverage under this Part.

d. Pregnant people. Members of this coverage group can be of any age. The pregnant person and each expected child are counted separately when constructing the household and determining family size. Eligibility extends for the duration of the pregnancy and, as of October 1, 2022, twelve (12) months post-partum. The coverage group includes all pregnant people with income up to one hundred fifty-three percent (253%) of the FPL. Pregnant people with income under one hundred ninety percent (190%) of the FPL who meet Medicaid requirements for citizenship/immigration status are eligible for medical coverage through Medicaid. Pregnant people with income above one hundred ninety percent (190%) of the FPL up to two hundred fifty-three percent (253%) of the FPL who meet Medicaid requirements for citizenship/immigration status and pregnant people with income up to two hundred fifty-three percent (253%) of the FPL who meet Medicaid requirements for citizenship/immigration status are eligible for medical coverage through CHIP. CHIP medical coverage for those pregnant people who do not meet Medicaid requirements for citizenship/immigration status is based on the eligibility status of the unborn child.

Retroactive medical coverage is available for up to ninety (90) days prior to the eligibility date for otherwise eligible pregnant people.

(1) As of October 1, 2022, twelve (12) month post-partum coverage shall be extended to people who:

(AA) Are not eligible for Medicaid under another Medicaid eligibility category; or

(BB) Do not have qualified non-citizen status for Medicaid, whose births are financed by Medicaid through coverage of the child and who, before October 1, 2022, were only eligible to receive State-only extended family planning benefits postpartum, as outlined in §05-2.6(A)(3) of this Chapter.

e. Children and Young Adults. Age is the defining characteristic of members of this MACC group. This coverage group includes:

(1) Infants under age one (1) unless a deemed newborn (see § 1.7(A) of this Part) up to age nineteen (19) who have family income up to two hundred sixty-one percent (261%) of the FPL; and

(2) All children, including all non-citizen children not legally present, up to the age of nineteen (19), who have income up to two hundred sixty-one percent (261%) of the FPL.

f. ACA Expansion Adults - The group consists of citizens and qualified non-citizens with income up to one hundred thirty-three percent (133%) of the FPL who meet the age characteristic and are not otherwise eligible for, or enrolled in, Medicare or Medicaid under any other State plan or Section 1115 waiver coverage group. Adults found eligible awaiting a determination for Supplemental Security Income (SSI) or the receipt of Social Security benefits are also eligible under this coverage group during the two (2) year application pending and benefit waiting periods.

B. MACC Group Income Eligibility - The income thresholds and ceilings for the MACC groups eligible through these pathways are summarized as follows:

MACC Group	Income Threshold - As percent of the FPL	Income Ceiling with the five percent (5%) disregard - As a percent of the FPL
a. Families	116%	121%
b. Parents/Caretakers	116%	141%
c. Pregnant People	253%	258%
d. Children/Young Adults	261%	266%
e. ACA Expansion Adults	133%	138%

C. There are currently multiple Medicaid coverage groups that are not subject to the MAGI. Eligibility for adults who are nineteen (19) years of age and older who are not subject to the MAGI standard is set forth as follows:

1. Persons twenty-one (21) years of age and older eligible for Medicaid based on receipt of Supplemental Security Income (SSI), Optional State Supplemental Payments (SSP), and/or SSI-protected status - §40-00-1.5(A)(3) of this Title;

2. Low income elders sixty-five (65) and older, and adults with disabilities (EAD) between the ages of nineteen (19) and sixty-four (64) with income up to one hundred percent (100%) of the FPL to who do not qualify for SSI and are eligible for or enrolled in in Medicare - §40-00-1.5(A)(1) of this Title;

3. Full or partial Medicare-Medicaid dual eligible beneficiaries participating in the Medicare Premium Payment Program - §40-00-1.5(A)(6) of this Title;

4. People eligible for Medicaid through the Breast and Cervical Cancer Treatment Program (BCCTP) - §40-00-1.6(A)(1) of this Title;

5. Adults seeking initial or continuing eligibility for Medicaid long-term services and supports (LTSS) who are eligible for or enrolled in Medicare or are age sixty-five (65) and older with service needs requiring the level of care typically provided in health institutions - §50-00-1.9(A)(3) of this Title;

6. Otherwise ineligible children with serious disabilities up to age eighteen (18) who qualify under Katie Beckett process because they are receiving the level of care at home that is typically provided in a health institution - Part 50-10-3 of this Title;

7. Medically needy eligible persons who become eligible for Medicaid by spending down excess income on allowable health expenses - §40-00-1.5(A)(2) of this Title.

D. Children and families exempt from the MAGI with eligibility covered under this Part are as set forth below:

1. No income determination required - Individuals and families up to age twenty-one (21) whose eligibility does not require an income determination for Medicaid, including those eligible on the basis of:

a. Supplemental Security Income (SSI). Children and young adults with disabilities determined by the Federal Social Security Administration (SSA) to be eligible for SSI benefits who are up to age nineteen (19) or in the custody of the State, up to age twenty- one (21), including those residing in health institutions; and

b. DCYF programs. Children and youth eligible on the basis of their participation in a DCYF foster care, kinship or guardian program whether in a home-based, residential or institutional setting, including young adults aging out of foster care in Rhode Island, up to age twenty-six (26) who are eligible under the Federal Foster Care Independence Act of 1999 (Chafee Act) as amended by the Patient Protection and Affordable Care Act, Pub. Law No. 111-148and the SUPPORT for Patients and Communities Act, Pub. Law No. 115-271.

c. Former Foster Youth Status. Children and youth eligible on the basis of their participation in foster care in a state or Tribe within a state other than Rhode Island, up to age twenty-six (26) who are eligible under the SUPPORT for Patients and Communities Act, Pub. Law No. 115-271.

2. Deemed eligibility - Infants born to Medicaid-eligible pregnant people are deemed eligible from date of birth to age one (1) without regard to changes in income or other factors as long as they remain residents of the State.

3. Transitional/extended Medicaid - Families with income above one hundred sixteen percent (116%) of the FPL who no longer qualify for Medicaid coverage under §1931 due to earnings from work, including recipients of the RI Works Program administered by the Rhode Island Department of Human Services may qualify for continued coverage through this pathway. Eligibility for extended Medicaid is for six (6) months, renewable up to a year as long as gross income is at or below one hundred seventy-five percent (175%) of the FPL.

210 R.I. Code R. 210-RICR-30-00-1.5

Amended effective 12/29/2022
Amended effective 12/11/2023