210 R.I. Code R. 210-RICR-30-00-1.7

Current through December 3, 2024

Section 210-RICR-30-00-1.7 - MACC and Non-MAGI Special Eligibility Categories

A. Deemed Newborn Eligibility - Babies born to Medicaid-eligible pregnant people who are residents of Rhode Island are deemed eligible from the date of birth. Once deemed eligible as a newborn, the infant remains eligible for one (1) year and, as such, is a non-MAGI eligibility pathway. Accordingly, retroactive coverage is available for periods prior to the application date if the newborn was otherwise deemed eligible. The Medicaid-eligible parent of the newborn must comply with the following:

1. Enumeration - The parent/caretaker of a newborn must obtain an SSN for a newborn. Failure to enumerate the child results in a sanction against the parent/caretaker, not the child. The child will remain eligible even if lacking an SSN because of parent/caretaker's failure to cooperate. The sanction against the mother is loss of her eligibility for failure to cooperate. This sanction will be removed once the mother meets the enumeration requirements; or

2. Record of birth - If the newborn's SSN is not provided at birth, Medicaid eligibility is provided under the mother' s SSN if the hospital record of birth is submitted by the parents. The hospital record of birth is a written document indicating that the newborn was discharged in the mother's care and information related to date of birth and verifying citizenship. The hospital record of birth must be signed by the appropriate authorized representative of the hospital. If the infant was not born in a hospital, proof of application for an SSN, self-attestation and signed attestation of an attending health provider or birthing assistant may be accepted as a record of birth.

3. Verification - The birth may be reported by the parent/caretaker, or another family member or friend, the parent/caretaker's Medicaid managed care plan, or the hospital in which the child was born. See § 1.7(A)(2) of this Part above for information pertaining to the hospital record of birth.

B. Federal law and Regulations prohibit the use of Federal matching funds for health care provided on the premises of correctional facilities to otherwise MACC-eligible persons while incarcerated. Accordingly, full Medicaid health coverage of such persons is suspended during periods of incarceration. While the suspension remains in effect, the State is responsible for reimbursing costs related to acute care hospital stays of twenty-four (24) or more hours, but only when the otherwise Medicaid-eligible incarcerated person receives that care off the premises of the correctional facility.

1. Reinstatement upon Release. Medicaid health coverage that has been suspended due to incarceration must be reinstated promptly by the Medicaid agency upon the person's release from a correctional facility.

2. Residency. Suspension of Medicaid health coverage is limited to Rhode Island residents while incarcerated in correctional facilities. Medicaid health coverage for Rhode Islanders incarcerated in the correctional facilities of other States or in a Federal penitentiary is terminated in accordance with the residency requirements set forth herein.

C. Infants. An infant born to an incarcerated pregnant person with suspended eligibility is treated as a deemed newborn in accordance with § 1.7(A) of this Part above and is qualified to receive Medicaid health coverage until the end of the month of the infant's first (1st) birthday.

D. Hospital Presumptive Eligibility - Under 42 C.F.R. § 435.1110 (2022), States must offer Medicaid coverage to individuals who are not already Medicaid members for a limited period. This form of "presumptive eligibility" is only available in certain circumstances when a qualified hospital determines, on the basis of preliminary information, that an individual has the characteristics for Medicaid eligibility. Such individuals are "presumed eligible" for Medicaid until the end of the following month or the date full eligibility is determined, whichever comes first. The State makes presumptive eligibility available to persons who have been determined by a qualified hospital to meet the characteristics of one (1) of the MACC groups eligible for Title XIX coverage. Persons eligible under CHIP are excluded. See Part 4 of this Subchapter, Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals, promulgated by EOHHS for additional detail on the provisions governing hospital presumptive eligibility determinations in Rhode Island.

E. Section 1931 Extended/Transitional Medicaid - Families eligible for Medicaid under §1931 may be eligible for an extended Medicaid for up to twelve (12) months when their family income exceeds the §1931 family eligibility ceiling. Although extended Medicaid is considered a non-MAGI pathway, families eligible under §1931 are a MACC coverage group. As such, their initial eligibility is determined using the MAGI standard and they are renewed on that basis until their income increases to the family limit of one hundred sixteen percent (116%) of the FPL. Extended Medicaid is only one of several Medicaid coverage options available to members of a household that no longer meets §1931 income requirements. There are MACC group and, some instances, IHCC group and commercial insurance alternatives through HealthSource RI that may be more beneficial and/or appropriate for family members losing §1931 coverage. However, all these beneficiaries are evaluated for extended Medicaid along with these other alternatives before §1931 coverage is terminated. Requirements for extended Medicaid are as follows:

1. Initial Eligibility Criteria - At the time a family becomes ineligible for §1931 M edicaid benefits, the State must verify and confirm, whether:

2. The family has a child living in the home who is under the age of eighteen (18) or between the age of eighteen (18) and nineteen (19) if the child is a full-time student in a secondary school, or at the equivalent level of vocational or technical training, and is reasonably expected to complete the program before or in the month of his/her nineteenth (19th) birthday. A student attending summer school full time, as defined by school authorities, is considered a full-time student for these purposes; and

3. Eligibility for §1931 M edicaid coverage was discontinued because of earned income of a parent/caretaker or other member of the family due to: employment; increased hours of employment; or an increase in wages.

4. Extended Medicaid is not provided to any beneficiary who has been legally determined to be ineligible for cash assistance because of fraud at any time during the last prior six (6) months in which the family received benefits.

5. Notice Requirements - A notice is sent informing the family of the right to extended Medicaid for up to the maximum of twelve (12) months. The notice also sets forth the following beneficiary responsibilities. The family must:

a. Submit a report which includes an accounting of the family's earned income and the "necessary child care" expenses;

b. Enroll in an employer's health plan (whether individual or family coverage) if it is offered at no cost to the parent/caretaker in accordance with the provisions related to the Rite Share Premium Assistance Program set forth in Subchapter 05 Part 3 of this Chapter; and

c. Report circumstances which could result in the discontinuance of extended benefits (e.g., no age appropriate child in the family or a move out-of-State).

6. Loss of Benefits Due to Employment - To receive extended Medicaid is employment of a parent/caretaker or other member(s) of the family whose earned income contributes to the family's loss of eligibility for §1931 M edicaid. Often employment linked with other changes, such as a parent returning to the home or a child turning eighteen (18), may combine to cause the loss of eligibility. While there must be a relationship between earned income and the loss of eligibility for §1931 M edicaid to qualify for extended Medicaid, the advent or increase in earned income need not be the only factor causing the loss.

7. Beneficiaries Eligible for Extended Medicaid - The first (1st) month of extended Medicaid is the first (1st) full or partial month in which the family loses eligibility for Medicaid health care coverage under Section 1931, but only in those instances in which eligibility under any other Medicaid coverage group is unavailable. If the family is eligible for Medicaid State Plan or waiver coverage, extended Medicaid will be denied.

8. Extended Medicaid is provided to those beneficiaries who:

a. Are living in the household, and whose needs and income were included in determining §1931 eligibility of the assistance unit at the time such benefits were discontinued;

b. Have needs and income would be taken into account in determining §1931 M edicaid eligibility using the MAGI standard if the family were applying for either of these programs in the current month. A child born after §1931 benefits are discontinued, or a child, parent or step-parent who returns home after §1931 benefits are discontinued, is included as a member of the family for purposes of providing extended Medicaid.

9. Receipt of Extended Medicaid -Extended Medicaid continues throughout the first seven (7) months following the loss of §1931 M edicaid eligibility unless:

a. No age-appropriate child is living in the family; or

b. The parent/caretaker refuses to apply for health coverage offered by the employer.

10. When it is determined that a family no longer has a child who meets the age requirements living in the home, Medicaid for all family members ends the last day of the month in which the family no longer includes such child.

11. Continuation of Extended Medicaid - To continue to receive the remaining months of extended Medicaid, up to the limit of the full twelve (12) months of the transitional medical program, families must:

a. Include a child who meets the age requirement living in the household; and

b. Timely file the earned income report when due in the seventh (7th) month; and

c. Pass the one hundred seventy-five percent (175%) of the FPL earned income test; and pass the parent/caretaker employment test.

12. Failure to Meet Continuation Requirements - If the family fails to pass the income test, the Medicaid agency discontinues extended Medicaid benefits on the last day of a reporting month.

13. Limits - The maximum amount of time under the extended Medicaid program is limited to twelve (12) months. The Medicaid agency must provide a notice of closing if eligibility is discontinued prior to the receipt of the maximum time allowed under the program's twelve (12) month time- limited benefits. Eligibility is always discontinued on the last day of a month.

14. Good Cause - A family may have reason to claim good cause for failure to comply with required action. Good cause may exist for any of the following which may lead to the termination of extended Medicaid:

a. Failure to timely submit an earned income report;

b. Failure of the parent/caretaker to be employed;

c. Failure to comply with any extended Medicaid requirements other than the above;

d. Failure to submit the earned income report or to include appropriate verifications, may exist if circumstances beyond the recipient's control prevent the requirement from being met when due.

e. Good cause includes circumstances beyond the beneficiary's control, such as, but not limited to: involuntary loss of employment; illness or incapacity; unanticipated household emergency; work demands or conditions that render continued employment unreasonable, such as working without being paid on schedule.

15. Discontinuing Extended Medicaid - Notice from the State is required if a family becomes ineligible for §1931 M edicaid for reasons related to employment.

16. Prior to termination of extended Medicaid, each member of the family is evaluated for Medicaid coverage in every other possible MACC and IHCC group category as well as for commercial coverage subsidized by the Federal and/or State government offered through HealthSource RI, the State's health insurance market. Notice to the beneficiary indicates the alternative forms of coverage available and how to enroll or if additional information is required to determine whether eligibility for these other cover options exists.

F. Children with Special Circumstances

1. This category includes children and youth who are or were in the care and custody of the Rhode Island Department of Children, Youth and Family and, by virtue of that status, are automatically eligible for Medicaid without a MAGI-based income determination. They are included in this Rule as they share the characteristics of the MACC group coverage group for children and youth though eligible through a non-MAGI pathway. However, members of these groups may be eligible for up to ninety (90) days of retroactive coverage prior to the eligibility date.

2. The DCYF is responsible for certifying the eligibility of children and youth in the coverage group and in making the referral for Medicaid to the appropriate unit of the designated State agency and for notifying the agency when there is a change in circumstances that may affect a child's Medicaid eligibility, coverage, or service delivery options. The change in circumstance could be related to placement, the child's financial status, or a return to the family and/or termination of participation in the applicable programs. Prior to any change that may result in the end of Medicaid eligibility, the DCYF must ensure that the beneficiary and/or his/her family or guardians are aware that alternative forms of Medicaid are available and provide assistance as appropriate.

3. Adoption Subsidy/IV-E Foster Children - This non-MAGI coverage group is the eligibility pathway for children in DCYF substitute care under the authority of Title IV-E of the U.S. Social Security Act. The coverage group includes foster children, children in kinship guardianship care and adopted children whose Medicaid eligibility is based on participation in the following DCYF administered, Title IV-E programs:

a. The Foster Care Maintenance Program - This Program provides federally-funded foster care payments on behalf of the following children: Children previously eligible under the Federal Foster Care Maintenance Program under Title IV-A of the Social Security Act, 42 U.S.C. §§ 601 - 619; Certain children voluntarily placed or involuntarily removed from their homes; and Children in public non- detention type facilities housing no more than twenty-five (25) children. Children for whom a cash payment is made under the foster care program are deemed eligible for Medicaid. Medicaid eligibility for children in the Foster Care Maintenance program exists as long as the Title IV-E payment continues to be made for them or up to the age of twenty-one (21) if still in foster care.

b. The Adoption Assistance Program - The Title IV-E authorized and funded adoption assistance program provides Federal funding for continuing payments for hard-to-place children with special needs. Children in this Program must be SSI beneficiaries at the time of adoption. An adoption subsidy cash payment is not a necessary condition of Medicaid eligibility for these adoption assistance children. They continue to be eligible for Medicaid as long as a Title IV-E adoption assistance agreement is in effect. An interlocutory order or final decree also need not exist.

c. Residency requirements - Title IV-E adoption assistance children, kinship guardianship assistance children, and Title IV-E foster care children are eligible for Medicaid in their States of residence. Accordingly, Rhode Island is required to provide Medicaid coverage to children eligible under this pathway as long as they remain residents of the State and under the care and custody of DCYF, even if services are being provided in a jurisdiction of another State.

4. Non IV-E Foster Child Under 18 - This coverage group includes children under the age of eighteen (18), or if a child is eighteen (18) years old, the child will complete high school before their nineteenth (19th) birthday, who are in foster family care or in a kinship guardianship care and are not eligible for Title IV-E.

5. Non IV-E, State Adoption Assistance - This coverage group is hard-to-place children for whom the State provides adoption/guardianship assistance and who are not eligible for Title IV-E. The basis of eligibility for Medicaid is deprivation of parental support occasioned by the child's separation from his/her family.

6. The determination of financial need. When a child is not living in a home maintained by the child's parents, the State considers only the child's own income and resources.

7. Age Limit. Medicaid under this coverage group may be provided until the child reaches the age of twenty-one (21).

8. Post Foster Care Medicaid Eligibility for individuals born before January 1, 2005 - The Foster Care Independence Act of 1999 established the John H. Chafee Foster Care Independence Program, 42 U.S.C. § 1396a(a)(10). This Medicaid eligibility pathway is open to youth who were in foster care in Rhode Island on their eighteenth (18th) birthday. Medicaid eligibility for youth qualifying for this coverage continues until the age of twenty-six (26) as long as the individuals remain residents of the State.

a. Living arrangement. A post foster care adolescent may be residing independently or with others (including family members).

b. Renewal. A renewal of Medicaid eligibility is completed once in a twelve (12) month period to ensure that the beneficiary eligible in this group is a resident of Rhode Island.

c. Limits. Under the terms of the Chafee Act, young adults may only qualify for Medicaid under this group if not otherwise eligible through SSI or as aged, blind or disabled and/or in need of long term services and supports. In addition, although eligible for the full scope of Medicaid State Plan and Section 1115 waiver services available to all adults, the EPSDT benefit for children continues up to the age of twenty-one (21) only.

9. Post Foster Care Medicaid Eligibility for individuals born on or after January 1, 2005 - The Foster Care Independence Act of 1999 established the John H. Chafee Foster Care Independence Program, 42 U.S.C. § 1396a(a)(10), and was later amended by the Patient Protection and Affordable Care Act, Pub. Law No. 111-148, and the SUPPORT for Patients and Communities Act, Pub. Law No. 115-271. This Medicaid eligibility pathway is open to individuals between the ages of 18 and 26 who were in foster care under the responsibility of a state or a Tribe within a state, including children who were cared for under the unaccompanied refugee minor program, and were enrolled in Medicaid upon the time their foster care assistance ended. An individual may qualify for this eligibility pathway even if the individual was in foster care in a state or Tribe within a state other than Rhode Island. Medicaid eligibility for youth qualifying for this coverage continues until the age of twenty-six (26) as long as the individual remains a resident of the State.

a. Living arrangement. A post foster care youth may be residing independently or with others (including family members).

b. Renewal. A renewal of Medicaid eligibility is completed once in a twelve (12) month period to ensure that the beneficiary eligible in this group is a resident of Rhode Island.

c. Limits: Individuals may only qualify for this group if they are not enrolled through a different Medicaid eligibility pathway, even if they meet the eligibility requirements of another eligibility pathway. Although eligible for the full scope of Medicaid State Plan and Section 1115 waiver services available to all adults, the EPSDT benefit for children continues up to the age of twenty-one (21) only.

210 R.I. Code R. 210-RICR-30-00-1.7

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