Section 210-RICR-30-00-1.8 - Cooperation RequirementsA. All applicants and beneficiaries subject to this Part must cooperate with an array of requirements as a condition of obtaining or retaining (post-eligibility) eligibility. Specific requirements related to application and renewal are located in Part 3 of this Subchapter and for the purposes of evaluating and verifying income are set forth in Part 5 of this Subchapter.B. Cooperation requirements applicable across populations are as follows:1. Third Party Liability (TPL) - Third Party Liability refers to any individual, entity (e.g., insurance company) or program (e.g., Medicare) that may be liable for all or part of a Medicaid applicant's coverage. Under §1902(a)(25) of the Social Security Act, 42 U.S.C. § 1396a(a)(25), the State is required to take all reasonable measures to identify legally liable third (3rd) parties and treat verified TPL as a resource of the Medicaid beneficiary once determined eligible. Applicants/beneficiaries must furnish information about all sources of TPL. The State and Medicaid managed care organizations, under contractual agreements with the State, are responsible for identifying and pursuing TPL for beneficiaries covered by employer-sponsored health insurance plans through the RIte Share program. Failure to cooperate with the TPL requirement or to enroll in a RIte Share plan as required in Subchapter 05 Part 3 of this Chapter results in the ineligibility of the parent. 2. Referral to Office of Child Support Services (OCSS) - All applicants reporting an absent parent are referred to the Office of Child Support Services within the Department of Human Services, once they have been determined eligible for Medicaid and received appropriate notice. Compliance with the OCSS requirement is a condition of retaining eligibility. As a condition of eligibility, an applicant who can legally assign rights for a dependent child born out of wedlock is required to do so and cooperate in establishing the parentage of that child for the purposes of obtaining medical care support and medical care payments for both the applicant and the child. Failure to cooperate in assigning rights results in a determination of ineligibility for the parent, unless a good cause exemption has been granted by the State. In instances when domestic violence may be the basis for an exemption to the cooperation requirement, referral to the Family Violence Option Project may be made to assist the parent seeking an exemption.3. RIte Share Premium Assistance Program - Individuals and families determined to have access to cost-effective employer-sponsored health insurance (ESI) are required to enroll in the ESI plan if so directed by the State. Members of the MACC groups with access to ESI who are eligible for Medicaid will be permitted to enroll in a Medicaid managed care plan, as appropriate. The Medicaid agency will conduct a post-enrollment review of those members with access to ESI to determine whether participation in RIte Share is required. The provisions governing the RIte Share program are located in Subchapter 05 Part 3 of this Chapter.C. Duty to Report - All Medicaid applicants and beneficiaries have a duty to report changes in income, family size, address, and access to ESI within ten (10) days of the date the change takes effect. Failure to make timely reports may result in the denial or discontinuation of Medicaid eligibility.D. A Medicaid applicant or member must have the opportunity to claim good cause for refusing to cooperate. Good cause may be claimed by contacting a DHS or EOHHS agency representative. To claim good cause, a person must state the basis of the claim in writing and present corroborative evidence within twenty (20) days of the claim; provide sufficient information to enable the investigation of the existence of the circumstance that is alleged as the cause for non-cooperation; or, provide sworn statements from other individuals supporting the claim.E. Basis for Claim. A determination of good cause is based on the evidence establishing or supporting the claim and/or an investigation by Medicaid agency staff of the circumstances used as justification for the claim of good cause for non-cooperation.F. State Requirements. The determination as to whether good cause exists must be made within thirty (30) days of the date the claim was made unless the agency needs additional time because the information required to verify the claim cannot be obtained within the time standard. The person making the claim must be notified accordingly, provided with the reason for the decision, and the right to appeal through the EOHHS Administrative Fair Hearing Process specified in Part 10-05-2 of this Title.G. A Medicaid beneficiary may terminate Medicaid eligibility at any time. Such requests must be made in writing and submitted to a State agency or HSRI representative in-person, via U.S. Mail, fax, on-line via the beneficiary's secure account, or made by telephone to HSRI when telephonic recording capabilities exist. The Medicaid agency is responsible for providing the Medicaid beneficiary with a formal notice of the voluntary termination of Medicaid eligibility that indicates the effective date, the impact of terminating eligibility for each member of the household, and the right of the beneficiary to reapply for Medicaid health coverage at any time.210 R.I. Code R. 210-RICR-30-00-1.8
Amended effective 12/29/2022
Amended effective 12/11/2023