Section 210-RICR-30-00-3.2 - Renewal of Eligibility for Medicaid Affordable Care Coverage Groups3.2.1Scope and PurposeA. All MACC group members are subject to MAGI-based renewals, focusing on the eligibility factors subject to change. Such factors include changes in income, household composition or family size (due to death, marital status, birth or adoption of child), and/or State residency. Children who are determined eligible for Medicaid will receive one (1) year of continuous eligibility (CE). Disenrollments for any reason that are followed by requests for eligibility reinstatements are also subject to this process for members of the MACC groups.3.2.2Responsibilities of the StateA. The State is responsible to ensure that the Medicaid renewal process occurs once every twelve (12) months for all MACC group members. Towards this end, the State must meet the following requirements:1. Basis of Renewal - The eligibility renewal must be based on information already available to the State to the full extent feasible. Accordingly, the State must use information about the Medicaid member from reliable sources including, but not limited to, the member's automated eligibility account, current paper records, or data bases that may be accessed through the Federal data hub or the State's own affordable care coverage eligibility system.2. Restrictions - The State must not request or use information when conducting renewals pertaining to: eligibility factors that are not subject to change or concern matters that are not relevant to continuation of Medicaid eligibility. Eligibility factors subject to change include income, household or family size, State residency and certain immigration statuses. Factors that are not subject to change include, but are not limited to, native born or naturalized U.S. citizenship, date of birth, and Social Security Number.3. Renewal Strategy - The State utilizes a passive "ex parte" renewal process for all MACC group members when determining continuing eligibility and whether a beneficiary who is losing coverage due to a change in an eligibility factor qualifies for Medicaid in another coverage group to the full extent feasible. This renewal method confirms eligibility factors subject to change through electronic data sources and only requires action on the part of the beneficiary if certain discrepancies are detected by the State or self-reported. The State will use both active and passive renewal methods until all MACC group members have been subject to a MAGI-based income eligibility determination at least once. Accordingly, the State will conduct renewals as follows:a. Initial review. The State redetermines eligibility at least sixty (60) days before the renewal date using information known to the IES and from various data sources and provides notice to the beneficiary indicating the results of this review. The notice contains the information that served as the basis for this eligibility review and indicates one (1) of the following:(1) Passive ex parte Renewal - Medicaid eligibility has been renewed "ex parte" and no further action on the part of the beneficiary is required unless, upon reviewing the information in the notice, the beneficiary identifies an error or a change in an eligibility factor subject to change that must be reported to the State; or(2) Modified Passive Renewal - Medicaid eligibility has not been renewed due to missing information or a discrepancy between sources of information related to an eligibility factor subject to change. In such instances, the notice contains an additional documentation request (ADR) specifying the type of information that must be submitted for the renewal of eligibility to proceed.b. Renewal decision. If the beneficiary is not required to take any action and does not find cause to self-report a change, Medicaid eligibility is continued automatically for another year, effective on the renewal date. However, in order to be considered in this final renewal decision, change self-reports and ADR responses must submitted at least thirty (30) days from the date of the renewal notice. The State redetermines eligibility based on this information. If the beneficiary receives an ADR and does not take the action required, this redetermination is based solely on the information known to the IES through self-attestations and applicable data sources. A formal notice is issued with the State's final renewal decision if eligibility is discontinued on this basis at least fifteen (15) days prior to the eligibility continuation or termination date. Information received by the State at any time prior to the eligibility termination date is considered. However, if the information is submitted after the tenth day of the renewal month, a change from managed care to fee-for-service service delivery may result.c. Reinstatement. A reinstatement of Medicaid eligibility is permitted without a full reapplication, in instances in which a beneficiary takes the actions required to resolve a discrepancy or information gap in the ninety (90) day period after eligibility is terminated.4. Consent - The State must obtain the consent of the Medicaid member to retrieve and verify electronically information related to eligibility factors subject to change including any federal tax information required to review income eligibility. Such consent is obtained during the initial application for Medicaid eligibility when the Medicaid member signs the application, under penalty of perjury.5. Enrollment - A Medicaid member whose eligibility has been continued through the annual renewal process must remain in the same Medicaid health plan unless the renewal occurs during an open enrollment period. If an open enrollment process is not underway at the time of renewal, the provisions set forth in Part 30-05-2 of this Title prevail.6. Access - The State must ensure that any application or supplemental forms required for renewal are accessible to persons who have limited proficiency in English or who have a disability.3.2.3Responsibilities of Medicaid MembersA. Medicaid members must ensure that the State has access to accurate and complete information about any eligibility factors subject to change at the time of the annual renewal. Accordingly:1. Consent - At the time of the initial application or first MAGI-based renewal, Medicaid members must provide the State with consent to retrieve and review any information not currently on record pertaining to the eligibility factors subject to change through electronic data matches conducted through the State's affordable coverage eligibility system. Once such consent is provided, the State may retrieve and review such information when conducting all subsequent annual renewals.2. Duty to Report -- Medicaid members are required to report changes in eligibility factors to the Medicaid agency within ten (10) days from the date the change takes effect. Self-reports are permitted through the eligibility system on-line portal. Medicaid members also may report such changes in person, via fax, by mail, or telephone with the assistance of HSRI, DHS agency representative, or Navigator. Failure to report in a timely manner, as noted above, may result in the discontinuation of Medicaid eligibility.3. Cooperation - Medicaid members must provide any documentation that otherwise cannot be obtained related to any eligibility factors subject to change when requested by the State. The information must be provided within the timeframe specified by the State in the notice to the Medicaid member stating the basis for making the agency's request.4. Voluntary Termination - A Medicaid member may request to be disenrolled from a Medicaid health plan or to terminate Medicaid eligibility at any time. Disenrollment results in the termination of Medicaid eligibility.5. Reliable Information - Medicaid members must sign under the penalty of perjury that all information provided to the Medicaid agency at the time of application and any annual renewals thereafter is accurate and truthful.210 R.I. Code R. 210-RICR-30-00-3.2
Amended effective 10/5/2021
Amended effective 10/1/2024