210 R.I. Code R. 210-RICR-30-05-2.24

Current through December 3, 2024

Section 210-RICR-30-05-2.24 - RHP In-Plan Capitated Benefits

A. The benefits which the MCO provides within the capitated (fixed cost per enrollee per month) benefit.

B. RHP comprehensive benefit package - The following benefits are included in the capitated rate on an annual basis, based on medical necessity:

SERVICE	SCOPE OF BENEFIT (ANNUAL) Including but not limited to:
Inpatient Hospital Care	As medically necessary. EOHHS shall be responsible for inpatient admissions or authorizations while Member was in Medicaid fee-for-service, prior to Member's enrollment in Health Plan. Contractor shall be responsible for inpatient admissions or authorizations, even after the Member has been disenrolled from Contractor's Health Plan and enrolled in another MCO or re-enrolled into Medicaid fee-for-service, until the management of the Member's care is formally transferred to the care of another MCO, another program option, or fee-for-service Medicaid.
Outpatient Hospital Services	Covered as needed, based on medical necessity. Includes physical therapy, occupational therapy, speech therapy, language therapy, hearing therapy, respiratory therapy, and other Medicaid covered services delivered in an outpatient hospital setting.
Therapies	Covered as medically necessary, includes physical therapy, occupational therapy, speech therapy, hearing therapy, respiratory therapy and other related therapies.
Physician/Provider Services	Covered as needed, based on medical necessity, including primary care, specialty care, obstetric and newborn care.
Family Planning Services	Enrolled female members have freedom of choice of providers for family planning services.
Prescription Drugs	Covered when prescribed by an MCO physician/provider. Generic substitution only unless provided for otherwise as described in the Managed Care Pharmacy Benefit Plan Protocols.
Non-Prescription Drugs	Covered when prescribed by a Health Plan physician/provider/APP. Limited to non-prescription drugs, as described in the Medicaid Managed Care Pharmacy Benefit Plan Protocols. Includes nicotine cessation supplies ordered by an MCO physician or APP. Includes medically necessary nutritional supplements ordered by an MCO physician or APP.
Laboratory Services	Covered when ordered by a Health Plan physician/provider including urine drug screens.
Radiology Services	Covered when ordered by a Health Plan physician/provider.
Diagnostic Services	Covered when ordered by a Health Plan physician/provider.
Mental Health and Substance Use - Outpatient & Inpatient	Covered as needed for all members, including residential substance use treatment for youth. Covered services include a full continuum of mental health and substance use disorder treatment, including but not limited to, community-based narcotic treatment, methadone, and community detox. Covered residential treatment includes therapeutic services but does not include room and board, except in a facility accredited by the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO"). Also includes, DCYF ordered administratively necessary days, or hospital-based detox, MH/SUD residential treatment (including minimum six (6) month SSTAR birth residential services), Mental Health Psychiatric Rehabilitative Residence (MHPRR), psychiatric rehabilitation day programs, Community Psychiatric Supportive Treatment (CPST),Crisis Intervention for individuals with severe and persistent mental illness (SPMI) enrolled in the Community Support Program (CSP), Opioid Treatment Program Health Homes (OTP), Assertive Community Treatment (ACT), Integrated Health Home (IHH), and services for individuals at CMHCs.
Home Health Services	Covered services include those services provided under a written plan of care authorized by a physician/provider including full-time, part-time, or intermittent skilled nursing care and certified nursing assistant services as well as physical therapy, occupational therapy, respiratory therapy and speech-language pathology, as ordered by an MCO physician. This service also includes medical social services, durable medical equipment and medical supplies for use at home. Home health services do not include respite care, relief care or day care.
Home Care Services	Covered services include those provided under a written plan of care authorized by a physician/provider including full-time, part-time or intermittent care by a licensed nurse or certified nursing assistant as well as; physical therapy, occupational therapy, respiratory therapy and speech therapy. Home care services include laboratory services and private duty nursing for a patient whose medical condition requires more skilled nursing than intermittent visiting nursing care. Home care services include personal care services, such as assisting the client with personal hygiene, dressing, feeding, transfer and ambulatory needs. Home care services also include homemaking services that are incidental to the client's health needs such as making the client's bed, cleaning the client's living areas such as bedroom and bathroom, and doing the client's laundry and shopping. Home care services do not include respite care, relief care or day care.
Preventive Services	Covered when ordered by a health plan physician/provider. Services include homemaker services, minor environmental modifications, physical therapy evaluation and services, and personal care services.
EPSDT Services	Provided to all children and young adults up to age twenty-one (21). Includes tracking, follow-up and outreach to children for initial visits, preventive visits, and follow-up visits. Includes inter-periodic screens as medically indicated. Includes multi-disciplinary evaluations and treatment, including, PT/OT/ST, for children with significant disabilities or developmental delays.
Emergency Room Service and Emergency Transportation Services	Covered both in- and out-of-State, for Emergency Services or when authorized by an MCO Provider, or in order to assess whether a condition warrants treatment as an emergency service.
Nursing Home Care and Skilled Nursing Facility Care	Covered when ordered by a Health Plan physician/provider. For Rhody Health Partners/Expansion members, the Contractor payments are limited to thirty (30) consecutive days. Please refer to the Nursing Home Status Form Policy. All skilled and custodial care covered. Contractor is responsible for notifying the State to begin dis-enrollment process. For RIte Care members, please refer to stop-loss provisions.
School-Based Clinic Services	Covered for RIte Care members as Medically Necessary at all designate sites.
Services of Other Practitioners	Covered if referred by an MCO physician. Practitioners certified and licensed by the State of Rhode Island including nurse practitioners, physicians' assistants, social workers, licensed dietitians, psychologists and licensed nurse midwives.
Court-ordered mental health and substance use services - criminal court	Covered for all members. Treatment must be provided in totality, as directed by the Court or other State official or body, such as a Probation Officer, the Rhode Island State Parole Board. If the length of stay is not prescribed on the court order, the MCOs may conduct Utilization Review on the length of stay. The MCOs must offer appropriate transitional care management to persons upon discharge and coordinate and/or arrange for in-plan medically necessary services to be in place after a court order expires. The following are examples of Criminal Court Ordered Benefits that must be provided in totality as an inplan benefit: Bail Ordered: Treatment is prescribed as a condition of bail/bond by the court. Condition of Parole: Treatment is prescribed as a condition of parole by the Parole Board. Condition of Probation: Treatment is prescribed as a condition of probation. Recommendation by a Probation State Official: Treatment is recommended by a State official (Probation Officer, Clinical social worker, etc.). Condition of Medical Parole: Person is released to treatment as a condition of their parole, by the Parole Board.
Court-ordered mental health and substance use treatment - civil court	All Civil Mental Health Court Ordered Treatment must be provided in totality as an in-plan benefit. All Regulations in the R.I. Gen. Laws § 40.1-5-5 must be followed. If the length of stay is not prescribed on the court order, the MCOs may conduct Utilization Review on the length of stay. The MCOs must offer appropriate transitional care management to persons upon discharge and coordinate and/or arrange for in-plan medically necessary services to be in place after a court order expires. Note the following are facilities where treatment may be ordered: The Eleanor Slater Hospital, Our Lady of Fatima Hospital, Rhode Island Hospital (including Hasbro), Landmark Medical Center, Newport Hospital, Roger Williams Medical Center, Butler Hospital (including the Kent Unit), Bradley Hospital, Community Mental Health Centers, Riverwood, and Fellowship. Any persons ordered to Eleanor Slater Hospital for more than seven (7) calendar days, will be dis-enrolled from the MCO at the end of the month, and be re-assigned into Medicaid FFS. Civil Court Ordered Treatment can be from the result of: a) Voluntary Admission b) Emergency Certification c) Civil Court Certification Court-ordered treatment that is not an in-plan benefit or to a non-network provider, is not the responsibility of the Contractor. Court ordered treatment is exempt from the fourteen (14) day prior authorization requirement for residential treatment.
Podiatry Services	Covered as ordered by Health Plan physician/provider.
Optometry Services	For children under twenty-one (21): Covered as medically necessary with no other limits. For adults twenty-one (21) and older: Benefit is limited to examinations that include refractions and provision of eyeglasses if needed once every two (2) years. Eyeglass lenses are covered more than once in two (2) years only if medically necessary. Eyeglass frames are covered only every two (2) years. Annual eye exams are covered for members who have diabetes. Other medically necessary treatment visits for illness or injury to the eye are covered.
Oral Health	Inpatient: Contractor is responsible for operating room charges and anesthesia services related to dental treatment received by a Medicaid beneficiary in an inpatient setting. Outpatient: Contractor is responsible for operating room charges and anesthesia services related to dental treatment received by a Medicaid beneficiary in an outpatient hospital setting. Oral Surgery: Treatment covered as medically necessary. As detailed in the Schedule of In-Plan Oral Health Benefits updated January 2017.
Hospice Services	Covered as ordered by an MCO physician/provider. Services limited to those covered by Medicare.
Durable Medical Equipment	Covered as ordered by an MCO physician/provider as medically necessary.
Adult Day Health	Day programs for frail seniors and other adults who need supervision and health services during the daytime. Adult Day Health programs offer nursing care, therapies, personal care assistance, social and recreational activities, meals, and other services in a community group setting. Adult Day Health programs are for adults who return to their homes and caregivers at the end of the day.
Children's Evaluations	Covered as needed, child sexual abuse evaluations (victim and perpetrator); parent child evaluations; fire setter evaluations; PANDA clinic evaluations; and other evaluations deemed medically necessary.
Nutrition Services	Covered as delivered by a registered or licensed dietitian for certain medical conditions and as referred by an MCO physician.
Group/Individual Education Programs	Including childbirth education classes, parenting classes, wellness/weight loss and tobacco cessation programs and services.
Interpreter Services	Covered as needed.
Transplant Services	Covered when ordered by an MCO physician.
HIV/AIDS Non-Medical Targeted Case	This program may be provided for people living with HIV/AIDS and for those at high risk for acquiring HIV (see provider manual for distinct eligibility criteria for
Management for People Living with HIV/AIDS (PLWH/As) and those at High Risk for acquiring HIV	beneficiaries to qualify for this service). These services provide a series of consistent and required "steps" such that all clients are provided with and Intake, Assessment, Care Plan. All providers must utilize an acuity index to monitor beneficiary severity. Case management services are specifically defined as services furnished to assist individuals who reside in a community setting or are transitioning to a community setting to gain access to needed medical, social, educational and other services, such as housing and transportation. Targeted case management can be furnished without regard to Medicaid's state-wideness or comparability requirements. This means that case management services may be limited to a specific group of individuals, such as HIV/AIDS, by age or health/mental health condition, or a specific area of the state. (Under EPSDT, of course, all children who require case management are entitled to receive it.) May include: Benefits/entitlement counseling and referral activities to assist eligible beneficiaries to obtain access to public and private programs for which they may be eligible All types of case management encounters and communications (face-to-face, telephone contact, other) Categorical populations designated as high risk, such as, transitional case management for incarcerated persons as they prepare to exit the correctional system; adolescents who have a behavioral health condition; sex workers; etc. A series of metrics and quality performance measures for both HIV case management for PLWH/s and those at high risk for HIV will be collected by providers and are required outcomes for delivering this service. Does not involve coordination and follow up of medical treatments.
AIDS Medical Case Management	Medical Case Management services (including treatment adherence) are a range of beneficiary-centered services that link beneficiaries with health care, psychosocial, and other services. The coordination and follow-up of medical treatments are components of medical case management. These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care, through ongoing assessment of the client's and other key family members' needs and personal support systems. Medical case management includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIVIAIDS treatments. Key activities include 1) Initial assessment of service needs; 2) Development of a comprehensive, individualized service plan; 3) Coordination of services required to implement the plan; 4) Monitoring the care; 5) Periodic re-evaluation and adaptation of the plan as necessary over the time beneficiary is enrolled in services. It includes beneficiary-specific advocacy and/or review of utilization of services. This includes all types of case management including face-to-face, phone contact, and any other form of communication.
Treatment for Gender Dysphoria	Comprehensive benefit package.
Rehabilitation Services	Physical, Occupational and Speech therapy services may be provided with physician orders by RI DOH licensed outpatient Rehabilitation Centers. These services supplement home health and outpatient hospital clinical rehabilitation services when the individual requires specialized rehabilitation services not available from a home health or outpatient hospital provider. See also EPSDT.
In Lieu of Service	All services as provided in § 2.9(C) of this Part can be utilized as an in Lieu of Service if alternative service or setting is a medically appropriate and cost-effective substitute for the covered service or setting.
Value Add Services	Services/equipment which are not in the State Plan but are cost effective, improve health and clinically appropriate.

C. EOHHS policy affects the access to and/or the scope and amount of several benefits as follows:

1. Prescriptions: Generic Policy. For RHP enrolled members, prescription benefits must be for generic drugs. Exceptions for limited brand coverage for certain therapeutic classes may be granted if approved by EOHHS, or the MCO acting in compliance with their contractual agreements with EOHHS, and in accordance with the criteria described below:

a. Availability of suitable within-class generic substitutes or out-of class alternatives.

b. Drugs with a narrow therapeutic range that are regarded as the standard of care for treating specific conditions.

c. Relative disruptions in care that may be brought on by changing treatment from one drug to another.

d. Relative medical management concerns for drugs that can only be used to treat patients with specific co-morbidities.

e. Relative clinical advantages and disadvantages of drugs within a therapeutic class.

f. Cost differentials between brand and generic alternatives.

g. Drugs that are required under Federal and State Regulations.

h. Demonstrated medical necessity and lack of efficacy on a case by case basis.

2. Non-emergency medical transportation (NEMT) policy. Responsibility for transportation services rests first with the member. If the member's condition, place of residence, or the location of medical provider does not permit the use of bus transportation, NEMT for the Medicaid enrollee may be arranged for by EOHHS or its agent for transportation to a Medicaid covered service from a Medicaid participating provider, including medical, dental, and behavioral health care services. NEMT services include bus passes, other RIPTA fare products, if authorized by EOHHS or its agent.

3. Interpretation services policy. EOHHS will notify the MCO when it knows of members who do not speak English as a first (1st) language who have either selected or been assigned to the MCO. If the MCO has more than fifty (50) members who speak a single language, it must make available general written materials, such as its member handbook, in that language.

a. Written material must be available in alternative formats, such as audio and large print, and in an appropriate manner that takes into consideration the special needs of those who are visually limited or have limited reading proficiency. All written materials for potential enrollees must include taglines in the prevalent non-English languages in the State, as well as large print, explaining the availability of written translations or oral interpretation to understand the information provided and the toll-free telephone number of the entity providing choice counseling services. All enrollees must be informed that information is available in alternative formats and how to access those formats.

4. Tracking, Follow-up, Outreach. These services are provided by the MCO in association with an initial visit with member's PCP; for preventive visits and prenatal visits; referrals that result from preventive visits; and for preventive dental visits. Outreach includes mail, phone, and home outreach, if necessary, for members who miss preventive and follow-up visits, and to resolve barriers to care such as language and transportation barriers.

210 R.I. Code R. 210-RICR-30-05-2.24

Amended effective 10/5/2021
Amended effective 12/12/2023
Amended effective 3/17/2024