Section 210-RICR-30-05-2.38 - Medicaid Members Exempt from Enrollment Managed CareA. Certain Medicaid members who would otherwise receive care through the RIte Care or RHP delivery systems may be granted exemptions from mandatory enrollment in an MCO for good cause in narrow range of "extraordinary circumstances" upon approval of EOHHS. An extraordinary circumstance, as defined for these purposes, is a situation, factor or set of factors that preclude a Medicaid member from obtaining the appropriate level of medically necessary care through the managed care delivery system - RIte Care or RHP - designated for the Medicaid member's coverage group. 1. Types of extraordinary circumstances - Such a situation, factor or set of factors may include the existence of a chronic, severe medical condition for which the member has a longstanding treatment relationship with a licensed health care practitioner who does not participate in any of the Medicaid MCOs in the delivery system designated to provide care to the member.2. Limits - A Medicaid member's preference to continue a treatment relationship with a particular physician or other health care practitioner who does not participate with an MCO in the member's designated delivery system does not constitute an "extraordinary circumstance" in and of itself.3. Exemption requests - Requests for exemption to mandatory enrollment in managed care due to extraordinary circumstances must be made in writing, include appropriate documentation (letter from physician, medical records, or other as indicated), and signed. Exemption requests should be routed to EOHHS.4. Agency actions and duration of exemption - EOHHS makes enrollment exemption determinations based on a consideration of the circumstances of each member's individual request. Once exempted, an individual can be exempt for as long as the extraordinary circumstance exists. Nonexempt Medicaid members in a household must follow the regular Medicaid MCO enrollment process.210 R.I. Code R. 210-RICR-30-05-2.38
Amended effective 10/5/2021
Amended effective 12/12/2023
Amended effective 3/17/2024