Section 210-RICR-30-05-3.23 - Good CauseA. EOHHS is responsible for determining whether good cause exists for an exception to the non-financial cooperation requirements for Medicaid eligibility contained in Subchapter 00 Part 1 of this Chapter and, more specifically, for participation in RIte Share, except as noted below: 1. Extraordinary circumstances - EOHHS must exempt a Medicaid beneficiary from RIte Share participation only when there are extraordinary circumstances which preclude the individual from receiving medically necessary care through the RIte Share-approved plan. For purposes of this exemption, "extraordinary circumstances" may include but not be limited to: a. The existence of an unusual and life-threatening medical condition which requires medical treatment that cannot be provided or arranged by the RIte Share plan whether it is provided through the custodial or non-custodial parent;b. The existence of a chronic, severe medical condition for which the Medicaid beneficiary has a long-standing treatment relationship for that condition with a provider who does not participate in the RIte Share plan and/or refuses to enroll as a Medicaid participating provider.2. Non-Custodial Parent (NCP) -a. EOHHS must exempt a Medicaid beneficiary from RIte Share participation if enrollment in the health plan of the non-custodial parent could result in reasonably anticipated physical and/or emotional harm to the child, custodial parent, or other relative with whom the child is living. Claims of physical and/or emotional harm must be determined by EOHHS to be of a genuine and serious nature. The emotional harm to the custodial parent or other relative with whom the child lives must be of such a serious nature that the capacity to care for the child adequately would be reduced.b. EOHHS may exempt a Medicaid beneficiary from RIte Share participation if the NCP's coverage has a limited Rhode Island provider network which would negatively impact access to care for the child.c. Corroborative evidence - Such evidence supporting a determination of good cause must be supplied to EOHHS. Corroborative evidence may include: court, medical, criminal, child protective services, Family Violence Option Program, social services, psychological, or law enforcement records which indicate that the non-custodial parent might inflict physical and or emotional harm on the child, custodial parent, or other relative with whom the child lives.3. Other programs - If good cause has been granted for any other benefit program administered by EOHHS or DHS, the good cause exemption will be honored by the RIte Share Program.4. Nature of request - Enrollment exemptions requested due to extraordinary circumstances must be in writing, with appropriate documentation (letter from physician, medical records, restraining orders, or others as indicated), and signed by the Medicaid beneficiary, parent/caretaker or person designated to make the request on their behalf.5. Basis of the determination - EOHHS makes RIte Share participation exemption determinations on a case by case basis after considering all required documentation and any other relevant information pertaining to the request. An exemption may be granted for any length of time during the period in which the extraordinary circumstances exist. When an exemption is granted, Medicaid beneficiaries are enrolled in the appropriate Medicaid managed care plan in accordance with Part 2 of this Subchapter.6. Limits - An individual's preference to continue a treatment relationship with a doctor or other health care provider who does not participate in the RIte Share plan or Medicaid program does not in and of itself constitute an "extraordinary circumstance."210 R.I. Code R. 210-RICR-30-05-3.23
Amended effective 8/6/2019