Section 210-RICR-30-05-3.3 - DefinitionsA. For the purposes of this section, the following definitions apply: 1. "Applicant" means a person seeking Medicaid coverage under this Part, in accordance with the provisions established in Rhode Island General Laws and Public Laws.2. "Cost-effective" means that the portion of the ESI that the State would subsidize, as well as wrap-around costs, would, on average, cost less to the State than enrolling that same individual/family in a Medicaid managed care plan.3. "Cost-sharing" means any deductibles or co-insurance associated with ESI.4. "Employee premium" means the monthly amount an individual or family is required to pay to the employer to obtain and maintain ESI coverage.5. "Employer-Sponsored Insurance" or "ESI" means health insurance or a group health plan offered to employees by an employer. This includes plans purchased by small employers through HealthSource RI.6. "Group health plan" means an employee benefits plan as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974 as qualified in R.I. Gen. Laws §§ 27-50-3(T)(1) and 27-18.6-2(15).7. "Health insurance coverage" or "Health benefit plan" means a policy, contract, certificate or agreement offered by a health insurance carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services as defined and qualified in R.I. Gen. Laws §§ 27-18.5-2(7), 27-18.6-2(14) and 27-50-3(U)(1).8. "Medicaid member" means a person who has been determined to be eligible for Medicaid benefits.9. "Modified Adjusted Gross Income" or "MAGI" means income, adjusted by any amount excluded from gross income under section 911 of the IRS Code, and any interest accrued. Social Security benefits are not included in gross income. The MAGI is the standard for determining income eligibility for all Medicaid affordable care coverage groups (RICR Title 210, Chapter 30 (Medicaid for Children, Families, and Affordable Care Act (ACA) Adults).10. "Policy holder" means the employee with access to ESI.11. "Rhode Island Works" or "RI Works" means the State's Temporary Assistance for Needy Families (TANF) program that provides assistance to low income needy families on the path to full employment and financial independence. The program is administered by the Rhode Island Department of Human Services, one of the four State agencies under the Executive Office of Health and Human Services (EOHHS) umbrella.12. "RIte Share-approved employer-sponsored insurance" means an ESI plan that meets the coverage and cost-effectiveness criteria for RIte Share.13. "RIte Share buy-in" means, in certain instances, individuals participating in RIte Share are subject to a buy-in requirement. This requirement applies to a family in which a Medicaid-eligible child is residing in a household with MAGI-based income above 150% of the FPL and must enroll in the RIte Share-approved ESI plan of a parent/caretaker - "the policy holder" - who is not eligible for Medicaid.14. "RIte Share Premium Assistance Program" means the Rhode Island Medicaid premium assistance program in which the State pays the eligible Medicaid member's share of the cost of enrolling in a RIte Share-approved ESI plan. This allows the State to share the cost of the health insurance coverage with the employer.15. "RIte Share Unit" means the entity within EOHHS responsible for assessing the cost-effectiveness of ESI, contacting employers about ESI as appropriate, initiating the RIte Share enrollment and disenrollment processes, handling member communications, and managing the overall operations of the RIte Share program.16. "Third party liability" or "TPL" means other health insurance coverage. This insurance is in addition to Medicaid and is usually provided through an employer. Since Medicaid is always payer of last resort, the TPL is always the primary coverage.17. "Wrap-around services or coverage" means any health care services not included in the ESI plan that would have been covered had the Medicaid member been enrolled in a Medicaid managed care plan (Part 2 of this Subchapter). Coverage of deductibles and co-insurance is included in the wrap. Co-payments to providers are not covered.210 R.I. Code R. 210-RICR-30-05-3.3
Amended effective 8/6/2019