Section 210-RICR-40-00-1.4 - DefinitionsA. For the purposes of this chapter, the following definitions apply: 1. "Affordable Care Act (ACA)" means The Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. 111-152), as amended by the Three Percent Withholding Repeal and Job Creation Act (Pub. L. 112-56).2. "Applicant" means the person in the household who, if determined eligible, would qualify for Medicaid in one of the Integrated Health Care Coverage groups on the basis of the provisions set forth herein.3. "Calendar quarter" means a period of three full calendar months beginning with January, April, July, or October.4. "Community Medicaid" means the term used to refer to IHCC groups that are provided with Medicaid health coverage for essential primary care and limited preventive services in some circumstances, but does not include more than thirty (30) days of continuous LTSS.5. "Executive Office of Health and Human Services (EOHHS)" means the state agency that is designated under the Medicaid State Plan as the Single State Agency responsible for the administration of the Title XIX Medicaid Program.6. "Dual Eligible Beneficiary" means a person who is enrolled in Medicaid and Medicare. The term includes elders and adults with disabilities who are enrolled in Medicare and receive Medicaid health coverage and/or financial assistance through the State's Medicare Premium Payment Program (MPPP).7. "Income Standard" means the maximum amount of countable income a person can have for Medicaid health coverage through an eligibility pathway or coverage group subsequent to all required exclusions, disregards, and deductions. Also referred to as the "income limit."8. "Long-Term Services and Supports (LTSS)" means a spectrum of services covered by the Rhode Island Medicaid program for persons with clinical and functional impairments and/or chronic illness that require the level of care typically provided in a health care institution. Medicaid LTSS includes skilled or custodial nursing facility care, therapeutic day services, and personal care as well as various home and community-based services. Medicaid beneficiaries eligible for LTSS are also provided with primary care essential benefits.9. "Managed Care Arrangement (MCA)" means a system, often a managed care organization (MCO) that uses capitated financing to deliver high quality services and promote healthy outcomes through a medical home. Such an arrangement also includes services and supports that optimize the health and independence of beneficiaries who are determined to need or be at risk for Medicaid funded LTSS. Section § 1.5 of this Part identifies the Medicaid managed care arrangements that serve IHCC elders, adults with disabilities and beneficiaries requiring LTSS; Medicaid Code of Administrative Rules Sections: RIte Care, Rhody Health Program, Enrollment, RIte Share Program, and Communities of Care pertain to managed Medicaid delivery systems for the MACC populations without regard to the basis for eligibility - MAGI, SSI, special requirements, etc.10. "Medicaid Affordable Care Coverage (MACC) Groups" means the populations whose income eligibility for Medicaid is determined on the basis of the Modified Adjusted Gross Income (MAGI) standard. Includes children up to age 19, parents/caretakers, pregnant women, and otherwise ineligible adults 19 to 64 in accordance with the provisions established in the Medicaid Code of Administrative Rules, Overview of the Affordable Care Coverage Groups. 11. "Medicaid Code of Administrative Rules (MCAR)" means the collection of administrative rules governing the Medicaid program in Rhode Island.12. "Primary Care Essential Benefits" means non-LTSS Medicaid health coverage, and includes an array of acute, subacute, and specialty essential benefits, as identified under the Medicaid State Plan, provided by licensed health professionals. These essential benefits include, but are not limited to: health promotion, disease prevention, health maintenance, counseling, patient education, various specialty services and diagnosis and treatment of acute and chronic medical and behavioral health illnesses and conditions in a variety of health care settings (e.g., office visits, inpatient, home care, day care, etc.).13. "Primary Care Provider" means a health care practitioner who is licensed as: a. a physician with a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine and is responsible for monitoring a beneficiary's overall health; orb. a nurse practitioner, clinical nurse specialist, or physician assistant and, to the extent licensure allows, is responsible for, or collaborates with a physician, monitoring a beneficiary's overall health.14. "Resource Standard" means the maximum amount of resources a person can have for Medicaid health coverage through an eligibility pathway or coverage group subsequent to the application of all required exclusions. Also referred to as the "resource limit."15. "Wrap-around Coverage" means the Medicaid benefits provided to a beneficiary who has another form of health insurance - e.g., Medicare or commercial plan - that serves as the principal payer for his or her health care, but that does not cover those benefits.210 R.I. Code R. 210-RICR-40-00-1.4