210 R.I. Code R. 210-RICR-40-00-2.6

Current through December 3, 2024

Section 210-RICR-40-00-2.6 - Application Review Process

2.6.1Scope and Purpose

This section provides an overview of the application review process for all IHCC groups identified in this chapter and the specific provisions that apply to Community Medicaid populations subject to eligibility determinations made by the State. As a result of programmatic changes in the State's IES required by the ACA, people are no longer required to apply for one particular category of Medicaid eligibility. Instead, to maximize access and choice, applicants are evaluated across a variety of MACC and IHCC pathways which apply different eligibility standards, requirements, and criteria. In short, the denial or termination of eligibility in one category does not preclude eligibility through another pathway. The State must consider all bases of eligibility.

2.6.2Conversion Process

A. The conversion to the State's new application review process requires new applicants and existing beneficiaries to be treated differently during the initial stages of implementation. A "new applicant", for these purposes, is a person who is not currently receiving Medicaid health coverage in any eligibility category. The conversion process is as follows:

1. New Applicants - New applicants are evaluated first using the MAGI methodology for the MACC groups.

2. Existing Beneficiaries - At the time of renewal, current IHCC beneficiaries are evaluated using the SSI income and resource standards to ensure continuity of coverage. In the process of this evaluation, an ancillary review of the information in the beneficiary's account along with updates from all available data sources is conducted to determine whether MAGI-based eligibility in one of the MACC groups is available. This review is only conducted if the beneficiary is under age 65 or 65 and older and the parent/caretaker of a Medicaid-eligible child. Upon completing this review, a notice is sent to the beneficiary indicating if an alternative form of coverage is available.

2.6.3General Rules

A. To the extent feasible, the person seeking initial or continuing eligibility is provided with the choice of eligibility pathways within and, in some instances, across the MACC and IHCC group categories. Again, MACC group eligibility is primarily income-based and uses the MAGI standard established in conjunction with federal health care reform. IHCC group eligibility is much more varied and, when not automatic due to participation in another federal program or special requirements, is based on both the SSI methodology and SSI-related characteristics. As there are significant distinctions between these two categories for obtaining eligibility, when choosing a pathway, the following should be taken into consideration:

1. Limits on Choice - Although the scope of primary care essential health coverage across Medicaid in the broad IHCC and MACC categories does not significantly vary, there are certain differences that may affect a person's choice of or access to certain eligibility pathways. In addition, federal and State policies also impose restrictions. The most common include:

a. Retroactive coverage. Under the State's Section 1115 demonstration waiver, retroactive coverage is not available to MACC group beneficiaries, including those who qualify for LTSS. Retroactive coverage is an included benefit through many of the IHCC pathways in which the State determines eligibility for Community Medicaid and Medicaid LTSS, as indicated in Subchapter 5 Part 3 of this Chapter.

b. Other Health Coverage. Federal law precludes persons who are eligible for or enrolled in Medicare from obtaining coverage through the MACC group for adults, ages 19 to 64. Other forms of health coverage, including both commercial insurance and government-sponsored, are generally not a bar to Medicaid eligibility through the MACC and IHCC pathways. In addition, the State's health insurance payment program - RIte Share - makes it possible for beneficiaries who have access to cost-effective Employer-Sponsored Insurance (ESI) to maintain coverage through work once they become Medicaid-eligible. Medicaid Code of Administrative Rules, RIte Share, provides details on RIte Share. The MPPP is also available to provide financial help to cover the costs of Medicare coverage for low-income elders and adults with disabilities.

c. Former SSI Recipients. All former SSI recipients who lose cash benefits due to increases in income are evaluated first for the SSI protected status groups located in Subchapter 5 Part 1 of this Chapter. In instances in which eligibility in one of these groups is unavailable, the person will be evaluated for the MACC and/or IHCC Community Medicaid pathways, to the extent the other limiting factors in this subsection allow, and provided with a choice of coverage options as appropriate.

d. Age. In general, persons 65 and older are ineligible for MAGI-based MACC group eligibility. Parents/caretakers of a Medicaid eligible child in this age group, including those enrolled in Medicare, are the only exceptions. Children and youth under 19 are generally not eligible in the IHCC groups. However, pregnant women, parents/caretakers and children with high health care expenses who have family income above the MACC group limit may seek MN eligibility through Community Medicaid using the SSI methodology. IHCC resource and deeming rules apply, unless the child is seeking LTSS through the Katie Beckett eligibility provision.

e. LTSS Preventive Level Services. These services are only available to adults with disabilities and elders who are eligible through the Community Medicaid pathways as EAD or MN.

f. Need for LTSS. All LTSS applicants are subject to a review of the transfer of assets, in accordance with applicable federal requirements and State laws and regulations governing estate recoveries, irrespective of whether initial income eligibility is determined using the MAGI standard or the SSI methodology. LTSS beneficiaries who are eligible through the MACC group pathway ARE NOT subject to resources limits, however.

g. Medically Needy (MN) Eligibility. For all non-LTSS applicants, MN eligibility is considered the last option for obtaining Medicaid coverage, both because the burden on beneficiaries is the most significant and the opportunities for coordinating and managing care are so limited. There is not a MN option for MACC group adults, unless they are eligible through the pathway for parents/caretakers. Accordingly, for these adults IHCC eligibility is the only avenue to MN coverage. For LTSS applicants, MN eligibility is also the last option; though the income eligibility limits are higher than through other eligibility pathways, beneficiary liability tends to be as well. In addition, access through this pathway limits access to SSP assistance (i.e., only available if income is at or below 300% of SSI) and the range of LTSS settings in some instances.

h. MPPP. Elders and adults with disabilities who are participating in the MPPP are only eligible for the MACC group for parents/caretakers. Otherwise, MPPP participants must access Medicaid financial help through the IHCC groups. In addition, participation in the MPPP has the potential to affect eligibility for Medicaid health coverage through the Community Medicaid MN pathway. As indicated in Subchapter 5 Part 2 of this Chapter, Medicare premiums are health expenses that count toward the amount a person must spenddown in order to obtain Medicaid coverage during the six month MN period. MPPP participants are not permitted to use these expenses toward a spenddown as they are paid by the State.

2. Eligibility Across Pathways - Eligibility specialists and application assisters must be available to provide applicants and beneficiaries with information about the impact the limits above have on the choice of eligibility pathways. Such information is also provided with paper applications and will be built into the self-service portal to assist applicants and beneficiaries in making reasoned choices about their Medicaid health options. The table below summarizes the major cross pathway eligibility opportunities by major Medicaid populations.

Selected Eligibility Cross Pathways By Population (Excludes beneficiaries eligible on basis of other programs)
Population	MACC Group - MAGI-Based (No Retroactive Coverage)	IHCC Group SSI methodology-based (Retroactive Coverage Possible)	Both MACC and IHCC Eligibility determined using both
Children, no need for LTSS	Up to MACC income limit (261% of FPL +5% disregard)	MN only if income above MACC limit and have high health expenses	Not Applicable
Child requiring LTSS-health institution over 30 days	Not applicable	MN-LTSS	Not Applicable
Child requiring LTSS-HCBS	Up to MACC income limit for children	Family income above MACC limit - Katie Beckett eligibility based on child's income only MN-LTSS	Not Applicable
Pregnant Women	Up to MACC income limit (253% of FPL + 5% disregard)	EAD or MN if disabled, but only until next renewal or birth of baby, whichever comes first; MN if non-disabled and income above MACC limit and have high health expenses LTSS	Option for MACC and MPPP if have Medicare
Adults 19-64, no Medicare	Up to MACC income limit (133% FPL + 5% disregard), LTSS with no resource limit	EAD or MN if have a disability and are seeking retroactive coverage LTSS	Not Applicable
Adults with disabilities 19-64	If no Medicare, up to MACC limit for adults, including while awaiting a disability determination by the State or SSA	EAD, MPPP and/or MN Sherlock Plan if working LTSS	Option MACC group for parents/caretakers and MPPP
Elders	Only if a parent/caretaker	EAD, MPPP, MN LTSS	Option MACC group for parents/caretakers and MPPP

3. Continuing Eligibility Reviews Prior to Termination of Coverage - The State must evaluate whether a beneficiary may qualify for Medicaid health coverage through an alternative pathway prior to the termination of eligibility. This requirement only applies when the reason for the termination is a change in an eligibility factor (e.g., age, income, resources or disability, relationship, etc.). The State uses any information known about the beneficiary through his or her account and electronic data sources to evaluate the options for continuing coverage. A beneficiary is informed in writing about this evaluation, which is referred to as an ex parte review, and of any additional materials that must be submitted to determine whether alternative forms of eligibility exist at least ten (10) days prior to the date the eligibility termination takes effect. Such notification is provided more than thirty (30) days in advance of the date of the agency action whenever feasible. In addition to evaluating beneficiaries for other forms of Medicaid eligibility, anyone under age 65 is also considered for commercial coverage with financial help through HSRI.

210 R.I. Code R. 210-RICR-40-00-2.6