Section 210-RICR-40-00-3.2 - Overview of the SSI Methodology3.2.1Scope and PurposeA. All Supplemental Security Income (SSI) recipients are automatically eligible for Medicaid. The State has agreed to determine the eligibility of persons who have an SSI characteristic - age sixty-five (65) and older, blind or disabled - but do not qualify for cash benefits using the SSI methodology and in a manner that is no more restrictive than the way it is applied for SSI. For the purposes of this Chapter, the methodology applies to adults with an SSI characteristic - often called SSI lookalikes - who have income at or below the SSI eligibility standard of about seventy-five percent (75%) of the Federal Poverty Level (FPL) as well as those in the State's optional coverage group for low-income elders and adults with disabilities and all populations that qualify for Medically Needy (MN) eligibility under the Medicaid State Plan. The SSI methodology also applies to persons seeking Medicaid Long Term Services and Supports (LTSS) as indicated in this Section.B. The basic tenets of the SSI methodology are established in the Social Security Administration's rules for determining eligibility for SSI which are set forth in federal regulations at 20 C.F.R. § 416.101et seq.3.2.2Organization of SSI Methodology Provisions in this ChapterA. Sections pertaining to the SSI treatment of income and resources and their application are as follows: 1. § 3.2 of this Part - Overview of Methodology2. § 3.3 of this Part - Treatment of Income3. § 3.6 of this Part - Treatment of Resources4. Subchapter 05 Part 1 of this Chapter - Community Medicaid B. Except as otherwise noted, the provisions in this Part apply to the determination of countable income and resources for Medicaid LTSS applicants and beneficiaries in the Integrated Health Care Coverage groups (IHCC). LTSS specific provisions related to the treatment of income and resources for IHCC members are set forth in Part 50-00-6 of this Title. The income of Affordable Care Act (ACA) expansion adults in the Medicaid Affordable Care Coverage (MACC) category is evaluated in accordance with Part 30-00-3 of this Title, except that the person seeking Medicaid LTSS is treated as a family of one (1) irrespective of whether they live at home or a health institution or community-based service setting. All Medicaid LTSS applicant and beneficiaries, without regard for the method of determining financial eligibility, are subject to the transfer of asset provisions in Part 50-00-6 of this Title.3.2.3DefinitionsA. For the purposes of this Section, the following meanings apply: 1. "Child" means someone who is not married, is not the head of a household, and is either under age eighteen (18) or is under age twenty-two (22) and a student for the purposes of IHCC group eligibility only. See definition of a child for MACC group eligibility in Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways, Part 30-00-1 of this Title.2. "Couple" means a person seeking initial or continuing eligibility for Medicaid and their spouse, regardless of whether the spouse is also an applicant or beneficiary unless otherwise indicated.3. "Federal benefit rate" or "FBR" means the amount of the monthly cash assistance authorized by the Social Security Administration for the recipients of the SSI program. The FBR is the SSI income eligibility standard, as adjusted for the number of cash recipients, living arrangement and SSP levels.4. "Financial responsibility unit" or "FRU" means the group of persons living with the person seeking Medicaid benefits whose income and resources are considered available when determining financial eligibility and, as such, may count and/or be attributed to others in the household when the deeming process applies.5. "Medicaid eligibility group" means the total number of persons counted in a household - that is, the family size involved - when identifying the FPL income level that applies when determining a person's Medicaid eligibility.6. "Medicaid health coverage" means the full scope of essential health care services and supports authorized under the State's Medicaid State Plan and/or Section 1115 demonstration waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315, and provided through an authorized Medicaid delivery system. The term does not apply to partial dual eligible persons who, under the provisions of this Chapter, qualify only for financial assistance through the Medicare Premium Payment Program (MPPP) to help pay Medicare cost-sharing.7. "Medically necessary service" means a medical, surgical, or other service required for the prevention, diagnosis, cure, or treatment of a health-related condition including any such services that are necessary to slow or prevent a decremental change in medical and/or mental health status.8. "Medically needy" or "MN" means the IHCC pathway for elders, persons with disabilities, parents/caretakers, and certain pregnant people and children with income above the limits for their applicable Medicaid coverage group who incur enough health expenses during a set period to spenddown to the eligibility threshold for coverage.9. "SSI methodology" means the basis for determining Medicaid eligibility that uses the definitions and calculations for evaluating income and resources established by the U.S. Social Security Administration (SSA) for the SSI program.3.2.4Key Elements of the SSI MethodologyA. Though the application of the SSI methodology sometimes varies across coverage groups, there are several key common elements, as follows: 1. Financial Determination - The basis for determining financial eligibility using the SSI methodology is a multi-step process for evaluating income and resources, including the formation of the FRU and Medicaid eligibility groups and the application of exclusions, deductions and disregards, all of which may be applied differently depending on eligibility pathway.2. Characteristic Requirements - Due to the historical tie to the SSI program, some IHCC Community Medicaid group members must have certain characteristics related to age, blindness and disability, or clinical status to qualify for Medicaid health coverage. General characteristic requirements that drive eligibility for Community Medicaid are in Subchapter 05 Part 1 of this Chapter. 3. LTSS Need and Level of Care - LTSS is a Medicaid State Plan benefit for both IHCC and MACC group beneficiaries who have the need for a level of care typically provided by a health care institution. Federal law defines "institution" narrowly in terms of three (3) specific types of health facilities - nursing facilities (NF), intermediate care facilities for persons with intellectual/developmental disabilities (ICF-ID), and hospitals. To qualify for Medicaid-funded LTSS, individuals must meet the functional/clinical criteria related to level of need for care in one (1) of these health institutions as described in Part 50-00-5 of this Title.4. General and Group Specific Eligibility Requirements - All persons seeking Medicaid benefits must also meet the general eligibility requirements related to residency, citizenship, third (3rd) party coverage and cooperation. The general eligibility requirements for IHCC Community Medicaid are specified in Subchapter 05 Part 1 of this Chapter as well as in the sections related to specific coverage group requirements. Documentation related to both financial and functional/clinical eligibility factors is specified in these same sections.5. Clinical Reviews - Clinical reviews may consist of a determination of disability, an assessment of functional need and/or health status, or an evaluation whether an applicant or beneficiary requires the level of care provided in a health institution. The criteria and processes for making these determinations may vary considerably in accordance with the type of Medicaid health coverage a person is seeking and the scope of Medicaid coverage available.a. The provisions governing clinical reviews for the determination of disability for non-LTSS, Community Medicaid are located in Subchapter 05 Part 1 of this Chapter. For Medicaid LTSS, the provisions governing functional/clinical eligibility are set forth in Part 50-00-5 of this Title; for Katie Beckett eligibility, clinical reviews are conducted in accordance with Part 50-10-3 of this Title.3.2.5IncomeA. The evaluation of income is the process that determines the amount that counts when determining financial eligibility using the SSI methodology. For these purposes, income is defined as follows: 1. Earned Income - Earned income is income from work and may be in cash or in-kind and may include more of a person's income than they actually receive if amounts are withheld because of a garnishment or to pay a debt or other legal obligation, or to make any other payments. See § 3.4 of this Part for more detailed information.2. Unearned Income - Unearned income is all income that is not earned through employment whether received in cash or in-kind. The provisions governing the counting of unearned income are also located in § 3.4 of this Part.B. The Rules governing the determination of countable income for IHCC category Community Medicaid members are in Subchapter 05 Part 1 of this Chapter. ACA expansion adult provisions related to income are set forth in Part 30-00-3 of this Title.C. Medically needy (MN) eligibility is an option for applicants and beneficiaries who have income above the limits established in this Part. See Subchapter 05 Part 2 of this Chapter for non-LTSS MN; provisions pertaining to medically needy eligibility for Medicaid LTSS are located in Part 50-00-2 of this Title.3.2.6ResourcesA. A resource is cash or other liquid assets or any real or personal property that a person (or spouse, if any) owns and could convert to cash to be used for support and maintenance. For the purposes of determining financial eligibility using the SSI methodology, the following distinctions apply:1. Liquid Resources - A liquid resource is any resource in the form of cash, or any other form which can be converted to cash within twenty (20) business days. Examples of resources that are ordinarily liquid are stocks, bonds, mutual fund shares, promissory notes, mortgages, life insurance policies, financial institution accounts (including savings, checking, and time deposits, also known as certificates of deposit) and similar items. Liquid resources, other than cash, are evaluated according to the person's equity in the resources.2. Non-liquid Resources - A non-liquid resource is a resource that is not in the form of cash or in any other form which cannot be converted to cash within twenty (20) business days. Examples of resources that are ordinarily non-liquid include loan agreements, household goods, automobiles, trucks, tractors, boats, machinery, livestock, buildings and land. Non-liquid resources are evaluated according to their equity value except when otherwise indicated. The equity value of an item is the price that it can reasonably be expected to sell for on the open market in the particular geographic area involved, minus any encumbrances.B. § 3.6 of this Part explains the types of resources and applicable exclusions in general when using the SSI method to determine financial eligibility. Subchapter 05 Part 1 of this Chapter focuses on Community Medicaid. Medicaid LTSS-specific provisions are located in Part 50-00-6 of this Title.3.2.7Income and Resource StandardsA. The following standards are used in the determination of the countable income and resources of an individual or couple when using the SSI method for determining Medicaid financial eligibility:1. Monthly Federal Benefit Rate (FBR) - The FBR is set by the Federal government and is based on the SSI monthly cash payment for an individual or couple. The FBR is reduced by one-third if the individual or couple lives in the household of another. Accordingly, the FBR serves as the SSI income eligibility standard and in the Medicaid eligibility determination process for calculating allowances and deeming purposes. The FBR is adjusted annually on January 1, as necessary, to reflect changes in the cost of living and published by the Social Security Administration. The FBR is also the basis for the income eligibility cap for LTSS in certain circumstances.2. Optional State Supplemental Payment (SSP) Limits - The limits for SSP eligibility are tied to SSI and EAD eligibility. SSP amounts are established by statute at R.I. Gen. Laws § 40-6-27. No SSP benefit is available if the beneficiary has income in excess of the amounts below: Optional State Supplement Payment (SSP) Limits |
Living Arrangement | Maximum Income Limits to Receive SSP |
| Individual | Couple |
(a) LTSS beneficiary living in a residential care and assisted living facility | 300% SSI FBR (individual) | Limited to Individuals only |
Category D | SSP (up to $332.00 per month) + SSI FBR (individual) |
(b) Non-LTSS beneficiary living in an assisted living residence | SSP (up to $332.00 per month) + SSI FBR (individual) |
(c) SSP Living in own household | SSP ($39.92) + SSI FBR (individual) | SSP ($79.38) + SSI FBR (couple) |
(d) Living in household of another | SSP ($51.92) + 2/3 SSI FBR (individual) | SSP ($97.30) + 2/3 SSI FBR (couple) |
| |
| Personal Needs Allowance | |
(e) Living in a Medicaid-funded institution Federal and State Supplement | $75.00 SSP ($45.00) + SSI FBR (individual) ($30.00) | $150.00 SSP ($90.00) + SSI FBR (couple) ($60.00) |
3. Medically Needy (MN) Monthly Income Standards - There are different MN income standards for determining eligibility for Community Medicaid and LTSS. a. Community Medicaid. For persons seeking non-LTSS Medicaid MN coverage, previously known as the flexible test of income, eligibility is reserved for applicants with income above the eligibility standard and high health care expenses who are able to spenddown to the applicable income limit during a specified MN eligibility period of six (6) months. MN beneficiaries are eligible for Medicaid health coverage once they have spent down to this limit, as indicated below. (1) Subchapter 05 Part 2 of this Chapter covers Community Medicaid MN eligibility in detail. Under the Rhode Island Medicaid State Plan, MN coverage is available to elders and adults with disabilities (EAD), and MACC group parents/caretakers, children and pregnant people. There is no MN option for MACC adults, ages nineteen (19) to sixty-four (64); members of this group who have a disability may apply through the EAD pathway and, if found to have a disability, may pursue Community Medicaid MN eligibility if they have income above one hundred percent (100%) of the FPL. All MN beneficiaries are subject to the SSI method for determining eligibility, though income limits vary as indicated in the table below. Accordingly, for the purposes of determining eligibility, all are treated as members of the Community Medicaid group (hereinafter referred to as the Community Medicaid MACC group MN), even though the general population to which they belong is sometimes covered under a MACC group, using the MAGI-standard, such as children and pregnant people.(2) Medically Needy Income Limit (MNIL). The MNIL provides the MN income eligibility threshold and is based on the limit set for the specific coverage group.b. LTSS. Persons seeking Medicaid LTSS who have income above the eligibility limits, but below the cost of care at the average private pay rate established in the institutional cost of care comparison as set forth in § 3.2.7(A)(3)(d) of this Part below in an institution or HCBS setting also may seek MN eligibility. The MN eligibility period for LTSS is one (1) month. The provisions governing MN eligibility for Medicaid LTSS are set forth in Part 50-00-2 of this Title.c. Medicaid LTSS MN Institutional Costs Comparison. To be eligible for Medicaid LTSS as medically needy, an applicant/beneficiary must have countable monthly income above the Federal cap (three hundred percent (300%) of the SSI federal benefit rate) and below the average cost of LTSS, at the private pay rate, in the health institution (nursing facility, ICF/I-DD, or long-term hospital) that typically provides the level of care they are seeking. The health institution private pay rate applies irrespective of whether LTSS is or will be provided in the health institution or at home or in a community-based service alternative. The LTSS MN eligibility requirements are set forth in greater detail in Part 50-00-2 of this Title. The private pay rates established below are also used as the divisor to determine the length of a penalty resulting from a disqualifying transfer as indicated in Part 50-00-6 of this Title. The average rates are as follows and take effect the first (1st) day of the month after the effective date of this Regulation: LTSS Medically Needy Eligibility Health Institution Costs - updated August 2023 |
Health Institution | Average Private Pay Rate-Monthly/Daily |
Nursing Facility, including skilled nursing | $10,190.00 / $335.00 |
Intermediate Care Facility for persons with intellectual or developmental disabilities | $22,350.00 / $735.00 |
Long-term care hospital | $55,500.00 / $1,825.00 |
4. Income Guidelines - Changed annually, the IHCC group income limits and, where applicable, companion SSI-related limits are as follows: Income Limits All IHCC Groups |
Coverage Group | Income Limits |
Elders and Adults with Disabilities (EAD) | At or below 100% FPL |
Community Medicaid Elders and adults with Disabilities Medically Needy (MN) | Above 100% FPL Spenddown to Medically Needy Income Limit |
Refugee Medicaid Assistance (RMA) MN | At or below 200% FPL Spenddown to Medically Needy Income Limit |
Community Medicaid MACC Group MN | Varies by population as indicated in Subchapter 05 Part 2 of this Chapter |
QMB | 100% FPL Add $20.00 |
SLMB | 120% FPL Add $20.00 |
QI | 135% FPL Add $20.00 |
Sherlock Plan | 250% FPL |
LTSS - SSI Pathway | SSI Income Limit |
LTSS - MAGI Pathway | Up to 133% of FPL and possible 5% disregard |
LTSS Special Income/HCBS (217 lookalikes) | Up to 300% SSI Level |
LTSS - MN Pathway | Up to cost of care |
5. Resource Standards - Federal regulations requires States that have expanded IHCC group eligibility to low-income elders and adults with disabilities up to one hundred percent (100%) of the FPL to use the same resource limits in effect for MN eligibility. Resource Standards for IHCC Groups |
Coverage Group | Limits |
Community Medicaid - EAD and MN | $4,000.00 (I) $6,000.00 (C) |
Community Medicaid - MACC Group MN | Not Applicable |
SSI - Protected Status | Varies by pathway. See Subchapter 05 Part 1 of this Chapter |
SSP - State Determination (EAD) | $4,000.00 (I) $6,000.00 (C) |
SSP - SSA Determination | $2,000.00 (I) $3,000.00 (C) |
Breast and Cervical Cancer | None |
Refugee Medicaid | None |
Sherlock Plan | $10,000.00 (I) $20,000.00 (C) |
LTSS - SSI | $2,000.00 |
LTSS - Special Income/HCBS (217 lookalikes) | $4,000.00 |
LTSS - Medically Needy | $4,000.00 |
MPPP | Varies by pathway - See Chart in Subchapter 05 Part 1 of this Chapter |
6. Student Earned Income Exclusion (SEIE) - For students under age twenty-two (22) and persons who are blind or living with a disabling impairment and regularly attending school, the SSI methodology provides an income exclusion. The income exclusion is adjusted annually to reflect Federal cost of living adjustments (COLAs), when there is one, and is published by the Social Security Administration.7. LTSS Spousal Impoverishment Standards - All values are published by the Federal Centers for Medicare and Medicaid Services (CMS).a. Minimum Monthly Maintenance of Need Allowance - The minimum amount of income that married individuals receiving services in institutional settings must be permitted to transfer to a spouse who is living in the community for the maintenance needs of the spouse. This value is updated July 1 annually.b. Maximum Monthly Maintenance of Need Allowance - The maximum amount of income that married individuals receiving services in institutional settings may be permitted to transfer to a spouse who is living in the community for the maintenance needs of the spouse. This value is updated January 1 annually.c. Community Spouse Monthly Housing Allowance - The amount that married individuals receiving services in institutional settings are permitted to transfer to a spouse who is living in the community for the housing needs of the spouse. This value is updated July 1 annually.d. Community Spouse Resources (updated January 1 annually)(1) Minimum - The minimum amount of resources that must be available to an individual with a spouse that is receiving services in an institutional setting.(2) Maximum - The maximum amount of resources that may be available to an individual with a spouse that is receiving services in an institutional setting.e. Home Equity Limit (updated January 1 annually)(1) The Home Equity Limit is the maximum value allowable for the State to attribute to an institutionalized individual's home when calculating the value of the individual's resources. Federal law permits states to choose a Home Equity Limit within a range set by CMS and the State uses the minimum Home Equity Limit allowable under CMS guidelines.8. Medically Needy Standards (updated January 1 annually) Family Size | MNIL Annual January 2024 | Monthly 2024 |
1 | $13,600.00 | $1,133.00 |
2 | $14,100.00 | $1,175.00 |
3 | $17,400.00 | $1,450.00 |
4 | $19,900.00 | $1,658.00 |
5 | $22,400.00 | $1,867.00 |
6 | $25,000.00 | $2,083.00 |
7 | $27,500.00 | $2,292.00 |
8 | $30,000.00 | $2,500.00 |
9 | $32,500.00 | $2,708.00 |
10 | $35,000.00 | $2,917.00 |
a. For each family member above ten (10), add two hundred eight dollars ($208.00) to the monthly rate or two thousand five hundred dollars ($2,500.00) to the annual rate.210 R.I. Code R. 210-RICR-40-00-3.2
Amended effective 1/8/2019
Amended effective 4/28/2020
Amended effective 11/5/2020
Amended effective 1/1/2021
Amended effective 6/3/2021
Amended effective 6/25/2021
Amended effective 9/12/2021
Amended effective 2/4/2022
Amended effective 6/17/2022
Amended effective 7/23/2022
Amended effective 4/22/2023
Amended effective 7/29/2023(EMERGENCY)
Amended effective 11/23/2023
Amended effective 5/20/2024