210 R.I. Code R. 210-RICR-40-05-1.5

Current through December 3, 2024

Section 210-RICR-40-05-1.5 - Eligibility for Elders and Adults with Disabilities

1.5.1Scope and Purpose

This section identifies the chief eligibility pathways for persons sixty-five (65) and older and nineteen (19) to sixty-four (64) who are living with a disabling impairment - adults with disabilities.

1.5.2EAD Eligibility Pathway - Low-income Elders and Adults with Disabilities

A. Under the Social Security Act, 42 U.S.C. § 1396(a), States have the option under the Medicaid State Plan of expanding eligibility to elders and adults with disabilities up to and inclusive of one hundred percent (100%) of the FPL. Rhode Island chose this option in 1999 and now refers to this categorically eligible expansion group by the acronym "EAD." The EAD coverage group has higher income and resource limits than the SSI program and serves, therefore, as the State's chief general eligibility pathway for anyone with an SSI characteristic who does not qualify for SSI benefits. Coverage group features are as follows:

1. Eligibility Criteria - To qualify for Medicaid coverage through the EAD eligibility pathway, a person must meet the general eligibility requirements related to residency, citizenship and cooperation set forth in § 1.9 of this Part and the following:

a. Characteristic Requirements. A person must be without SSI and meet the characteristic requirements with respect to:

(1) Age. Sixty-five (65) and older; or

(2) Disability. Determined by the State's Medicaid Assessment and Review Team (MART) to meet the applicable SSI disability standards; or

(3) Blindness. Federal Regulations preclude States that have expanded SSI-based eligibility to income above the SSI standard (at or below seventy-five percent (75%)) to treat blindness as a distinct eligibility characteristic. Accordingly, applicants who are blind and are ineligible for SSI or an SSI Protected Status are subject to a MART disability determination.

b. Financial Requirements. The person must meet income and resource standards for EAD eligibility based on the SSI methodology as follows:

(1) Income. Total countable income must be at or below one hundred percent (100%) of the FPL for the family size involved; and

(2) Resources. Total countable resources must not exceed four thousand dollars ($4,000.00) for an individual and six thousand dollars ($6,000.00) for a couple.

2. Determination Process - The application review process evaluates all persons seeking Medicaid for eligibility through a MACC group using the MAGI standard. Anyone who self-reports a disabling impairment or who is sixty-five (65) or older is then evaluated for Community Medicaid eligibility through the pathways set forth in this section. Federal Regulations at 42 C.F.R. § 435.404 require EOHHS to provide anyone determined eligible through multiple pathways to choose the coverage group that best suits their needs.

3. Continuing Eligibility - With implementation of the State's integrated eligibility system (IES), EOHHS is instituting a modified passive renewal process. Beneficiaries are required to review and update a pre-populated form containing information obtained in their accounts and updated monthly or quarterly through electronic data matches about eligibility factors subject to change. Detailed provisions pertaining to the passive renewal process are set forth in §00-2.7.2(A)(5) of this Chapter. EOHHS will postpone the processing of annual Medicaid eligibility renewals that fall during the novel Coronavirus Disease (COVID-19) declaration of emergency for sixty (60) days or until the termination of the COVID-19 declaration of emergency, whichever is longer. This includes the suspension of periodic data checks for unemployment, State Wage Information Collection Agency (SWICA), TALX (the Employment Verification System at HRSA) and other sources and suspension of quarterly post-eligibility verifications.

4. Agency Responsibilities - The EOHHS is responsible for overseeing the evaluation of applications for EAD eligibility, enrollment, and processing renewals. In addition, prior to ending Medicaid health coverage, the EOHHS must ensure that a review is conducted to determine whether eligibility exists through any other eligibility pathway. Other responsibilities are set forth in greater detail, as indicated, in other sections of this Rule.

1.5.3Medically Needy (MN) Eligibility Pathway

Medically needy eligibility is available to certain IHCC group members who do not need LTSS (Different rules apply for LTSS eligibility as indicated in the Medicaid Code of Administrative Rules, Flexible Test of Income). Under the Rhode Island Medicaid State Plan, MN coverage is an option for elders and adults with disabilities, parents/caretakers, children and pregnant women. Adults nineteen (19) to sixty-four (64) in the MACC group do not qualify for MN coverage, and must therefore reapply through the Community Medicaid MN pathway. There is also a MN pathway for Refugee Medicaid Assistance as indicated in §1.7.3 of this Part. See Part 2 of this Subchapter for provisions related to the Community Medicaid MN pathway.

1.5.4SSI and SSP Recipients and SSI Protected Status

A. Federal law requires the States to provide Medicaid health coverage to SSI and SSP recipients. There are certain circumstances in which SSI recipients who lose or otherwise no longer qualify for full cash assistance benefits are afforded "protected status" which allows them to retain their Medicaid eligibility. In such instances, the person is treated as if he or she is an SSI recipient for Medicaid eligibility purposes. The Medicaid SSI, SSP and protected status coverage groups are described below:

1. SSI Recipients - There is no distinct State-based eligibility pathway for SSI recipients. Medicaid eligibility is automatic upon approval of SSI. The SSA determines eligibility for SSI and notifies the State of the SSI recipient's eligibility through an electronic data exchange. The State is responsible for enrollment and the provision of Medicaid health coverage until SSI eligibility ceases unless protected status is available. The EOHHS is responsible for determining whether EAD coverage is available through an alternative Medicaid eligibility pathway for SSI recipients without protected status who have or are about to lose SSI.

2. State Supplement Payment (SSP) Recipients - Persons who are eligible to receive the optional State-funded supplemental payment are automatically eligible for Medicaid health coverage under the Medicaid State Plan.

a. Eligibility criteria. To qualify, a person must be an SSI recipient, a former SSI recipient with Medicaid protected status, or a person who meets the criteria for EAD or LTSS and resides in one (1) of several pre-approved SSP living arrangements as specified in R.I. Gen. Laws § 40-6-27.2.

b. Determination process. The SSA determines eligibility for SSP for SSI recipients. As the State agency that shares responsibility with the SSA for administering the SSI program in Rhode Island, the Rhode Island Department of Human Services (DHS) requires non-SSI recipients to qualify for SSP on the basis of the EAD or applicable LTSS eligibility criteria. Eligibility criteria for all other SSP categories are located in 218-RICR-20-00-5, Supplemental Security Income and State Supplemental Payment Rules and Regulations.

c. Continuing eligibility. Renewal of Medicaid for SSP recipients is conducted in accordance with the requirements for SSI or EAD, depending on the basis of eligibility, and the applicable requirements related to living arrangement. The amount of the payment, which depends on a characteristic, living arrangement and certain other factors, is not considered in determining countable income for continuing Medicaid eligibility purposes. Medicaid eligibility based solely on SSP ceases when a recipient no longer qualifies for the payment unless there is another basis for coverage. EOHHS will postpone the processing of annual Medicaid eligibility renewals that fall during the novel Coronavirus Disease (COVID-19) declaration of emergency for sixty (60) days or until the termination of the COVID-19 declaration of emergency, whichever is longer. This includes the suspension of periodic data checks for unemployment, SWICA, TALX and other sources and suspension of quarterly post-eligibility verifications.

d. Agency responsibilities. The SSA determines initial eligibility for SSP using the SSI methodology and any additional criteria required by the State. DHS determines eligibility for non-SSI recipients through the State's IES. The EOHHS and DHS share responsibility for certifying that a beneficiary qualifies for SSP cash assistance in Category D (assisted living) and Category F (community supportive living arrangements) based on living arrangement. A need for a Medicaid LTSS is an eligibility condition for Category F.

e. Applicant/beneficiary responsibilities. SSP beneficiaries must meet all specified application and general eligibility requirements and provide the evidence required to certify payment based on living arrangement.

3. Pickle Amendment Eligibility Pathway - Since enacted in 1977, §503 of Pub. Law 94-566, known as the "Pickle Amendment," protected Medicaid eligibility for certain persons who receive Social Security or Retirement, Survivor, or Disability Insurance (RSDI) benefits. The Pickle Amendment requires the State to apply certain income disregards using a specific federal formula, which essentially deems the person an SSI recipient for Medicaid eligibility purposes.

a. Eligibility Criteria. Pickle Amendment coverage is available for a person who meets all other SSI eligibility criteria and:

(1) Was simultaneously entitled to receive both Social Security RSDI and SSI in some month after April 1977;

(2) Receives income that would qualify him or her for SSI after deducting all RSDI cost-of-living adjustments (COLA) received since the last month in which the person was eligible for both RSDI and SSI; and

(3) Is currently ineligible for SSI and eligible for and receiving RSDI.

b. Determination process. When determining Pickle eligibility, the current SSI Federal benefit rate plus any SSP payment is compared to the person's other countable income plus the amount of the RSDI benefit at the time SSI/SSP eligibility was lost. The COLA at the time Pickle eligibility is determined is disregarded in this calculation as are any COLAs for years prior up to and including the year SSI payments ceased, as long as the date the increase occurred is after April 1977. The result of this calculation is the "Protected Benefit Amount" (PBA) and is used as the basis for determining continuing Pickle Amendment eligibility. Income of any financially responsible family members is factored into the PBA calculation. All other general eligibility criteria apply; however, a MART determination of disability is not required.

c. Continuing eligibility. Persons eligible under the Pickle Amendment are subject to EAD passive renewal requirements. The COLA disregards continue to apply as long as income permits. As the SSI benefit rises from year to year, it may increase to an amount that exceeds the RSDI and the countable income amount at the time SSI eligibility ceased. At this point, the State discontinues Pickle Amendment eligibility and determines whether eligibility through an alternative pathway is available.

d. Agency responsibilities. SSA informs the State annually about potential "Pickles" at cost-of-living adjustment (COLA) time. The EOHHS is responsible for applying the COLA disregards when determining EAD eligibility of anyone who may qualify for Medicaid in this group. If found ineligible on this basis, the State also evaluates whether Medicaid is available through any other pathway.

e. Applicant/beneficiary responsibilities. Potential members of this coverage group must provide any additional information that may be required to determine eligibility and comply with the applicable general requirements for SSI-based eligibility set forth in § 1.9 of this Part.

f. Table of RSDI Cost-of-Living Adjustments. For a history of automatic cost-of-living adjustments, see: https://www.ssa.gov/cola/#:~:text=Beginning%20in%201975%2C%20Social%20Security,value%20from%20Social%20Security%20benefits.

4. Employed Persons with Disabilities, 42 U.S.C. § 1619(a)

a. Working persons with disabilities who have gross earnings at or above the SSI income standard may qualify for continuing payments, and thus Medicaid health coverage, providing they meet all SSI non-disability requirements. The following must be met for 42 U.S.C. § 1619(a) coverage:

(1) Eligibility Criteria. To qualify, the person receiving SSI based on disability must have gross earnings at or above the SSI income standard and:

(AA) Maintain disability status while working;

(BB) Meet all other SSI eligibility criteria;

(CC) Have been eligible for and received a regular SSI payment based on disability for a previous month within the current SSI eligibility period.

(2) Determination process. As long as the beneficiary meets the criteria for 42 U.S.C. § 1619(a), no income or resource standards apply e.g., income can be above the EAD limits set forth in §1.5.2 of this Part.

(3) Continuing Eligibility. Medicaid health care coverage for members of this group is automatic and continues until ended by the SSA for any reason for which it may be granted.

(4) Agency responsibilities. The SSA determines initial and continuing eligibility and notifies the EOHHS on a monthly basis of beneficiaries who qualify for 42 U.S.C. § 1619(a) coverage. The EOHHS is responsible for determining whether beneficiaries who no longer qualify are eligible through an alternative eligibility pathway.

5. Medicaid While Working, 42 U.S.C. § 1619(b) of the Social Security Act, provides Medicaid to employed persons with disabilities who no longer qualify for 42 U.S.C. § 1619(a) but need coverage to continue working. This pathway preserves Medicaid eligibility when a working person's total countable income, both earned and unearned, including deemed income, is too high for an SSI cash payment. Unlike 42 U.S.C. § 1619(a) coverage, 42 U.S.C. § 1619(b) provides "Medicaid While Working" protection when SSI cash benefits are no longer available. Medicaid health coverage is preserved for both members of a couple under 42 U.S.C. § 1619(b) if each is working, and their total combined income would result in the loss of SSI cash benefits, even if the income of one (1) would not alone trigger non-payment status. However, a non-working spouse has no protection under 42 U.S.C. § 1619(b) and loses Medicaid when the earned income of his or her spouse exceeds the limits for SSI cash benefits. For Community Medicaid health coverage through this pathway, the following apply:

a. Eligibility Criteria. A person must have received an SSI cash payment based on disability, including under 42 U.S.C. § 1619(a), for at least one (1) month in the most recent SSI benefit period, and

(1) Continue to meet the disability criteria for SSI payments except for earnings;

(2) Have insufficient earnings to replace the SSI/SSP cash benefit, Medicaid health coverage, and/or personal care or attendant services that would be available if they did not have such earnings; and

(3) Need Medicaid health coverage to continue to work or obtain employment.

b. Determination process. As long as the beneficiary meets the eligibility criteria for Medicaid While Working, and income remains below the 42 U.S.C. § 1619(b) threshold for Rhode Island, which changes annually and can be obtained on the Social Security Administration's website, no income or resource standards apply.

c. Continuing Eligibility. Medicaid coverage for members of this group is automatic and continues until ended by the SSA for any reason for which it may be granted or income exceeds the threshold for Rhode Island.

d. Agency responsibilities. The SSA determines initial and continuing eligibility and notifies the EOHHS on a monthly basis of beneficiaries who qualify in this coverage group. The EOHHS is responsible for determining whether beneficiaries who no longer qualify, are eligible for Medicaid through an alternative eligibility pathway.

6. Protected Surviving Spouses - In the Omnibus Budget Reconciliation Act of 1990, Pub. Law 101-508 (OBRA '90, 1990 U.S.C.C.A.N. 2374). Congress permanently revised eligibility standards set in §1634(b) of the Social Security Act to protect access to Medicaid health coverage for divorced and surviving spouses who lose SSI eligibility as a result of RSDI benefits.

a. Eligibility criteria. To qualify, a person must be between the ages of fifty (50) and sixty-five (65) and meet all other eligibility criteria for SSI except for income and the following:

(1) Were it not for RSDI benefits, the person would continue to be eligible for SSI and/or SSP;

(2) Received an SSI payment the month before RSDI payments began; and

(3) Must not eligible for Medicare Part A (hospital coverage insurance).

b. Determination process. For the purposes of Medicaid eligibility, the State must disregard the RSDI benefit and consider a person who meets these criteria a deemed SSI recipient until they become eligible for Medicare Part A.

c. Continuing eligibility. Medicaid eligibility in this coverage group ends on the first (1st) day of the month the beneficiary becomes eligible for Medicare Part A.

d. Agency responsibilities. The SSA notifies the EOHHS that an SSI recipient losing eligibility may qualify for Medicaid through this pathway. Notification is also provided to the State of the date in which Medicare Part A becomes available. The State then determines whether coverage is available through EAD or another alternative eligibility pathway. The RSDI disregard, the basis for protected status, is no longer included in the determination of countable income when the person is being evaluated for these other forms of Medicaid health coverage.

7. Adult Dependent Child with Disabilities - 42 U.S.C. § 1634 of the Social Security Act provides protection of Medicaid eligibility status for certain adult children with disabilities who lose SSI due to income from a parent's RSDI benefits or Social Security Disability (SSD) benefits from the adult child's own work record. For the purposes of this coverage, "adult child" includes an adopted child, or, in some cases, a stepchild, grandchild, or step grandchild who is unmarried and is age eighteen (18) or older. When determining EAD eligibility for members of this group, the parent's RSDI or child's SSD benefit is disregarded to preserve continuing Medicaid eligibility.

a. Eligibility criteria. To qualify for this eligibility pathway, a person must be:

(1) At least eighteen (18) years of age;

(2) Living with a disabling impairment that began prior to the age of twenty-two (22);

(3) An SSI recipient based on blindness or a disabling impairment; and

(4) No longer be qualified for SSI due to income resulting only from either the RSDI benefits associated with the retirement, death or disability of a parent or an SSD benefit paid to an adult child with disabilities.

b. Determination process. RSDI or SSD benefits paid to the beneficiary are disregarded when calculating countable income. SSI rules for the treatment of income otherwise apply. Protected eligibility is granted if the RSDI or the SSD benefit is the ONLY source of additional income.

c. Continuing eligibility. Protected status as a result of the RSDI or SSD disregard continues to apply as long as the beneficiary meets the disability/blindness criteria, there are no additional sources of increased countable income, and resources remain within the applicable limits.

d. Agency responsibilities. SSA notifies the State when a recipient loses SSI on this basis and qualifies for the disregards for eligibility through this pathway. The EOHHS is responsible for determining whether other relevant criteria for continuation of protected status and application of the disregard is warranted. Beneficiaries who lose protected status must be evaluated for alternate forms of Medicaid eligibility before their coverage is terminated.

8. Divorced or Surviving Spouses with Disabilities - This coverage group consists of surviving and divorced spouses who have been determined disabled and lose SSI and/or SSP due to receipt of the RSDI Disabled Widow Benefits (DWB). For Medicaid purposes, these persons are deemed to be SSI recipients until they are entitled to receive Medicare. The SSA is responsible for informing the State of persons who are eligible for continuing eligibility on this basis.

9. State Supplemental Recipients, 12/73 - This coverage group consists of Medicaid beneficiaries eligible under the Medicaid State Plan on the basis of SSI in December 1973 and their spouses who continue to live with them and are essential to their well-being. Medicaid eligibility of the spouse continues as long as the SSI recipient remains eligible under the 1973 eligibility requirements. The SSA notifies the State of persons who are deemed eligible in this group.

10. Surviving Spouses with Disabilities Affected by Actuarial Changes - The Social Security Amendments of 1983, Pub. Law 98-21, eliminated an actuarial reduction formula applied to the RSDI benefits of surviving spouses with disabilities who became entitled to RSDI benefits before age sixty (60). To offset the loss of Medicaid eligibility that occurred as a result, the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, Pub. Law 99-272, restored Medicaid eligibility for any surviving spouses with disabilities who lost coverage and filed an application for Medicaid before July 1, 1988. SSA notifies the State of any SSI recipients who may qualify for Medicaid coverage via this eligibility pathway. Eligibility continues until such time as coverage through another Medicaid eligibility pathway becomes available or the beneficiary's countable income exceeds the total of the SSI benefit rate and the RSDI payment at the time protected status was initially conferred.

210 R.I. Code R. 210-RICR-40-05-1.5

Amended effective 11/5/2020
Amended effective 6/3/2021
Amended effective 4/9/2023
Amended effective 7/29/2023(EMERGENCY)
Amended effective 11/27/2023