210 R.I. Code R. 210-RICR-40-05-1.9

Current through December 3, 2024

Section 210-RICR-40-05-1.9 - Community Medicaid General Eligibility Requirements

1.9.1Scope and Purpose

All applicants for Medicaid in the IHCC groups must meet general eligibility requirements in addition to those related to income, resources, and clinical need.

1.9.2Characteristic Requirements

A. Unless specifically exempt, a person applying for Community Medicaid when eligibility is determined by the State must establish their categorical relationship to SSI by qualifying on the basis of one (1) of the following characteristics:

1. Age - A person qualifying on the basis of age must be at least sixty-five (65) years of age in or before the month in which eligibility begins.

a. Verification: An applicant's age is verified electronically with information about date of birth from the SSA and/or the Rhode Island Department of Health, Division of Vital Statistics. If data matches are unsuccessful, an applicant is required to provide paper documentation of date of birth to support a self-attestation of age.

2. Disability - Determined to meet the SSI disability criteria applied by the MART, or the SSA for SSI cash benefits or RSDI or SSD. Note: An applicant must be determined disabled due to blindness by the MART or by an entity of the SSA. If income is at or below SSI income standard, a disability determination for blindness is NOT required.

1.9.3Non-Financial Criteria

A. Applicants must also meet all of the following non-financial eligibility criteria for Medicaid:

1. Social Security Number - Each person applying for Medicaid must have a Social Security Number (SSN) as a condition of eligibility for the program.

a. Condition of Eligibility. Applicants must be notified prior to or while completing the application that furnishing an SSN is a condition of eligibility. Only members of a household who are applying for Medicaid are required to provide an SSN, however. An SSN of a non-applicant may be requested to verify income. Refusal of a non-applicant to provide an SSN cannot be used as a basis for denying eligibility to an applicant who has provided an SSN. If an SSN is unavailable, other proof of income must be accepted.

b. Limits on Use. Applicants must also be informed that their SSN will be utilized only in the administration of the Medicaid program, including in verifying income and eligibility.

c. Verification. SSN is verified through an electronic data-match with the SSA. Applicants must provide documentation of SSN if the data match fails. Paper documentation indicating that an application for an SSN has been made is required for applicants who do not have an SSN at the time of application.

2. Residency - A person must be a resident of Rhode Island to be eligible for Medicaid. The State of residence of a person is determined according to the following:

a. SSP. For persons receiving an SSP payment, the State of residence is the State paying the supplement. Exception: Persons involved in work of a transient nature or who have moved to the State to seek employment may claim Rhode Island as their State of residence and be granted Medicaid in Rhode Island if they meet all other eligibility criteria. These persons may be granted Rhode Island Medicaid even though they continue to receive a State supplemental payment from another State.

b. Persons under twenty-one (21). Residency is determined as follows for minors:

(1) A person who is blind or living with a disabling impairment under the age of twenty-one (21) who is not residing in an institution, the State of residence is the State in which the person is living.

(2) Any person residing in a health care or treatment facility who is under the age of twenty-one (21), or who is twenty-one (21) or older and became incapable of indicating intent prior to the age of twenty-one (21), the State of residence is that of:

(AA) The parents or legal guardian, if one (1) has been appointed, or

(BB) The parent applying for Medicaid on behalf of the person if the parents live in different States, or

(CC) The person or party who has filed the application on behalf of the applicant if the applicant has been abandoned by his or her parents and does not have a legal guardian.

c. Persons twenty-one (21) and older. For adults age twenty-one (21) or older, residence is determined as follows:

(1) If not living in an institution, the State of residence is the one in which the person is living:

(AA) With intent to remain permanently or for an indefinite period of time;

(BB) While incapable of stating intent; or

(CC) After entering with a job commitment or in pursuit of employment whether or not currently employed.

(2) A person age twenty-one (21) or older who is residing in a health institution and became incapable of stating intent at or after age twenty-one (21), residing is in the State in which the person is physically present, unless another State arranged for placement in a Rhode Island institution.

(3) For any other person age twenty-one (21) or older living in an institutional setting, residence is in the State where the person is living with the intention to remain permanently or for an indefinite period, unless another State has made a placement. A person living in a health care institution cannot be considered a Rhode Island resident if he or she owns a home in another State and has an intent to return there even if the likelihood of return is apparently nil.

d. Absence Due to Military Assignment. A blind or impaired child who travels out of the State for an indefinite period with a parent in the armed forces is no longer eligible for Medicaid or SSP even if SSI benefits continue.

e. Temporary Absence. Temporary absences from Rhode Island for any of the following purposes do not interrupt or end Rhode Island residence:

(1) Obtaining necessary health care;

(2) Visiting;

(3) Obtaining education or training under a program of the Rhode Island Office of Rehabilitation Services (ORS), work incentive or higher education program, or

(4) Residing in an LTSS facility in another State, if arranged by an agent of the State of Rhode Island, unless the person or his/her parents or guardian, as applicable, stated an intent to abandon Rhode Island residence and to reside outside Rhode Island upon discharge from LTSS.

f. Placement in Rhode Island Institutions. When an agent of another State arranges for a person's placement in a Rhode Island institution, the person remains a resident of the State which made the placement, irrespective of the person's intent.

g. Incapable of Stating Intent. Persons are incapable of stating intent regarding residence if they are judged to be legally incapable of doing so or there is medical documentation or other documentation acceptable for such purposes that supports a finding that they are incapable of stating intent.

h. Residence as Payment Requirement. A person must be a resident of Rhode Island at the time a medical service is rendered in order for Rhode Island Medicaid to pay for that service. The service does not, however, have to be rendered in Rhode Island.

i. Specific Prohibitions. Under Federal law, the State may not deny Medicaid eligibility to an applicant for any of the following reasons:

(1) Failure to reside in the State for a specified period; or

(2) Failure of a person receiving care in an institutional setting to establish residence in the State before entering the institution if otherwise satisfying the residency rules set forth in this section; or

(3) Temporary absence from the State if the person intends to return when the purpose of the absence has been accomplished, unless another State has determined that the person is a resident there for purposes of Medicaid; or

(4) Failure to have a permanent or fixed address. Homeless persons may designate a mailing address.

j. Verification - At the time of initial application for Medicaid, self-attestation of Rhode Island residency is accepted and/or verified electronically and the intent to remain is accepted unless required for the evaluation of resources or income that has been earned by the applicant in another State.

3. Living Arrangements - A person's living arrangement is a factor when determining eligibility for programs and payment amounts that may directly or indirectly affect access to Medicaid for certain Medicaid services. In addition, incarceration is also a factor that affects eligibility status and access to Medicaid coverage.

a. Financial eligibility. The financial responsibility of relatives varies depending upon the type of living arrangement. Thus, when determining financial eligibility, the living arrangements of individuals and couples matter as follows:

(1) Living in own home such as a house, apartment, or mobile home or someone else's household affects Medicaid MACC household composition and RIte Share participation and thus is a factor considered in the process noted in §1.9.3(A)(2) of this Part.

(2) Residing in a community-based group care or board and care facility such as assisted living, supportive home for persons with developmental disabilities or behavioral health needs. Determines Medicaid eligibility group size and cap on room and board charges and allowances and contributions to cost of care;

(3) Residing in a health care or treatment institution such as a hospital, nursing facility, intermediate care facility for persons with intellectual disabilities, residential care facility for adults or children requiring treatment or rehabilitation services. An institution is, for these purposes, an establishment that furnishes food, shelter and some health treatment, services, and/or supports to four (4) or more persons unrelated to the proprietor. Determines Medicaid eligibility group size and countable income;

(4) Persons who are homeless are considered to be living in their own homes if they reside in a shelter or move from one temporary living arrangement to another for more than six (6) months during a calendar year.

b. SSP. Eligibility for and the amount of the optional State supplemental payment is affected by the following living arrangements which, in turn, may determine a Medicaid beneficiary's choice of care settings:

(1) Residence in a hospital or nursing facility for the whole month and Medicaid pays for over one half (1/2) of the cost of care;

(2) Medicaid LTSS beneficiary living in either an appropriately certified residence/home participating in the Medicaid Community Supportive Living Program established under R.I. Gen. Laws § 40-8.13-12, or Medicaid certified assisted living residence authorized in accordance with R.I. Gen. Laws § 40-6-27;

(3) Medicaid beneficiary who is SSI or EAD eligible (non-LTSS) and is residing in an assisted living residence;

(4) Medicaid beneficiary under twenty-one (21) residing in a hospital or nursing facility for the entire month and private insurance and/or Medicaid together pay over one half (1/2) of the cost of care; or

(5) Medicaid beneficiary of an age or IHCC group residing in a public or private health care treatment facility and Medicaid is paying for more than one half (1/2) of the cost of care. If residing in the facility for the whole month, the SSP payment is limited to forty-five dollars ($45.00).

c. Verification - For both Medicaid eligibility (a) and SSP (b), self-attestation of living arrangement is accepted during initial application for persons living in their own homes or in someone else's household. Documentation certifying that a person is or will be residing in a community-based residence that qualifies for one (1) of the special SSP payments is required. Proof of living in a health care or treatment institution must be provided when no other source of verification is available. Notification to EOHHS and DHS of change in living arrangement from a community-based to an institutional setting or the reverse is mandatory and must be made within ten (10) days of the date the change occurs for all applicants and beneficiaries.

d. Correctional Facility. While living in a correctional facility, including a juvenile facility, Medicaid health coverage for otherwise IHCC eligible persons is suspended except for in-patient and emergency services provided outside of the facility. Residence in a correctional facility begins on the date of incarceration and continues until the date the person is released from the correctional facility. A person transferred from a correctional facility to a hospital for part or all of the sentencing period is considered to be still living in the correctional facility for general eligibility purposes, unless the exemption for Medicaid coverage of in-patient and emergency care applies.

e. Verification. Self-attestation of incarceration is accepted initially and then verified through information exchanges with the Rhode Island Department of Corrections (DOC). In addition, electronic data matches with DOC records are conducted on a regular basis in conjunction with the post-eligibility verification process.

4. Citizenship and Immigration Status - Immigration and citizenship status affect Community Medicaid eligibility as follows:

a. Citizen or Qualified Non-citizen. An applicant for coverage in one (1) of the IHCC groups must be a United States citizen or a lawfully present "qualified" non-citizen immigrant who has been in the U.S. for five (5) years or more. Lawfully present qualified non-citizens include persons in the U.S. as legal permanent residents (LPR), with humanitarian statuses or as a result of such circumstances (e.g., refugees, asylum applicants, temporary protected status), valid non-immigrant visas, and legal status conferred by other Federal laws (temporary resident, LIFE Act, Pub. Law 106-553and 106-554, Family Unity Act, 8 C.F.R. Part 236(B), etc.). There are exceptions in Federal law and, more generally, under the Rhode Island Medicaid Program which permit qualified non-citizens who might otherwise be subject to the bar to obtain Medicaid health coverage. These exceptions are located in Part 30-00-1 of this Title, Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways. General exceptions specific to Rhode Island are as follows:

(1) Pregnant women are eligible if they meet all other requirements regardless of immigration status.

(2) Lawfully present children who meet all other requirements are eligible during the five (5) year bar under the State's Children's Health Insurance Program (CHIP) State Plan. Eligibility under CHIP also extends to lawfully present children in the U.S. on non-immigrant visas who are treated as qualified non-citizens exempt from the five (5) year bar.

b. Non-qualified Non-citizen. With the exception of pregnant women, adult "non-qualified" non-citizens are not eligible for Medicaid. Non-qualified non-citizens are persons from other nations who are not considered to be immigrants under current Federal law, including those in the United States on a time-limited visa (such as visitors or persons in the U.S. on official business) and those who are present in the country without proper documentation (includes people with no or expired status). Non-qualified non-citizens may obtain Medicaid health coverage in emergency situations only, as indicated in §1.7.5 of this Part. Non-emergency services may be obtained through Federally Qualified Community Health Centers.

(1) Lawfully present adult non-citizens may be eligible for commercial coverage with financial assistance, through HSRI. Further information is available at: www.healthsourceri.org.

c. Verification: Individuals who are applying for coverage must provide their immigration and citizenship status. Non-applicants in the FRU are exempt from the requirement. Any information provided by an applicant on paper or electronically must be used only for verifying status. Acceptable documentation, when required, is set forth in Part 10-00-3 of this Title, Medicaid and Children's Health Insurance Program (CHIP) Non-Financial General Eligibility Requirements.

5. Other Forms of Cooperation - Rhode Island's Medicaid State Plan states that as a condition of eligibility for Medicaid, applicants must at the time of application:

a. Agree to cooperate in identifying and providing information to assist the State in pursuing any third (3rd) party who may be liable to pay for care and services;

b. Agree to cooperate with the State in obtaining medical support and payments (e.g., signing papers necessary to pursue payments from absent parents);

c. Agree to apply for eligibility for any other forms of public assistance which may be available upon receiving notification from the EOHHS in accordance with Part 10-00-3 of this Title, Medicaid and Children's Health Insurance Program (CHIP) Non-Financial General Eligibility Requirements;

d. Enroll in a RIte Share-approved employer-sponsored health insurance plan if cost-effective to do so, in accordance with Part 30-05-3 of this Title, RIte Share Premium Assistance Program; and

e. Agree to cooperate in establishing the paternity of a child born out of wedlock for whom the applicant can legally assign rights.

1.9.4Good Cause for Failing to Cooperate

A. A Medicaid applicant or beneficiary must have the opportunity to claim good cause for refusing to cooperate. Good cause may be claimed by contacting an agency representative. To claim good cause, a person must state the basis of the claim in writing and present corroborative evidence within twenty (20) days of the claim; provide sufficient information to enable the investigation of the existence of the circumstance that is alleged as the cause for non-cooperation; or, provide sworn statements from other persons supporting the claim.

1. A determination of good cause is based on the evidence establishing or supporting the claim and/or an investigation by EOHHS agency staff of the circumstances used as justification for the claim of good cause for non-cooperation.

2. The determination as to whether good cause exists must be made within thirty (30) days of the date the claim was made unless the agency needs additional time because the information required to verify the claim cannot be obtained within the time standard. The person making the claim must be notified accordingly.

B. Upon making a final determination, notice must be sent to the person making the claim. The notice must include the right to appeal through the EOHHS Administrative Fair Hearing Process set forth in Part 10-05-2 of this Title, Appeals Process and Procedures for EOHHS Agencies and Programs, or its successor Regulation.

210 R.I. Code R. 210-RICR-40-05-1.9

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