Section 210-RICR-40-10-1.2 - DefinitionsA. For the purpose of this Rule, the following terms are defined as follows: 1. "Appeal" means a request to review an "adverse benefit determination" based on medical necessity, appropriateness, health care setting, and effectiveness.2. "Categorical eligibility" means an applicant/beneficiary included in an IHCC group who is eligible for Medicaid health coverage on the basis of income, resources, a characteristic, and/or a level of need in a mandatory or optional coverage group under the Medicaid State Plan, or who is treated as such, under the State's Section 1115 demonstration waiver, in accordance with Title XIX. It excludes persons who must spenddown to become eligible for Medicaid health coverage as medically needy.3. "Elders and adults with disabilities" or "EAD" means the Medicaid IHCC group established by R.I. Gen. Laws Chapter 40-8.5 for adults with an SSI characteristic related to age (elders sixty-five (65) years of age or older) or disability.4. "Executive Office of Health and Human Services" or "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.5. "Full dual eligible" means a beneficiary who is enrolled in Medicare Parts A and B and is eligible for Medicaid Health Coverage through an IHCC or MACC group for elders and adults with disabilities on the basis of income, resources and, when applicable, a characteristic or need for LTSS.6. "Grievance" means an expression of dissatisfaction about any matter other than an action associated with an adverse benefit determination and includes complaints about the quality of care or services provided, and aspects of interpersonal relations such as rudeness of a provider or an employee or a failure to respect an enrollee's rights.7. "Integrated Health Care Coverage Group" or "IHCC" means any Medicaid coverage group consisting of adults who are eligible on the basis of receipt of Supplemental Security Income (SSI), SSI protected status, the SSI income methodology and a related characteristic (age or disability), or as a result of participation in another federal or State program (e.g., Breast and Cervical Cancer). Includes beneficiaries eligible for community Medicaid (non-long-term care), Medicaid-funded LTSS, and the Medicare Premium Payment Program (MPP).8. "Integrated Care Initiative" or "ICI" means a Medicaid initiative that delivers integrated and coordinated services to certain Medicaid and Medicare enrolled (MME) beneficiaries through a managed care arrangement. The ICI includes services from across the care continuum including primary, subacute, and long-term care. The Medicare-Medicaid Plan (MMP) was established through ICI.9. "Long-term services and supports" or "LTSS" means a spectrum of services covered by the Rhode Island Medicaid program that are required by individuals with functional impairments and/or chronic illness, and includes skilled or custodial nursing facility care, as well as various home and community-based services.10. "Managed care arrangement" or "MCA" means a system that may use capitated financing to deliver high quality services and promote and optimize health 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. An MCA includes any arrangement under which an MCO or contracted entity is granted some or all of the responsibility for providing and/or paying for long-term care services and supports through a contractual agreement with the Medicaid program.11. "Managed care organization" or "MCO" means an entity that provides health plan(s) that integrate an efficient financing mechanism with quality service delivery, provides a "medical home" to assure appropriate care and deter unnecessary services, and emphasizes preventive and primary care.12. "Medicaid Affordable Care Coverage Groups" or "MACC" means a classification of persons eligible to receive Medicaid based on similar characteristics who are subject to the MAGI standard for determining income eligibility as outlined in Part 30-00-1 of this Title.13. "Medicaid and Medicare enrolled" or "MME" means full dual eligible or partial dual eligible plus beneficiaries who are receiving Medicaid health coverage, are enrolled in Medicare Part A, enrolled in Medicare Part B, and eligible to enroll in Medicare Part D.14. "Medicaid health coverage" means the full scope of health care services and supports authorized under the State's Medicaid State Plan and/or Section 1115 demonstration waiver provided through an authorized Medicaid delivery system. The term encompasses the scope of health coverage available to categorically and medically needy eligible beneficiaries as well as those who are treated as such under the State's Section 1115 demonstration waiver. However, the term does not apply to partial dual eligible persons who, under the provisions of this section, qualify only for financial assistance through the MPPP to help pay Medicare cost-sharing.15. "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 prevent or slow a decremental change in either medical or mental health status.16. "Medically needy" means an IHCC group for elders and persons with disabilities who have high medical expenses and income that exceeds the maximum eligibility threshold for Medicaid. For non-LTSS beneficiaries in this coverage group, Medicaid eligibility and coverage occur when the amount they spend on medical expenses meets the medically needy income limit established by the State. For LTSS beneficiaries, excess income must be contributed toward the cost of care. Non-LTSS medically needy beneficiaries are covered on a fee-for-service basis.17. "Medicare-Medicaid Plan" or "MMP" is an integrated managed care plan under contract with the Federal Centers for Medicare and Medicaid Services (CMS) and EOHHS to provide fully integrated Medicare and Medicaid benefits to eligible MME beneficiaries.18. "Member" or "Enrollee" means a Medicaid-eligible person receiving benefits through Rhody Health Partners, a Medicare-Medicaid Plan, or the Program for All-Inclusive Care for the Elderly.19. "Partial dual eligible" means a Medicare beneficiary who does not meet the requirements for Medicaid Health Coverage, but who is eligible for the State's Medicare Premium Payment Program (MPP).20. "Partial dual eligible plus" means a Medicare beneficiary who is eligible for Medicaid health coverage as medically needy and the MPP.21. "Person-centered planning" means an individualized approach to planning that supports an individual to share his or her desires and goals, to consider different options for support, and to learn about the benefits and risks of each option. Person-centered planning places the individual at the center of decision-making. It is designed to enable people to direct their own services and supports to live a meaningful life that maximizes independence and community participation. Person-centered planning is a process that is directed by the individual, with impartial assistance and supported decision-making when helpful. Person-centered planning teams may include people who are close to the individual, as well as people who can help to bring about needed change for the person and access to appropriate services. However, at all times, the individual is empowered to decide who is part of the planning team. Person-centered planning must meet the requirements of 42 C.F.R. § 441.301(c)(1) including, but not limited to, ensuring that a person has sufficient and necessary information in a form he/she can understand to make informed choices, enabling the person to direct the process to the maximum extent possible, and conducting planning meetings at times and in locations that are convenient to the individual.22. "Primary care" means an array of primary, acute, and specialty services provided by licensed health professionals that includes, but is 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, inpatient, care, home care, day care).23. "Program of All Inclusive Care for the Elderly" or "PACE" means a risk-based managed care service delivery option for beneficiaries who have Medicare and/or Medicaid coverage and meet the financial and clinical criteria for a nursing facility level of long-term services and supports. Beneficiaries must be fifty-five (55) years or older to participate in this option.24. "Rhody Health Options" or "RHO" means the capitated managed care delivery system operating under contract with EOHHS to manage and coordinate Medicaid covered services and supports, including LTSS, for eligible MNM and MME beneficiaries and to coordinate Medicaid covered services with Medicare covered services for eligible MME beneficiaries. RHO terminates as service delivery option on September 30, 2018.25. "Rhody Health Partners" or "RHP" means the Medicaid managed care service delivery option for adults in the IHCC groups that provides primary/acute and specialty care through a medical home that focuses on prevention and promoting healthy outcomes. The Rules for RHP for adults ages nineteen to sixty-four (19 - 64) in the MACC groups are located in Part 30-05-2 of this Title.26. "SSI income standard" 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 for the Supplemental Security Income (SSI) program.27. "SSI protected status" means the class of beneficiaries who retain categorical eligibility for Medicaid even though they are no longer eligible for SSI due to certain changes in income or resources.210 R.I. Code R. 210-RICR-40-10-1.2
Amended effective 10/5/2021