210 R.I. Code R. 210-RICR-40-10-1.3

Current through December 3, 2024

Section 210-RICR-40-10-1.3 - Rhody Health Partners (RHP)

1.3.1Authority and Scope

A. In 2005, R.I. Gen. Laws § 40-8.5-1.1 authorized the Medicaid agency to establish mandatory managed care delivery systems for adults nineteen (19) years of age or older who are eligible on the basis of participation in the Supplemental Security Income (SSI) program (see §00-1.5 of this Chapter) or an SSI-related characteristic associated with age or a disability and income. In Rhode Island, persons with SSI-related characteristics are eligible under the Medicaid State Plan option for low-income elders and adults living with disabilities (EAD) in accordance with R.I. Gen. Laws Chapter 40-8.5. The requirements for adults in associated special eligibility groups that have unique financial (e.g., SSI Protected Status) or clinical criteria (e.g., breast and cervical cancer coverage group) or limited benefits (e.g., partial dual eligible group and the Medicare Premium Payment Program) are also located in §05-1.6 of this Chapter.

B. Beneficiaries eligible in these coverage groups who do not require LTSS are sometimes referred to as "Community Medicaid" and are members of the State's Integrated Health Care Coverage (IHCC) groups. The provisions governing eligibility set forth in Subchapter 05 Part 1 of this Chapter and §00-3.1.2 of this Chapter and enrollment as established herein will remain in effect unless or until replaced.

C. IHCC group beneficiaries who are eligible on the basis of SSI income standard, do not require LTSS, and do not have third (3^rd) party coverage are subject to mandatory enrollment in a Rhody Health Partners (RHP) Medicaid managed care plan. Eligible beneficiaries have the choice of two (2) RHP-participating health plans.

1.3.2EOHHS Responsibilities

A. EOHHS, or its designee, is responsible for determining the eligibility of members in the IHCC groups in accordance with requirements established in the applicable sections of Federal and State laws, Rules and Regulations unless deemed eligible by virtue of receipt of SSI. In general, persons will be informed of their enrollment options at the time a determination of eligibility is made.

B. IHCC group beneficiaries who are eligible on the basis of SSI income standard, do not require LTSS, and do not have third (3^rd) party coverage are subject to mandatory enrollment in an RHP Medicaid managed care plan. EOHHS enters into contractual arrangements with the MCOs offering RHP plans that assure access to high quality Medicaid covered services and supports. EOHHS is also responsible for informing beneficiaries of their service delivery options and initiating enrollment in a participating RHP plan.

1.3.3RHP Enrollees

A. Enrollment in an RHP plan typically occurs no more than thirty (30) days from the date of the determination of eligibility unless excluded from enrollment.

B. Excluded from RHP enrollment. Beneficiaries in the following categories are excluded from enrollment in an RHP plan and may be enrolled in an alternative Medicaid managed care arrangement:

1. Third-Party Coverage - SSI and EAD eligible beneficiaries who are enrolled in Medicare Parts A and/or B or have other third (3^rd) party coverage are not subject to mandatory enrollment in an RHP plan.

2. Exempt Due to Age - SSI and EAD beneficiaries who are between the ages of nineteen (19) and twenty-one (21) are exempt from mandatory enrollment in RHP and receive all Medicaid health coverage on a fee-for-service basis.

3. Medically Needy Eligible, Non-LTSS - Beneficiaries who are determined eligible as medically needy due to excess income and resources are also exempt from enrollment in managed care. Medicaid health coverage for beneficiaries in this category is provided in accordance with the provisions of Subchapter 05 Part 2 of this Chapter.

4. The excluded populations receive all Medicaid covered services on a fee-for-service basis, unless they are otherwise eligible for another Medicaid delivery system. In addition, during the period while awaiting plan enrollment, beneficiaries eligible for RHP receive health coverage on a fee-for-service basis.

1.3.4RHP Enrollment Process

A. RHP-eligible beneficiaries have the choice of two (2) participating plans. EOHHS employs a formula, or algorithm, to assign prospective enrollees to a health plan. Eligible beneficiaries are sent a letter from EOHHS at least forty-five (45) days prior to the enrollment effective date notifying them of their health plan assignment and the enrollment effective date. The letter also includes information on their health plan choices. Beneficiaries are given at least thirty (30) days to review the health plan enrollment assignment and request a change. At the end of this timeframe, EOHHS enrolls the beneficiary, effective the first (1^st) day of the following month, as follows:

1. Beneficiary Action - If the beneficiary makes a choice to change health plan assignment, EOHHS initiates enrollment, as appropriate, into the selected RHP plan.

2. No Beneficiary Action - If a beneficiary does not respond within the allotted timeframe, the beneficiary is enrolled in the assigned RHP plan.

3. Delivery System Changes -Enrollment into RHP is always prospective in nature. Medicaid beneficiaries are required to remain enrolled in this service delivery option, but they can request reassignment to another plan within the first (1^st) ninety (90) days of enrollment. They are also authorized to transfer from one MCO to another once a year during an open enrollment period. Medicaid enrollees who challenge an auto-assignment decision or seek to change plans more than ninety (90) days after enrollment in the health plan must submit a written request to the Medicaid agency and show good cause, as provided in Subchapter 00 Part 2 of this Chapter for reassignment to another plan. A written decision must be rendered by the Medicaid agency within ten (10) days of receiving the written request and is subject to appeal, as described in Part 10-05-2 of this Title. If a beneficiary becomes eligible for LTSS and:

a. Does not have Medicare, essential primary care services through RHP are continued if the LTSS is provided in a home or community-based setting; in such cases, all LTSS is provided on a fee-for-service basis. If LTSS is provided in a health institution such as a nursing facility, EOHHS initiates RHP disenrollment and all Medicaid covered services, including essential primary care services and LTSS are provided fee-for-service;

b. Is eligible for or enrolled in Medicare, EOHHS initiates RHP disenrollment and, if eligible, offers the alternative option of enrolling in Medicaid LTSS managed care arrangements such as the Program for All-Inclusive Care for the Elderly (PACE), a Medicare-Medicaid Plan, or a fee-for-service (FFS) alternative.

4. Auto Re-Assignment after Resumption of Eligibility - Medicaid beneficiaries who are disenrolled from RHP due to a loss of eligibility and who regain eligibility within sixty (60) calendar days are automatically reenrolled, or assigned, back into the managed care service delivery option they were in previously if they do not make a plan selection. If more than sixty (60) calendar days have elapsed, the enrollment process will follow the process established in this section.

1.3.5RHP Member Disenrollment

A. Disenrollment from an RHP plan may be initiated by EOHHS or the plan in a limited number of circumstances as follows:

1. EOHHS Initiated Disenrollment - Reasons for EOHHS-initiated disenrollment from an RHP plan include but are not limited to:

a. Death;

b. No longer Medicaid eligible;

c. Eligibility error;

d. Enrolled in Medicare or other third (3^rd) party coverage;

e. Placement in a long-term care institution - such as a nursing facility - for more than thirty (30) consecutive days;

f. Placement in Eleanor Slater, Tavares, or an out-of-State hospital;

g. Incarceration; or

h. Eligibility for Medicaid LTSS in a facility.

2. Member Disenrollment Requested by RHP plan - An RHP plan may request in writing the disenrollment of a member whose continued enrollment seriously impairs the plan's ability to furnish services to either the particular member or to other members. An RHP plan is not permitted to request disenrollment of a member due to:

a. An adverse change in the member's health status;

b. The member's utilization of medical services; or

c. Uncooperative behavior resulting from the member's special needs.

3. All plan-initiated disenrollments are subject to approval by EOHHS, after an administrative review of the facts of the case has taken place. Beneficiaries have the right to appeal EOHHS' disenrollment decision (see Part 10-05-2 this Title). EOHHS will determine the disenrollment date as appropriate, based on the results of this review.

1.3.6Grievances, Appeals and Hearings

A. Federal law requires that Medicaid MCOs have a system in place for enrollees that includes a grievance process, an appeal process, and access to an administrative fair hearing through the State Administrative Fair Hearing Process. For in-plan services, RHP members must exhaust the internal MCO Level I and Level II appeals process before requesting an EOHHS hearing. Regulations governing the appeals process for out-of-plan services are found in Part 10-05-2 of this Title.

1. Types of Internal Appeals - The plan must maintain internal policies and procedures to conform to state reporting policies and implement a process for logging appeals. Appeals filed with a managed care plan fall into three (3) categories:

a. Medical Emergency. An MCO must decide the appeal within seventy-two (72) hours when a treating provider, such as a doctor who takes care of the member, determines the care to be an emergency and all necessary information has been received by the MCO.

b. Non-Emergency Medical Care. The two (2) levels of a nonemergency medical care appeal are as follows:

(1) For the initial level of appeal, the MCO must decide the appeal within fifteen (15) days from the date that all necessary information is dated as received by the MCO. If the initial decision is adverse to the member, then the MCO must offer the second (2^nd) level of appeal.

(2) For the second (2^nd) level of appeal, the MCO must make a decision within fifteen (15) days of the date that all necessary information is dated as received by the MCO.

c. Non-Medical Care. If the appeal involves a problem other than medical care, the MCO must resolve the appeal within thirty (30) days of the date that all necessary information is dated as received by the MCO.

2. External Appeal. RHP members who exhaust the health plan's internal appeal processes may choose to initiate an "external appeal," in accordance with Part 10-05-5 of this Title. A member does not have to exhaust the third (3^rd) level appeal before accessing an EOHHS hearing.

3. Regulations governing the appeals process are found in Part 10-05-2 of this Title.

210 R.I. Code R. 210-RICR-40-10-1.3

Amended effective 10/5/2021