210 R.I. Code R. 210-RICR-40-10-1.4

Current through December 3, 2024

Section 210-RICR-40-10-1.4 - RHP Benefit Package

A. The IHCC groups participating in RHP under this section receive the full scope of services covered under the Medicaid State Plan and the State's Section 1115 waiver. Covered services may be provided through the managed care plan or through the fee-for-service delivery system if the service is "out-of-plan" - that is, not included in the managed care plan but covered under Medicaid. Fee-for-service benefits may be furnished either by the managed care provider or by any participating provider.

1. Access to Benefits - Each RHP member selects a primary care provider (PCP) who performs necessary medical care and coordinates referrals to specialty care. The PCP orders treatment determined to be medically necessary in accordance with the health plan's policies. Prior authorization rules may apply, as required by the Medicaid agency.

2. Delivery of Benefits - In-plan services are paid for on a capitated basis.

3. Medical Necessity - The standard of "medical necessity" is used as the basis for determining whether access to a Medicaid covered service is required and appropriate. Medically necessary services must be provided in the most cost-efficient and appropriate setting and must not be provided solely for the convenience of the member or service provider.

4. Medicaid Benefits - The coverage provided through RHP is categorized as follows:

RHP Benefits
(a) In-Plan	(b) Out-of-Plan
Inpatient Hospital Care	Dental Services
Outpatient Hospital Services	Court-ordered Mental Health and Substance Abuse Services Ordered to a Non-Network Facility or Provider
Physician Services	Non-Emergency Transportation Services (The health plan is required to coordinate with EOHHS' non-emergency transportation broker.)
Family Planning Services	Nursing home Services in Excess of 30 Consecutive Days
Prescription Drugs	Residential Services for Beneficiaries with Intellectual and Developmental Disabilities
Non-Prescription Drugs
Laboratory Services	Center of Excellence for Opioids
Radiology Services	Peer Recovery Specialist
Diagnostic Services	Recovery Navigation Program (RNP) Long-term care services and supports after 30 days
Outpatient & Inpatient Mental Health and Substance Use Services
Court-ordered Mental Health and Substance Abuse Services - Criminal Court
Court-ordered Mental Health and Substance Abuse Treatment - Civil Court
Home Health Services
Emergency Room Service and Emergency Transportation Services
Nursing Home Care and Skilled Nursing Facility Care for the first 30 days
Services of Other Practitioners
Podiatry Services
Optometry Services
Oral Health
Hospice Services
Durable Medical Equipment
Group/Education Programs
Interpreter Services
Transplant Services
Adult Day Services
HIV/AIDS Non-Medical Targeted Case Management for People Living with HIV/AIDS and those at High Risk for Acquiring HIV
AIDS Medical Case Management
Opioid Treatment Provider Health Home
Preventive services, including: Homemaker Minor Environmental Modifications Physical Therapy Evaluation and Services

210 R.I. Code R. 210-RICR-40-10-1.4

Amended effective 10/5/2021