Section 210-RICR-40-10-1.5 - Integrated Care Initiative (ICI)1.5.1Authority and OverviewA. In accordance with R.I. Gen. Laws Chapter 40-8.13, the State's Section 1115 W aiver Demonstration, and other Federal waivers and authorities, EOHHS has developed and implemented the ICI to expand access to comprehensive care management and services through a managed care delivery system known as the Medicare-Medicaid Plan (MMP).B. Under the authority of a special Federal Financial Alignment Demonstration, the MMP integrates and coordinates Medicare and Medicaid covered services through a managed care arrangement for MME beneficiaries. Enrollment is voluntary for eligible beneficiaries. The operations of the MMP are bound by a three (3) way agreement between EOHHS, the Federal Centers for Medicare and Medicaid Services (CMS), and the participating MCO.1.5.2EOHHS ResponsibilitiesA. As the single State agency for Medicaid, EOHHS oversees administration of the program and is responsible for ensuring that eligibility determinations and enrollment procedures are conducted in accordance with applicable Federal and State laws and Regulations. To enroll in the MMP, applicants must qualify as an MME in accordance with the applicable provisions set forth herein. Enrollment in PACE is a standing option for eligible beneficiaries. Applicants are processed as summarized below: 1. Eligibility Determinations - EOHHS or its designee is responsible for determining the eligibility of applicants for Medicaid and Medicaid-funded LTSS, including those who have third (3rd) party coverage through Medicare. All LTSS applicants must meet financial and clinical criteria related to the need for an institutional level of care set forth in Part 50-00-5 of this Title and Part 50-00-6 of this Title. The eligibility duties of EOHHS also include: a. Level of Need. EOHHS applies clinical criteria to determine whether and to what extent the needs of an applicant/beneficiary require the level of care provided in an institutional setting - nursing facility, hospital, intermediate care facility for intellectual disabilities. EOHHS is also responsible for identifying beneficiaries for whom there is unlikely to be an improvement in functional/medical status.b. Beneficiary Liability. EOHHS determines the amount LTSS beneficiaries must pay toward the cost of the care - beneficiary liability - through a process referred to as the post-eligibility treatment of income (PETI). All beneficiaries of Medicaid-funded LTSS are required under the Medicaid State Plan and the State's Section 1115 W aiver to contribute to the cost of the services they receive to the full extent their income and resources allow, irrespective of care setting or service delivery option. Failure to make such payments may result in termination of eligibility for noncooperation (See Part 50-00-8 of this Title).c. Person Centered Planning and Service Arrangements. In addition to determining eligibility and beneficiary liability for Medicaid LTSS, EOHHS is responsible for engaging beneficiaries in person-centered care planning in which the beneficiary leads an assessment and discussion of his or her needs and goals and information about various care options. This process includes the development of a service plan that corresponds to the beneficiary's needs and goals and assists beneficiaries and their families in selecting the appropriate service delivery option and making care arrangements. In response to the novel Coronavirus Disease (COVID-19), EOHHS will postpone in-person, person centered planning.2. Service Delivery Options and Enrollment - EOHHS assures that every beneficiary has access to health coverage through the service delivery options provided for in Federal and State law that most appropriately meet his/her needs. Once a determination of eligibility has been made, beneficiaries are evaluated for enrollment in managed care versus fee-for service.1.5.3Service Delivery OptionsA. EOHHS provides the following delivery options to Medicaid beneficiaries who meet program participation criteria: 1. Medicare-Medicaid Plan (MMP) - The MMP is a managed care service delivery system designed to manage and coordinate the full spectrum of both Medicaid and Medicare services for Medicare and Medicaid (MME) adults. See § 1.7 of this Part for more information on the MMP.2. PACE - PACE is a service delivery option for beneficiaries who have Medicare and/or Medicaid coverage and meet a "high" or "highest" level of need for LTSS in accordance with Part 50-00-5 of this Title. Beneficiaries must be fifty-five (55) years old or older to participate in this option. See § 1.13 of this Part for more information on PACE.3. Fee-for-service - Beneficiaries participating in the MMP receive at least some of their Medicaid health coverage on a fee-for-service basis. Beneficiaries eligible for the MMP, and PACE also have the option to obtain all of their Medicaid covered services on a fee-for-service basis.4. Care Management Entity provide care coordination and assistance to beneficiaries in Medicaid fee-for-service who are not eligible for enrollment in managed care. The Care Management Entity provides beneficiaries assistance with: a. Navigating the health care systemb. Care management, client advocacy, and health educationc. Working with a person's primary care provider andd. Provides links to community resources.5. Participation in Care Management is voluntary. The State targets eligible beneficiaries for care management based upon clinical need and functional status.210 R.I. Code R. 210-RICR-40-10-1.5
Amended effective 10/5/2021