210 R.I. Code R. 210-RICR-40-10-1.7

Current through December 3, 2024

Section 210-RICR-40-10-1.7 - Medicare-Medicaid Plan (MMP)

1.7.1Overview

Under the authority of a special Federal Financial Alignment Demonstration, the MMP is designed to manage and coordinate the full spectrum of both Medicaid and Medicare services for Medicare and Medicaid (MME) adults. Enrollment is voluntary for eligible beneficiaries. A three (3) way agreement between EOHHS, the MCO operating the MMP, and the Federal Centers for Medicare and Medicaid Services (CMS) governs the organization, financing, and delivery of Medicaid and Medicare services to MME beneficiaries who choose to participate.

1.7.2MMP Participation Criteria

A. MME beneficiaries are eligible for participation in the MMP if they are age twenty-one (21) and older as follows:

1. MME Enrollees - Medicare-Medicaid beneficiaries who are receiving Medicaid health coverage, enrolled in Medicare Part A, enrolled in Medicare Part B, and eligible to enroll in Medicare Part D. This cohort includes MME and other Community Medicaid IHCC group beneficiaries as well as those who need LTSS. Eligible MME beneficiaries include:

a. Members of the IHCC groups receiving Community Medicaid, including persons with serious and persistent mental illness, who do not need LTSS;

b. MAGI-eligible adults in the MACC group for parents/caretakers;

c. LTSS recipients residing in institutional or home and community-based settings including those qualifying for the level of care provided in a nursing facility and intermediate care facility for persons with intellectual disabilities (ICF-ID) - such as nursing facility, assisted living and ID group home residents as well as those residing in their own homes; and

d. Persons with End Stage Renal Disease (ESRD) at the time of enrollment.

2. MME beneficiaries are entitled to Medicaid State Plan and Section 1115 waiver services that are not covered by Medicare.

3. Excluded Beneficiaries - Certain Medicaid beneficiaries are excluded from participating in the MMP as indicated below:

a. Beneficiaries excluded from the MMP.

b. Medicare beneficiaries who are not eligible for Medicaid health coverage, including partial dual eligible beneficiaries who participate in the Medicaid Premium Payment Program (MPP) as Qualified Medicare Beneficiaries (QMBs), Specified Low-Income Beneficiaries (SLMBs), and Qualifying Individuals (QIs).

c. Dual Eligible beneficiaries who are not qualified to enroll in all segments of Medicare.

d. Medicaid beneficiaries residing in Tavares, Eleanor Slater, or out-of-State hospitals.

e. Beneficiaries who are in hospice on the effective enrollment date. Enrollees who elect hospice care after they are enrolled in the MMP can remain in the MMP.

f. Beneficiaries who reside out-of-State for six (6) consecutive months or longer.

g. Beneficiaries who are eligible for the Medicaid Buy-In Program for Working People with Disabilities (known as the "The Sherlock Plan" in Rhode Island).

h. Dual eligible beneficiaries who are between the ages of nineteen (19) and twenty (20) are exempt from enrollment in managed care and receive all Medicaid health coverage on a fee-for-service basis.

i. Beneficiaries who are determined eligible as medically needy for Community Medicaid due to excess income and resources are exempt from enrollment in managed care.

1.7.3MMP Service Delivery Option

MMP participating beneficiaries receive services through a managed care arrangement operating under contract with EOHHS and CMS. MMP enrollees receive services through a health plan offered by an MCO. The operations of the MMP are bound by a three (3) way agreement with EOHHS and CMS to integrate the full range of Medicare and Medicaid services (primary care, acute care, specialty care, behavioral health care, and LTSS) in accordance with a rate structure that includes Federal and State funding streams for all MME adults. Accordingly, the MMP must provide accessible, high-quality services and supports focused on optimizing the health and independence of one of the most fragile Medicaid populations. Enrollment in the MMP is voluntary.

1.7.4MMP Enrollment

A. The MMP offers MME beneficiaries the opportunity to obtain comprehensive integrated services through a single health plan.

1. Passive or Auto-Enrollment - Eligible beneficiaries may be passively enrolled by EOHHS, or auto-enrolled, in the MMP unless they are excluded from passive enrollment on the basis of one (1) of the following criteria:

a. The MME beneficiary is enrolled in a Medicare Advantage plan that is not operated by the same MCO as the MMP;

b. The beneficiary has been auto-enrolled by CMS into a Medicare Part D plan in the same calendar year that the MME would qualify for the MMP;

c. The MME is currently enrolled in comprehensive health insurance coverage through a private commercial plan or group health plan provided through an employer, union, or TRICARE; or

d. The beneficiary has affirmatively opted-out of passive enrollment into an MMP or a Medicare Part D plan.

2. Opt-in Enrollment - Eligible beneficiaries may be offered the option to opt into the MMP. MME beneficiaries who are not eligible for passive enrollment will be offered the opportunity to opt-in to an MMP by completing an application in writing or via phone. Individuals enrolled in PACE may elect to enroll and participate in the MMP if they choose to disenroll from PACE.

1.7.5Enrollment Information

A. EOHHS is responsible for ensuring that all MME beneficiaries who meet the criteria to participate in the MMP have access to the information necessary to make a reasoned choice about their coverage options. As indicated in § 1.2(A) (25) of this Part, the person-centered planning process plays a critical role in ensuring that beneficiaries are aware of the full range of service delivery options available to them based on their level of need and personal goals. Accordingly, prospective participants are sent a written communication informing them of the option to enroll in an MMP, as well as information on the availability of independent enrollment options counseling and other supports to help beneficiaries make informed enrollment decisions. Eligible individuals who opt-out of or do not enroll in an MMP have the option to enroll in PACE if eligible, or receive all Medicaid covered services - including LTSS - on a fee-for-service basis, unless they are otherwise eligible for another Medicaid delivery system.

B. Communications with MME beneficiaries who qualify to participate in the MMP includes information about each of the following:

1. Enrollment Opt-In and Opt-Out Process - Participation in an MMP is voluntary. MME beneficiaries eligible for passive enrollment are informed that they may choose to opt out of enrollment in the MMP and are provided with instructions on how to proceed. MME beneficiaries eligible for passive enrollment who opt-out may choose any of the alternative service delivery options for which they may qualify. Eligible beneficiaries who are not passively enrolled are provided with instructions on how to enroll in an MMP.

2. Decision Timeframe - Eligible beneficiaries may enroll in an operational MMP at any time up until six (6) months prior to the end of the Federal demonstration under which the MMP was implemented. The Federal demonstration is scheduled to end on December 31, 2020. Information is provided about enrollment decision time-frames as follows:

a. Passive Enrollment. Beneficiaries eligible for passive enrollment into the MMP are sent a first (1^st) notification that they will be passively enrolled between sixty (60) and ninety (90) days prior to the effective date of enrollment; a second (2^nd) reminder notification is sent to the beneficiary at least thirty (30) days prior to the effective date of enrollment. If the beneficiary makes an enrollment choice within the specified timeframe, EOHHS initiates enrollment accordingly. If a beneficiary does not respond within the specified timeframe, enrollment in the MMP proceeds in accordance with the terms specified in the initial communication from EOHHS.

b. Opt-in Enrollment. MME beneficiaries who are eligible for the MMP but are not passively enrolled may be sent a notification that they have the option to enroll in an MMP. Opt-in enrollment requests received through the tenth (10^th) day of the month will take effect on the first (1^st) day of the following calendar month. Opt-in enrollment requests received on the eleventh (11^th) day of the month or later will take effect on the first (1^st) day of the second (2^nd) month after the request was submitted. Beneficiaries do not need to make an enrollment decision to opt into the MMP within a specified timeframe after receiving notice from EOHHS informing them that they are eligible to enroll in the MMP. However, no new enrollments will be accepted during the six (6) months prior to the end date for the Federal demonstration under which the MMP was implemented. The Federal demonstration is scheduled to end on December 31, 2020.

3. Opportunity to Change - Beneficiaries who are being passively enrolled or who opt-in to an MMP may cancel their enrollment any time prior to their effective enrollment date. Once enrolled, beneficiaries may change service delivery options on a monthly basis at any time, but enrollment in the MMP will continue through the end of the month. The requested change will be effective on the first (1^st) day of the following month. Beneficiaries who cancel enrollment into or voluntarily disenroll from an MMP will be enrolled in fee-for-service (FFS), effective the first (1^st) day of the following month. Beneficiaries who voluntarily disenroll from the MMP plan can choose to re-enroll in the plan on a monthly basis if they continue to be eligible for enrollment in the MMP, but they will not be passively enrolled in the MMP. Beneficiaries may also be eligible for enrollment in PACE (see § 1.13 of this Part).

4. Auto Re-Assignment after Resumption of Eligibility - MME beneficiaries who are disenrolled from an MMP due to a loss of eligibility are eligible for re-enrollment in the plan if eligibility is reinstated and they otherwise meet the requirements for enrollment. Beneficiaries eligible for re-enrollment will be passively enrolled if they meet the requirements for passive enrollment. Otherwise, they will be offered opt-in enrollment.

1.7.6MMP Member Disenrollment

A. EOHHS Initiated Disenrollment - Reasons for EOHHS disenrollment from an MMP include but are not limited to:

1. Death;

2. No longer eligible for Medicaid;

3. Loss of Medicare Part A and/or Part B;

4. Enrollment into a Medicare Advantage (Part C) plan or Medicare Part D prescription drug plan;

5. Eligibility error;

6. Placement in Eleanor Slater Hospital, Tavares, or out-of-State residential hospital;

7. Incarceration;

8. Changed State of residence;

9. Enrollment in PACE; and

10. Opt-out to fee-for-service.

B. Beneficiaries who are involuntarily disenrolled because of incarceration are provided Medicaid coverage on a fee-for-service basis. Beneficiaries who are involuntarily disenrolled for any other reason and remain eligible for Medicaid coverage are enrolled in FFS.

C. Medicare-Medicaid Plan Disenrollment Request - The Medicare-Medicaid plan may make a written request to EOHHS and CMS asking that a particular member be disenrolled. Any such request is only considered by EOHHS and CMS when made on the grounds that the member's continued enrollment seriously impairs the entity's capacity to furnish services to either the particular member or other members, the member knowingly provided fraudulent information on the MMP enrollment form that materially affected his/her eligibility to enroll in the MMP, or the member intentionally permitted others to use his/her member identification card to obtain services under the MMP. EOHHS and CMS do not permit disenrollment requests based on:

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

2. The member's utilization of medical services;

3. Uncooperative or disruptive behavior resulting from the member's special needs;

4. The member exercising treatment decisions with which the MCO or the MCO's provider(s) disagree; or

5. Diminished or diminishing mental capacity of the member.

D. Beneficiaries who are involuntarily disenrolled based on a written request by the MMP receive their Medicaid benefits on a fee-for-service basis.

E. Disenrollment Review - All disenrollments are subject to approval by EOHHS and CMS. Beneficiaries have the right to appeal EOHHS' and CMS' disenrollment decision (see Part 10-05-2 of this Title). EOHHS and CMS determine jointly the disenrollment date as appropriate.

1.7.7Grievances, Appeals and Hearings

A. MMP members have multiple avenues for contesting decisions that affect their health coverage, including EOHHS and CMS administrative fair hearings. The process is as follows:

1. MMP Grievances - Grievances directed toward the MMP may be internal or external.

a. Internal or plan level grievances. MMP members, or their authorized representatives, can file a grievance with the MCO or a participating provider at any time by calling or writing the MCO or the provider. The MCO must require providers to forward grievances to the MCO. If the MMP member is requesting remedial action related to a Medicare issue, the member must file the grievance with the MCO or the provider no later than sixty (60) days after the event or incident triggering the incident (see Part 10-05-2 of this Title). The MCO must respond, orally or in writing, to an internal grievance within thirty (30) days after the MCO receives the grievance. The MCO must respond, orally or in writing, within twenty-four (24) hours whenever the MCO extends the timeframe for a decision or refuses to grant a request for an expedited grievance.

b. External. MMP members, or their authorized representatives, can file a grievance by contacting 1-800 -MEDICARE or EOHHS. Any grievance filed with EOHHS will be reviewed by a joint EOHHS-CMS contract oversight team and be made available to the MCO.

2. MMP Appeals - The process for handling appeals varies depending on whether the beneficiary is disputing an action related to Medicaid or Medicare coverage. For services covered under Medicare Part D, MMP members must follow the appeals process established by CMS in Subparts M and U of 42 C.F.R. Part 423 . For services covered by Medicare Part A, Medicare Part B, and/or Medicaid in-plan services, MMP members must complete one (1) level of internal appeal before requesting an external review. Regulations governing the appeals process for Medicaid out-of-plan services are found in Part 10-05-2 of this Title. The process for filing subsequent appeals after the first level internal appeal is as follows:

a. Services covered by Medicare Part A and/or B. Subsequent appeals after the first (1^st) level internal appeal for traditional Medicare A and B services that are not fully in favor of the enrollee will be automatically forwarded to the Medicare Independent Review Entity (IRE) by the MMP.

b. Services covered by Medicaid only. Subsequent appeals for services covered by Medicaid only (including, but not limited to, LTSS and behavioral health) may be made to the EOHHS Hearing Office and/or to the Rhode Island External Review Entity per State Regulations (Part 10-05-2 of this Title) after the first (1^st) plan-level Appeal has been completed. If an appeal is filed with both the Rhode Island External Review Entity and the EOHHS Hearing Office, the MCO will be bound by any determination in favor of the member that is closest to the relief requested by the member. Appeals related to drugs excluded from Medicare Part D that are covered by Medicaid must be filed with the MMP in accordance with Part 10-05-2 of this Title, and Subchapter 00 Part 2 of this Chapter, and the requirements contained herein.

c. Services covered by both Medicare and Medicaid. After the first (1^st) level internal appeal, appeals for services for which Medicare and Medicaid overlap (including, but not limited to, home health, durable medical equipment, and skilled therapies, but excluding Part D) will be auto-forwarded to the IRE by the MMP.

d. After the first (1^st) plan-level appeal for Medicare and Medicaid overlapping services, a member may file a request for a hearing with the EOHHS State Fair Hearing Office. After the first (1^st) plan-level appeal for Medicare and Medicaid overlap services, a member may also file a request for a hearing with the Rhode Island External Review Entity per State Regulations (Part 10-05-2 of this Title). If an appeal is filed with both the IRE and either the Rhode Island External Review Entity or the EOHHS Hearing Office, the MCO will be bound by any determination in favor of the member that is closest to the relief requested by the member.

3. Internal appeals timeframes

a. First (1^st) Level. An MMP member must file a first (1^st) level internal appeal with the plan within sixty (60) calendar days following the date of the notice of adverse action that generates the appeal.

b. Standard appeals. For first (1^st) level internal appeals, the MMP must render a decision within thirty (30) calendar days of the date that the appeal request has been received by the managed care entity. The MMP can extend the deadline for a decision by up to fourteen (14) days if requested by the beneficiary or if the delay is in the beneficiary's best interest.

c. Expedited appeals. For first (1^st) level internal appeals, the MMP must render a decision within seventy-two (72) hours of the date that the appeal request has been received by the managed care entity when either the MMP or the member's provider determines that standard appeal resolution could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function. The MMP can extend the deadline for a decision by up to fourteen (14) days if requested by the beneficiary or if the delay is in the beneficiary's best interest.

1.7.8MMP Benefit Package

A. The MMP provides a comprehensive benefit package to members that includes a full continuum of Medicare and Medicaid services as follows:

1. Medicare - Medicare Parts A, B, and D-funded medically necessary services.

2. Medicaid Services - 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. Medicaid services may be in-plan or out-of-plan. In-plan services are paid for on a capitated basis. Certain Medicaid-covered services are considered "out-of-plan" and are provided on a fee-for service basis. The MMP is not responsible for delivering or reimbursing out-of-plan services but is expected to coordinate in-plan services with out-of-plan services. Out-of-plan services are provided by existing Medicaid-approved providers who are reimbursed directly by Medicaid on a fee-for-service basis. The Medicaid coverage provided through the MMP is categorized as follows:

MMP Medicaid Benefits

MMP Medicaid Benefits
(a) In-Plan		(b) Out-of-Plan
(01)	Inpatient Hospital Care	(01)	Dental Services
(02)	Outpatient Hospital Services	(02)	Non-Emergency Transportation Services (The health plan is required to coordinate with EOHHS' nonemergency transportation broker)
(03)	Physical Therapy Evaluation and Services	(03)	Residential Services for Clients with Intellectual and Developmental Disabilities
(04)	Physician Services	(04)
(05)	Care Management Services
(06)	Family Planning Services
(07)	Prescription Drugs
(08)	Non-Prescription Drugs
(09)	Laboratory Services
(10)	Radiology Services
(11)	Diagnostic Services
(12)	Mental Health and Substance Use Disorder Treatment- Outpatient/Inpatient
(13)	Home Health Services
(14)	Emergency Room Service and Emergency Transportation Services
(15)	Nursing Home Care and Skilled Nursing Facility Care
(16)	Services of Other Practitioners
(17)	Podiatry Services
(18)	Optometry Services
(19)	Oral Health
(20)	Hospice Services
(21)	Durable Medical Equipment
(22)	Environmental Modifications (Home Accessibility Adaptations)
(23)	Special Medical Equipment (Minor Assistive Devices)
(24)	Adult Day Health
(25)	Nutrition Services
(26)	Group/Individual Education Programs
(27)	Interpreter Services
(28)	Transplant Services
(29)	HIV/AIDS Non-Medical Targeted Case Management for People Living with HIV/AIDS and those that are at High Risk for Acquiring HIV
(30)	AIDS Medical Case Management
(31)	Court-ordered Mental Health and Substance Abuse Services - Criminal Court
(32)	Court-ordered Mental Health and Substance Abuse Treatment - Civil Court
(33)	Telemedicine
(34)	Preventive Services, including: Homemaker Personal Care Services Minor Environmental Modifications Physical Therapy Evaluation and Services Respite
(35)	Long Term Services and Supports, including: Homemaker Meals on Wheels (Home Delivered Meals) Personal Emergency Response (PERS) Skilled Nursing Services (LPN Services) Community Transition Services Residential Supports Day Supports Supported Employment RIte @ Home (Supported Living Arrangements-Shared Living)* Private Duty Nursing Supports for Consumer Direction (Supports Facilitation) Self- Directed Goods and Services Financial Management Services (Fiscal Intermediary) Senior Companion (Adult Companion Services) Assisted Living Personal Care Assistance Services Respite Rehabilitation Services
(36)	Opioid Treatment Provider Health Home

210 R.I. Code R. 210-RICR-40-10-1.7

Amended effective 10/5/2021