Section 210-RICR-40-15-1.5 - Community Medicaid Eligibility for Low-income Elders and Adults with Disabilities (EAD)A. Working adults with disabilities who do not qualify for SSI due to excess income may be eligible for initial or continuing Medicaid coverage through the EAD pathway pursuant to Subchapter 05 Part 1 of this Title or as medically needy under Part Subchapter 05 Part 2 of this Chapter. All EAD beneficiaries are entitled to primary care essential benefits and any necessary work supports covered under the Medicaid State Plan or Section 1115 D emonstration Waiver.B. Working adults with disabilities may obtain initial or continuing eligibility through the following: 1. Work-related protections - Some applicants/beneficiaries may qualify for several of the same special provisions available to applicants and beneficiaries that reduce or protect earned income set forth in Subchapter 00 Part 3 of this Chapter, including but not limited to:a. PASS Disregard - Income, whether earned or unearned, of a person who is blind or living with a disabling impairment may be excluded if such income is needed to fulfill a Plan for Achieving Self-Support (PASS). This exclusion does not apply to applicants who are age sixty-five (65) or older, unless the applicant was receiving SSI or State Supplemental Payment (SSP) before reaching that age. For additional information on the PASS, see the Federal SSI Regulations at 20 C.F.R. §§ 416.1180 through 416.1182.b. Impairment-Related Work Expenses - Earned income used by a person with disabilities to pay impairment-related work expenses is disregarded. For the disregard to apply, the person must have a disability and be under age sixty-five (65) or have been eligible for and received SSI based on disability for the month before reaching age sixty-five (65). In addition, the following must be met: (1) The severity of the impairment must require the person to purchase or rent items and services in order to work;(2) The expense must be reasonable given the nature of the disability or impairment and the type of employment, as determined by the agency;(3) The expense must be paid in cash (including checks, money orders, credit cards and/or charge cards) by the person and must not be reimbursable from another source, such as Medicare or private insurance; and(4) The payment for the expense must be made in a month the person receives earned income and anticipated work or worked and used the services or the item purchased, or the person must be working and pay the expense before earned income is received.(5) Impairment-related work expenses that may qualify for this disregard are described in Federal SSI Regulations at 20 C.F.R. § 416.976.b. Student Child Earned Income Exclusions (SEIE) - For a student under age twenty-two (22) or a person who is blind or disabled and regularly attending school, a set amount of earned income per month up to a yearly maximum may be excluded. The Federal government determines the monthly and maximum amounts based on variety of factors and adjusts the figures annually to reflect increases in the cost of living. The amount of the exclusion is set by the Federal government and updated on an annual basis. The amount of the exclusion is located in §00-3.1.7(A)(6) of this Chapter.c. Work-Related Expenses of Blind Persons - Earned income used to meet any expenses reasonably attributable to the earning of the income by a person who is blind and under age sixty-five (65) or received SSI as a blind person for the month before reaching the age of sixty-five (65). Further, expenses may be disregarded if the person has an approved plan for self-support (PASS). The amounts must be reasonable and not exceed the earned income of the blind person or a blind spouse. See references on PASS, including types of expenses that qualify for this disregard in §00-3.3.2(A)(3) of this Chapter.d. RI Works Under a PASS. In accordance with RI Works Regulations, RI Works payments administered by the RI Department of Human Services under a PASS are excluded. However, RI Works payments unless excluded under a PASS, are countable income.2. Community Medicaid Medically Needy - Coverage is available to elders and persons with disabilities with high medical expenses who have income above the EAD countable income limit of one hundred percent (100%) of the FPL, but otherwise meet all of the general eligibility requirements for Medicaid as set forth in §05-1.9 of this Chapter. Work related disregards identified in § 1.5(B) of this Part are taken into account when determining financial eligibility for the Community Medicaid pathway Medically needy. Beneficiaries have the option of consulting with an agency eligibility specialist when considering whether the Medically needy pathway provides them with the level Medicaid benefits and coverage they need while continuing to work. The Sherlock pathway may be a more appropriate option in some instances due to the following: a. Scope of coverage. Until excess income over the eligibility limit has been exhausted during the six (6) month spenddown period, beneficiaries who choose this pathway are responsible for paying out-of-pocket for all health care expenses that are not covered by a third (3rd) party such as Medicare or a commercial plan, including for any necessary work supports. Expenses associated with third (3rd) party coverage, such as premiums, co-pays and deductibles do count toward the spenddown. See Subchapter 05 Part 2 of this Chapter on the Medically needy eligibility pathway for additional information.b. Continuing eligibility. Renewal of Medically needy eligibility and the initiation of another spenddown period may require a redetermination of countable income through the integrated eligibility system (IES).3. Sherlock Plan for Working People with Disabilities - Applicants who qualify for Medicaid coverage under more than one (1) eligibility pathway may choose the one (1) most suited to their unique needs. Accordingly, the Sherlock eligibility pathway is also available for applicants and beneficiaries who qualify through the medically needy pathway but are unable to obtain the supports they need through a spenddown.C. The respective roles and responsibilities of the State and applicants/beneficiaries with disabilities who are working and seeking initial or continuing Medicaid coverage through the EAD are set forth in §05-1.5 of this Chapter.210 R.I. Code R. 210-RICR-40-15-1.5
Amended effective 10/5/2021