Section 210-RICR-40-15-1.6 - Medicaid Affordable Care Coverage (MACC) MAGI-eligible AdultsA. Working adults with disabilities who are eligible through the Medicaid Affordable Care Coverage groups in: the ACA adult expansion pathway for persons ages nineteen (19) through sixty-four (64); the parent/caretaker pathway; or pregnant women pathway may obtain the work-related services and supports they need through their Medicaid managed care plan or, if enrolled in fee-for-service or a RIte Share approved employer-sponsored insurance plan, through certified Medicaid providers. Pre-authorization of services by the plan or Medicaid provider is required unless a disability determination has been made by the EOHHS Medicaid Review Team (MART) or another government entity such as the Federal Social Security Administration (SSA).B. There are no special disregards for working adults with disabilities available through the MAGI method for determining income eligibility. However, MACC eligible beneficiaries, including those who qualify for Medicaid LTSS, are not liable under Federal law to pay a share of the costs of their care.C. If earnings from work increase income above the applicable MACC group eligibility limit, applicants and beneficiaries must seek coverage through an alternative Medicaid eligibility pathway that uses the SSI method and requires a formal disability determination by the MART, unless such a determination has already been made by another government authority including the SSA. The IES automatically evaluates persons for these alternative forms of eligibility if they do not qualify for MACC group coverage due to excess income. Depending on a person's income and resources and level of need, the available pathways are as follows: 1. Community Medicaid (Non-LTSS) - The two (2) alternative eligibility pathways for MACC eligible working adults with disabilities who do not require or meet the level of care criteria for the full scope of Medicaid long-term services and supports are: Community Medicaid EAD, including the Medically needy pathway as specified in §05-1.5 of this Chapter and above, and the Sherlock pathway, as set forth in § 1.8 of this Part. The SSI work-related income disregards indicated in § 1.4(B)(1) of this Part are applied and a disability determination by the MART or SSA is required;2. Medicaid LTSS - MAGI-eligible working adults with disabilities who meet the level of care requirements for Medicaid long-term services must be determined disabled to obtain work-related services and supports. If income exceeds the MACC group limit due to earnings from work, eligibility may continue to be available through the LTSS/SSI-related pathways including LTSS Medically needy (§ 1.7 of this Part), or the Sherlock pathway (§ 1.8 of this Part). The SSI work-related income disregards indicated in § 1.4(B)(1) of this Part are applied and a disability determination by the MART or SSA is required.210 R.I. Code R. 210-RICR-40-15-1.6
Amended effective 10/5/2021