Section 210-RICR-40-15-1.7 - Medicaid Long-term Services and Supports (LTSS)1.7.1Eligibility Determination ProcessAdults with disabilities who are seeking LTSS - both current Medicaid beneficiaries and new applicants - who do not qualify for MACC group LTSS are evaluated for eligibility across the pathways set forth in §50-00-1.8 of this Title using the SSI method. Accordingly, they may qualify for the work-related income disregards identified in § 1.4(B)(1) of this Part (above) in the eligibility determination process. A separate disability determination by the MART is not required for applicants/beneficiaries who meet the clinical/functional level of care criteria for Medicaid LTSS.
1.7.2Service PlanAll Medicaid LTSS beneficiaries must have a service plan that ties benefits to their functional and clinical needs. If employment supports are needed, the role of work, if any, and any associated employment supports must be a component of this plan. For LTSS beneficiaries choosing home and community-based services, the service plan must reflect the decisions they make about their health goals established in the person-centered planning process set forth in 42 C.F.R. § 441.725 and in Part 50-10-1 of this Title. The development of a service plan is guided by agency representatives as the components may vary depending on the type of a person's disability, program requirements, and associated provisions under the Section 1115 waiver and Medicaid State Plan. Accordingly, specific guidance is provided on this process. In response to the novel Coronavirus Disease (COVID-19), EOHHS will postpone in-person person centered planning.
1.7.3Cost of CareA. In accordance with Federal requirements, under the State's Medicaid State Plan and Section 1115 waiver, all LTSS Medicaid beneficiaries eligible based on the SSI method who can afford to do so must pay a portion of income toward the cost of their care. A beneficiary's liability for the cost of care is calculated in the post-eligibility treatment of income process in accordance with Part 50-00-8 of this Title and is based on gross monthly income - earned and unearned - less certain deductions or "allowances." To encourage LTSS beneficiaries who have disabilities to work, there are special allowances which require the State to exclude some or all of the beneficiary's earned income when determining the amount available to be applied toward the cost of care.1. HCBS - The following are special allowances for Medicaid LTSS working adults with disabilities who are receiving home and community-based services: a. Programs for persons with intellectual/developmental disabilities. The Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) Development Disabilities (DD) Program administers programs for persons with DD, including those who work and qualify for Medicaid HCBS integrated employment supports. To further BHDDH employment first goals, the State has implemented the I/DD-Special Maintenance Needs Allowance (I/DD-MNA). (1) Purpose. The I/DD-MNA reduces the amount of income that is available to pay toward the LTSS cost of care through a series of standard and special allowances that protect a higher portion of the earned income of working adults with disabilities than is permitted for other beneficiaries.(2) Allowance order. In determining available income, all other allowances identified in Part 50-00-8 of this Title pertaining to the post-eligibility treatment of income are applied first. (The sequence of deductions is contained in §50-00-8.5(C) of this Title). Once this calculation is complete, available income is reduced further by the I/DD-MNA which deducts any earned income up to but not to exceed three hundred percent (300%) of the SSI income standard. The amount of income remaining after this final allowance is applied constitutes the beneficiary's liability for LTSS. The SSI income standard changes annually and is located in Subchapter 00 Part 3 of this Chapter.b. Habilitation program. The EOHHS administers the Medicaid HCBS habilitation program for adults with disabilities. Beneficiaries who are participating in integrated community employment support activities under the auspices of the habilitation program receive the full scope of Medicaid State Plan and waiver benefits and qualify for the same I/DD-MNA and earned income allowances available to persons with development disabilities identified in paragraph (a) above.2. Health institutions - LTSS beneficiaries residing in health institutions including long-term acute and psychiatric hospitals may be eligible for the therapeutic employment allowance, identified in §50-00-8.6(A)(2)(a) of this Title.B. A beneficiary's liability may increase or decline when there are changes in income. The State provides timely notice of any changes in beneficiary liability that may result at least ten (10) days before the start of the month when the change takes effect.1.7.4LTSS Options and ResponsibilitiesA. There are alternative LTSS eligibility pathways if employment affects a beneficiary's financial state. If income increases, eligibility is automatically evaluated for each pathway with a higher limit, from SSI through the Sherlock pathway. The process proceeds as follows:1. LTSS Medically Needy pathway - The LTSS Medically needy pathway for working adults with disabilities functions like all other SSI-related LTSS eligibility categories even though there is a spenddown period. The income limit for the LTSS Medically needy pathway is set at the actual reimbursement rate paid by the State; the spenddown period is one (1) rather than six (6) months. Therefore, a beneficiary is and remains eligible for coverage as LTSS Medically needy without interruption providing countable income, less any allowances permitted, is applied toward the cost of care each month. The scope of coverage available to an LTSS Medically needy eligible working adult with disabilities is the same as with all other LTSS eligibility pathways.2. LTSS Sherlock pathway - Working adults with disabilities seeking initial or continuing Medicaid LTSS who have countable assets (liquid resources and real property) above the resource eligibility limits of four thousand dollars ($4,000.00) for a single person and six thousand dollars ($6,000.00) for a couple may qualify for coverage through the Sherlock pathway. Income, whether earned or unearned, does not affect Medicaid LTSS eligibility unless the total exceeds the cost of care at the private pay rate, in accordance with §50-05-2.5 of this Title. As indicated in § 1.8 of this Part below, to qualify for the LTSS Sherlock pathway, a formal disability determination must be made by the MART or the SSA and the SSI for calculating countable income and resources applies, including the applicable work-related disregards. EOHHS will continue eligibility for individuals that may have a change in employment status that occur during the novel Coronavirus Disease (COVID-19) declaration of emergency until the termination of the Federal novel coronavirus declaration of emergency. Changes in employment after the termination of the Federal novel coronavirus declaration of emergency will follow the provisions in §1.8.5 of this Part.B. The respective roles and responsibilities of the State and LTSS applicants/beneficiaries with disabilities who are working seeking initial or continuing LTSS Medicaid coverage are as set forth in Part 50-00-1 of this Title.210 R.I. Code R. 210-RICR-40-15-1.7
Amended effective 10/5/2021