Section 210-RICR-40-15-1.8 - The Sherlock PlanA. The Sherlock Plan for Working People with Disabilities is an SSI-related eligibility pathway for working adults with disabilities established pursuant to the Balanced Budget Act of 1997 (42 U.S.C. § 1396a(a)(10)(ii) (XIII)) and R.I. Gen. Laws at §40-8.7-1. The State law is based on the option under the Federal law to establish a Medicaid eligibility pathway for adults with disabilities who are either unable to afford or obtain health coverage and/or the services and supports they need to work.B. Adults with disabilities eligible through the Sherlock pathway are entitled to the full scope of Medicaid benefits and home and community-based services and supports necessary to facilitate and/or maintain employment. This is the same scope of coverage available to all Medicaid-eligible adults with disabilities who work, without regard to eligibility pathway. The special provisions in the SSI method established in Subchapter 00 Part 3 of this Title, and reiterated herein at § 1.4, of this Part may apply. To ensure continuation of EOHHS' eligibility for enhanced Federal funding, EOHHS will continue eligibility for individuals that may have a change in employment status that occur during the Federal novel Coronavirus Disease (COVID-19) 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.C. The Sherlock eligibility pathway is open to adults with disabilities who are working and seeking: 1. Non-LTSS Medicaid primary care essential benefit coverage with HCBS services including employment supports; or2. Medicaid LTSS coverage including integrated employment supports.D. To qualify through the Sherlock pathway, a person must be determined disabled by a State or Federal government authority using the criteria established for the SSI program except for the provisions related to substantial gainful.1. General eligibility requirements -To be Sherlock-eligible, a person must: a. Meet the non-financial eligibility requirements set forth in Part 1000-3 of this Title and:b. Be between nineteen (19) and sixty-four (64) years of age; andc. Have proof of active, paid employment such as a pay stub or current quarterly U.S. Internal Revenue Service (IRS) tax statement (for those who are self-employed).2. Financial eligibility - Applicants for Sherlock eligibility are subject to the requirements for counting income and resources set forth in Subchapter 00 Part 3 of this Title. The following income and resource standards apply: a. Income. Countable earned net income must be no greater than two hundred fifty percent (250%) of the FPL. Countable income is defined as the total of earned income remaining after all SSI-related disregards are applied; andb. Resources. Total countable resources must be no greater than ten thousand dollars ($10,000.00) (individual) or twenty thousand dollars ($20,000.00) (couple). Medical savings accounts, retirement accounts, or accounts determined to be for the purposes of maintaining independence are not counted as a resource; approved items that are necessary for a person to remain employed are also not counted as a resource (such as a wheelchair accessible van).3. Retroactive coverage - As an SSI-related coverage group, applicants may be eligible for up to ninety (90) days of retroactive coverage. Eligibility for retroactive coverage is determined in accordance with Subchapter 05 Part 2 of this Title once the premium or cost of care requirements set forth below in §1.8.2 of this Part have been met.1.8.1Access to Employer-Based Health InsuranceSherlock applicants who have access to employer-based health insurance are required to enroll in the plan as a condition of eligibility if the plan has been determined by EOHHS to meet the cost-effective criteria established for the RIte Share program in Part 30-05-1 of this Title. Medicaid will pay the employee's share of the monthly premium. Enrollment of the applicant in the employer-based health insurance plan is without regard to any enrollment season restrictions. All Medicaid services that are unavailable through the employer plan are covered through a wrap-around by Medicaid certified providers.
1.8.2Types of Cost SharingA. Depending on their gross countable income from all sources, both LTSS and non-LTSS Sherlock beneficiaries may be required to pay a share of the cost of coverage. Non-LTSS Sherlock beneficiaries subject to a cost share are required to pay a premium; LTSS Sherlock beneficiaries who have a cost share have the choice of paying a portion of income or premium. 1. Sherlock Premium - To calculate a premium, the earned income of the Sherlock beneficiary and his or her spouse are added together and then all SSI-related disregards are applied. The remaining earned income is added to the unearned income of the beneficiary or couple and are assigned a premium based on the buy-in payment rates in Part 30-05-3 of this Title, entitled RIte Share Premium Assistance Program. a. Premiums must be paid in full before retroactive coverage for allowable health care expenses is made available by the State.b. Sherlock beneficiaries may deduct premium amounts from the total amount of any unpaid medical bills in the retroactive coverage eligibility period.2. LTSS Sherlock beneficiary liability - The State bases its calculation of a LTSS Sherlock beneficiary's liability for the cost of care in accordance with the post-eligibility treatment of income rules set forth in Part 50-00-8 of this Title. A LTSS Sherlock beneficiary is entitled to all the allowances set forth therein when determining the amount of income available to pay toward the cost of care.3. Sherlock LTSS beneficiary choice - The State calculates both the monthly premium and the beneficiary liability for Sherlock LTSS beneficiaries. An LTSS eligibility specialist is responsible for informing the beneficiary of the premium versus beneficiary liability costs and assisting the beneficiary in making an appropriate choice. The State does not impose or collect a cost share until a Sherlock LTSS beneficiary has been so informed and made a choice. Coverage may not be delayed or denied pending the beneficiary's decision.1.8.3Cost-Share Collection MethodsA. Sherlock beneficiaries are required to make monthly cost share payments, without regard to type. A Sherlock LTSS beneficiary opting to pay beneficiary liability - if any - rather than a premium, must pay his or her provider each month in accordance with the provisions set forth in Part 50-00-8 of this Title.B. All Sherlock beneficiaries required to pay a premium have payment options as follows:1. Electronic Funds Transfer (EFT) - The beneficiary may request that a financial institution of choice withdraw the monthly payment from a personal account and make payment directly to the State through an electronic funds transfer to EOHHS. The State provides the required form for making such a request and withdraws the premium amount on the third (3rd) day of the month. Notification is provided by the State if the transfer fails.2. Wage Withholding - The Sherlock beneficiary may request that an employer withhold the premium amount and then make the payment to Medicaid through an EFT. The Sherlock beneficiary is given a special form requesting wage withholding and deposit or transfer to take to his/her employer to be completed and mailed.3. Direct Pay - The Sherlock beneficiary may pay the premium to Medicaid by check or money order every month. A premium payment coupon and pre-addressed envelope will be provided to the family before the premium is due. The check or money order and the premium payment coupon are mailed or delivered to the Medicaid fiscal agent.1.8.4Non-Payment Sherlock Cost ShareA. Non-payment of premiums is treated in the same manner as for RIte Share participants as detailed in Part 30-05-3 of this Title.B. The provisions governing non-payment of beneficiary liability are set forth in the LTSS post-eligibility treatment of income rule contained in Part 50-00-8 of this Title.1.8.5Loss of Employment or EligibilityA. A Sherlock beneficiary who loses employment may retain eligibility for up to four (4) months by continuing to pay the applicable cost share, whether a premium or beneficiary liability payment. If the person is still unemployed at the end of the four (4) month period, Sherlock eligibility is terminated. Prior to taking this action, the State evaluates the Sherlock beneficiary for all other forms of Medicaid eligibility as well as for coverage for a commercial plan through HSRI, the State's health insurance marketplace.B. A person who is no longer eligible for Medicaid through the Sherlock pathway may retain approved medical savings accounts and retirement account assets in the amount held on the last full day of eligibility. These medical savings account and/or retirement account assets will be considered non-countable assets for purposes of Medicaid eligibility under any other coverage group. Paper documentation must be provided verifying the balances of these accounts as of the last date of Sherlock eligibility if it is to be disregarded for other forms of Medicaid coverage.1.8.6Available ServicesA. Services include the full scope of categorical Medicaid benefits, home and community-based services, including personal care services provided through an agency or through a self-directed program, and services needed to facilitate and/or maintain employment. The applicant/beneficiaries' services are coordinated through the appropriate unit in EOHHS, DHS or BHDDH or a contractual designee of the agency. Long-term care services and supports are listed in Part 50-00-1 of this Title entitled, Medicaid Long-Term Services and Supports: Overview and Eligibility Pathways.B. Services to maintain and support employment are determined when developing a service plan, or through an assessment of need utilizing a state approved assessment instrument or an EOHHS approved prior authorization plan. Authorized personal care services may be provided in the home, workplace or other necessary setting (such as a physician office).210 R.I. Code R. 210-RICR-40-15-1.8
Amended effective 10/5/2021