Section 210-RICR-50-00-1.10 - Expedited EligibilityA. Expedited eligibility is a special process authorized under the State's Section 1115 demonstration for adults age nineteen (19) and over seeking LTSS in a home and community-based setting. The purpose of this special process is to provide a limited package of HCBS for no more than ninety (90) days to applicants who meet the need for LTSS in a home or community-based setting as specified in § 1.7(A)(2)(b) of this Part and prefer to remain in or transition to a home or community-based setting for a health institution while a full determination of eligibility is being made. 1. Eligibility criteria - To be considered for expedited eligibility, new applicants must submit a full and completed application for Medicaid LTSS and self-attest to meeting the Medicaid LTSS general and financial eligibility requirements for their appropriate coverage group - that is, elder, adult with disability, MACC group adult and so forth. Existing beneficiaries must notify an LTSS eligibility specialist and provide any supplemental information required to initiate an expedited eligibility review. The need for LTSS must be established in accordance with applicable functional/clinical criteria established by EOHHS by a licensed treating physician or appropriately qualified health practitioner or provider.2. Applicable circumstances - Expedited eligibility is the default eligibility for new applicants and existing non-LTSS Medicaid beneficiaries who meet the requirements set forth in this Part in the following circumstances: a. Discharge from a hospital. Discharge must be to a home or community-based setting from a hospital or ancillary health institution after an acute care admission.b. Discharge from a from a short-term health institution stay Discharge or transition to a home and community-based setting from a nursing facility or subacute care facility for a short-term stay or skilled rehabilitation if the services provided are not covered as a Medicaid LTSS benefit and, as such, Medicaid reimbursement for the stay is not required.c. Expanded need. A person seeking LTSS eligibility who is receiving preventive level services authorized by EOHHS in accordance with Part 40-05-1 of this Title and has expanded needs or is determined by a treating health practitioner to have the need for in-home assistance to supplement skilled homecare or hospice services currently in place; or to extend to the period after skilled services have ended.B. Expedited eligibility benefits are limited to maximum of: twenty (20) hours weekly of personal care/homemaker services; three (3) days weekly of adult day services; and/or limited skilled nursing services based upon level of need. Upon approval of Medicaid LTSS, the beneficiary qualifies to receive full coverage. The following also apply:1. Limited duration - The expedited eligibility benefit package is available for up to ninety (90) days or until the eligibility decision is rendered, whichever comes first.2. Exemptions - There is no PETI conducted in conjunction with expedited eligibility and, as a consequence, no required contribution toward the cost of care during the ninety (90) coverage period. Retroactive eligibility is not available, though costs incurred and unpaid for Medicaid covered services prior to the LTSS application filing date are considered when determining eligibility for full coverage.3. Restrictions - Under the terms of the State's Section 1115 demonstration waiver, expedited eligibility is not available for LTSS in a health institution setting.210 R.I. Code R. 210-RICR-50-00-1.10
Amended effective 10/5/2021
Amended effective 12/29/2022