Section 210-RICR-50-00-1.7 - Qualifying for Medicaid LTSSA. Under Title XIX, the federal Medicaid law, an applicant for LTSS must be either a current beneficiary or possess an income, clinical/functional, or age-related characteristic related to a MAGI eligible or SSI population AND have an established need to qualify to apply. With the enactment of the Federal Affordable Care Act of 2010, Federal law requires that Medicare, commercial health insurers, and group health plans provide as part of the primary care essential benefit package up to thirty (30) days of subacute and rehabilitative care for persons who have had an acute care incident requiring services in a health institution. Medicaid is also required to provide this benefit. Both existing beneficiaries and new applicants must have established a continuing need for LTSS - that is, for an institutional level of care - to qualify for Medicaid LTSS once the thirty (30) days of essential benefit coverage is exhausted. This need in previous Rhode Island Medicaid Rules was referred to as "considered institutionalized" for the purposes of determining Medicaid LTSS eligibility as indicated below:1. Existing beneficiaries - Under the Medicaid State Plan, all Medicaid beneficiaries are eligible for up to thirty (30) days of LTSS coverage in addition to the required thirty (30) day essential benefit period of acute and subacute care in a health care institution as part of their non-LTSS primary essential benefit coverage. A separate determination of eligibility or change in service delivery is not required for this period of coverage. Therefore, an existing beneficiary may qualify to apply for Medicaid LTSS without a change in eligibility or service delivery options if they have received the required period of continuous coverage is provided in this manner or, if seeking LTSS in the home and community-based setting, they require or are receiving at least one (1) Medicaid covered LTSS benefit to address a functional need that otherwise would require care in an institutional setting. The Medicaid MCOs and DHS eligibility specialists are available to provide assistance to existing beneficiaries during this period.2. New applicants - New Applicants are considered to have such a need if they have met one (1) of the following:a. Received the level of services typically provided in a NF, ICF-ID, or LTH setting for at least thirty (30) consecutive days and are expected to have a continued need for such services or have:(1) Obtained acute care services in a hospital or similar health facility for at least thirty (30) consecutive days and are seeking LTSS;(2) Received Medicaid preventive level services while residing at home or in a community-based care setting for at least thirty (30) consecutive days;(3) Been determined to have needs that require the level of services typically provided in a health care institution for at least thirty (30) consecutive days or would require such services were those in the home and community-based setting not provided.b. Received or required at least one (1) Medicaid covered LTSS benefit at home or in a community-based setting to address a functional/clinical need that would otherwise necessitate the type of LTSS typically provided in a health institution.210 R.I. Code R. 210-RICR-50-00-1.7
Amended effective 10/5/2021
Amended effective 12/29/2022