Section 210-RICR-50-00-1.8 - Eligibility Determination ProcessA. There is a multiphase process for determining eligibility and authorization for Medicaid LTSS that includes the following steps:1. Information, Referral, Options Counseling - Prior to initiating the application process and/or at any step during the eligibility determination sequence, applicants and/or their family members or authorized representatives may seek information, referral and/or options counseling to assist them in navigating the LTSS system. Part 4 of this Subchapter sets forth role of this service.2. Person-centered Planning - Upon making application for LTSS, the person-centered planning process must begin for anyone seeking HCBS. The process is available, at the applicant's option, for LTSS in a health care institution as well. Person-centered planning is an individualized approach to planning that places the applicant at the center of decisionmaking thereby enabling him/her to direct his/her own services and supports in accordance with his/her own desires, goals and preferences, with impartial assistance and supported decision-making when helpful. Accordingly, the person-centered planning is an on-going process that continues through the eligibility determination process through to the authorization of services and thereafter. In accordance with 45 C.F.R. § 441.301(c)(1), the State must ensure that throughout this process, the applicant has sufficient and necessary information in a form he/she can understand to make informed choices and direct the planning process to the maximum extent possible. See Part 4 of this Subchapter for specific provisions.3. Eligibility Determination Factors - To gain access to LTSS, the information provided by applicants is evaluated across the eligibility factors identified below, though not necessarily in a specific order:a. General eligibility factors. All persons seeking initial or continuing Medicaid LTSS must meet the general requirements for the program related to residency, citizenship and immigration status, and Social Security Numbers and the like. The application form must be completed and signed along with the authorizations necessary to conduct electronic data matches to verify income and resources; and to request personal health information to assess and review clinical/functional level of need. General eligibility factors for MACC MAGI-based LTSS eligibility are located in §30 -00-1.5(C) of this Title and for SSI-based LTSS eligibility in Part 5 of this Subchapter. Existing beneficiaries seeking LTSS must only update general eligibility information if there have been changes since the point of their last renewal.b. Clinical/functional eligibility factors. An assessment of clinical and functional needs serves as the basis for a level of care determination and is conducted for all persons seeking Medicaid LTSS, without regard to eligibility pathway. This assessment is based on needs-based criteria that evaluate clinical, functional, social and behavioral needs as well as environmental factors. A Medicaid Assessment and Review Team (MART) determination of disability status is not required unless the applicant is seeking LTSS coverage while working through the Sherlock Plan or unless the applicant has been deemed to have a disability by the Social Security Administration. In response to the novel Coronavirus Disease (COVID-19), until the end of the Federal declaration of the COVID-19 public health emergency, EOHHS will temporarily conduct level of care determinations/redeterminations for all LTSS eligibility pathways via phone and physician records. The responsibilities for assessing need vary for each institutional level of care as follows:(1) Nursing Facility. The State established clinical and functional disability criteria under the Section 1115 waiver which assess the scope of a beneficiary's need for a NF level of care. The EOHHS is responsible for assessing the level of need of persons seeking Medicaid coverage of LTSS typically provided in a NF and long-term hospital care, including home and community-based alternatives. As indicated in Part 5 of this Subchapter, the scope of a person's clinical/functional need for a NF level of care (high or highest) affects the type of LTSS available to the person and thus the choice of setting (institutional and/or HCBS).(2) Intermediate care facilities for persons with intellectual disabilities. The BHDDH uses needs-based criteria to evaluate clinical/functional eligibility for the ICF/ID level of care that incorporate the requirements set forth in State law (R.I. Gen. Laws § 40.1-22-6), the scope of services and supports required, and the impact of familial, social, and environmental factors that affect the choice of setting.(3) Long-term Hospital Care. Each agency serving beneficiaries who may require Medicaid LTSS in a hospital setting is authorized under the State's 1115 waiver to tailor the clinical/functional criteria to meet their population's general and unique needs within the parameters of applicable Federal Regulations and laws. This applies to persons seeking services through the EOHHS Habilitation Program that were authorized prior to establishment of the Section 1115 demonstration in 2009 under the State's Section 1915(c) Habilitation Waiver and the various programs administered by the BHDDH. EOHHS determines clinical/functional eligibility for applicants seeking an LTH level of care through the Medicaid Habilitation program and certain persons referred by the BHDDH for admission to the State's Eleanor Slater Hospital.(4) Children with Special Health Care Needs. Children with disabilities and/or serious chronic and disabling conditions may require a NF, ICF/ID or LTH level of care at home or in an institutional-setting. The process for assessing level of need for children who are eligible based on the MAGI, SSI or custody of the State's Department of Children, Youth and Families (DCYF) is conducted by multiple entities under the auspices of the early, periodic, screening, detection and treatment (EPSDT) in Part 30-00-1 of this Title. The designated unit of EOHHS determines clinical/functional eligibility for children who do not qualify for coverage through one (1) of these pathways and are seeking coverage of LTSS in a home setting in accordance with the provisions located in Subchapter 10 Part 3 of this Chapter. Continuing eligibility for current beneficiaries is based on the method used to determine initial eligibility and, if no basis for coverage is found, across the remaining pathways.c. Financial Eligibility Factors. LTSS eligibility specialists in the Department of Human Services (DHS) are responsible for determining financial eligibility through the IES and related systems. The financial requirements pertain to an array of factors including the calculation of countable income and resources using the MAGI or SSI method and the allocation of resources and transfer of asset requirements that are unique to the determination of LTSS eligibility. Both of the following apply to new and existing beneficiaries seeking LTSS without regard to basis of eligibility and are explained in greater detail in Part 6 of this Subchapter. (1) Allocation of resources with spouses/dependents. The evaluation and allocation of resources at the point the need for LTSS is established and/or at the time of application is required for LTSS applicants who have spouses. This process, referred to as the Community (Non-LTSS) Spouse Resource Allowance (SRA), allocates the joint resources of couples in accordance with Federal standards to ensure a sufficient amount is protected for the non-LTSS spouse's needs - that is, unavailable to pay for the costs of care for the LTSS applicant/beneficiary. The allocation of resources at this state of the eligibility process is distinct from that which occurs when determining the amount of income a beneficiary must pay toward the cost of care in the "posteligibility" treatment of income. LTSS MAGI beneficiaries are subject to allocation of resource requirements but are exempt from the post-eligibility treatment process.(2) Transfer of assets. The determination of financial eligibility for Medicaid LTSS requires that the State review whether an applicant made a "disqualifying" transfer of assets - liquid resources and real property - in the sixty (60) month period before the need for LTSS was established. A transfer is deemed to be disqualifying if the asset was conveyed for less than fair market value. Under Federal law, such a transfer is presumed to have been made to reduce assets for the expressed purpose of gaining Medicaid LTSS eligibility. The State is required to impose a penalty period, during which Medicaid coverage for LTSS is unavailable, that is equal to the amount of the disqualifying transfer divided by the average cost of care at the private pay rate.B. Once eligibility has been determined, payment for Medicaid LTSS becomes available only after the following inter-related steps are completed:1. Service Plan - Development of a service plan ensures that a beneficiary is or will be able to attain the full scope of services required to meet his/her needs in the choice of LTSS living arrangement. Towards this end, LTSS specialists from across the EOHHS agencies and their community partners and contractual agents consider the results of the clinical/functional needs-based assessment, more intensive evaluations, as appropriate, and/or the consensus decisions made in the person-centered planning process for HCBS or the results of the PASRR for nursing facility care to help ensure that every beneficiary receives the right services, at the right time, and in the most appropriate setting.2. Post-Eligibility Treatment of Income (PETI) - Under the State's Section 1115 waiver, all non-MAGI eligible LTSS beneficiaries are subject to the PETI process. PETI is the basis for calculating a beneficiary's liability to pay toward the cost of care. During this process, income is evaluated a second (2nd) time, Federal spousal impoverishment requirements are applied, if appropriate, and additional deductions from income are taken for personal needs, non-covered health care costs like insurance premiums, and other allowable expenses. PETI varies somewhat depending on the type of Medicaid LTSS - in a health institution or HCBS - selected by a beneficiary and the requirements of his/her service plan. Accordingly, the development of the service plan and the beneficiary's health care priorities and preferences established in the person-centered planning process are important factors that must be considered when calculating beneficiary liability. The PETI process is set forth in detail in Part 8 of this Subchapter.3. Authorization of Payment for LTSS - Authorization of Medicaid LTSS is required before a payment is made for coverage provided to a beneficiary. This process entails a complex set of transactions in which information about the scope of services approved and/or utilized and the beneficiary's liability are transmitted from the IES to the State's Medicaid claims system (Medicaid Management Information System or "MMIS"). Once these transactions are completed, payment is authorized to an LTSS provider dating back to the eligibility date - the first (1st) day of the month in which the application was filed - and prospectively unless retroactive eligibility has been approved.210 R.I. Code R. 210-RICR-50-00-1.8
Amended effective 10/5/2021
Amended effective 12/29/2022