210 R.I. Code R. 210-RICR-50-00-1.9

Current through December 3, 2024

Section 210-RICR-50-00-1.9 - Eligibility Pathways

A. The eligibility pathways available to persons seeking Medicaid LTSS have different requirements all of which are automatically taken into account when application information is processed. As indicated below, the process for determining eligibility and the sequence may vary for members of a particular population depending on the pathways available.

1. SSI and SSI-related Groups - SSI recipients and members of certain SSI- related groups are automatically eligibility for Medicaid based on a determination by SSA as indicated in Part 40-00-3 of this Title. Federal Regulations at 42 C.F.R. § 435.603(j) specifically exclude Medicaid determinations of eligibility for members of this group, including for LTSS, using the MAGI standard except in instances in which an SSI recipient no longer meets disability criteria and loses cash assistance on this basis. Special provisions also apply to Medicaid LTSS beneficiaries who are receiving SSI and are expected to need LTSS coverage for ninety (90) days or less. Accordingly, access to LTSS proceeds as follows:

a. Eligibility Criteria. Medicaid beneficiaries who are SSI-eligible and need LTSS are subject to the clinical/functional eligibility factors required for an institutional level of care set forth in Subchapter 05 Part 1 of this Chapter as well as the financial eligibility requirements related to the transfer of assets. The resource limit is set at two thousand dollars ($2,000.00).

b. Special Conditions. Re-evaluation of income and resources is not required unless current eligibility is based on different Medicaid group size (couple v. individual) or there is a change in income or resources resulting from need for or use of LTSS. In addition:

(1) SSI recipients who have §1619(b) status, as indicated in §40-05-1.5.4 of this Title, remain eligible for two (2) months of continuing SSI cash assistance if admitted to an LTH, such as Eleanor Slater Hospital or an equivalent HCBS setting; and

(2) SSI recipients who obtain Medicaid LTSS for a period not expected to exceed ninety (90) days may continue to receive SSI cash assistance during this time to maintain a community residence. Such income is excluded in the financial eligibility determination sequence, including the post-eligibility treatment of income.

c. Determination Process. SSI recipients are not subject to a MAGI determination and a re-evaluation of income/resource eligibility using the SSI method is not required when applying for LTSS. Although a review of functional/clinical eligibility is conducted, a full assessment of level of care needs may be waived for certain populations based on their type of disability as indicated in Part 5 of this Subchapter. All other steps in the eligibility determination process apply to the extent that the special Rules applicable to the treatment of SSI income allow, as indicated in Part 40-00-3 of this Title.

d. Retroactive Coverage. Retroactive coverage is available for any allowable non-Medicaid covered LTSS expenses in the ninety (90) day period prior to the eligibility date in circumstances in which the applicant for LTSS was not enrolled in Medicaid at that time.

2. Adults 19 to 64 - All persons seeking initial or continuing eligibility for Medicaid LTSS in this age group are evaluated across several pathways unless they are currently eligible for Medicaid.

a. Eligibility Criteria. Applicants are subject to the general and functional/clinical eligibility requirements. Not all financial eligibility factors such as resource limits apply, as indicated. The financial eligibility requirements vary across pathways; if a beneficiary is determined ineligible in the current category (existing beneficiaries) or a pathway of choice (new applicants), the IES automatically evaluates whether eligibility through another pathway exists up to and including the medically needy pathway. The process generally proceeds as follows:

(1) MACC Group for MAGI-eligible Adults: Income limit - one hundred thirty-three percent (133%) of the FPL; No resource limit.

(2) IHCC non-SSI eligible Adults with Disabilities in Community Medicaid: Income limit - one hundred percent (100%) of the FPL; Resource Limit - four thousand dollars ($4,000.00). Applies to new applicants and existing beneficiaries.

(3) Special Income/HCBS: Income limit - three hundred percent (300%) of the SSI standard; Resource Limit - four thousand dollars ($4,000.00). New applicants only.

(4) Medically Needy: Income limit - Cost of Care; Resource Limit - four thousand dollars ($4,000.00). New applicants only

b. Special Conditions. Several eligibility pathways have special conditions that target or exclude certain populations:

(1) MACC Group for MAGI-eligible Adults: Pathway is closed to persons who are sixty-five (65) and older or who are eligible for or enrolled in Medicare. In addition to the exemption from a resource limit, PETI rules do not apply and, as a result, beneficiaries in this group do not have to pay a portion of income toward the cost of care. Spousal impoverishment protections, guaranteed through the SSI method, are also unavailable through this pathway.

(2) IHCC non-SSI adults with disabilities in Community Medicaid: Current beneficiaries may request to be assessed for an LTSS level of care and provide only the information related to financial eligibility factors to evaluate the transfer of assets, the allocation of resources between spouses/dependents, and beneficiary liability in accordance with Part 8 of this Subchapter. Existing beneficiaries seeking Medicaid LTSS under the Sherlock Plan must apply pursuant to the requirements set forth in Part 40-15-1 of this Title.

(3) Special Income: Pathway for new applicants with income above the Community Medicaid limit (up to three hundred percent (300%) of the SSI benefit rate) and adults with disabilities in the IHCC medically needy group who are seeking care in a health institution such as a hospital or nursing facility.

(4) HCBS: Reserved for persons seeking Medicaid LTSS in the HCBS setting who would, absent these services, have the "high" or "highest" need for an institutional level of care. Generally, these are new applicants for Medicaid.

(5) Medically Needy: Countable income must be below the average cost of care in the applicable institutional setting, as set forth in Part 40-05-2 of this Title. Special income deductions also apply.

c. Determination Process. The principal distinction in the determination process aside from the difference in eligibility criteria is the method for evaluating income - MAGI v. SSI - as indicated below:

(1) New Applicants for Medicaid - When applying for Medicaid LTSS, all new applicants who are under age sixty-five (65) and are neither enrolled in or eligible for Medicare are evaluated first to determine whether eligibility using the MAGI method for the MACC group for adults exists. Transfer of asset requirements are applied and an applicant must provide any information about liquid resources and real property necessary to complete that step in the eligibility process. If a new applicant under age sixty-five (65) is found ineligible for the MAGI-based MACC group coverage, or is requesting retroactive coverage, the SSI method is used to determine financial eligibility and all steps in the LTSS determination process, including PETI apply.

(2) Current Medicaid Beneficiaries - Current Medicaid beneficiaries who are seeking LTSS remain within the eligibility category that serves as the basis for their existing eligibility and are only referred as appropriate if LTSS eligibility in this category would be denied due to the supplemental information provided when seeking LTSS. Adults with disabilities who are receiving non-LTSS Community Medicaid under Chapter 40 of this Title are referred for a determination of clinical/functional eligibility, in the same manner as those who are SSI-eligible, while the required financial eligibility factors unique to LTSS are reviewed. All beneficiaries can initiate the LTSS eligibility determination by contacting a DHS LTSS eligibility specialist and completing the applicable sections of the integrated health and human services application form, or an alternative form designated for this purpose, or updating their accounts in the IES Consumer Portal.

d. Retroactive Coverage. Retroactive coverage for up to ninety (90) days is available for LTSS applicants in this population who are determined eligible using the SSI method. Under the terms of the State's Section 1115 demonstration waiver, all MAGI-eligible MACC groups, including the ACA expansion adults, do not have access to retroactive coverage unless eligible as a pregnant woman under the terms and conditions of the State's Section 1115 waiver.

3. Elders 65 and older - The eligibility pathways for persons sixty-five (65) years of age and older vary somewhat when compared to those available for persons between nineteen (19) and sixty-four (64) as specified above. The chief distinction is that members of this population are not evaluated for MAGI-based eligibility even if they are the parents/caretakers of a Medicaid eligible child. Differences in criteria by pathway are as follows:

a. Eligibility Criteria. All persons seeking Medicaid LTSS are evaluated using the SSI method through to the authorization of services; MAGI-based eligibility is not permitted under applicable Federal law. Although the income requirements vary, the resource limit is four thousand dollars ($4,000.00) for an individual applicant across pathways:

(1) IHCC non-SSI eligible elders in Community Medicaid: Income limit - one hundred percent (100%) of the FPL; Resource Limit - four thousand dollars ($4,000.00).

(2) Special Income/HCBS: Income limit - three hundred percent (300%) of the SSI standard; Resource Limit - four thousand dollars ($4,000.00).

(3) Medically Needy: Income limit - Cost of Care; Resource Limit - four thousand dollars ($4,000.00).

b. Special Conditions. The special conditions for adults with disabilities whose eligibility is determined using the SSI method also apply to elders.

c. Determination Process. The principal distinction in the determination process for members of this population is also a function of whether a person is a new applicant or current Medicaid beneficiary.

(1) New Applicants for Medicaid - When applying for Medicaid LTSS, all new applicants who are sixty-five (65) year of age and older are subject to a full financial eligibility review using the SSI method as well a determination of clinical/functional eligibility and all the steps in the LTSS determination process, including PETI apply.

(2) Current Medicaid Beneficiaries - Current Medicaid beneficiaries who are sixty-five (65) and older and eligible and receiving non-LTSS MACC Medicaid as a parent/caretaker under Chapter 30 of this Title are referred for both a full financial eligibility review using the SSI method, which requires that they provide additional information related to their own and joint spousal resources, and functional/clinical eligibility review. Current beneficiaries eligible for non-LTSS Community Medicaid under Chapter 40 of this Title are referred for a determination of clinical/functional eligibility, in the same manner as those who are SSI-eligible, while the required financial eligibility factors unique to LTSS are reviewed. All beneficiaries can initiate the LTSS eligibility determination by contacting a DHS LTSS eligibility specialist and completing the applicable sections of the integrated health and human services application form, or an alternative form designated for this purpose, or updating their accounts in the IES Consumer Portal.

d. Retroactive Coverage. Retroactive coverage is available for a period of up to ninety (90) day for LTSS applicants evaluated on the basis of the SSI method. Accordingly, all elders are eligible for retroactive coverage.

4. Children up to Age Nineteen (19) - Children requiring LTSS are generally evaluated for MACC group eligibility and provided the services and supports they need under the authorities included in the Medicaid State Plan without requiring a separate determination of eligibility. As indicated in Subchapter 10 Part 3 of this Chapter, there is also a separate eligibility pathway known as Katie Beckett (KB), which was established by Congress for children with serious illnesses and/or disabilities who are receiving care at home and, as a result, would otherwise be ineligible for Medicaid. These children would most likely be eligible if they were receiving care in an institution. The KB pathway, which is named after the young woman who inspired its creation by Congress, applies the SSI institutional Rules to provide Medicaid coverage available to these otherwise ineligible children by deeming their parents' income as unavailable to them. Accordingly, children eligible through the KB pathway receive the full scope of Medicaid State Plan and Section 1115 waiver services, including Early, Periodic, Screening, Detection and Treatment (EPSDT), provided to children with severe chronic diseases and/or disabling impairments who qualify in the MACC group pathway based on MAGI pursuant to Subchapter 10 Part 3 of this Chapter. The eligibility pathways differ as follows:

a. Eligibility Criteria. All children seeking initial or continuing eligibility for Medicaid LTSS coverage shall meet the general requirements for eligibility, however, notwithstanding any language to the contrary contained in the Rhode Island Code of Regulations, children under the age of nineteen (19) are not required to meet citizenship and immigration status eligibility requirements or to have been assigned a SSN. Financial and clinical requirements vary depending on pathway. Eligibility standards by pathway are set at:

(1) MACC group for children: Family income limit - two hundred sixty-one percent (261%) FPL; no resource limit.

(2) Katie Beckett: Child income limit - Special income limit for LTSS - Federal benefit rate; resource limit - four thousand dollars ($4,000.00); no income or resource deeming.

b. Special Conditions. The special conditions apply only to the KB eligibility pathway. To be eligible, the child must have a disabling impairment and needs requiring the level of care typically provided in a health institution (NF, ICF-ID, LTH) and live at home. A cost effectiveness test applies; that is, the cost of care at home must be at or below cost of care provided in a health care institution. The child must be otherwise ineligible for Medicaid based on family income,

c. Determination Process. The eligibility system considers all children seeking Medicaid eligibility in the MACC group for children first, in accordance with the income limits set in Part 30-00-1 of this Title and the MAGI eligibility process in Part 30-00-5 of this Title.

d. Retroactive Coverage. Retroactive coverage is available for KB eligible beneficiaries, but is unavailable for MACC group eligible beneficiaries, including children with special needs.

210 R.I. Code R. 210-RICR-50-00-1.9

Amended effective 10/5/2021
Amended effective 12/29/2022