Section 210-RICR-50-00-2.5 - Medically Needy Eligibility Determination ProcessA. To be considered for the medically needy pathway, an otherwise Medicaid eligible person must have income above the Federal cap of three hundred percent (300%) of the SSI rate. The LTSS eligibility requirements for Medicaid LTSS are outlined in § 1.9 of this Subchapter and are set forth in greater detail throughout this Part. All LTSS applicants with countable income above the Federal cap are automatically evaluated for the MN eligibility pathway. Total countable income must be at or below the projected cost for the type of LTSS the person is seeking or receiving, at the private pay rate, adjusted annually as set forth in § 2.6 of this Part.B. Eligibility is determined in accordance with the following: 1. Excess income amount - The person's countable income for the month is determined based on the provisions set forth in Part 40-00-3 of this Title, pertaining to the SSI methodology. If income is above the Federal cap after all required disregards and exclusions have been applied, the medically needy income limit (MNIL) is deducted from remaining income. This is the total amount of excess income that must be absorbed to obtain MN eligibility for LTSS.2. Income and Institutional Cost Comparison - The projected cost of LTSS at the private pay rate in the applicable health institution - nursing facility (NF), intermediate care facility for intellectually/developmentally disabled individuals (ICF/I-DD), or long-term hospital (LTH) - is deducted from the excess income. a. If excess income is absorbed by the cost of LTSS, the person is MN eligible and the provisions related to the post-eligibility treatment of income (PETI), set forth in Part 8 of this Subchapter, are applied to determine the amount of the person's gross income that is available to be applied toward the cost of care each month.b. If excess income is not absorbed, the remaining income provides the basis for determining the LTSS MN spenddown for the projected budget period once the PETI Rules are applied. Allowable expenses are deducted in accordance with §2.6.1(B) of this Part below.3. Spenddown - A MN LTSS spenddown is based on the amount of excess income remaining after all required reductions are taken in the PETI process. Income protected in the PETI process is unavailable and therefore is excluded in the calculation of the spenddown. Once protected income is subtracted, the total spenddown is the amount of allowable expenses a person must incur to meet the MNIL. a. Otherwise Medicaid eligible due to a penalty. PETI does not apply when a person who is subject to penalty period for LTSS coverage is otherwise eligible for Medicaid. Therefore, during such a penalty period, in which Medicaid LTSS coverage is not available, all countable income is available for spenddown purposes.b. Verification. The State determines whether the applicant/beneficiary has sufficient allowable expenses each month - both incurred and projected - to meet this spenddown. Proof that incurred allowable expenses meet the monthly spenddown may be required as indicated in §2.6.1 of this Part below.4. Monthly projected spenddown period - The State uses a one (1) month budget period to determine beneficiary liability and therefore the amount of the spenddown required to maintain eligibility. a. Start date. A one (1) month budget period begins with the first (1st) calendar month during which the person receives LTSS for any part of the month, applies for Medicaid coverage for that month, and meets all other requirements for Medicaid eligibility.b. End date. A one (1) month budget period ends with the last calendar month during which the person received LTSS for any part of the month and meets all other eligibility requirements.C. LTSS MN coverage begins on the first (1st) day of the budget period in which allowable expenses meet or exceed the spenddown requirement when using health insurance cost and noncovered health expenses to meet the MNIL. Eligibility becomes effective later than the first (1st) day of the month when a spenddown requirement is met using covered medical expenses. Medicaid LTSS coverage continues to the end of the budget period unless there is a change in income. 1. Penalty period and MN eligibility - The penalty start date for a person seeking LTSS MN eligibility is the date the spenddown is met. If the spenddown is not met in the month of application or the next month, the person is ineligible for LTSS MN coverage and the State must determine whether Community Medicaid MN eligibility is available based on a six (6) month spenddown period.2. Overlapping providers - Applicants and beneficiaries are responsible for health expenses incurred before the date of eligibility. If receiving LTSS for more than one (1) provider on the date that coverage begins, the applicant/beneficiary must decide which services he or she will be responsible for paying and which providers Medicaid will cover.210 R.I. Code R. 210-RICR-50-00-2.5
Amended effective 2/23/2021
Amended effective 12/28/2023