Section 210-RICR-50-00-8.9 - Determination and Collection of Beneficiary LiabilityA. PETI income is the amount of an LTSS beneficiary's income that is applied to the LTSS Medicaid cost of care after the deduction of all available allowances. If the beneficiary's gross income is depleted by the allowances deducted - PETI income is zero dollars ($0.00) - there is no beneficiary liability and no payment toward the Medicaid cost of care is required. 1. Agency Responsibilities - In determining and applying PETI income for beneficiary liability purposes, the agency has the following responsibilities:a. Calculation of beneficiary liability. In general, the determination of beneficiary liability is based on the income and resources of the applicant beginning on the eligibility date, which is the first (1st) day of the month in which an application is filed and date stamped as received by the agency. There is no beneficiary liability for services covered during the ninety (90) day retroactive period which begins in the month prior to the filing of the application.b. Collection date. The obligation to pay beneficiary liability varies by type of LTSS when eligibility is determined by the State in a month after the application is filed irrespective of the eligibility date as follows: (1) HCBS beneficiaries - Beneficiary liability begins on the first (1st) day of the month in which a determination of eligibility is made. If eligibility is determined in a month after the application was filed, beneficiary liability does not accrue retroactively back to the eligibility date, however. Therefore, collection of beneficiary liability for HCBS beneficiaries is always prospective and begins on the first (1st) day of the calendar month after eligibility is determined by the State.(2) NF and other health institutions. LTSS beneficiaries residing in health institutions are obligated to pay what they can afford toward the cost of care beginning on the date of admission. Accordingly, for beneficiaries who were residing in such institutions on the date the application was filed, liability toward the cost of care begins on the eligibility date - the first (1st) day of the month in which an application is filed - irrespective of the date eligibility is actually determined by the State. Thus, beneficiary liability does accrue retroactively for LTSS beneficiaries residing in health care institutions.c. Reductions. In instances in which the LTSS applicant has no spouse or dependents and has incurred LTSS costs during the period an application is pending, liability for the cost of care may be reduced for the first (1st) month to take these additional costs into consideration.d. Adjustments. In general beneficiary liability must be recalculated at any time there is a change in a factor that was used as the basis for an allowance including, but not limited to, the death of the non-LTSS spouse, sale of a home, change in living arrangement, income, or scope of benefits. Beneficiary liability is also adjusted prospectively, even in situations in which a beneficiary did not make a timely report of such a change. The only exceptions to prospective adjustments are as follows: (1) Partial month eligibility. Beneficiary liability is adjusted when a LTSS beneficiary receives services for less than a full month due to death, discharge, or change in LTSS living arrangement, such as nursing facility to home.(2) Beneficiary Overpayments. Retroactive adjustments are made when an agency system error resulted in an overpayment liability by a beneficiary for one (1) month or more. The adjustments date back to the first (1st) of the month when the error was made. Retroactive adjustments are NOT made when beneficiary liability is understated.e. Notice. Beneficiary liability may not be imposed without first providing prior notice to the beneficiary indicating the amount of the monthly payment and appeal rights. This requirement applies at the time of the initial eligibility determination in the benefit decision notice and Medicaid LTSS renewals as well as at any time there is reassessment of need indicating a change in living arrangement is required, such as the beneficiary no longer has the highest need for a NF level of care.f. Provider notification. Notification is provided to the health care institution or HCBS provider if there are any changes to beneficiary liability.2. Beneficiary Responsibilities - To ensure beneficiary liability is implemented in a fair and accurate manner, the LTSS beneficiary must:a. Payment. The LTSS beneficiary must pay beneficiary liability in the amount required to the provider in accordance with § 8.9(A) of this Part unless specifically notified otherwise. Upon confirming that a beneficiary has failed to make payment for three (3) consecutive months, the State may take action to resolve the debt or terminate services. Prior to taking an action, the State issues a notice informing the beneficiary that Medicaid-funded HCBS will be terminated in thirty (30) days unless an appeal based on hardship is made in accordance with the requirements set forth herein. If an appeal is filed in a timely manner, Medicaid HCBS will continue until a final decision is rendered. The provider is not responsible for collecting the monthly payment during the appeal period. However, if no exception is granted, HCBS terminates until the debt to the State is settled or appropriate repayment arrangements are made as indicated by the EOHHS Hearing Officer. LTSS beneficiaries receiving SSI are exempt from the repayment and penalty requirements set herein.b. Notification of changes. The LTSS beneficiary must notify the agency of changes in any factor that served as the basis for an allowance/deduction, as set forth in this Part, within no more than ten (10) days from the date the change takes effect.c. Medicaid-certified LTSS Provider Responsibilities - The LTSS provider - whether a health care institution or HCBS provider must:(1) Payment. Accept the liability amount from the LTSS beneficiary.(2) Refunds. Overpayments of beneficiary liability must be refunded to the LTSS beneficiary, such as when retroactive adjustments are made.210 R.I. Code R. 210-RICR-50-00-8.9
Amended effective 6/3/2021
Amended effective 9/2/2021
Amended Effective 11/3/2021
Amended effective 7/29/2023(EMERGENCY)
Amended effective 11/22/2023