210 R.I. Code R. 210-RICR-50-10-3.4

Current through December 3, 2024

Section 210-RICR-50-10-3.4 - Special Conditions

A. To qualify for Medicaid LTSS through the KB provision, a child must be under nineteen (19) years of age and meet the general Medicaid requirements pertaining to residency. The Regulations at Parts 30-00-1 and 10-00-3 of this Title governing citizenship and immigration status for children up to age nineteen (19) also apply to the KB State Plan option. In addition, the following conditions must be met:

1. Financial Eligibility - Children seeking coverage for an institutional level of care at home who do not meet the eligibility criteria for MACC using the MAGI standard are subject to a financial eligibility review of income and resources using the SSI method for Community Medicaid, as set forth in Part 40-00-3 of this Title with the following exception -

a. Parental assets unavailable. When seeking Medicaid LTSS under the KB provision, the assets - income and resources - of the parent(s) or legal guardian(s) are deemed to be unavailable to the child applying for coverage. Accordingly, the financial eligibility determination is based on the child's income and resources. The standards that apply are the Federal benefit rate relative to income and up to the medically needy limit of four thousand dollars ($4,000.00) in resources. This is the SSI method of treatment of income and resources that applies when a child with special needs is seeking coverage in an institutional setting.

b. Excluded expenses. In the calculation of countable income, any payments for in-home supportive services provided to the child which are covered by Medicaid or other Federal, State or local government programs are excluded.

2. Clinical Eligibility - Upon application for coverage under the KB provision, a determination of clinical eligibility is made. There are two (2) reviews included in this determination:

a. Disability review. The disability status of the child is reviewed using the applicable SSI criteria. Information provided by a child's primary health care practitioner and ancillary providers is used as the basis for this review. Appropriate consents and authorizations must be provided by the applicant's parents/guardian to ensure full access to health care records and evaluations required for the disability review.

b. Level of need. After the disability determination, the child's need for an institutional level of care using needs-based criteria related to functional and health status is considered.

c. Clinical determination. Based on the disability and level of care reviews, a determination is made on whether the child has disabling impairments and/or complex health needs that:

(1) Require the level of care typically provided in an institution; and

(2) The required services can be safely provided in the community.

3. The standards and criteria used to make the disability and level of care determinations are available on paper by contacting the Katie Beckett Unit at 401-574-8474 and on the EOHHS website at: http://www.eohhs.ri.gov/Consumer/FamilieswithChildren/ChildrenwithSpecialNeeds/KatieBeckett.aspx

a. A child must meet Federal criteria for childhood disability. Under Title XVI of the Social Security Act, a child under age nineteen (19) will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that cause(s) marked and severe functional limitations, and that has lasted or can be expected to last for a continuous period of not less than twelve (12) months, or can be expected to result in death. (A complete description of the Social Security Administration requirements can be found in Disability Evaluation Under Social Security - also known as the Blue Book).

b. As provided in 42 C.F.R. § 435.225(b)(1), a child must require the level of care provided in a hospital (or psychiatric hospital), intermediate care facility for the intellectually disabled (ICF/ID), or nursing facility. Without appropriate interventions and supports (both at home and in the community), the child would either reside in an institution or be at immediate risk for institutional placement.

B. Cost Effectiveness Test - Both the decision on disability and level of care must be determined prior to the institutional versus home care cost-effectiveness comparison. Thus, the final step in determining eligibility under the KB provision is a comparison of the costs of providing the care a child needs at home versus in a health care institutional setting. If the costs of care at home are found to be higher, coverage under the KB provision must be denied.

1. Basis of comparison. The gross average monthly cost for providing care in the applicable health care institution - Nursing Facility, Intermediate Care Facility - Intellectual Disabilities (ICF-ID), or Hospital - as dictated by the child's needs is compared to the total gross monthly cost for allowed homecare services.

2. Institutional costs. This amount is determined on an annual basis and is set forth in Subchapter 00 Part 2 of this Chapter by institution.

3. Allowed home care cost. The gross monthly costs for the following are included in this calculation:

a. Certified home health agency services, including skilled nursing; physical speech; occupational therapy; and home health aide services; and

b. Purchase or rental of durable medical equipment;

c. Home based therapeutic services; and

d. Minor assistive devices, minor home modifications, and other special equipment.

4. These costs are only taken into consideration if they are not covered or reimbursed by a third-party including, but not limited to, private commercial insurance and other publicly financed programs administered by a government agency or body, such as a school district.

5. Determination of cost-effectiveness. Upon taking these costs into consideration, cost-effectiveness is determined as follows:

a. KB Eligibility approved. If the total estimated cost of care in the home is less than the total estimated cost of care in the appropriate institution, home care is considered to be cost-effective, this special condition is met and a child who is otherwise eligible under the KB provision qualifies for the full scope of Medicaid benefits.

b. KB Eligibility denied. If the total estimated cost of services required to meet a child's needs at home exceeds the cost of institutional care, the child is ineligible under the KB provision, even if the child meets all other eligibility requirements.

6. Eligibility determinations for Medicaid/KB. Determinations for KB must take no longer than ninety (90) days from the date the completed application is received. The application remains open after that period if the Medicaid agency or its eligibility designee (DHS) or agents (application entities) are responsible for delays in the determination.

210 R.I. Code R. 210-RICR-50-10-3.4

Amended effective 12/29/2022
Amended effective 10/1/2024