Section 210-RICR-30-00-1.7 - MACC Group General Eligibility RequirementsA. All applicants for MACC Group eligibility must meet State residency requirements. Applicants for MACC Group eligibility who are over the age of nineteen (19) must meet citizenship/immigration status requirements. There are also certain cooperation requirements. Adults must typically meet the cooperation requirements, whether applying for themselves or on behalf of a dependent child. Verification of these requirements is an automated process conducted through electronic data matches. Failure to meet Medicaid general eligibility requirements or provide supporting documentation upon request is considered non-cooperation and generally results in the denial or discontinuation of eligibility. Children are exempt from sanctions due to non-cooperation. The scope and application of each of these eligibility requirements are as follows:
1. Age - "Age" is one of the principal factors affecting eligibility for Medicaid and assignment to the appropriate Medicaid service delivery system MACC group.2. MACC Group Age Limits - The age requirements associated with each of the MACC groups are as follows: MACC Coverage Groups | Age Requirements |
Families and Parents/Caretakers | Parents/Caretakers of any age Dependent child up to age eighteen (18) or nineteen (19) if enrolled in school full-time |
Pregnant People | Any age |
Children and Young Adults | Up to age nineteen (19) |
ACA Expansion Adults | Ages nineteen (19) to sixty-four (64) |
a. Verification - An applicant's self-attestation of age and identity is accepted at the time of application. Post-eligibility electronic verification of date of birth is conducted through the U.S. Social Security Administration (SSA) and/or the Rhode Island Department of Health, Division of Vital Statistics. This information is used to determine capitation rates for enrollees in Medicaid managed care plans; these rates vary by age. If electronic verification is unsuccessful, submission of paper documentation may be required for these purposes. See Part 5 of this Subchapter for satisfactory forms of documentation.3. Social Security Number - To support verification of age, income, and citizenship/immigration status, individual applying for Medicaid who have been assigned a Social Security Number (including children) shall provide their Social Security Number (SSN) as a condition of eligibility for the program. a. Only members of a household who are applying for Medicaid coverage are required to provide an SSN. An SSN of a non-applicant may be requested to electronically verify income. However, unwillingness on the part of a non-applicant to provide an SSN upon request shall not be used as the basis for denying eligibility to an applicant who has provided an SSN. If an SSN is unavailable, other proof of income shall be accepted.b. Limits on Use - Applicants shall also be informed that an SSN can be utilized only in the administration of the Medicaid program, including for use in verifying age and income eligibility.c. Verification - An SSN is verified through an electronic data-match with the SSA. Applicants (not including children) must provide documentation of SSN if the data match fails. Acceptable forms of documentation are identified in Part 5 of this Subchapter.4. State Residency - Anyone who is applying for eligibility must be a resident of the State. Any person living in the State voluntarily, who intends to reside in Rhode Island for any reason is considered a resident of the State. Under Federal Regulations a person does not need a fixed address in the State to be considered a Rhode Island resident. Therefore, homelessness is not a bar to eligibility.a. For individuals who are twenty-one (21) years of age or older,, or under the age of twenty-one (21) and capable of expressing intent as an emancipated or married individual - If the applicant is not living in an institution, the State of residence is the State where the applicant is living voluntarily with the intention to reside; or entered voluntarily with a job commitment or seeking employment, whether or not currently employed.b. For individuals under the age twenty-one (21) who are not emancipated or married - If the applicant is not living in an institution, the State of residence is the State where the child/young adult resides or the State of the parent/care-taker with whom the child lives. Under the requirements of this provision, the residence of a pregnant person's unborn child is, the State in which the pregnant person resides. A non-citizen pregnant person who lives in Rhode Island is considered to be a resident, irrespective of whether the person's immigration status indicates they are in the country permanently or for a limited time (i.e., in the United States on a temporary visa of any kind).c. For individuals living in institutions - Most Medicaid applicants living in institutional settings are not included in the MACC groups.d. Disputes - If there is a dispute over residency for determining Medicaid eligibility, the applicant is a resident of the State in which the applicant is physically located. The MAGI standard of the State where the applicant is physically located applies when determining eligibility.e. Verification - Self-attestation of the intent to remain in the State is accepted. Evidence that an applicant is receiving public benefits in another State may result in a denial of eligibility if paper documentation of residency is not provided.5. Citizenship and Immigration Status - The citizenship requirements for Medicaid eligibility for individuals and families in MACC groups vary depending on the basis of eligibility. Some non-citizens are not eligible for Medicaid; some are eligible for Medicaid only after a five (5) year waiting period; and some are eligible without a waiting period. Children up to the age of nineteen (19) are not subject to citizenship requirements to be eligible for Medicaid, and pregnant people are not subject to citizenship requirements under CHIP.a. Non-Citizens ineligible Except in Emergency Situations (1) Non-qualified non-citizens. The non-qualified category of non-citizens includes citizens of other nations who are not considered to be immigrants under current Federal law, including those in the United States on temporary or time-limited visa (such as visitors and students) and those who are present in the country without proper documentation (includes people with no or expired status).(2) Non-qualified non-citizens who are adults are not eligible for Medicaid, except in emergency situations (Part 10-00-3 of this Title). Non-emergency services may be obtained through Federally Qualified Community Health Centers. See Rhode Island Community Health Association at www.richa.org.b. Non-Citizens barred from Medicaid During Five (5) Year Waiting Period (1) Qualified non-citizens. The qualified non-citizens category includes persons who are citizens of other nations who are lawfully present in the United States. Qualified non-citizens are barred from Medicaid for a waiting period of five (5) years under Federal law. Certain exemptions from the bar apply:c. Non-Citizens Exempt from the Five (5) Year Waiting Period(1) Qualified non-citizen children up to the age of nineteen (19) who are lawfully present in the United States but who were born in another nation are eligible for Medicaid as members of the MACC group for children and young adults. Children in this subcategory of qualified non-citizens are eligible during the five (5) year bar under an option contained in Title XXI, the Children's Health Insurance Program (CHIP). Qualified non-citizen pregnant people are also eligible for Medicaid in the MACC group, under an option in CHIP.(2) There are several other subcategories of non-citizens who are exempt from the five (5) year bar as specified in Part 10-00-3 of this Title. All non-exempt qualified non-citizens are eligible to obtain coverage through State and Federal health insurance marketplaces, such as HealthSource RI.com in Rhode Island, and may be qualified for certain tax credits.d. Non-qualified non-citizen pregnant people in the applicable MACC group are eligible for Medicaid coverage. The pregnant person's eligibility is tied to the eligibility of the baby they are carrying. For the purposes of MACC group eligibility, the baby in utero is deemed to be a United States citizen and Rhode Island resident and remains so as a newborn as long the birth occurs in Rhode Island.e. Verification of citizenship/immigration status - All members of a household applying for Medicaid coverage shall provide their immigration and citizenship status. However, no adverse eligibility determination shall be made regarding children up to the age of nineteen (19) for whom citizenship/immigration status is not provided. Non-applicants are exempt from this requirement. Any information provided by an applicant or obtained through electronic verification under § 1.7(A)(5)(e) of this Part shall only be used to verify status. Under the ACA, citizenship and immigration status are verified: (1) Electronically. The Medicaid agency shall use electronic verification through the Federal hub (see Part 5 of this Subchapter) to the full extent feasible through: (AA) Social Security Administration (SSA) or Rhode Island Department of Health, Division of Vital Statistics for citizens.(BB) U.S. Citizenship and Immigration Services (USCIS) for non-U.S. adult citizens via the Systematic Alien Verification for Entitlements (SAVE) database.(2) Non-electronic. If unable to verify immigration status electronically, enrollees have an opportunity to provide other documents or to fix the records.(3) Self-Attestation. An applicant's attestation is accepted without electronic verification providing appropriate paper documentation is provided to the Medicaid agency within ninety (90) days of the eligibility determination. Failure to provide the required documentation within that period results in a termination of Medicaid and the initiation of the Medicaid recoupment process.6. Relationship - The State evaluates the relationship of household members applying for the MACC group for families and parent/caretakers using the following:a. Caretaker Relative - For the purposes of MACC group eligibility, parent/caretaker is any adult living with a Medicaid-eligible dependent child who has assumed primary responsibility for that child. This definition includes, but is not limited to:(1) Father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew or niece;(2) The spouse of such parent or relative, even after the marriage is terminated by death or divorce; or(3) Another relative of the child based on blood, adoption or marriage; domestic partner of parent or other caretaker relative. If the parents are in the household, it is presumed that other members in the household are not assuming primary responsibility for the child's care.(4) Dependent child - For the purposes of determining eligibility the members of the MACC group for families and parents/caretakers, a dependent child is a child under the age of eighteen (18) or under the age of nineteen (19) if enrolled full-time in school.b. Verification - Self-attestation on the application is accepted as verification of relationship, except for deeming of newborns.210 R.I. Code R. 210-RICR-30-00-1.7
Amended effective 12/29/2022
Amended effective 12/11/2023
Amended effective 12/26/2024