Section 210-RICR-30-05-2.4 - DefinitionsA. For the purposes of this Rule, the following definitions apply:1. "Advance practice provider" or "APP" means and includes physician assistants, certified nurse practitioners, psychiatric clinical nurse specialists, and certified nurse midwives. These individuals must maintain compliance with all applicable statutes and regulations and not exceed their scopes of practice.2. "Appeal" means a formal request by a covered person or provider for reconsideration of a decision, such as a utilization review recommendation, a benefit payment, or administrative action.3. "Applicant" means a person seeking Medicaid coverage under this Part, in accordance with the provisions established in Rhode Island General Laws and Public Laws.4. "Care manager" means a nurse or social worker with specialized training in providing care management services.5. "Complementary alternative medicine" or "CAM" means treatment from a chiropractor, acupuncturist, and/or massage therapist.6. "Days" means calendar days.7. "Employer sponsored insurance" or "ESI" means health insurance or a group health plan offered to employees by an employer. This includes plans purchased by small employers through HealthSourceRI.8. "Enrollee" means a Medicaid member or "beneficiary" who is enrolled in a Medicaid managed care plan.9. "Executive Office of Health and Human Services" or "EOHHS" means the State agency established in 2006 under the provisions of R.I. Gen. Laws Chapter 42-7.2 within the executive branch of State government and serves as the principal agency for the purposes of managing the Departments of Children, Youth, and Families (DCYF); Health (DOH); Human Services (DHS); and Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH). The EOHHS is designated as the "single state agency," authorized under Title XIX of the U.S. Social Security Act, 42 U.S.C. §§ 1396-1396w-7, and, as such, is legally responsible for the program/fiscal management and administration of the Medicaid Program.10. "Grievance" means an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to: a. Quality of care or services provided;b. Aspects of interpersonal relationships such as rudeness of a provider or employee;c. Failure to respect the member's rights regardless of whether remedial action is requested;d. Right to dispute an extension of time proposed by the MCO to make an authorization decision.11. "In lieu of services" means cost effective alternative services/equipment, even where those services/equipment are not identified as an in-plan benefit, when the use of such alternative services/equipment are medically appropriate and cost effective, such as the purchase of an air conditioner, where clinically appropriate, which helps a beneficiary avoid hospitalization.12. "Limited English proficiency" or "LEP" means that enrollees do not speak English as their primary language and may have a limited ability to read, write, speak, or understand English and may be eligible to receive language assistance for a particular type of service, benefit, or encounter.13. "Managed care organization" or "MCO" means a health plan system that integrates an efficient financing mechanism with quality service delivery, provides a "medical home" to assure appropriate care and deter unnecessary services, and emphasizes preventive and primary care.14. "Medicaid affordable care coverage group" or "MACC" means a classification of persons eligible to receive Medicaid based on similar characteristics who are subject to the MAGI standard for determining income eligibility as follows:a. Families and Parents/Caretakers with income up to one hundred forty-one percent (141%) of the Federal Poverty Level (FPL) - Includes families and parents/caretakers who live with and are responsible for dependent children under the age of eighteen (18) or nineteen (19) if enrolled in school full-time. It also includes families eligible for time-limited transitional Medicaid.b. Pregnant women. Members of this coverage group can be of any age. The pregnant woman and each expected child are counted separately when constructing the household and determining family size. Eligibility extends for the duration of the pregnancy and two (2) months post-partum. The coverage group includes all pregnant women with income up to two hundred fifty-three percent (253%) of the FPL, regardless of whether the legal basis of eligibility is Medicaid or CHIP, including pregnant women who are non-citizen residents of the State. The unborn child's citizenship and residence is the basis for eligibility.c. Children and Young Adults. Age is the defining characteristic of members of this MACC group. This coverage group includes: infants under age one (1), children from age one (1) to age nineteen (19) with income up to two hundred sixty-one percent (261%) of the FPL; and qualified and legally present non-citizen infants and children up to the age of nineteen (19), who have income up to two hundred sixty-one percent (261%) of the FPL.d. Adults 19-64. This is the new Medicaid State Plan expansion coverage group established in conjunction with implementation of the ACA. The group consists of citizens and qualified non-citizens with income up to one hundred thirty-three percent (133%) of the FPL who meet the age characteristic and are not otherwise eligible for, or enrolled in, Medicaid under any other State plan or Section 1115 waiver coverage group. Adults found eligible for Social Security benefits are also eligible under this coverage group during the two (2) year waiting period.15. "Medically needy" means a classification of persons eligible to receive Medicaid based upon similar characteristics who are subject to the MAGI standard for determining income eligibility.16. "Navigator" means a person working for a State-contracted organization with certified assisters who have expertise in Medicaid eligibility and enrollment.17. "Non-MAGI coverage group" means a Medicaid coverage group that is not subject to the modified adjusted gross income eligibility determination. Includes Medicaid for persons who are aged, blind or living with disabilities and persons in need of long-term services and supports as well as individuals who qualify for Medicaid based on their eligibility for another publicly-funded program, including children in foster care, anyone receiving Supplemental Security Income (SSI) or eligible for or enrolled in the Medicare Premium Assistance Program.18. "Peer navigator" means paraprofessionals with specialized training who are community resource specialists employed and supervised by peer advocacy organizations.19. "Prospective Medicaid enrollee" means a Medicaid beneficiary or family who has not enrolled in an MCO.20. "Prudent layperson standard" means the standard used to determine the need for an emergency room visit. An "emergency" is defined as a condition that a prudent layperson "who possesses an average knowledge of health and medicine" expects may result in: a. Placing a patient in serious jeopardy;b. Serious impairment of bodily function; orc. Serious dysfunction of any bodily organs.21. "Rhody health partners" means the Medicaid managed care program that delivers affordable health coverage to eligible adults without dependent children, ages nineteen (19) to sixty-four (64), under § 2.18 of this Part and adults with disabilities eligible under Part 40-10-1 of this Title.22. "RIte care" means the Medicaid managed care delivery system for eligible families, pregnant women, children up to age nineteen (19), young adults older than age nineteen (19), and foster children (DCYF custody) (see § 2.1 of this Part).23. "RIte share" means the Medicaid premium assistance program for eligible individuals and families who have access to cost-effective commercial coverage.24. "Section 1115 Waiver" means the waiver authorized pursuant to §1115 of the Social Security Act, 42 U.S.C. § 1315.25. "Section 1931" or "§1931" means §1931 of the Social Security Act, 42 U.S.C. § 1396u-1.26. "Title IV-E" means Title IV-E of the Social Security Act, 42 U.S.C. §§ 670-679c.27. "Title XIX" means Title XIX of the Social Security Act, 42 U.S.C. §§ 1396-1396w-728. "Urgent medical problem" means a medical, physical, or mental condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of medical attention within twenty-four (24) hours could reasonably be expected to result in:a. Placing the patient's health in serious jeopardy;b. Serious impairment to bodily function; orc. Serious dysfunction of any bodily organ or part.210 R.I. Code R. 210-RICR-30-05-2.4
Amended effective 10/5/2021
Amended effective 12/12/2023
Amended effective 3/17/2024