Section 210-RICR-40-05-1.7 - Special Coverage Groups1.7.1OverviewThere are certain IHCC groups that are exempt from various income and/or resource requirements because they provide coverage to people with unique characteristics and/or health needs.
1.7.2Breast and Cervical CancerA. The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Pub. Law 106-354), amended Title XIX to include an optional Medicaid coverage group for uninsured women who are screened and need treatment for breast or cervical cancer or for precancerous conditions of the breast or cervix. The Rhode Island Department of Health (DOH), Women's Cancer Screening Program, is responsible for administering the screening required for Medicaid eligibility through this pathway. 1. Eligibility Criteria - To qualify, an applicant must be under age sixty-five (65) and receive screening for breast or cervical cancer under the CDC Breast and Cervical Cancer Early Detection Program administered by DOH and found to need treatment for either breast or cervical cancer, or a precancerous condition of the breast or cervix. In addition, an applicant must not be Medicaid eligible in another coverage group or have access to or be enrolled in a health insurance plan that provides essential benefits, as defined in Federal Regulations at 42 C.F.R. § 447.56. All general requirements for Medicaid must also be met. There is no resource limit. Retroactive eligibility is available for eligible members of this coverage group and no disability determination is required.2. Determination process - Members of this coverage group are not required to meet EAD income and resource limits or those established for other Medicaid eligibility pathways. Under the State's §1115 waiver, income eligibility for members of this coverage group is set at two hundred fifty percent (250%) of the FPL. In addition, presumptive eligibility is also available to women who meet the screening requirements, prior to a full determination of Medicaid eligibility, if the woman is a resident of the State.3. Continuing eligibility - A redetermination of Medicaid eligibility must be made periodically to determine whether the beneficiary continues to meet all eligibility requirements. Eligibility ends when the beneficiary: a. Attains age sixty-five (65);b. Acquires qualified health insurance/creditable coverage;c. No longer requires treatment for breast or cervical cancer;d. Fails to complete a scheduled redetermination;e. Is no longer a Rhode Island resident; ORf. Otherwise does not meet the eligibility requirements for the program.4. Agency responsibilities - The DOH administers the screening and application segments of the program. EOHHS conducts redeterminations and renewals and is responsible for providing timely notice and the right to appeal when any change in eligibility occurs.5. Applicant/beneficiary responsibilities - Beneficiaries are responsible for providing timely and accurate information about the status of their condition/treatment prior to the date of redetermination or at intervals specified.1.7.3Refugee Medical Assistance (RMA) - MN OptionA. Refugee Medical Assistance (RMA) is a one hundred percent (100%) Federally-funded program for individuals and families operating under the auspices of the U.S. Department of Health and Human Services, Office of Refugee Resettlement (ORR). RMA is an eligibility pathway for individuals and families who are otherwise ineligible for Medicaid. Until enactment of the ACA, all persons seeking RMA were evaluated using the SSI methodology through the MN eligibility pathway. The ORR has waived these requirements and directed that, prior to a determination for RMA, States should evaluate all participants in its programs for Medicaid and commercial coverage, using the MAGI methodology (MACC groups under the Medicaid Code of Administrative Rules, Overview of Affordable Care Coverage Groups and HSRI) and SSI-related coverage (§ 1.5 of this Part) before pursuing RMA through the MN pathway. 1. Eligibility Criteria - Any member of the Federal resettlement program for refugees who has income at or below two hundred percent (200%) of the FPL and is otherwise ineligible for Medicaid or an HSRI plan providing financial help, may apply for RMA using the MN process. This includes adults nineteen (19) to sixty-four (64) who have no other Medicaid MN eligibility option and certain persons in need of LTSS. The criteria set forth in §1.11.6 of this Part for Community Medicaid apply for establishing the spenddown period and allowable expenses except there are no resource requirements and deeming is not permitted.2. Determination Process - All persons seeking Medicaid coverage who have refugee status are evaluated for MACC group eligibility first using the MAGI before being evaluated for IHCC group coverage using the SSI methodology or special eligibility requirements in this section. This includes the MN pathways identified in Community Medicaid: Medically Needy Eligibility, Part 2 of this Subchapter, for elders, adults with disabilities, children, parents/caretakers, and pregnant women. If determined ineligible through these pathways, the person is evaluated for coverage through HSRI and then the MN eligibility pathway through RMA. The RMA MN eligibility pathway requires a beneficiary to spenddown to the MNIL for elders and adults with disabilities, adjusted for family size.3. Continuing Eligibility - Receipt of RMA under the characteristic of "refugee" is limited to the first eight (8) months residing in the United States, beginning with the month the refugee initially entered the United States, or the entrant was issued documentation of eligible status by the Federal government. a. Coverage Limit. Coverage and one hundred percent (100%) Federal matching funds continue until the end of the eighth (8th) month or the date in which the person no longer meets the immigration status requirement, whichever comes first. Prior to ending eligibility for Medicaid through this pathway, a review of other possible forms of Medicaid eligibility is conducted by the State.b. No Five Year Bar. Federal law exempts refugees from the five (5) year bar for qualified non-citizens established under §401 of the U.S. Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, 42 U.S.C. § 1305. Once the (8) eight month RMA period ends, States are required to continue Medicaid eligibility under any other coverage group for which a refugee may qualify providing all other requirements are met. (See Part 30-00-1 of this Title, Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways, for more immigration information.) Renewals for continuing coverage are conducted in accordance with the applicable coverage group requirements including six (6) month budget periods through the MN pathway.4. Agency responsibilities - Beneficiaries eligible under this section are required to meet the spenddown requirements set forth in Part 2 of this Subchapter. The agency is responsible for ensuring that the spenddown period coincides with the eligibility period. In addition, the EOHHS must evaluate each applicant/beneficiary in this group for MAGI-based Medicaid and HSRI eligibility prior to granting MN eligibility. Federal payment for eight (8) months is provided regardless of pathway.5. Applicant/beneficiary responsibilities - Beneficiaries are responsible for meeting the spenddown requirements set forth in Part 2 of this Subchapter.1.7.4Sherlock PlanThe Sherlock Plan Medicaid for Working People with Disabilities Program is an SSI-related IHCC group comprised of working adults with disabilities pursuant to the Balanced Budget Act of 1997, 42 U.S.C. § 1396a(a)(10)(ii) (XIII). Eligibility for the Sherlock Plan is included in Subchapter 15 Part 1 of this Chapter, Medicaid Code of Administrative Rules, Section 1373: Medicaid for Working People with Disabilities Program, which focuses on Medicaid eligibility for adults with disabilities who are working.
1.7.5Emergency MedicaidA. Medicaid health coverage is available to non-citizens in emergency situations without regard to immigration status. 1. Eligibility Criteria - To qualify for emergency Medicaid, a non-citizen must meet all of the eligibility requirements for a MACC or an IHCC group, except for immigration status. Persons seeking emergency Medicaid are evaluated as follows: a. Persons under age sixty-five (65). All persons in this group are evaluated for the MACC groups identified in Part 30-00-1 of this Title, Medicaid Affordable Care Coverage Groups Overview and Eligibility Pathways, using the MAGI, at the income limit applicable for the population to which they belong - e.g., child, adult or parent/caretaker, pregnant woman. There is no resource limit and no determination of disability.b. Elder sixty-five (65) and older. Non-citizens in this category are evaluated using the IHCC Community Medicaid EAD eligibility requirements and income standard. Resource limits apply, but there is no determination of disability.c. Medically Needy. Persons who are ineligible under §§1.7.5(1)(a) or (b) of this Part because their income is too high, may seek coverage through the IHCC pathway as MN in accordance with §1.5.3 of this Part and Part 2 of this Subchapter in detail.d. In addition, the person must require treatment for an emergency health condition in accordance with the prudent layperson standard - as defined in the Federal Balanced Budget Act of 1997, Pub. Law 105-33 - as specified below and obtain such services from a certified Medicaid provider. Such an emergency health condition is:(1) A health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. During the novel Coronavirus Disease (COVID-19) declaration of emergency, a diagnosis of, and treatment for, COVID-19 is to be considered an emergency health condition.2. Determination Process - Emergency service providers - typically an acute care facility such as a hospital - provides assistance with completing any required forms upon determining, in conjunction with the presumptive eligibility process specified in Part 30-00-4 of this Title, Presumptive Eligibility for Medicaid as Determined by Rhode Island Hospitals, that emergency Medicaid coverage may be required. In situations in which eligibility for emergency Medicaid cannot be determined or ascertained in this process, an agency eligibility specialist is contacted to provide the non-citizen with assistance in applying for coverage and assuring payment is made for any of the Medicaid-covered emergency services rendered. MN eligibility is available, as a last resort, for non-citizens who have income above the applicable eligibility limits for other coverage groups if the costs incurred for emergency services are sufficient for a spenddown. Payments to providers are typically made post-treatment.3. Continuing Eligibility - Emergency Medicaid coverage is limited to the period in which the emergency health condition is treated. Under applicable Federal Regulations, such coverage does not include any follow-up services deemed medically necessary to prevent the need in the future for emergency services for the same illness, disease or condition in an acute care facility.4. Agency responsibilities - The EOHHS is responsible for assisting in the application process and making timely payment for services provided under this Subsection, including for any services billed separately by licensed providers and professionals as long as the costs were incurred during the emergency health period for the condition specified.5. Applicant/beneficiary responsibilities - Applicants must provide timely and accurate information on all eligibility factors unrelated to immigration status required for making a determination for Medicaid health coverage.210 R.I. Code R. § 210-RICR-40-05-1.7
Amended effective 11/5/2020
Amended effective 6/3/2021
Amended effective 4/9/2023
Amended effective 7/29/2023(EMERGENCY)
Amended effective 11/27/2023