Section 210-RICR-50-00-1.6 - Scope of LTSS CoverageA. Upon being determined eligible for Medicaid LTSS, a beneficiary is entitled to Medicaid State Plan and Section 1115 waiver services across the care continuum. Subchapters 05 and 10 of this Chapter identify the LTSS covered services and the various Medicaid LTSS programs that serve beneficiaries with specific types of health needs, including the following: 1. Primary care essential benefits. All LTSS Medicaid beneficiaries are entitled to receive the primary care essential health benefits available to beneficiaries in the MACC and IHCC groups, covered under the Medicaid State Plan and Section 1115 demonstration waiver, including primary and preventive care as well as acute and subacute services. If a beneficiary has third (3rd) party insurance, such as Medicare or commercial insurance that does not provide the full scope of Medicaid benefits, Medicaid provides wrap-around coverage for any Medicaid services that are unavailable.2. Institutional and home and community-based care. Medicaid LTSS beneficiaries are eligible for the full scope of LTSS covered by the Medicaid State Plan and Section 1115 waiver. As the State uses needs-based criteria to determine the scope of services a beneficiary is authorized to receive, Medicaid LTSS coverage varies along with a beneficiary's functional capacity and acuity needs, social environment, access to family and other third (3rd) party supports, and personal choices. The range of Medicaid LTSS extends from 24/7 comprehensive care in a health institution to a limited package of services in a community-based setting, to one (1), a few, or a bundle of home and community core and ancillary services in the home.B. Medicaid beneficiaries who are receiving primary care essential benefits through a managed care plan or fee-for-service through a MACC group MAGI pathway pursuant to Part 30-00-1 of this Title (ACA Expansion Adults) or a IHCC group SSI (Supplemental Security Income or SSI eligible and SSI-protected status and Elders and Adults with Disabilities or EAD) pathway in accordance with Part 40-00-1 of this Title may be eligible for Medicaid LTSS preventive (see §40-05-1.8 of this Title) or full benefits if they meet certain clinical/functional and financial eligibility criteria. The State uses information known about the beneficiary when determining eligibility for LTSS for current Medicaid beneficiaries to the full extent feasible. The additional information required, as out-lined below, may be provided by completing the applicable sections of the DHS-2 form, or designated supplemental form, or by updating an on-line account as appropriate: Basis of Eligibility | Supplemental Information Required from Existing Beneficiaries Seeking LTSS |
Preventive LTSS Clinical/function (See Part 40-05-1 of this Title) | Functional/clinical Level of Need (See Part 5 of this Subchapter) | Financial Eligibility - Allocation of resources and transfer of assets - Part 40-00-3 of this Title and Part 6 of this Subchapter) | Post-eligibility Treatment of Income (See Part 8 of this Subchapter) |
1. SSI | Documentation from health provider | Documentation from health provider | Limited to current information on spouse and dependents as related to spousal impoverishment and transfer of assets | Applies - information related to allowances including income and expenses of spouse and dependents |
2. EAD | Documentation from health provider | Documentation from health provider | Limited to sixty (60) months pre-application of information on spouse and dependents as related to spousal impoverishment and transfer of assets | Applies - information related to allowances income and expenses of spouse and dependents |
3. ACA Expansion Adults | Not applicable | Documentation from health provider | Limited sixty (60) months of pre-application information on resources of self, spouse and dependents as related to transfer of assets only | Not applicable |
210 R.I. Code R. 210-RICR-50-00-1.6
Amended effective 10/5/2021
Amended effective 12/29/2022