Statutes, codes, and regulations
Rhode Island Administrative Code
Title 220 - Department of AdministrationChapter 90 - Health Benefits ExchangeSubchapter 00 - N/A
Part 1 - Rules and Regulations Pertaining to HealthSource RI
Section 220-RICR-90-00-1.8 - Application and Renewal Process

220 R.I. Code R. 220-RICR-90-00-1.8

Download
PDF
Current through December 26, 2024
Section 220-RICR-90-00-1.8 - Application and Renewal Process
A. Integrated Eligibility System - In September 2016, the State of Rhode Island implemented its new Integrated Eligibility System (IES) which has the capacity to cross-walk with the agency that administers the State's Medicaid program, EOHHS, and, through a single application process, evaluate eligibility for QHP and publicly financed health coverage. This section focuses on the application and renewal processes that have been established in conjunction with the implementation of the IES.
B. Access Points - The State is committed to pursuing a "No Wrong Door" policy that offers individuals multiple application and renewal access points which all lead to the State's IES.
1. Self-Service - Individuals seeking initial or continuing eligibility have the option of accessing the eligibility system online using a self-service portal through links on the HealthSource RI (healthsourceri.com) Executive Office of Health and Human Services (eohhs.ri.gov) and Department of Human Services (dhs.ri.gov) websites.
2. Assisted Service - Individuals may also apply on paper and submit forms via mail to the address specified thereon or deliver in person to HealthSource RI's walk-in center.
3. Individuals may also visit the HealthSource RI walk-in center or contact the HealthSource RI contact center directly for assistance with an application.
C. Automatic Renewal Process - An individual enrolled in a QHP will receive notice prior to the end of each Benefit Year indicating whether their health insurance coverage can be automatically renewed for the following Benefit Year. If the individual's health insurance coverage can be automatically renewed, then the individual's notice will include the matched plan and estimated cost for the coverage. Individuals must make payment in full by the relevant payment deadlines, as established by the Exchange, for the health insurance plan to become effective in the new Benefit Year. If the individual/family misses the payment deadline for the first (1st) month of the upcoming Benefit Year, their application will be cancelled and coverage will not effectuate.
1. Notwithstanding the other provisions of this section, HealthSource RI will not automatically renew individuals such that coverage in their new plan, as compared to their existing plan, adds or eliminates comprehensive coverage for abortion services, as defined in 45 C.F.R. § 156.280(d)(1), which is incorporated above at § 1.3 of this Part. Individuals who are not automatically renewed as a result of this subsection will be sent a notice, in coordination with their annual open enrollment notice, that provides an explanation regarding the reason they have not been automatically renewed and detail the steps they will need to take in order to select a plan for the upcoming year. This notice will also provide a list of plans that do and do not cover comprehensive abortion services.
D. Direct Transition from Medicaid to QHP following the COVID-19 Public Health Emergency - The Exchange will automatically enroll eligible individuals who lose Medicaid in accordance with this section.
1. Eligibility - An individual is eligible for automatic enrollment under § 1.8(D) of this Part if the individual is:
a. Disenrolled from Medicaid after the end of the COVID-19 Public Health Emergency or the end of the continuous enrollment condition established under §6008(b)(3) of the Families First Coronavirus Relief Act of 2020, whichever comes first;
b. Eligible for a special enrollment period under 45 C.F.R. § 155.420(d)(1);
c. Redetermined eligible for APTCs and CSRs by the Exchange; and
d. Has a household income, as defined in 26 C.F.R. § 1.36B-1(e), that is expected to be under two hundred percent (200%) of the FPL at the time of redetermination.
2. Plan Assignment and APTC Authorization - Upon determination that an individual is eligible for automatic enrollment under § 1.8(D) of this Part, the Exchange may use the available information in the IES to authorize APTCs on behalf of the applicable tax filer and, at the option of the Exchange, automatically enroll the individual or individuals in either:
a. The second (2nd) lowest cost silver plan available through the Exchange; or
b. A silver level plan offered by the eligible individual's previous Medicaid managed care plan issuer and available through the Exchange or, if no such plan exists, a similar plan available through the Exchange.
3. Payment of the First and Second Month's Premium and Coverage Effectuation - The Exchange may utilize funds appropriated from the State Fiscal Recovery Fund to the Exchange or funds otherwise appropriated by the Rhode Island General Assembly to the Exchange to pay the first (1st) and second (2nd) month's premium for an individual who:
a. Meets the eligibility requirements under §§ 1.8(D)(1)(a) and (c) of this Part;
b. Has a household income, as defined in 26 C.F.R. § 1.36B-1(e), that is expected to be less than or equal to two hundred fifty percent (250%) FPL; and is either
c. Automatically enrolled in a QHP available through the Exchange; or
d. Actively selects a QHP and/or dental plan available through the Exchange with an effective date less than five (5) months later than the last day that the individual had coverage under his or her previous Medicaid managed care plan, provided that the individual is eligible for a special enrollment period under 45 C.F.R. § 155.420 at the time of plan selection.
4. Premium Payment Applied After APTCs - The Exchange shall limit premium payment under § 1.8(D)(3) of this Part to the portion of the premium owed after APTCs have been applied. If an individual elects to accept less than the full amount of APTCs for which the individual is determined eligible under 45 C.F.R. § 155.310(d)(2), the Exchange will not utilize funds under § 1.8(D)(3) of this Part to pay that portion of the premium.
5. Coverage Effective Dates - For an individual who is automatically enrolled, QHP coverage under § 1.8(D) of this Part will be effective the day after the last day the individual had coverage under his or her previous Medicaid managed care plan.
6. Opt Out - An eligible individual may choose to opt out of automatic enrollment under § 1.8(D) of this Part for up to sixty (60) days after the last day the individual had coverage under his or her previous Medicaid managed care plan. If an individual elects to opt out, the individual's QHP enrollment will be cancelled. The Exchange will then inform the individual that services received in the cancelled period will not be covered.
7. Notice - The Exchange will provide an eligible individual who is automatically enrolled under § 1.8(D) of this Part with a notice or notices that include the following information:
a. The QHP in which the individual is enrolled;
b. The individual's QHP coverage effective date;
c. The individual's APTC eligibility;
d. The individual's right to select another available plan and any relevant deadlines for that selection; and
e. The individual's right to opt out of automatic enrollment as permitted by § 1.8(D)(6) of this Part.
8. Notice Timing - The Exchange will provide the notice required by § 1.8(D)(7) of this Part as soon as reasonably practical, but in no event later than the day before an eligible individual's QHP coverage begins.
9. Duration of Program - The automatic enrollment and premium payment program under § 1.8(D) of this Part will be available to eligible individuals for up to fourteen (14) months after the month in which the continuous enrollment condition ends, consistent with the Center for Medicaid and CHIP Services Information Bulletin issued by the Centers for Medicare and Medicaid Services on January 5, 2023. If the Centers for Medicare and Medicaid Services extends the timeframe beyond fourteen (14) months, the Exchange may make this automatic enrollment and premium payment program available to qualified individuals during the extended period.
10. Availability of Funds - Notwithstanding §§ 1.8(D)(1), (3) and (9) of this Part, the Exchange may uniformly restrict or otherwise reduce eligibility for automatic enrollment and premium payment in the case of limited funding availability.
11. Termination of Program Due to Increase in Required Contribution Percentage under §36B(b)(3)(A) of the Internal Revenue Code - Notwithstanding §§ 1.8(D)(1), (3) and (9) of this Part, the Exchange may terminate this automatic enrollment and premium payment program if an individual whose household income is expected to be no greater than one hundred fifty percent (150%) FPL is required to contribute an amount greater than zero (0) for purposes of calculating the premium assistance amount, as defined in §36B(b)(3)(A) of the Internal Revenue Code.
12. Alternate Income Verification Process - The Exchange must determine an individual's income eligibility for the program established under § 1.8(D) of this Part, as well as for APTCs and for CSRs, based on the data available to the Exchange from the State Wage Information Collection Agency if:
a. The individual did not complete the Medicaid renewal form required by 42 C.F.R. §§ 435.916 and 457.343 in the timeframe required by the Rhode Island Medicaid agency;
b. The Exchange determines that the individual's application attestation regarding annual household income for the applicable Benefit Year is not reasonably compatible with the data available to the Exchange from the State Wage Information Collection Agency;
c. The data available to the Exchange from the State Wage Information Collection Agency indicates that the individual's annual household income is expected to be greater than or equal to one hundred percent (100%) FPL for the applicable Benefit Year; and
d. The individual otherwise meets the eligibility requirements specified in § 1.8(D)(1) of this Part.
13. Appeals - An individual has the right to an appeal of an eligibility determination based on this section pursuant to the appeals process described in these Regulations and 210-RICR- 10-05-2, Appeals Process and Procedures for EOHHS Agencies and Programs, if applicable.

220 R.I. Code R. 220-RICR-90-00-1.8

Amended effective 12/22/2019
Amended effective 12/31/2020
Amended effective 4/2/2023