Rhode Island Code of Regulations
Title 210 - Executive Office of Health and Human Services
Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults
Subchapter 05 - Service Delivery Options
Part 2 - Medicaid Managed Care Delivery Options
Section 210-RICR-30-05-2.38 - Medicaid Members Exempt from Enrollment Managed Care
Universal Citation: 210 RI Code of Rules 30 05 2.38
Current through March 25, 2025
A. Certain Medicaid members who would otherwise receive care through the RIte Care or RHP delivery systems may be granted exemptions from mandatory enrollment in an MCO for good cause in narrow range of "extraordinary circumstances" upon approval of EOHHS. An extraordinary circumstance, as defined for these purposes, is a situation, factor or set of factors that preclude a Medicaid member from obtaining the appropriate level of medically necessary care through the managed care delivery system - RIte Care or RHP - designated for the Medicaid member's coverage group.
1. Types of extraordinary circumstances -
Such a situation, factor or set of factors may include the existence of a
chronic, severe medical condition for which the member has a longstanding
treatment relationship with a licensed health care practitioner who does not
participate in any of the Medicaid MCOs in the delivery system designated to
provide care to the member.
2.
Limits - A Medicaid member's preference to continue a treatment relationship
with a particular physician or other health care practitioner who does not
participate with an MCO in the member's designated delivery system does not
constitute an "extraordinary circumstance" in and of itself.
3. Exemption requests - Requests for
exemption to mandatory enrollment in managed care due to extraordinary
circumstances must be made in writing, include appropriate documentation
(letter from physician, medical records, or other as indicated), and signed.
Exemption requests should be routed to EOHHS.
4. Agency actions and duration of exemption -
EOHHS makes enrollment exemption determinations based on a consideration of the
circumstances of each member's individual request. Once exempted, an individual
can be exempt for as long as the extraordinary circumstance exists. Nonexempt
Medicaid members in a household must follow the regular Medicaid MCO enrollment
process.
Disclaimer: These regulations may not be the most recent version. Rhode Island may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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