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-30-05-2.4 - Definitions
Universal Citation: 210 RI Code of Rules 30 05 2.4
Current through March 25, 2025
A. 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; or
c. 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-7
28. "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; or
c. Serious
dysfunction of any bodily organ or part.
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