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-30-05-2.53 - Medicaid Member Rights and Protections

Universal Citation: 210 RI Code of Rules 30 05 2.53

Current through March 25, 2025

A. All Medicaid members are guaranteed access to quality health care delivered in a timely and respectful manner. To ensure this goal is met, the following rights and protections must be clearly stipulated by both EOHHS and the MCO.

1. Enrollment - EOHHS will make every effort to provide the following:
a. Multilingual services to all people who do not speak English;

b. Written enrollment information will be provided in a clear and easy-to-understand format;

c. Enrollment information provided by the MCO must include detailed information on how to obtain transportation services, second opinions, interpreter services, referrals, emergency services and out-of-State services unavailable in Rhode Island. Information must also be provided regarding switching primary care providers, disenrollment for good cause, the in-plan grievance process and the EOHHS appeals process;

d. The State will conduct a special enrollment outreach effort for beneficiaries who are homeless or who live in transitional housing;

e. Once a Medicaid member is enrolled, the MCO will conduct a special enrollment outreach effort for any enrollees who are homeless or who live in transitional housing;

f. The MCO is prohibited from engaging in any door-to-door or telemarketing or any other similar unfair marketing practices;

g. Enrollees will be provided with counseling assistance in the selection process for their primary care providers;

h. Medicaid members who receive on-going care from a primary care provider or specialist will be advised by the non-biased enrollment counselor which providers are participating in each MCO option so as to promote continuity of care;

i. If a Medicaid member is auto-assigned to an MCO, the member, within ninety (90) days, may dispute that assignment through the right to rebuttal. A decision by EOHHS must be rendered within ten (10) days of the filing of the rebuttal and is subject to appeal.

2. Second Opinions and Switching Doctors - Every Medicaid member must be informed of the following:
a. MCOs must provide, at their expense, a second (2nd) opinion within the MCO upon an enrollee's request. A decision on the request for a second (2nd) opinion will be made in a timely manner and approval shall not be unreasonably withheld;

b. A Medicaid member is entitled to a second (2nd) surgical opinion by a plan physician, or if the referral is made by a plan physician, to a second (2nd) surgical opinion by a non-participating physician;

c. Medicaid members have the right to switch providers within the MCO, upon request.

d. Members who are denied a second (2nd) opinion or denied the right to switch providers will have the right to appeal, as set forth in Part 10-05-2 of this Title, Appeals Process and Procedures for EOHHS Agencies and Programs for additional information.

3. Disenrollment - The following apply to requests for disenrollment, as indicated:
a. Medicaid members may request to disenroll from any MCO for the remainder of an enrollment period for any of the reasons established in § 2.34 of this Part;

b. A rapid disenrollment process must be provided for individuals and families who are dislocated and move to another area due to homelessness, domestic abuse, or other similar crises, if they cannot access in-plan services within a reasonable distance from their new location;

4. Interpreter Services - Plans are encouraged to provide availability to twenty-four (24) hour interpreter services for every language group enrolled by the health plan for all points of contact, especially telephone contact. In addition, reasonable attempts must be made by the plans to have written materials, such as forms and membership manuals, translated into other languages. If the health plan has more than fifty (50) members who speak a single language, it must make available general written materials, such as its member handbook, in that language. Interpreter services are provided if a plan has more than one hundred (100) members or ten percent (10%) of its Medicaid membership, whichever is less, who speak a single language other than English as a first language.
a. Written material must be available in alternative formats, such as audio and large print, and in an appropriate manner that takes into consideration the special needs of those who are visually limited or have limited reading proficiency. All written materials for potential enrollees must include taglines in the prevalent non-English languages in the State, as well as large print, explaining the availability of written translations or oral interpretation to understand the information provided and the toll-free telephone number of the entity providing choice counseling services. All enrollees must be informed that information is available in alternative formats and how to access those formats.

5. Exceptions Based on Safety Needs - Providers, MCOs and the State must consider the personal safety of a beneficiary in instances of domestic violence in all of the following matters:
a. Enrollment policies;

b. Disenrollment policies;

c. Second (2nd) opinions;

d. Switching primary care physicians/practitioners; and

e. Grievance procedures.

6. Referral to Rhode Island Legal Services - Notices to Medicaid members must include information indicating that they may represent themselves or be represented by someone else such as a lawyer, relative, or another person in the hearing and appeal process. Notices must also provide information regarding free legal help available at Rhode Island Legal Services.

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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