Rhode Island Code of Regulations
Title 210 - Executive Office of Health and Human Services
Chapter 40 - Medicaid for Elders and Adults with Disabilities
Subchapter 10 - Managed Care
Part 1 - Managed Care Service Delivery Arrangements
Section 210-RICR-40-10-1.4 - RHP Benefit Package

Universal Citation: 210 RI Code of Rules 40 10 1.4

Current through June 23, 2025

A. The IHCC groups participating in RHP under this section receive the full scope of services covered under the Medicaid State Plan and the State's Section 1115 waiver. Covered services may be provided through the managed care plan or through the fee-for-service delivery system if the service is "out-of-plan" - that is, not included in the managed care plan but covered under Medicaid. Fee-for-service benefits may be furnished either by the managed care provider or by any participating provider.

1. Access to Benefits - Each RHP member selects a primary care provider (PCP) who performs necessary medical care and coordinates referrals to specialty care. The PCP orders treatment determined to be medically necessary in accordance with the health plan's policies. Prior authorization rules may apply, as required by the Medicaid agency.

2. Delivery of Benefits - In-plan services are paid for on a capitated basis.

3. Medical Necessity - The standard of "medical necessity" is used as the basis for determining whether access to a Medicaid covered service is required and appropriate. Medically necessary services must be provided in the most cost-efficient and appropriate setting and must not be provided solely for the convenience of the member or service provider.

4. Medicaid Benefits - The coverage provided through RHP is categorized as follows:

RHP Benefits

(a) In-Plan

(b) Out-of-Plan

Inpatient Hospital Care

Dental Services

Outpatient Hospital Services

Court-ordered Mental Health and Substance Abuse Services Ordered to a Non-Network Facility or Provider

Physician Services

Non-Emergency Transportation Services (The health plan is required to coordinate with EOHHS' non-emergency transportation broker.)

Family Planning Services

Nursing home Services in Excess of 30

Consecutive Days

Prescription Drugs

Residential Services for Beneficiaries with Intellectual and Developmental Disabilities

Non-Prescription Drugs

Laboratory Services

Center of Excellence for Opioids

Radiology Services

Peer Recovery Specialist

Diagnostic Services

Recovery Navigation Program (RNP)

Long-term care services and supports after 30 days

Outpatient & Inpatient Mental Health and Substance Use Services

Court-ordered Mental Health and Substance Abuse Services - Criminal Court

Court-ordered Mental Health and Substance Abuse Treatment - Civil Court

Home Health Services

Emergency Room Service and Emergency Transportation Services

Nursing Home Care and Skilled Nursing Facility Care for the first 30 days

Services of Other Practitioners

Podiatry Services

Optometry Services

Oral Health

Hospice Services

Durable Medical Equipment

Group/Education Programs

Interpreter Services

Transplant Services

Adult Day Services

HIV/AIDS Non-Medical Targeted Case Management for People Living with HIV/AIDS and those at High Risk for Acquiring HIV

AIDS Medical Case Management

Opioid Treatment Provider Health Home

Preventive services, including:

Homemaker

Minor Environmental Modifications

Physical Therapy Evaluation and 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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