210-RICR-40-05-1
A. This Part is promulgated pursuant to Federal authorities as follows:
A. The purpose of this Rule is to establish and describe the Community Medicaid IHCC groups and the requirements for determining Medicaid eligibility. The summary table below shows each of these groups and the agency authorized to determine eligibility or the basis for eligibility:
| Community Medicaid Eligibility Pathways | |
| IHCC Group | Agency Responsible for Determining Eligibility |
| Low-income Elders and Adults with Disabilities (EAD) | EOHHS |
| SSI Recipients | Social Security Administration (SSA) |
| SSP Recipients | SSA and EOHHS |
| Pickle Amendment | EOHHS |
| Employed Adults with Disabilities under § 1619(a), 42 U.S.C. § 1382h(a) | SSA |
| Medicaid While Working under § 1619(b), 42 U.S.C. § 1382h(b) | SSA |
| Protected Surviving Spouses | EOHHS |
| Adult Children with Disabilities | EOHHS |
| Divorced/Surviving Spouses with Disabilities | SSA |
| SSP Recipients, 12/73 | EOHHS |
| Divorced/Surviving Spouses with Disabilities – Actuarial Changes | SSA |
| Breast and Cervical Cancer Screening and Treatment | Department of Health (DOH) |
| Refugee Medicaid Assistance (RMA) | EOHHS |
| Sherlock Plan | EOHHS |
| Ticket to Work Plan | EOHHS |
A. For the purposes of this Section, the following definitions apply:
A. This Section identifies the primary eligibility pathways for persons sixty-five (65) and older and nineteen (19) to sixty-four (64) with disabilities.
A. Under § 1902 the Social Security Act, 42 U.S.C. § 1396a, States have the option under the Medicaid State Plan of expanding eligibility to elders and adults with disabilities (EAD) up to and inclusive of one hundred percent (100%) of the federal poverty level (FPL). R.I. Gen. Laws § 40-8.5-1 establishes the categorically needy EAD coverage group. The EAD coverage group has higher income and resource limits than the SSI program and serves, therefore, as the State’s primary general eligibility pathway for anyone with an SSI characteristic who does not qualify for SSI benefits. Coverage group features are as follows:
1. Eligibility Criteria – To qualify for Medicaid coverage through the EAD eligibility pathway, a person must meet the general eligibility requirements related to residency, citizenship and cooperation set forth in § 1.10 of this Part and the following:
a. Characteristic Requirements. A person must be without SSI and meet the characteristic requirements with respect to:
b. Financial Requirements. The person must meet income and resource standards for EAD eligibility based on the SSI methodology as follows:
4. Agency Responsibilities – The EOHHS is responsible for overseeing the evaluation of applications for EAD eligibility, enrollment, and processing renewals, with the Department of Human Services (DHS) as its designated agent pursuant to the terms of an interagency agreement. In addition, prior to ending Medicaid health coverage, the EOHHS must ensure that a review is conducted to determine whether eligibility exists through any other eligibility pathway. Other responsibilities are set forth in greater detail, as indicated, in other sections of this Rule.
A. Medically needy eligibility is available to certain IHCC group members who do not need LTSS. Different rules apply for LTSS MN eligibility as indicated in Part 50-00-2 of this Title. Under the Rhode Island Medicaid State Plan, MN coverage is an option for elders and adults with disabilities, parents/caretakers, children and pregnant people. Adults age nineteen (19) to sixty-four (64) in the MACC group do not qualify for MN coverage, and must therefore reapply through the Community Medicaid MN pathway. There is also a MN pathway for Refugee Medicaid Assistance as indicated in § 1.8.3 of this Part. See Part 2 of this Subchapter for provisions related to the Community Medicaid MN pathway.
A. Federal law requires the States to provide Medicaid health coverage to SSI and SSP recipients. There are certain circumstances in which SSI recipients who lose or otherwise no longer qualify for full cash assistance benefits are afforded “protected status” which allows them to retain their Medicaid eligibility. In such instances, the person is treated as if they are an SSI recipient for Medicaid eligibility purposes. The Medicaid SSI, SSP and protected status coverage groups are described below:
2. State Supplement Payment (SSP) Recipients – Persons who are eligible to receive the optional State-funded supplemental payment are automatically eligible for Medicaid health coverage under the Medicaid State Plan.
3. Pickle Amendment Eligibility Pathway – Since enacted in 1977, § 503 of Pub. Law No. 94-566, known as the “Pickle Amendment,” protected Medicaid eligibility for certain persons who receive Social Security or Retirement, Survivor, or Disability Insurance (RSDI) benefits. The Pickle Amendment requires the State to apply certain income disregards using a specific federal formula, which essentially deems the person an SSI recipient for Medicaid eligibility purposes.
a. Eligibility Criteria. Pickle Amendment coverage is available for a person who meets all other SSI eligibility criteria and:
4. Employed Persons with Disabilities, § 1619(a) of the Social Security Act, 42 U.S.C. § 1382h(a)
a. Working persons with disabilities who have gross earnings at or above the SSI income standard may qualify for continuing payments, and thus Medicaid health coverage, providing they meet all SSI non-disability requirements. The following must be met for coverage under § 1619(a) of the Social Security Act, 42 U.S.C. § 1382h(a):
(1) Eligibility Criteria. To qualify, the person receiving SSI based on disability must have gross earnings at or above the SSI income standard and:
5. Medicaid While Working, § 1619(b) of the Social Security Act, 42 U.S.C. § 1382h(b), provides Medicaid to employed persons with disabilities who no longer qualify for coverage under the above provision (§ 1.6.4(A)(4) of this Part) but need coverage to continue working. This pathway preserves Medicaid eligibility when a working person’s total countable income, both earned and unearned, including deemed income, is too high for an SSI cash payment. This pathway provides “Medicaid While Working” protection when SSI cash benefits are no longer available. Medicaid health coverage is preserved for both members of a couple if each is working, and their total combined income would result in the loss of SSI cash benefits, even if the income of one (1) would not alone trigger non-payment status. However, a non-working spouse has no protection and loses Medicaid when the earned income of their spouse exceeds the limits for SSI cash benefits. For Community Medicaid health coverage through this pathway, the following apply:
a. Eligibility Criteria. A person must have received an SSI cash payment based on disability, including under 42 U.S.C. § 1382h(a), for at least one (1) month in the most recent SSI benefit period, and
6. Protected Surviving Spouses – In the Omnibus Budget Reconciliation Act of 1990, Pub. Law No. 101-508, Congress permanently revised eligibility standards set in § 1634(b) of the Social Security Act, 42 U.S.C. § 1383c(b), to protect access to Medicaid health coverage for divorced and surviving spouses who lose SSI eligibility as a result of RSDI benefits.
a. Eligibility criteria. To qualify, a person must be between the ages of fifty (50) and sixty-five (65) and meet all other eligibility criteria for SSI except for income and the following:
7. Adult Dependent Child with Disabilities – § 1634 of the Social Security Act, 42 U.S.C. § 1383c, provides protection of Medicaid eligibility status for certain adult children with disabilities who lose SSI due to income from a parent’s RSDI benefits or Social Security Disability Insurance (SSDI) benefits from the adult child’s own work record. For the purposes of this coverage, “adult child” includes an adopted child, or, in some cases, a stepchild, grandchild, or step grandchild who is unmarried and is age eighteen (18) or older. When determining EAD eligibility for members of this group, the parent’s RSDI or child’s SSDI benefit is disregarded to preserve continuing Medicaid eligibility.
a. Eligibility criteria. To qualify for this eligibility pathway, a person must be:
A. The Medicare Premium Payment Program (MPPP) helps low-income elders age sixty-five (65) and older and adults with disabilities pay all or some of the costs of Medicare Part A and Part B premiums, deductibles and co-payments.
1. Basis of Eligibility – A person’s income and resources, as calculated using the SSI methodology, determine which type of Medicare premium assistance is available. Members of this coverage group are known as “dual eligible,” as they qualify for both Medicare and Medicaid, as defined below:
2. Medicare Coverage and the MPPP – Medicare provides the following types of coverage:
e. Medicaid wraps around Medicare’s coverage by providing financial assistance to beneficiaries in the form of payment of Medicare premiums and cost-sharing, as well as coverage of some benefits not included in the Medicare program. Not all dual eligible beneficiaries receive the same level of Medicaid benefits, as indicated below.
A. The specific eligibility requirements and benefits coverage groups included in the MPPP pathway are as follows:
1. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) – Financial assistance in this group is provided to beneficiaries who are eligible for or enrolled in Medicare Part A, have countable income of one hundred percent (100%) of FPL or less and resources that do not exceed the amounts set annually by the Federal government. For partial dual eligible QMBs:
3. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) – These individuals are entitled to Medicare Part A, have countable income of greater than one hundred percent (100%) FPL, but less than one hundred twenty percent (120%) FPL, resources within the federally defined limits, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only.
6. Qualified Disabled and Working Individuals (QDWIs) – This pathway covers beneficiaries who lost their Medicare Part A benefits due to their return to work. They must be eligible to purchase Medicare Part A benefits, have countable income of two hundred percent (200%) FPL or less and resources that do not exceed twice the limit for SSI eligibility EAD limits of four thousand dollars ($4,000.00) for an individual or six thousand dollars ($6,000.00) for a couple), and must not be otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only.
7. Qualifying Individuals-1 (QI-1) – To qualify for eligibility through this pathway, beneficiaries must be entitled to Medicare Part A, have countable income of at least one hundred twenty percent (120%) FPL, but less than one hundred thirty-five percent (135%) FPL, resources that do not exceed the amounts set by the Federal government, and be otherwise ineligible for Medicaid. Medicaid pays Medicare Part B premiums only. Federal matching funds for members of this group is one hundred percent (100%) and, as such, the availability of financial assistance through QI-1 eligibility is contingent on Federal appropriations. For members of this group:
8. MN and QMB (+) and SLMB (+) – Participation in the MPPP may adversely affect the income eligibility of a person seeking initial or continuing Medicaid health coverage through the MN pathway. As the State pays some or all Medicare costs for MPPP participants, these allowable health expenses cannot be counted toward a MN spenddown. This, in turn, may make it difficult to obtain Medicaid health coverage for high costs services that are covered only in part or not at all by Medicare. MPPP enrollment may also affect other forms of Medicaid eligibility if it changes the way income or resources are counted. An agency eligibility specialist should be consulted by an applicant or beneficiary who is concerned that enrolling in the MPPP will affect access to Medicaid health coverage.
A. There are multiple application pathways for pursuing MPPP eligibility.
2. LIS and Social Security Administration (SSA) – An application for the LIS program is available online at: https://secure.ssa.gov/i1020/start or by calling 1-800-772-1213 or TTY 1-800-325-0778, Monday-Friday, 7 a.m. – 7 p.m. The State uses information provided by the SSA for determining LIS eligibility to initiate an application for the MPPP, when appropriate.
A. Persons seeking MPPP assistance are subject to the SSI methodology for determining financial eligibility, though the income and resource standards specific to the MPPP coverage group, as indicated in § 1.7 of this Part, are applied. A disability determination is not required for MPPP financial help only. Continuing eligibility is determined using a modified passive renewal process (See Subchapter 00 Part 2 of this Chapter).
A. The following provides a summary of the MPPP eligibility pathways by coverage group that shows financial eligibility limits and the benefits provided:
| MPPP Eligibility Pathways | |||
| Coverage Group | Full or Partial Eligible | Income and Resource Limits Individual/Couple | Benefits |
| QMB | Partial Dual | 100% FPLAll MPPP applicants receive a $20.00 income disregard.Resources may not exceed the maximum resource standard for the QMB group permitted by the federal Centers for Medicare and Medicaid Services (CMS) | Entitled to Medicare Part A and qualify for Medicaid payment of:Medicare Part A premiums (if needed)Medicare Part B premiumsCertain premiums charged by Medicare Advantage plansMedicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D, the Medicare drug program) |
| QMB+ | Full Dual | 100% FPL$4,000.00 / $6,000.00 | All of the above AND Medicaid health coverage |
| SLMB | Partial Dual | 101% – 120% FPL Resources may not exceed the maximum standard for the SLMB group published by CMS | Entitled to Medicare Part A and qualify for Medicaid payment of:Medicare Part B premiums |
| SLMB + | Full Dual | 101% – 120 % FPL$4,000.00 / $6,000.00 | Same as above AND:Certain premiums charged by Medicare Advantage plansMedicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D, the Medicare drug program)Full Medicaid Coverage |
| QI | Partial Dual | 121% – 135% FPLResources may not exceed the maximum standard for the QI group published by CMS | Entitled to Medicare Part A and qualify for Medicaid payment of:Medicare Part B premiums |
| QWDI | Partial Dual | 200% FPL$4,000.00 – Individual$6,000.00 – Couple | Lost Medicare Part A benefits because of return to work but eligible to purchase Medicare Part A and qualify for Medicaid payment of:Medicare Part A premiums |
A. There are certain IHCC groups that are exempt from various income and/or resource requirements because they provide coverage to people with unique characteristics and/or health needs.
A. The Breast and Cervical Cancer Prevention and Treatment Act of 2000, Pub. L. No. 106-354, amended Title XIX of the Social Security Act, 42 U.S.C. §§ 1396-1396w-7, to include an optional Medicaid coverage group for uninsured people who are screened and need treatment for breast or cervical cancer or for precancerous conditions of the breast or cervix. The Rhode Island Department of Health (DOH), Women’s Cancer Screening Program, is responsible for administering the screening required for Medicaid eligibility through this pathway.
3. Continuing eligibility – A redetermination of Medicaid eligibility must be made periodically to determine whether the beneficiary continues to meet all eligibility requirements. Eligibility ends when the beneficiary:
5. Applicant/beneficiary responsibilities – Beneficiaries are responsible for providing timely and accurate information about the status of their condition/treatment prior to the date of redetermination or at intervals specified.
A. Refugee Medical Assistance (RMA) is a one hundred percent (100%) Federally-funded program for individuals and families operating under the auspices of the U.S. Department of Health and Human Services, Office of Refugee Resettlement (ORR). RMA is an eligibility pathway for individuals and families who are otherwise ineligible for Medicaid. Until enactment of the ACA, all persons seeking RMA were evaluated using the SSI methodology through the MN eligibility pathway. The ORR has waived these requirements and directed that, prior to a determination for RMA, States should evaluate all participants in its programs for Medicaid and commercial coverage, using the MAGI methodology (MACC groups under Part 30-00-1 of this Title) and SSI-related coverage (§ 1.6 of this Part) before pursuing RMA through the MN pathway.
3. Continuing Eligibility – Receipt of RMA under the characteristic of "refugee" is limited to the first eight (8) months residing in the United States, beginning with the month the refugee initially entered the United States, or the entrant was issued documentation of eligible status by the Federal government.
5. Applicant/beneficiary responsibilities – Beneficiaries are responsible for meeting the spenddown requirements set forth in Part 2 of this Subchapter.
A. The Sherlock Plan Medicaid for Working People with Disabilities Program is an SSI-related IHCC group comprised of working adults with disabilities age sixty-five (65) and older pursuant to 42 U.S.C. § 1396a(a)(10)(ii)(XIII). The Ticket to Work Plan is an SSI-related IHCC group comprised of working adults with disabilities ages sixteen (16) to sixty-four (64) pursuant to 42 U.S.C. § 1396a(a)(10)(ii)(XV). Eligibility for the Sherlock and Ticket to Work Plans is included in Subchapter 15 Part 1 of this Chapter, which focuses on Medicaid eligibility for adults with disabilities who are working.
A. Medicaid health coverage is available to non-citizens in emergency situations without regard to immigration status.
1. Eligibility Criteria – To qualify for emergency Medicaid, a non-citizen must meet all of the eligibility requirements for a MACC or an IHCC group, except for immigration status. Persons seeking emergency Medicaid are evaluated as follows:
d. In addition, the person must require treatment for an emergency health condition in accordance with the prudent layperson standard – as defined in the Balanced Budget Act of 1997, Pub. Law No. 105-33 – as specified below and obtain such services from a certified Medicaid provider. Such an emergency health condition is:
A. Under the terms of the State’s Section 1115 Waiver, Community Medicaid beneficiaries who do not yet need Medicaid LTSS but are at risk for the nursing facility institutional level of care have access to LTSS preventive services. Beneficiaries who meet the needs-based criteria for these LTSS preventive services are eligible for a limited range of home and community-based services and supports along with the full range of primary care essential benefits they are entitled to receive. The goal of preventive services is to delay or avert LTSS institutionalization or more extensive and intensive home and community-based care.
A. Depending on a beneficiary’s needs, the following LTSS preventive services may be available to Community Medicaid beneficiaries:
1. Limited Certified Nursing Assistant/Homemaker Services – These services include general household tasks (e.g., meal preparation and routine household care) and are available when a beneficiary can no longer perform them on their own and there is no other person available to provide assistance. Limited personal care may also be available.
2. Minor Environmental Modifications – Minor modifications may be available to a beneficiary to facilitate independence and the ability to live at home or in the community safely. Such modifications may include: grab bars, versa frame (toilet safety frame), handheld shower and/or diverter valve, raised toilet seats, and simple devices, such as: eating utensils, a transfer bath bench, shower chair, aids for personal care (e.g. reachers) and standing poles.
A. To qualify, the beneficiary’s Health Care provider must provide documentation that that one (1) or more LTSS preventive services will improve or maintain the ability of a beneficiary to perform Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs) and/or delay or mitigate the need for intensive home and community-based or institutionally based care.
A. To qualify for preventive level services, there must be no other form of coverage for the services provided and no other person or agency responsible or capable for doing so.
A. All applicants for Medicaid in the IHCC groups must meet general eligibility requirements in addition to those related to income, resources, and clinical need.
A. Unless specifically exempt, a person applying for Community Medicaid when eligibility is determined by the State must establish their categorical relationship to SSI by qualifying on the basis of one (1) of the following characteristics:
1. Age – A person qualifying on the basis of age must be at least sixty-five (65) years of age in or before the month in which eligibility begins.
2. Disability – Determined to meet the SSI disability criteria applied by the MART, or the SSA for SSI cash benefits or RSDI or SSDI. Note: An applicant must be determined disabled due to blindness by the MART or by an entity of the SSA. If income is at or below SSI income standard, a disability determination for blindness is not required.
A. Applicants must also meet all of the following non-financial eligibility criteria for Medicaid:
1. Social Security Number – Each person applying for Medicaid must have a Social Security Number (SSN) as a condition of eligibility for the program.
2. Residency – A person must be a resident of Rhode Island to be eligible for Medicaid. The State of residence of a person is determined according to the following:
b. Persons under twenty-one (21). Residency is determined as follows for minors:
(2) Any person residing in a health care or treatment facility who is under the age of twenty-one (21), or who is twenty-one (21) or older and became incapable of indicating intent prior to the age of twenty-one (21), the State of residence is that of:
c. Persons twenty-one (21) and older. For adults age twenty-one (21) or older, residence is determined as follows:
(1) If not living in an institution, the State of residence is the one in which the person is living:
e. Temporary Absence. Temporary absences from Rhode Island for any of the following purposes do not interrupt or end Rhode Island residence:
i. Specific Prohibitions. Under Federal law, the State may not deny Medicaid eligibility to an applicant for any of the following reasons:
3. Living Arrangements – A person’s living arrangement is a factor when determining eligibility for programs and payment amounts that may directly or indirectly affect access to Medicaid for certain Medicaid services. In addition, incarceration is also a factor that affects eligibility status and access to Medicaid coverage.
a. Financial eligibility. The financial responsibility of relatives varies depending upon the type of living arrangement. Thus, when determining financial eligibility, the living arrangements of individuals and couples matter as follows:
b. SSP. Eligibility for and the amount of the optional State supplemental payment is affected by the following living arrangements which, in turn, may determine a Medicaid beneficiary’s choice of care settings:
4. Citizenship and Immigration Status – Immigration and citizenship status affect Community Medicaid eligibility as follows:
a. Citizen or Qualified Non-citizen. An applicant for coverage in one (1) of the IHCC groups must be a United States citizen or a lawfully present “qualified” non-citizen immigrant who has been in the U.S. for five (5) years or more. Lawfully present qualified non-citizens include persons in the U.S. as legal permanent residents (LPR), with humanitarian statuses or as a result of such circumstances (e.g., refugees, asylum applicants, temporary protected status), valid non-immigrant visas, and legal status conferred by other Federal laws (temporary resident, LIFE Act, Pub. Law No. 106-553 and 106-554, Family Unity Act, 8 C.F.R. Part 236 Subpart B (2023), etc.). There are exceptions in Federal law and, more generally, under the Rhode Island Medicaid Program which permit qualified non-citizens who might otherwise be subject to the bar to obtain Medicaid health coverage. These exceptions are located in Part 30-00-1 of this Title. General exceptions specific to Rhode Island are as follows:
b. Non-qualified Non-citizen. With the exception of pregnant people, adult “non-qualified” non-citizens are not eligible for Medicaid. Non-qualified non-citizens are persons from other nations who are not considered to be immigrants under current Federal law, including those in the United States on a time-limited visa (such as visitors or persons in the U.S. on official business) and those who are present in the country without proper documentation (includes people with no or expired status). Non-qualified non-citizens may obtain Medicaid health coverage in emergency situations only, as indicated in § 1.8.5 of this Part. Non-emergency services may be obtained through Federally Qualified Community Health Centers.
5. Other Forms of Cooperation – Rhode Island’s Medicaid State Plan states that as a condition of eligibility for Medicaid, applicants must at the time of application:
e. Agree to cooperate in establishing the paternity of a child born out of wedlock for whom the applicant can legally assign rights.
A. A Medicaid applicant or beneficiary must have the opportunity to claim good cause for refusing to cooperate. Good cause may be claimed by contacting an agency representative. To claim good cause, a person must state the basis of the claim in writing and present corroborative evidence within twenty (20) days of the claim; provide sufficient information to enable the investigation of the existence of the circumstance that is alleged as the cause for non-cooperation; or, provide sworn statements from other persons supporting the claim.
A. Disability determinations are made by the State’s Medicaid Assessment and Review Team (MART) in accordance with the applicable requirements of the SSA based on information supplied by the applicant and by reports obtained from treating physicians and other health care professionals. Anyone who is blind and is seeking IHCC group Community Medicaid who does not qualify for SSI or has never received a determination of disability on that basis by a government agency, is subject to an evaluation by the MART.
A. For the purposes of IHCC groups providing Community Medicaid, the standards for determining whether a person has a disability centers on:
3. Application of Standards – The disability determination standards that apply for Community Medicaid vary by age:
d. Working Persons with Disabilities. Applicants who have disabilities but who are working are exempt from the SGA step of the sequential evaluation of the disability determination. This exemption applies if the person otherwise meets the requirements set forth for coverage under Subchapter 15 Part 1 of this Chapter, or other related provisions for adults with disabilities.
A. This Subsection explains the five (5) step sequential review process the MART uses when determining whether an applicant who is age nineteen (19) or older meets the SSI disability criteria. When using the review process, the MART considers all the evidence in an applicant’s case record in a series of sequential steps. Upon making a determination of disability at any step in the sequence, the review process stops and the MART does not proceed to the next step. If no determination is made, the MART proceeds from one (1) step to the next in order until a decision is made. The steps are as follows:
2. Step Two (2) – A determination is made whether the individual has a medically determinable impairment that is severe, or a combination of impairments that is severe (20 C.F.R. § 416.920(c) (2023)) and whether the impairment has lasted or is expected to last for a continuous period of at least twelve (12) months (20 C.F.R. § 416.909 (2023)). If the durational standard is not met, the MART will find that the individual is not disabled.
b. In determining severity, the MART considers the combined effect of all of an individual's impairments without regard to whether any such impairment, if considered separately, would be sufficient severity (20 C.F.R. § 416.923 (2023)).
5. Step Five (5) – At the fifth (5th) and last step, the MART considers the assessment of the person’s residual functional capacity, age, education, and work experience to determine if the person is able to make an adjustment to other work. If a person is found to be able to make an adjustment to other work, the MART determines the person is not disabled. If the person is not able to make such an adjustment to other work, the MART will find the person to be disabled.
A. All adults over age nineteen (19) applying for Medicaid are evaluated by the Integrated Eligibility System using the MAGI standard before consideration using the SSI-methodology. The application includes questions about a person’s need for care, previous or pending disability determinations and the need for retroactive Medicaid, which provides coverage for certain health expenses incurred in the three (3) months prior to making application.
1. Referral to the MART – Applicants who indicate on the Medicaid application that they have been determined to have a disabling condition by a government agency and/or are seeking retroactive eligibility are referred to the MART for a disability review if they:
2. Limits on Referral – In accordance with Federal Regulations at 42 C.F.R. § 435.541 (2023), when a person is seeking Medicaid on the basis of a disability, the following limitations apply:
3. These limits on referrals to the MART do not apply if the person is seeking Medicaid as a non-cash recipient with income above the SSI standard through the EAD pathway and the person has not applied for SSI cash benefits; has applied and has been found ineligible for SSI for a reason other than disability; or the SSA has not made a determination on a disability related application within ninety (90) days from the date the application for Medicaid was filed with the SSA.
A. Continuing eligibility for beneficiaries eligible due to a disability is multifaceted.
2. MART Periodic Reviews – These reviews must focus on whether there has been any medical improvement in a beneficiary’s impairment since the comparison point decision and, if so, whether the improvement is related to the beneficiary’s ability to work. For these purposes:
3. The MART must conduct these reviews in accordance with Federal SSI Regulations at 20 C.F.R. § 404.1594 (2023) and the schedule for conducting reviews identified at 20 C.F.R. § 416.990 (2023). This schedule indicates the reviews must generally be conducted as follows:
5. The eligibility of Medicaid beneficiaries who are sixty-five (65) and older are renewed on an annual basis in accordance with the provisions located in Subchapter 00 Part 2 of this Chapter.
A. To determine a person’s eligibility using the SSI methodology, a comparison is made between the countable income and resources of the applicant’s FRU and the income limits applicable to the Medicaid eligibility IHCC group. Once these groups have been established, financial eligibility is determined in accordance with the provisions for the SSI treatment of income and resources set forth in Subchapter 00 Part 3 of this Chapter, and/or the special eligibility requirements in § 1.8 of this Part. This Section focuses on the financial eligibility determination process for the Community Medicaid pathways in which the State is responsible for initial and continuing eligibility.
A. The Medicaid eligibility group for Community Medicaid when determined by the State is as follows:
2. Groups for Adults with Spouses – When two (2) spouses are living together, both the person requesting Medicaid and the applicant’s spouse are considered members of the applicant’s Medicaid eligibility group – a “couple” or group of two (2) – unless one (1) of the exceptions specified below applies. This is true whether or not the spouse is also requesting Medicaid.
a. Living together. A couple is considered living together in any of the following circumstances:
b. Exceptions. Adult applicants with spouses are treated as an “individual” for eligibility purposes in the following circumstances:
4. Parent-Child – When a parent and dependent child living together are both seeking Medicaid in IHCC groups in which the SSI methodology applies, they are treated as two (2) Medicaid groups of one (1), if the parent is not living with a spouse. If the parent is living with a spouse, the parents are treated as a Medicaid group of two (2) and the child as a Medicaid group of one (1). When a parent/caretaker is seeking MN eligibility, any MAGI-eligible members of the household are excluded from the eligibility group.
A. The financial responsibility unit (FRU) consists of the persons whose income and resources are considered available to the applicant or beneficiary in the eligibility determination. The FRU is relevant for deeming purposes for non-LTSS Medicaid and in determining eligibility for certain IHCC Community Medicaid coverage groups. The following subsections set forth the Rules for determining membership in the FRU and the portion of income considered available to the person seeking Medicaid:
1. FRU Composition for Citizens – The FRU for citizens and sponsored non-citizens differs due to deeming requirements. For citizens, the FRU consists of the person seeking Medicaid and, as appropriate, a spouse, parent, and/or dependent child. Other members of the household are not included in the FRU even if they make financial contributions.
2. FRU for Sponsored Non-citizens – The FRU for a non-citizen admitted to the United States on or after August 22, 1996, based on a sponsorship under the Immigration and Nationality Act (INA), 8 C.F.R. Part 204 (2023), includes the income and resources of the sponsor and the sponsor’s spouse, if the spouse is living with the sponsor, when all four (4) of the following conditions are met:
e. The financial responsibility of a sponsor continues until the noncitizen is naturalized or credited with forty (40) qualifying quarters of coverage by the SSA.
A. For Community Medicaid, the determination of income eligibility using the SSI methodology follows a set sequence of calculations related to the application of exclusions and disregards as set forth in Subchapter 00 Part 3 of this Chapter. Unearned income exclusions and disregards are applied first.
1. Order of Unearned Income Exclusions and Disregards – Unearned income is countable as income in the earliest month it is received by the person; credited to a person’s account; or set aside for the person’s use. The order for applying exclusions and disregards is as follows:
b. Medicaid. The following types of unearned income are excluded or disregarded in the order indicated:
(3) Grants, scholarships, fellowships, or gifts used for paying educational expenses are excluded or countable depending upon their use:
(10) Support and maintenance assistance based on need:
(14) Federal housing assistance provided by:
(21) Gifts to children with life-threatening conditions from an organization described in § 501(c)(3) of the Internal Revenue Code of 1986, Pub. Law No. 99-514, within the following limitations:
2. Order of Earned Income Exclusions – In general, earned income disregards and exclusions are applied in the following order:
b. SSI Methodology. The following types of earned income are excluded or disregarded in order:
3. Unused exclusions and disregards – When calculating countable income, the limitations below apply:
e. The twenty dollars ($20.00) general and sixty-five dollars ($65.00) earned income exclusions are applied only once to a couple, even when both members have income, since the couple's earned income is combined in determining Medicaid eligibility.
A. To deem income is to attribute one (1) person’s countable income in the calculation of another person’s countable income. Income deeming requirements are based on the FRU rather than the Medicaid eligibility group rule. A person may be included in the Medicaid eligibility group without being included in the FRU (e.g., the sibling of a child seeking MN eligibility) and having their income deemed to an applicant or non-applicant in the household. The general rules for determining countable income related to the application of earned and unearned income exclusions identified above in § 1.12.4 of this Part are applied. In addition:
B. Spouse-to-Spouse – Except as indicated in the situations noted below, the income of a NAPP spouse is deemed to an applicant if the spouses live together. If an applicant is not divorced but is legally separated from their spouse, and continues to live in the same household, the NAPP spouse’s income is deemed. In the following situations, spouse-to-spouse income deeming does not apply:
2. The applicant is seeking coverage under the Sherlock Plan as a working adult with a disability in accordance with Subchapter 15 Part 1 of this Chapter.
a. Deeming. The amount of income that is deemed to the applicant spouse is calculated by subtracting from the NAPP spouse's gross income:
C. Parent-to-Child – Except in the situations noted below for MN eligibility, the income of a biological or adoptive parent is deemed to a child who is under age eighteen (18) and living with a parent as long as the child has not been legally emancipated. When the father is not married to the child’s mother, the father’s income is only deemed to the child if they reside together and paternity has been established.
1. In the following situations, the income of a parent is NOT deemed to a child:
2. Deeming Rules: The amount of income deemed from parent to child requires a multi-step calculation of income that must be followed in the sequence below:
D. Other Household Members – When determining a person’s initial or continuing eligibility, income is NOT deemed from a:
E. Sponsor Deeming – Sponsor deeming rules apply to non-citizens who are sponsored by one (1) or more individuals under a signed Affidavit of Support (USCIS I-864), unless one (1) of the following exceptions applies:
1. Exceptions to Sponsor Deeming. Sponsor deeming does not apply to sponsored non-citizens when:
2. General rules of sponsor deeming. Income of a sponsor and the sponsor’s spouse is deemed to each non-citizen covered by the affidavit regardless of whether the sponsor actually contributes to the non-citizen’s support and maintenance needs. Income is deemed even if the sponsor or the sponsor’s spouse is receiving public assistance in Rhode Island or another State. The following types of income of the sponsoring individual/couple are deemed:
3. If the sponsor is not a member of the FRU or is a member of the Medicaid eligibility group whose income is not deemed under income deeming rules in § 1.12.5(E) of this Part, the following apply:
b. The sponsor or the sponsor’s spouse’s income are considered available and are not excluded.
A. The State uses a more simplified process for counting resources for Community Medicaid, as explained in Subchapter 00 Part 3 of this Chapter, which permits attestations about the value of certain resources during the application process when determining financial eligibility. For Medicaid LTSS eligibility, full verification of resources and a transfer of asset review are required for IHCC group members prior to the determination of eligibility and authorization of services. There is no review of the transfer of assets for Community Medicaid.
2. Application of Exclusions – Both federally mandated and program specific exclusions are applied for resources of a Community Medicaid applicant or beneficiary, the following items are excluded in the following order in the amounts indicated:
w. Any annuity paid by a State to a person (or their spouse) based on the State's determination that the person is a veteran (as defined in 38 U.S.C. § 101) and blind, living with a disabling impairment, or aged.
A. To deem resources is to count one (1) person’s resources in the calculation of another person’s countable resources. As with income deeming, resource deeming requirements apply to members of the FRU, which is not always the same as the Medicaid eligibility group. Only the resources of the applicant's spouse or the parent(s) of a child are considered for the purposes of deeming resources. The deeming process proceeds as follows:
1. Spouse-to-Spouse – In deeming resources from one (1) spouse to the other, only the resources of the couple are considered.
3. Parent-to-child – In deeming resources from a parent to a child, the resources of a child consist of whatever resources the child has in their own right plus whatever resources are deemed to the child from their parent(s).