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RHODE ISLAND GOVERNMENT REGISTER
PUBLIC NOTICE OF PROPOSED RULEMAKING
AGENCY: Executive Office of Health and Human Services
DIVISION: Medicaid Policy Unit
RULE IDENTIFIER: 210-RICR-30-00-3 ERLID #TBD
REGULATION TITLE: Medicaid Application and Renewal Processes
RULEMAKING ACTION: Regular promulgation process
Direct Final: N/A
TYPE OF FILING: Amendments TIMETABLE FOR ACTION ON THE PROPOSED RULE: Public comment will end on Monday, April 30, 2018.
SUMMARY OF PROPOSED RULE: The purpose of this rule is to set forth the application and renewal processes for members of the Medicaid Affordable Care Coverage (MACC) groups subject to MAGI-based income eligibility determinations. The rule also sets forth the respective roles and responsibilities of the EOHHS, its eligibility agents, and applicants/ beneficiaries. In addition, the rule establishes the application and renewal processes for children in the Integrated Health Care Coverage (IHCC) groups who are exempt from MAGI determinations under federal law and regulations and, therefore, the Medicaid State Plan because their eligibility is tied to participation in other publicly funded programs including federal Supplemental Security Income (SSI), and the programs for children and youth at-risk or in the custody of the Rhode Island Department of Children, Youth and Families (DCYF). COMMENTS INVITED: All interested parties are invited to submit written or oral comments concerning the proposed regulations by Monday, April 30, 2018 to the address listed below.
ADDRESSES FOR PUBLIC COMMENT SUBMISSIONS: All written comments or objections should be sent to the Secretary of EOHHS, Eric J. Beane, c/o Elizabeth Shelov, Medicaid Policy Office, Rhode Island Executive Office of Health & Human Services Mailing Address: Virks Building, Room 315, 3 West Road, Cranston, RI 02920 Email Address: [email protected]
WHERE COMMENTS MAY BE INSPECTED: Mailing Address: Executive Office of Health & Human Services, Virks Building, Room 315, 3 West Road, Cranston, RI 02920 PUBLIC HEARING INFORMATION: If a public hearing is requested, the place of the public hearing is accessible to individuals who are handicapped. If communication assistance (readers/ interpreters/captioners) is needed, or any other accommodation to ensure equal participation, please call (401) 462-6266 or RI Relay 711 at least three (3) business days prior to the meeting so arrangements can be made to provide such assistance at no cost to the person requesting.
ALTERNATIVE PUBLIC HEARING TEXT: In accordance with R.I. Gen. Laws § 42-35-2.8, an oral hearing will be granted if requested by twenty-five (25) persons, by an agency or by an association having at least twenty-five (25) members. A request for an oral hearing must be made within ten (10) days of this notice. FOR FUTHER INFORMATION CONTACT: Elizabeth Shelov, Interdepartmental Project Manager, Medicaid Policy Office, Rhode Island Executive Office of Health & Human Services, Virks Building, Room 315, 3 West Road, Cranston, RI 02920 or [email protected] SUPPLEMENTARY INFORMATION: Regulatory Analysis Summary and Supporting Documentation: Societal costs and benefits have not been calculated in this instance. To be in conformity with federal law, regulations, guidance and state law, the state has little discretion in promulgating this rule.
For full regulatory analysis or supporting documentation see agency contact person above.
Authority for This Rulemaking: Federal Laws -Title IVE, Title XIX, Title XXI of the U.S. Social Security Act and ACA. Federal Regulations – 42 CFR §§ 435.603; 435.902-910; 435.916. 435.1025; The Medicaid State Plan and the Title XIX, Section 1115 (a) Demonstration Waiver (11-W-00242/1), effective through December 31, 2018. State authorities – R.I. Gen. Laws Chapters 40-6, 40-8, 42-7.2. Regulatory Findings: In the development of the proposed regulation, consideration was given to: (1) alternative approaches; (2) overlap or duplication with other statutory and regulatory provisions; and (3) significant economic impact on small business. No alternative approach, duplication, or overlap was identified based upon available information. The Proposed Adoption: These proposed rules have incorporated and consolidated the Medicaid Code of Administrative Rules (MCAR), Sections 1303 and 1306, into one rule, “Medicaid Application and Renewal Processes.” The rule has been revised to be in conformity with current federal and state statutes and regulations; and to comply with the re-codification requirements of the Rhode Island Secretary of State.
MCAR Section # Name of Regulation ERLID 1. 1303 Application Process for Medicaid Affordable
Coverage 8047
2. 1306 Renewal of Eligibility for Medicaid Affordable Care Coverage Groups
7804
STATE OF RHODE ISLAND EXECUTIVE OFFICE OF HEALTH & HUMAN SERVICES
PUBLIC NOTICE OF PROPOSED RULE-MAKING
Section 210-RICR-30-00-3
“Medicaid Application and Renewal Processes”
The Secretary of the Executive Office of Health and Human Services (EOHHS) has under consideration the promulgation of an amended regulation entitled, “Medicaid Application and Renewal Processes” - Section 210-RICR-30-00-3.
These regulations are being promulgated pursuant to the authority contained in the following: Federal Laws -Title IVE, Title XIX, Title XXI of the U.S. Social Security Act and ACA. Federal Regulations – 42 CFR §§ 435.603; 435.902-910; 435.916. 435.1025; The Medicaid State Plan and the Title XIX, Section 1115 (a) Demonstration Waiver (11-W-00242/1), effective through December 31, 2018. State authorities – R.I. Gen. Laws Chapters 40-6, 40-8, 42-7.2.
In accordance with R.I. Gen. Laws 42-35-2.8(c), an opportunity for a hearing will be granted if a request is received by twenty-five (25) persons, or by a governmental agency, or by an association having not less than twenty-five (25) members, within ten (10) days of this notice that is posted in accordance with R.I. Gen. Laws 42-35-2.8(a). A hearing must be open to the public, recorded, and held at least five (5) days before the end of the public comment period.
In the development of these proposed regulations, consideration was given to the following: (1) alternative approaches; (2) overlap or duplication with other statutory and regulatory provisions; and (3) significant economic impact on small businesses in Rhode Island. No alternative approach, duplication or overlap, or impact upon small businesses was identified based upon available information. These proposed rules are accessible on the R.I. Secretary of State’s website: http://www.sos.ri.gov/ProposedRules/, the EOHHS website: www.eohhs.ri.gov, or available in hard copy upon request (401 462-1575 or RI Relay, dial 711). Interested persons should submit data, views, written comments by Monday, April 30, 2018 to: Elizabeth Shelov, Medicaid Policy Office, RI Executive Office of Health & Human Services, Virks Building, 3 West Road, Room 315, Cranston, RI 02920 or [email protected].
The Executive Office of Health and Human Services does not discriminate against individuals based on race, color, national origin, sex, gender identity or expression, sexual orientation, religious belief, political belief or handicap in acceptance for or provision of services or employment in its programs or activities.
The EOHHS in the Virks Building is accessible to persons with disabilities. If communication assistance (readers /interpreters /captioners) is needed, or any other accommodation to ensure equal participation, please notify the EOHHS at (401) 462-6266 (hearing/speech impaired, dial 711) at least three (3) business days prior to the event so arrangements can be made to provide such assistance at no cost to the person requesting.
Original signed by: Eric J. Beane, Secretary Signed this 27th day of March 2018
210-RICR-30-00-3
Title 210 - Executive Office of Health and Human Services
Chapter 30 - Medicaid for Children, Families and Affordable Care Act (ACA) Adults
Subchapter 00 – N/A
Part 3 – Medicaid Application and Renewal Process
3.1 Application Process for Medicaid Affordable Coverage: No Wrong Door
3.1.1 SCOPE, AND PURPOSE, AND LEGAL AUTHORITY
A. One of the central goals of the federal Affordable Coverage Act (hereinafter the ACA) of 2010 (Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq.) was to improve access to and the availability of affordable health coverage. Toward this end, the State of Rhode Island is committed to making the process of applying for affordable health coverage easy to navigate and understand. In keeping with this commitment, the State established a new on-line system for determining eligibility for affordable coverage that enables consumers to apply on-line, or in-person, by telephone or through the mail from a variety of settings. ACA mandated that the states reform the Medicaid application and renewal system to make it easier for consumers to navigate and gain access to and retain affordable health care coverage.
B. The purpose of this rule is to set forth the application and renewal processes for members of the Medicaid Affordable Care Coverage (MACC) groups subject to MAGI-based income eligibility determinations. The rule also sets forth the respective roles and responsibilities of the EOHHS, its eligibility agents, and applicants/ beneficiaries. In addition, the rule establishes the application and renewal processes for children in the Integrated Health Care Coverage (IHCC) groups who are exempt from MAGI determinations under federal law and regulations and, therefore, the Medicaid State Plan because their eligibility is tied to participation in other publicly funded programs including federal Supplemental Security Income (SSI), and the programs for children and youth at-risk or in the custody of the Rhode Island Department of Children, Youth and Families (DCYF).
The Executive Office of Health and Human Services (EOHHS), the Medicaid Single State Agency (hereinafter the Medicaid agency), accepts applications through the State’s on-line eligibility system for all consumers in the following Medicaid Coverage groups.
Families and Parents/Caretakers with income up to 133% of the Federal Poverty Level (FPL) – Includes families and parents/caretakers who live
with and are responsible for dependent children under the age of 18 or 19 if enrolled in school full-time. It also includes families eligible for time-limited transitional Medicaid.
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 months post-partum. The coverage group includes all pregnant women with income up to 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.
Children and Young Adults. Age is the defining characteristic of members of this MACC group. This coverage group includes: infants under age 1, children from age 1 to age 19 with income up to 261% of the FPL; and qualified and legally present non-citizen infants and children up to the age of 19, who have income up to 261% of the FPL.
Adults 19-64. This is the 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 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.
The purpose of this rule is to describe the application process for members of these coverage groups and to set forth the respective roles and responsibilities of the Medicaid agency and applicants. Applicants using the new eligibility system will be evaluated for affordable coverage paid for in whole or in part by Medicaid, tax credits, and other forms of subsidies. The process of determining eligibility through the system is fully automated and, as such, provides applicants with greater access to coverage irrespective of the application starting point.
C. This Part is promulgated pursuant to:
1. Federal authorities as follows:
a. Federal Laws -Title IVE, Title XIX, Title XXI of the U.S. Social Security Act and ACA.
b. Federal Regulations – 42 CFR §§ 435.603; 435.902-910; 435.916. 435.1025
c. The Medicaid State Plan and the Title XIX, Section 1115 (a) Demonstration Waiver (11-W-00242/1), effective through December 31, 2018.
2. State authorities – R.I. Gen. Laws Chapters 40-6, 40-8, 42-7.2.
3.1.2 DEFINITIONS
A. As used herein, the terms below have the meanings described:
“Active renewal” means a method for determining continuing eligibility which requires the Medicaid beneficiary/member to take an action or engage directly with the Medicaid agency as a condition of renewal. Includes requiring Medicaid members to reapply, provide written or electronic consent allowing access to protected personal information, and/or updating, signing and resubmitting pre-populated paper or on-line forms pertaining to eligibility factors.
1. “Application access points” means the various contact points where consumers or their representatives can access the application process either directly through the State’s integrated eligibility system’s web consumer portal (on-line) or with the assistance of EOHHS, the Department of Human Services (DHS), or Contact Center HealthSource RI (HSRI) representatives, or an application entity designated by the state for such purposes (in-person, by telephone or a mail-in application).
2. “Application entity” means an organization or firm acting on a State agency’s behalf that provides applicants for affordable coverage with an application access point including the EOHHS, the Department of Human Services (DHS), the HealthSource RI (HSRI) benefits exchange, the Contact Center and any organizations designated for such purposes that maintain a staff of certified navigators or in-person assistors.
“Attestation” means a person authenticates by signature that a statement or document is genuine and true.
3. “Enrollee” means a Medicaid member or beneficiary who is enrolled in a Medicaid managed care plan.
4. “Integrated Health and Human Services Eligibility System" or "IES” means the state's eligibility system that enables applicants, through a single application, to be considered for several human service programs simultaneously, including affordable health coverage and human services.
5. “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 beginning January 1, 2014 as follows: as set forth in Part 1 Chapter 30 of this Title.
a. Families and Parents/Caretakers with income up to 133% of the Federal Poverty Level (FPL) – Includes families and parents/caretakers who live with and are responsible for dependent children under the age of 18, or 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 months post-partum. The coverage group includes all pregnant women with income up to 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 1, children from age 1 to age 19 with income up to 261% of the FPL; and qualified and legally present non-citizen infants and children up to the age of 19, who have income up to 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 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.
8. “Medicaid Code of Administrative Rules” or “MCAR” means the compilation of rules governing the Rhode Island Medicaid program promulgated in accordance with the State’s Administrative Procedures Act (R.I.G.L. § 42-35).
9. “Medicaid member” means a person who has been determined to be an eligible Medicaid beneficiary.
6. “Modified Adjusted Gross Income” or “MAGI standard” means the method for evaluating Medicaid income eligibility, adjusted by any amount excluded from gross income under section 911 of the IRS Code, and any interest accrued. Social Security benefits are not included in gross
income. using the modified adjusted gross income (MAGI) standard established under the ACA. The MAGI is the standard for determining income eligibility for all Medicaid affordable care coverage MACC groups. (MCAR section 1301).
7. “Modified passive renewal” means a method for determining continuing eligibility using electronic data sources and information provided by beneficiaries. This method is only used when the eligibility factors subject to change cannot be evaluated fully by the available electronic data sources or information in the beneficiary’s account. This process may also be used when there is insufficient information to determine whether a beneficiary who is losing coverage due to a change in an eligibility factor is eligible in another coverage group, such as when a MACC adult is about to turn sixty-five (65) and must be evaluated using the SSI methodology specified in Chapter 40 of this Title.
8. “Navigator” means a person working for a State-contracted organization with certified assisters who have expertise in Medicaid eligibility and enrollment.
“New Applicant” means an individual or family who was not enrolled in and receiving Medicaid coverage on the January 1, 2014, effective date of this rule. The term does not apply to individual and families who were receiving coverage and were disenrolled for any reason; nor does it apply to parents with income between from 133% to 175% of the FPL who lost eligibility for Medicaid coverage beginning on January 1, 2014 as a result of the eligibility roll-backs mandated under RI law (see Public Law 13-144, section 40-8.4-4 of the Rhode Island General Laws, as amended).
9. “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 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 and anyone receiving Supplemental Security Income (SSI), or participating in the Medicare Premium Assistance Program. For the purposes of this Part, the term refers to the children and youth who are eligible for Medicaid based on their participation in another publicly funded program and/or by federal law, including infants born to Medicaid eligible mothers, recipients of Supplemental Security Income (SSI) cash assistance under age twenty-one (21), and children and youth who are, or in some instances were, in the care and/or custody of the Rhode Island Department of Children, Youth and Families (DCYF).
10. “Passive or ex parte renewal” means a method for determining continuing eligibility that does not require the Medicaid member to take an action or
engage directly with the Medicaid agency as a condition of renewal. Electronic review and verification of eligibility factors subject to change is conducted by using the Medicaid member’s prior consent -to access protected personal information. that uses electronic data sources to confirm ongoing eligibility without information or action on the part of a beneficiary, unless certain types of discrepancies are detected. The Medicaid agency State may require members to resolve discrepancies in pre-populated forms or in on-line accounts.
3.1.3 APPLICATION ACCESS POINTS
A. Both Under the State’s “No Wrong Door Policy”, and the federal law stipulate that the Medicaid agency must provide consumers must have easy access to with a choice of application access points. New applicants for affordable coverage may access the eligibility system and complete the application process through application entities that have been designated for this purpose and on their own or with assistance, if necessary, through any of the following access points:
1. On-line Self-Service Consumer Portal -- Applicants have the option of accessing the eligibility system and applying on-line using a self-service portal through links on the EOHHS (eohhs.ri.gov) and DHS (dhs.ri.gov) websites or directly through HSRI (HealthSourceRI.com). There are also kiosks located in DHS field offices that provide direct access to the on-line self-service portal. The information applicants provide on-line is entered directly into the eligibility system IES and is processed electronically in real-time. For these reasons, the Medicaid agency encourages all new applicants to select the on-line option and complete and submit the application electronically whenever feasible. NOTE: Applicants using the on-line system will have to establish their identity electronically to create an account. If an identity match cannot be completed on-line, documentation may be provided via upload, fax, mail, or in-person.
2. In-person or by telephone – Applicants may apply in-person at DHS field offices with the assistance of an agency representative or on their own using kiosks established for this purpose. The Contact Center also provides access to walk-in applicants and consumers who make contact by telephone. If an applicant is unwilling or unable to apply on-line, an agency or Contact Center representative must enter the information into the eligibility system portal IES on the applicant’s behalf.
3. On-paper – Applicants may submit paper applications in-person or by U.S. Mail, e-mail transmissions, and facsimile transmissions to the address specified on the application. Paper applications are available on-line, through the U.S. Mail upon written request or telephone request (1-855-609-3304 840-4774 or 1-888-657-3173 (TTY), or in-person at any DHS field office or the Contact Center. Upon receipt, an agency or Contact Center representative must enter the information provided on the paper
application directly into the eligibility system portal and submit the application for a determination on the applicant’s behalf.
4. Application Entities – Applicants may access the eligibility system with the assistance of application entities that provide navigators or other in-person assisters (IPAs). Members of these entities assist applicants in completing paper applications or applying through the on-line portal. A list of these application entities is available from the Contact Center or on-line by visiting the EOHHS website (www.eohhs.ri.gov ).
3.1.4 COMPLETING AND SUBMITTING THE APPLICATION
A. In general, the process of completing and submitting an application proceeds in accordance with the following:
1. Account Creation -- To initiate the application process, the applicant, agency or Contact Center representative, or application entity assisting the applicant, must create a login and establish an account in the eligibility system.
a. The applicant must provide personally identifiable information for the purpose of creating an on-line account as a form of and establishing identify proof identity during this process. Verification of this information is automated through the federal data hub (see MCAR section 1308, “Verification/Datahub”). Documentation proving verifying identity may be required if the automated verification process is unsuccessful. Acceptable forms of identity proof include, but are not limited to, a driver’s license, school registration, voter registration card, etc. Documents may be submitted via mail, fax, on-line upload, to a DHS Office, or the Contact Center HSRI. (See the Medicaid Code of Administrative Rules MCAR section 1308, “Verification/Datahub” for additional information).
b. Once identity is verified, the Medicaid agency must conduct account matches in accordance with MCAR section 1308 of the Medicaid Code of Administrative Rules to determine whether the applicant or members of the applicant’s household have other accounts or are currently receiving benefits. It is the Medicaid agency’s State’s responsibility to resolve account matching issues and notify the applicant of any necessary actions.
2. Account Duration – An application account is open for a period of ninety (90) days. Applicants must restart the process if they have not completed and submitted an application within that period.
a. Applications may be started at any time. Once started, progress can be saved at any point and the application returned to at a later
time. Incomplete applications not submitted within ninety (90) days are automatically deleted in the eligibility system.
b. Eligibility determinations for Medicaid. Determinations must be made in no more than within thirty (30) days from the date the completed application is received. The application remains open after that period if the Medicaid agency State or its eligibility designee (DHS) or agents (application entities) are responsible for delays in the eligibility determination.
c. Temporary eligibility period. If there are discrepancies between an applicant’s attestations and electronic data matches on immigration or citizenship eligibility factors, eligibility is granted for a period of no more than ninety (90) days. The application remains open during this period to allow the applicant sufficient time to obtain necessary documentation. (See Medicaid Code of Administrative Rules MCAR sections §§ 1308.09 and 1308.10, “Verification/ Datahub”).
3. Application Materials – Applicants must answer all the required questions for each member of their household. Application questions focus on the need for all types of affordable coverage and specific Medicaid eligibility criteria related to the applicable MACC group. In general, applicants will be able to provide answers to the application questions with information used when filing federal tax forms and/or documents commonly used for identification and income verification purposes. When applying through the web portal on-line, electronic verification through data matches will limit the applicant’s need to refer to these materials. However, when using a paper application, access to these materials may be necessary. Materials that may be of assistance in such instances include, but are not limited to:
a. Federal tax filing status
b. Household/family size
c. Social Security numbers
d. Birth dates
e. Passport or other immigration numbers
f. Federal tax returns
g. Information about any health coverage available to you or your family, including any information you have about the health insurance your current employer offers even if you are not covered by your employer’s insurance plan
h. W-2 forms with salary and wage information if you work for an employer
i. 1099 forms, if you are self-employed.
4. Application Completeness – Before a determination of eligibility is made, all questions on the application must be completed. Applicants must be informed and offered the opportunity to provide any additional documentation or explanations necessary to proceed to the determination of eligibility. Such information will be provided to applicants immediately through a notification from the eligibility system when using the self-service portal. The agency or Contact Center HSRI, or application entity entering the information into the eligibility system on the applicant’s behalf, must provide this information to the applicant immediately once it becomes available, by letter or phone if the applicant is not present. Applicants must be informed that they have the option to submit any additional documentation or materials that may be required to complete the determination of eligibility through an on-line upload, by email, U.S. Mail, fax, telephone or in-person. However, the application filing date is not established until the completed form is submitted.
5. Voluntary Withdrawal. An applicant may request that an application for Medicaid health coverage be withdrawn at any time either through their secure on-line account or by submitting the request in writing via the U.S. Mail or fax to the EOHHS or DHS agency or a Contact Center HSRI representative. Withdrawal of the application may also be made by telephone to the Contact Center HSRI. The Medicaid agency State sends a notice to the applicant verifying the time and date of the voluntary withdrawal and indicating that the applicant may reapply at any time.
3.1.5 ATTESTATION OF APPLICATION INFORMATION
A. All questions on the application must be answered in a truthful and accurate manner. Every applicant must self-attest to the truthfulness and accuracy of the question responses and documentation submitted by providing an electronic signature under penalty of perjury. The Medicaid agency must verify information electronically to the fullest extent feasible and must verify applicant attestations in accordance with the procedures set forth in the Medicaid Code of Administrative Rules section 1308.
1. Electronic Matches – Federal and State Data Sources: The eligibility system verifies attestations through electronic data matches to the fullest extent feasible with external sources such as the U.S. Social Security Administration (SSA) and Internal Revenue Service (IRS) and RI agencies such as the Division of Motor Vehicles (DMV), the Office of Vital Statistics and the Department of Labor and Training (DLT). The eligibility factors subject to verification are specified in the Medicaid Code of Administrative
Rules MCAR section 1305, “Eligibility Requirements”; the verification process is located in MCAR section 1308 of the Medicaid Code of Administrative Rules, “Verification/Datahub.”
2. Attestation -- Before an application can be submitted, the applicant, or the person/entity acting on the applicant’s behalf, must provide the necessary attestations authenticate by signature that the information provided is genuine, correct, and true. When applying on-line, the attestation is conducted electronically. An agency or Contact Center HSRI representative or an authorized application entity must verify that the application was signed (e.g., mail application), a voice signature was obtained (telephone application), or that the applicant signed a declaration in-person. The signature provided by the applicant in these instances is an attestation to both the applicant’s identity and the truthfulness and accuracy of the information on the application. After a complete application with a declaration has been submitted, the applicant will receive an eligibility determination for each household member seeking coverage. There are circumstances when an applicant’s attestations and verification data matches show discrepancies. (See MCAR section 1308, “Verification/ Datahub” of the Medicaid Code of Administrative Rules for the provisions governing reconciliation of such differences).
3.1.6 PRIVACY OF APPLICATION INFORMATION
Application information must only be used to determine eligibility and what types of coverage a person is qualified to receive. Accordingly, the Medicaid agency State, Contact Center HSRI, or application entity must maintain the privacy and confidentiality of all application information and in the manner required by applicable federal and state laws and regulations and as provided in Part 1 of Subchapter 05 of Chapter 10 of this Title.
3.1.7 NOTICE OF DETERMINATION OF ELIGIBILITY
A. Once an application is completed and the required verifications are performed, eligibility for Medicaid and other forms of affordable coverage is made for each member of the household. (For information on other forms of affordable coverage, see www.HealthSourceRI.com or call the Contact Center HSRI at 1-855-609-3304 840-4774).
B. Household members determined Medicaid-eligible may enroll immediately in the health plan of choice. A formal notice will be generated after the determination indicating which household members are eligible for Medicaid or other forms of affordable coverage, the legal basis for the determination of eligibility, and the plan in which each household member is enrolled, if applicable. The notice will be sent via the applicant’s secure on-line account if opting to receive agency communications in such a manner or by mail in a reasonable time period. A
“reasonable time” period usually will not exceed ten (10) business days, but in no instance will it extend beyond the 30-day application period.
C. The notice must also advise the applicant of the right to appeal and request a hearing, in accordance with MCAR section 0100, “Complaints and Appeals.”
3.1.8 AGENCY AND APPLICANT ROLES AND RESPONSIBILITIES
A. The Medicaid agency State and applicants have shared and distinct responsibilities in the application process.
1. Medicaid agency -- Under current state and federal laws, the Medicaid State Agency is required to:
a. Assist applicants in completing all necessary forms.
b. Provide applicants with an interpreter or translator services upon request.
c. Assure all information applicants provide is kept confidential unless otherwise authorized to share with other state and federal agencies for the purposes of verification and enrollment.
d. Make timely determinations of eligibility in accordance with applicable laws and regulations.
e. Accept appeals and hold hearings on agency actions related to eligibility decisions in accordance with MCAR Section 0110, “Complaints and Appeals.” and the Department of Human Services’ rule #0110. (Note: the health insurance marketplace is referred to as the “RI Health Benefits Exchange” in Section 0110 of the Medicaid Code of Administrative Rules).
f. Provide a mechanism for beneficiaries to voluntarily withdraw eligibility for Medicaid health coverage at any time by submitting a written request via the U.S. Mail or fax to the EOHHS or DHS agency or a Contact Center an HSRI representative.
2. Applicant Rights and Responsibilities -- All applicants have the following:
a. Applicant Rights --The right to obtain help in completing forms; to an interpreter or translator, upon request; to be treated free from discrimination on the basis of race, color, national origin, sex, gender identity or sexual orientation, age or disability; to have personal information remain confidential; and to file an appeal and request a hearing on eligibility actions.
b. Applicant Responsibilities -- The responsibility to:
(1) Disclose certain information including Social Security numbers and proof necessary to determine eligibility;
(2) Report changes in income, family size and other application information as soon as possible; and
(3) Sign the application and thereby agree to comply with any applicable laws related to the type of eligibility requested and the coverage received.
For Further Information or to Obtain Assistance Applications for affordable coverage are available online on the following websites: www.eohhs.ri.gov www.dhs.ri.gov www.HealthSourceRI.com Applicants may also apply in-person at one of the Department of Human Services offices or by U.S. mail. Request an application by calling 1-855-609-3304 or TTY 1-888-657-3173.
For assistance finding a place to apply or for assistance completing the application, please call: 1-855-609-3304 or 1- 855-840-HSRI (4774). Severability If any provisions of these Regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable.
3.2 Renewal of Eligibility for Medicaid Affordable Care Coverage Groups
OVERVIEW
One of the longstanding federal Medicaid policies is that eligibility must be redetermined once every year and the scope of these annual reviews must be limited to eligibility factors that are subject to change – income or residency, for example. State Medicaid agencies are also prohibited under federal Medicaid law from requiring beneficiaries to provide information unrelated to either continuing eligibility or a factor that is not subject to change, such as date of birth or United States citizenship. The onus for discontinuing Medicaid eligibility in this process thus falls to the State.
The federal Affordable Care Act of 2010 not only reaffirmed these policies but took them a step further by requiring the states to automate continuing eligibility reviews to the full extent feasible and to recast the process as eligibility renewal instead of redetermination or recertification. Accordingly, effective January 1, 2014, the Medicaid agency is implementing a new automated eligibility renewal process for all individuals and families subject to the Modified Adjusted Gross Income (MAGI) standard set forth in section 1307, of Medicaid Code of Administrative Rules (MCAR).
3.2.1 SCOPE AND PURPOSE All Medicaid MACC group members will be are subject to MAGI-based
redeterminations, based on the requirements for the appropriate MACC group (MCAR section 1305), renewals, if there is a change in any eligibility factor. focusing on the eligibility factors subject to change. Such factors include changes in income, household composition or family size (e.g., due to death, marital status, birth or adoption of child), and/or immigration status State residency. Disenrollments for any reason that are followed by requests for eligibility reinstatements are also subject to redeterminations through this process for members of the MACC groups. irrespective of whether eligibility was established prior to or beginning on January 1, 2014.
LIMITATIONS
The provisions of this rule do not apply to parents with income between from 133% to 175% of the Federal Poverty Level (FPL) who lost eligibility for Medicaid coverage beginning on January 1, 2014 as a result of the eligibility roll-backs mandated under RI law (see Public Law 13-144, section 40-8.4-4 of the Rhode Island General Laws, as amended).
Medicaid-eligible individuals in non-MAGI coverage groups identified in MCAR 1301, are not subject to this rule and should refer to the redetermination requirements for their specific coverage group in the applicable sections of the MCAR.
3.2.2 RESPONSIBILITIES OF THE MEDICAID AGENCY STATE
A. It is incumbent on the The Medicaid agency State is responsible to ensure that the Medicaid renewal process occurs at least once every twelve (12) months, and no more frequently than every twelve (12) months for all MACC group members. Towards this end, the Medicaid agency State must meet the following requirements:
1. Basis of Renewal – The eligibility renewal must be based on information already available to the Medicaid agency State to the full extent feasible. Accordingly, the Medicaid agency State must use information about the Medicaid member from reliable sources including, but not limited to, the member’s automated eligibility account, current paper records, or data bases that may be accessed through the federal data hub or the State’s own affordable care coverage eligibility system. (MCAR section 1308).
2. Restrictions – The Medicaid agency State must not request or use information when conducting renewals pertaining to: eligibility factors that are not subject to change or concern matters that are not relevant to continuation of Medicaid eligibility. Eligibility factors subject to change include income, household or family size, State residency and certain immigration statuses. Factors that are not subject to change include, but
are not limited to, native born or naturalized U.S. citizenship, date of birth, and Social Security Number.
3. Renewal Strategy – The State utilizes a passive “ex parte” renewal process for all MACC group members when determining continuing eligibility and whether a beneficiary who is losing coverage due to a change in an eligibility factor qualifies for Medicaid in another coverage group to the full extent feasible. This renewal method confirms eligibility factors subject to change through electronic data sources and only requires action on the part of the beneficiary if certain discrepancies are detected by the State or self-reported. The State will use both active and passive renewal methods until all MACC group members have been subject to a MAGI-based income eligibility determination at least once. Accordingly, the State will conduct renewals as follows:
a. Initial review. The State redetermines eligibility at least sixty (60) days before the renewal date using information known to the IES and from various data sources and provides notice to the beneficiary indicating the results of this review. The notice contains the information that served as the basis for this eligibility review and indicates one of the following:
(1) Passive Ex Parte Renewal -- Medicaid eligibility has been renewed “ex parte” and no further action on the part of the beneficiary is required unless, upon reviewing the information in the notice, the beneficiary identifies an error or a change in an eligibility factor subject to change that must be reported to the State; or
(2) Modified Passive Renewal --Medicaid eligibility has not been renewed due to missing information or a discrepancy between sources of information related to an eligibility factor subject to change. In such instances, the notice contains an additional documentation request (ADR) specifying the type of information that must be submitted for the renewal of eligibility to proceed.
b. Renewal decision. If the beneficiary is not required to take any action and does not find cause to self-report a change, Medicaid eligibility is continued automatically for another year, effective on the renewal date. However, in order to be considered in this final renewal decision, change self-reports and ADR responses must submitted at least thirty (30) days from the date of the renewal notice. The State redetermines eligibility based on this information. If the beneficiary receives an ADR and does not take the action required, this redetermination is based solely on the information known to the IES through self-attestations and applicable data
sources. A formal notice is issued with the State’s final renewal decision if eligibility is discontinued on this basis at least fifteen (15) days prior to the eligibility continuation or termination date. Information received by the State at any time prior to the eligibility termination date is considered. However, if the information is submitted after the tenth day of the renewal month, a change from managed care to fee-for-service service delivery may result.
c. Reinstatement. A reinstatement of Medicaid eligibility is permitted without a full reapplication, in instances in which a beneficiary takes the actions required to resolve a discrepancy or information gap in the ninety (90) day period after eligibility is terminated.
Notice – The Medicaid agency must provide timely notice of:
Renewal Date. A notice of the date of the annual renewal must be sent at least thirty (30) days prior to the renewal date. The notice must provide the Medicaid member with information on the renewal process along with instructions on how to complete any actions that are conditions of renewal. A statement of the consequences for not taking necessary actions, if any, and the right to appeal and request an administrative fair hearing must also be included. As indicated in section 1306.05.04 below, the scope of the Medicaid member’s direct participation in the process varies depending on whether the Medicaid agency is implementing an active versus passive approach to renewal.
Agency Action. The Medicaid agency must provide Medicaid members with a notice stating the outcome of the renewal process and explaining the basis for any agency action. In instances in which continuation of eligibility depends on the Medicaid member taking action, such as providing paper documentation or reviewing information, the notice must state the nature of the action required, establish a timeline for completing the action and indicate the consequences for failure to do so, and indicate how the Medicaid beneficiary can obtain assistance from the Medicaid agency, whether through the representative of the Contact Center or the Department of Human Services (DHS) field offices. The right to appeal and request an administrative fair hearing in accordance with MCAR section 0110, must also be included.
4. Consent – The Medicaid agency State must obtain the consent of the Medicaid member to retrieve and verify electronically information related to eligibility factors subject to change including any federal tax information required to review income eligibility. Such consent may be is obtained during the initial application for Medicaid eligibility when the Medicaid member signs the application, (see MCAR section 1303) under penalty of
perjury. or at the first time a Medicaid member is subject to a MAGI-based renewal.
Renewal Strategy – The Medicaid agency will use both active and passive renewal methods until all MACC group members have been subject to a MAGI-based income eligibility determination at least once. Accordingly, the Medicaid agency will conduct renewals as follows:
Active Renewals. The Medicaid agency will use an active renewal method for all individuals and families who are seeking continuing eligibility using the MAGI standard for the first time. In this process, Medicaid members will be required to ensure the accuracy and completeness of any information on record related to an eligibility factor subject to change. In addition, the Medicaid member must provide consent to the Medicaid agency permitting automated retrieval of federal tax information for income verification purposes for all subsequent renewals. A pre-populated form containing relevant eligibility information will be provided to the member to review and update and return with consent necessary to use passive method for future renewals.
Passive Renewals. After the initial determination using the MAGI standard, whether at the time of application or first renewal, the Medicaid agency will use a passive renewal method. Medicaid members will be provided with timely notice of the annual renewal and a pre-populated form containing information about eligibility factors subject to change. The form will developed, with the Medicaid member’s prior consent, by retrieving applicable protected personal information electronically to update eligibility records and conducting verification through the federal hub and State data bases. The Medicaid agency must advise the Medicaid member of the duty to report any changes related to these factors before the date of the annual renewal. Eligibility is continued unless such a report is received or any discrepancies that may surface in the data matches remain unresolved. Such changes may be self-reported through the eligibility system web portal or in-person, via fax, on-line, or by mail or telephone with the assistance of a Contact Center or DHS agency representative, or Navigator.
5. Enrollment – A Medicaid member whose eligibility has been continued through the annual renewal process must remain in the same Medicaid health plan unless the renewal occurs during an open enrollment period. If an open enrollment process is not underway at the time of renewal, the provisions set forth in MCAR section 1311 Part 2, Subchapter 05 of this Chapter prevail.
6. Access – The Medicaid agency State must ensure that any application or supplemental forms required for renewal are accessible to persons who have limited proficiency in English or who have a disability.
3.2.3 RESPONSIBILITIES OF MEDICAID MEMBERS
A. Medicaid members must ensure that the Medicaid agency State has access to accurate and complete information about any eligibility factors subject to change at the time of the annual renewal. Accordingly:
1. Consent – At the time of the initial application or first MAGI-based renewal, Medicaid members must provide the Medicaid agency State with consent to retrieve and review any information not currently on record pertaining to the eligibility factors subject to change through electronic data matches conducted through the State’s affordable coverage eligibility system. Once such consent is provided, the Medicaid agency State may retrieve and review such information when conducting all subsequent annual renewals.
2. Duty to Report -- Medicaid members are required to report changes in eligibility factors to the Medicaid agency within ten (10) days from the date the change takes effect. Self-reports are permitted through the eligibility system on-line portal. Medicaid members also may report such changes in person, via fax, by mail, or telephone with the assistance of Contact Center HSRI, or DHS agency representative, or Navigator. Failure to report in a timely manner, as noted above, may result- in the discontinuation of Medicaid eligibility.
3. Cooperation – Medicaid members must provide any documentation that otherwise cannot be obtained related to any eligibility factors subject to change when requested by the Medicaid agency State. The information must be provided within the timeframe specified by the Medicaid agency State in the notice to the Medicaid member stating the basis for making the agency’s request.
4. Voluntary Termination -- A Medicaid member may request to be disenrolled from a Medicaid health plan or to terminate Medicaid eligibility at any time. Disenrollment results in the termination of Medicaid eligibility. Once Medicaid coverage is terminated, the penalties established under the individual mandate in the federal Affordable Care Act of 2010 apply unless the former Medicaid member obtains an alternate form of health insurance coverage.
5. Reliable Information – Medicaid members must sign under the penalty of perjury that all information provided to the Medicaid agency at the time of application and any annual renewals thereafter is accurate and truthful.
3.3 Information
3.3.1 For Further Information or to Obtain Assistance
A. Applications for affordable coverage are available online on the following websites:
1. www.eohhs.ri.gov
2. www.dhs.ri.gov
3. www.HealthSourceRI.com
B. Applicants may also apply in person at one of the Department of Human Services DHS offices or by U.S. Mail. Request an application by calling 1-855-609-3304 840-4774 and or TTY 1-888-657-3173.
C. For assistance finding a place to apply or for assistance completing the application, please call: 1-855-609-3304 or 1-855-840-HSRI (4774).
3.4 Severability
If any provisions of these regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these regulations which can be given effect, and to this end the provisions of these regulations are declared to be severable.