OVERVIEW OF PROGRAMS

The Rhode Island Medical Assistance Program includes FFS Medicaid, as well as RIte Care, Rhode Island’s Section 1115 Medicaid Managed Care Program and Long Term Care services, including institutional and home and community-based services (HCBS).  RIte Care does not cover other waiver populations or programs.
The Medical Assistance program is administered by the Rhode Island Department of Human Services (DHS).
Eligibility is determined by local offices of DHS.  These offices can be located by city or town on the DHS website at www.dhs.state.ri.us/dhs/doffices.htm.

The S-CHIP program in Rhode Island is predominantly a Medicaid expansion program; there is a separate program for pregnant aliens.  The benefit packages and delivery systems are the same for recipients covered under Medical Assistance and S-CHIP.  Any differences between the two programs are transparent to providers and recipients.

If an applicant applies for and is determined eligible for Medical Assistance (families with children, pregnant women and children under age 19), and if his/her employer (or spouse’s employer) offers a DHS-approved health insurance plan, the applicant is enrolled in RIte Share.  RIte Share is a premium assistance program for families to obtain insurance coverage through an employer.  RIte Share pays for all or part of the employee’s share of the health insurance premium.  RIte Share also pays copayments and for services covered by Medicaid but not by the private insurance as wraparound services.  If the employer does not offer a DHS-approved health insurance plan or if the employee is not eligible to receive it, the applicant is enrolled in RIte Care.

Applicant’s home and life insurance policy (below a certain face value) are not counted as resources/assets when determining eligibility. There is no resource/asset test for RIte Care, RIte Share, or S-CHIP.

MEDICAID

Categories for Adults

RIte Care for pregnant women

Income cannot exceed 350% of FPL.
No asset limit.

Women up to 150% of FPL are covered under Medicaid.
Women between 150% and 250% of FPL are covered under the S-CHIP Medicaid expansion. Pregnant aliens up to 250% of FPL are covered under the separate S-CHIP program.
Women between 250% and 350% of FPL are covered with state funds.  All receive the same RIte Care comprehensive benefit package.

“Extended Family Planning” is a restricted benefit package available for a 24-month period from 60 days postpartum to 26 months postpartum to women who attained Medical Assistance eligibility by virtue of pregnancy. This does not apply to pregnant aliens.

Categories for Families/Children

RIte Care for children up to age 19

Income cannot exceed 250% of FPL.
No asset test.

This includes children funded through S-CHIP.

TANF

Individuals and families

Those who meet the income and asset eligibility requirements in effect for Aid to Families with Dependent Children (AFDC) on July 16, 1996 are eligible for Medicaid.

These families qualify for RIte Care.

TANF is called the Family Independence Program (FIP) in Rhode Island.

Medically Needy

Individuals who are not considered to be “categorically needy”

Applicants whose income exceeds Medicaid income limits but have medical expenses that can be used to “spend down” their income to qualify.

“Spenddown” is similar to a deductible.  Members must incur medical expenses in the amount of their excess income each month before becoming eligible for Medicaid.

Podiatry services and outpatient hospital clinic and emergency room services are not covered benefits for medically needy eligibles.

Elderly/Disabled

Adults over age 65

Must be eligible for or receiving Supplemental Security Income (SSI) or meet income and asset requirements.
Income cannot exceed approximately $700/month.
Asset limits:  $4,000 for an individual or $6,000 for a couple.

Individuals with disabilities (adults and children)

Must be eligible for or receiving Supplemental Security Income (SSI) or meet income and asset requirements.
Income cannot exceed approximately $700/month.
Asset limits:  $4,000 for an individual or $6,000 for a couple.

Beginning in September 2003, the State will be enrolling children with special health care needs into RIte Care on a mandatory basis.

Children with disabilities may fall under the “Katie Beckett” provision of Medicaid, which states that only the child’s income and assets may be considered in the eligibility determination.

Long Term Care
·         Individuals age 65 and over
·         Individuals with disabilities

Income cannot exceed the cost of care.

Includes institutional care as well as Home and Community-Based Services (HCBS).  All applicants are assessed to determine their medical and functional status and only those determined to need an institution or nursing facility-level of care are eligible.

Residents in institutions may receive any of the services included in the regular Medical Assistance scope of services to the extent that they do not duplicate services included in the facility per diem rate.

Home and Community-Based Services are covered under the 1915(c) waiver program.

Qualified Medicare Beneficiaries (QMB)

Income cannot exceed 100% of FPL.
Asset limits:  $4,000 for one person and $6,000 for a couple.

Medicaid pays Medicare premiums, deductibles and coinsurance.

Qualified Working Disabled Individuals (QWD)

Income cannot exceed 200% of FPL.
Asset limits:  $4,000 for one person and $6,000 for a couple.

Medicaid pays Medicare Part A premiums.

Specified Low-income Medicare Beneficiaries (SLMB)

Income must be greater than 100% of FPL but cannot exceed 120% of FPL.
Asset limits:  $4,000 for one person and $6,000 for a couple.

Medicaid pays Medicare Part B premiums.

Qualified Individuals (QI-1)

Income must be greater than 120% of FPL but cannot exceed 135% of FPL.
Asset limits:  $4,000 for one person and $6,000 for a couple

Medicaid pays Medicare Part B premiums.

CHIP

Children under age 19

See coverage groups for childrenunder Medicaid. Under the Section 1115 S-CHIP waiver, income cannot exceed 185 of FPL for parents and relative caretakers of children enrolled in RIte Care. There is no asset test.

The S-CHIP program in Rhode Island is predominantly a Medicaid expansion program.  See above Medicaid categories.