Human Services

CHAPTER 40-8.13
Long-Term Managed Care Arrangements

SECTION 40-8.13-1

§ 40-8.13-1. Definitions.

For purposes of this section the following terms shall have the meanings indicated:

(1) "Beneficiary" means an individual who is eligible for medical assistance under the Rhode Island Medicaid state plan established in accordance with 42 U.S.C. § 1396, and includes individuals who are additionally eligible for benefits under the Medicare program (42 U.S.C. § 1395 et seq.) or other health plan.

(2) "Duals Demonstration Project" means a demonstration project established pursuant to the financial alignment demonstration established under section 2602 of the Patient Protection and Affordable Care Act (Pub. L. 111-148) [42 U.S.C. § 1315b], involving a three-way contract between Rhode Island, the Federal Centers for Medicare and Medicaid Services ("CMS") and qualified health plans, and covering health care services provided to beneficiaries.

(3) "EOHHS" means the Rhode Island executive office of health and human services.

(4) "EOHHS level of care tool" refers to a set of criteria established by EOHHS and used in January, 2014 to determine the long-term care needs of a beneficiary as well as the appropriate setting for delivery of that care.

(5) "Long-term care services and supports" means a spectrum of services covered by the Rhode Island Medicaid program and/or the Medicare program, that are required by individuals with functional impairments and/or chronic illness, and includes skilled or custodial nursing facility care, as well as various home and community-based services.

(6) "Managed long-term care arrangement" means any arrangement under which a managed care organization is granted some or all of the responsibility for providing and/or paying for long-term care services and supports that would otherwise be provided or paid under the Rhode Island Medicaid program. The term includes, but is not limited to, a duals demonstration project, and/or phase I and phase II of the integrated care initiative established by the executive office of health and human services.

(7) "Managed care organization" means any health plan, health maintenance organization, managed care plan, or other person or entity that enters into a contract with the state under which it is granted the authority to arrange for the provision of, and/or payment for, long-term care supports and services to eligible beneficiaries under a managed long-term care arrangement.

(8) "Plan of care" means a care plan established by a nursing facility in accordance with state and federal regulations, and which identifies specific care and services provided to a beneficiary.

History of Section.
(P.L. 2014, ch. 145, art. 18, § 6.)