Title 40
Human Services

Chapter 8
Medical Assistance

§ 40-8-6.1. Provider care during pendency of application.

(a) Definitions. The following terms shall have the meanings indicated:

“Applied income” — The amount of income a Medicaid beneficiary is required to contribute to the cost of his or her care.

“Authorized representative” — An individual who signs an application for Medicaid benefits on behalf of a Medicaid applicant.

“Complete application” — An application for Medicaid benefits filed by, or on behalf of, an individual receiving care and services from a long-term-care provider (LTC provider), including attachments and supplemental information as necessary, that provides sufficient information for the secretary or designee to determine the applicant’s eligibility for coverage. An application shall not be disqualified from status as a complete application hereunder except for failure on the part of the Medicaid applicant, or his or her authorized representative, to provide necessary information or documentation, or to take any other action necessary to make the application a complete application.

“Long-term-care provider (LTC provider)” means any of the following: a home-care provider, home nursing-care provider or nursing facility licensed pursuant to the provisions of chapter 17 of title 23; an assisted-living residence provider licensed pursuant to chapter 17.4 of title 23; an adult-day-services provider licensed pursuant to § 23-1-52; or a Program of All-Inclusive Care for the Elderly (PACE) as certified by the Centers for Medicare and Medicaid Services (CMS) and participating in the Rhode Island Medicaid program. As used in this chapter, the terms “long-term-care provider” and “LTC provider” are interchangeable.

“Medicaid applicant” — An individual who is receiving care from an LTC provider during the pendency of an application for Medicaid benefits.

“Release” means a written document that:

(1) Indicates consent to the disclosure to an LTC provider by the secretary or designee;

(2) Of information concerning an application for Medicaid benefits filed on behalf of a resident or patient of that LTC provider;

(3) For the purpose of ensuring the ability to be paid for its services by that LTC provider; and

(4) That includes the following elements:

(i) The name of the LTC provider;

(ii) A description of the information that may be disclosed under the release;

(iii) The name of the person or persons acting on behalf of the LTC provider to whom the information may be disclosed;

(iv) The period of time for which the release will be in effect, which may extend from the date of the application for benefits until the expiration of any appeal, or any appeal period, following the determination of that application; and

(v) The signature of the Medicaid applicant, or authorized representative, or other person legally authorized to sign on behalf of the Medicaid applicant, such as guardian or attorney-in-fact.

“Secretary” means the secretary of the Rhode Island executive office of health and human services.

“Uncompensated care” — Care and services provided by an LTC provider to a Medicaid applicant without receiving compensation therefore from Medicaid, Medicare, the Medicaid applicant, or other source. The acceptance of any payment representing actual or estimated applied income shall not disqualify the care and services provided from qualifying as uncompensated care.

(b)(1) Uncompensated care during pendency of an application for benefits. A nursing facility may not discharge a Medicaid applicant for non-payment of the facility’s bill during the pendency of a complete application; nor may a nursing facility charge a Medicaid applicant for care provided during the pendency of a complete application, except for an amount representing the estimated, applied income. A nursing facility may discharge a Medicaid applicant for non-payment of the facility’s bill during the pendency of an application for Medicaid coverage that is not a complete application, but only if the nursing facility has provided the patient (and his or her authorized representative, if known) with thirty (30) days’ written notice of its intention to do so, and the application remains incomplete during that thirty-day (30) period.

(2) Uncompensated care while determination is overdue. When a complete application has been pending for ninety (90) days or longer, then upon the request of an LTC provider providing uncompensated care, the state shall make payment to the LTC provider for the care provided to the applicant in full as though the application were approved, beginning on the date of such request. Payment under this subsection shall not be made for the period prior to the LTC provider’s request, but shall continue thereafter until the application is decided. In the event the application is denied, the state shall not have any right of recovery, offset, or recoupment with respect to payments made hereunder for the period of determination. In the event the application is approved, the state may offset payments due for the period between the date of the application and the determination by any amounts paid hereunder.

(c) Notice of application status. When an LTC provider is providing uncompensated care to a Medicaid applicant, then the LTC provider may inform the secretary or designee of its status, and the secretary or designee shall thereafter inform the nursing facility of any decision on the application at the time the decision is rendered and, if coverage is approved, of the date that coverage will begin. In addition, an LTC provider providing uncompensated care to a Medicaid applicant may inquire of the secretary or designee as to the status of that individual’s application, and the secretary or designee shall respond within five business days as follows:

(1) Without release — If the LTC provider has not obtained a signed release, the secretary or designee must provide the following information, only, in writing: (i) Whether or not the application has been approved; (ii) The identity of any authorized representative; and (iii) If the application has not yet been decided, whether or not the application is a complete application.

(2) With release — If the LTC provider has obtained a signed release, the secretary or designee must additionally provide any further information requested by the LTC provider, to the extent that the release permits its disclosure.