Provider billing and cost‑sharing obligations

For services eligible under both Medicare and Medicaid, contracted providers must accept the MA Health Plan’s Medicare reimbursement as payment in full or bill Rhode Island Medicaid for any additional Medicare cost‑sharing that Medicaid will reimburse; providers must not impose cost‑sharing that exceeds what would be permitted under Title XIX if the individual were not enrolled in the plan. The MA Health Plan will re‑educate providers who inappropriately bill Dual Eligible members and must track each enrollee’s accrued out‑of‑pocket spending and alert enrollees and providers when the MOOP is reached per federal regulations.

• Accept MA Medicare reimbursement as payment in full or bill Medicaid for additional Medicaid‑reimbursable cost sharing.
• Do not impose cost‑sharing beyond Title XIX limits for the individual.
• Be subject to provider re‑education if found to be inappropriately billing Dual Eligible members.
• MA Health Plan will track accrued out‑of‑pocket spending and notify when MOOP is reached (42 CFR §422.100(f)(4),(5)(iii); §422.101(d)).

Daily admission notifications and provider directory data exchange

The MA Health Plan must supply daily automated notification files identifying hospital and SNF admissions, discharges, and transfers for Dual Eligible members via an SFTP upload using a mutually agreed template; EOHHS will provide an electronic file of Medicaid participating providers so the MA Health Plan can list dual‑participating providers in its directory.

• Upload a daily automated file (seven days/week) to SFTP identifying admissions the MA was made aware of within the prior 48 hours using the agreed template.
• Use the electronic data file from EOHHS of Medicaid participating providers to list providers participating in both Medicaid FFS and the D‑SNP in the MA provider directory.

Medicaid benefits coordinated by the MA Health Plan

Medicaid benefits the MA Health Plan coordinates include Adult Day Health (covered as needed based on medical necessity), AIDS Medical Case Management (medical care management including intake, assessment, individualized care plan development, monitoring, treatment adherence counseling and reporting to EOHHS), and emergency/non‑emergent ground medical transportation for patients who cannot sit, stand, or walk.

• Adult Day Health: day programs providing nursing, therapies, personal care, social activities and meals; covered as needed based on medical necessity.
• AIDS Medical Case Management: intake, assessment, comprehensive individualized care plan (ICP) development, coordination, monitoring, treatment adherence counseling; reporting requirements to EOHHS.
• Emergency/non‑emergent ground medical transportation: covered only for patients unable to sit, stand, or walk; only ground transport is covered.

Prior authorization exceptions and requirements

Court‑ordered residential treatment is exempt from the 14‑day prior authorization requirement for residential treatment and must be provided in totality as directed by the court; if length of stay is not specified on the court order, FFS Medicaid may conduct Utilization Review. Separately, medically necessary chiropractic services beyond the 12 annual visit limit require prior authorization.

• Court‑ordered mental health/substance use residential treatment: exempt from the 14‑day prior authorization requirement and must be provided as directed by court/state official.
• If the court order does not prescribe length of stay, FFS Medicaid may review the length of stay.
• Chiropractic services are limited to 12 visits annually; visits beyond 12 require prior authorization.

Respite allocation and six‑month release

Respite hours for eligible individuals are preapproved by EOHHS, allocated to the Individual/Family, and released in six‑month increments; each eligible person may receive up to 100 hours of respite services per year and LTSS eligibility as determined by EOHHS is required to receive these services.

• Individual/Family receives an EOHHS‑recommended and approved allocation of respite hours.
• Hours are released in six (6) month increments and the Individual/Family determines usage patterns.
• Each eligible person may receive up to 100 hours of respite services per year.
• LTSS eligibility as determined by EOHHS is required to access respite services.

Referrals and physician prescriptions required for specialty and therapy services

Specialty care services are covered only if referred by a Health Care Professional, and all therapy services (including physical, occupational, speech, hearing, respiratory therapy) must be prescribed by a physician; speech therapy must be performed by a licensed therapist and therapy must be directly related to an active physician‑designed plan of care and medically necessary.

• Specialty care: covered if referred by a Health Care Professional (physicians, nurse practitioners, PAs, etc.).
• All therapy services require a physician’s prescription and must be provided by appropriately licensed therapists.
• Therapies must be medically necessary and directly related to an active plan of care designed by the prescribing physician.