CurrentExecutive Office of Health and Human ServicesPolicy N/A

Rhode Island EPSDT periodicity schedule (table of contents excerpt)

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Part of the EOHHS contract materials (amended July 1, 2023); this excerpt contains the table of contents, definitions, and header pages — no explicit coverage criteria in this window.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyRhode Island EPSDT periodicity schedule (table of contents excerpt)

Policy CodePolicy N/A

Change TypeAdministrative update (TOC/header) — no material coverage changes

Effective DateJul 1, 2023

Last ReviewJul 1, 2023

Next Review DateN/A

Key ActionContractors must accept enrollment data in the EOHHS format and enroll members effective the first day of the following month, mailing enrollment notices within 10 calendar days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks in this window (0-19)

Table of contentsTOC present

Jul 1, 2023amendment date

10,000

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CurrentExecutive Office of Health and Human ServicesPolicy N/A

Rhode Island EPSDT periodicity schedule (table of contents excerpt)

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Part of the EOHHS contract materials (amended July 1, 2023); this excerpt contains the table of contents, definitions, and header pages — no explicit coverage criteria in this window.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyRhode Island EPSDT periodicity schedule (table of contents excerpt)

Policy CodePolicy N/A

Change TypeAdministrative update (TOC/header) — no material coverage changes

Effective DateJul 1, 2023

Last ReviewJul 1, 2023

Next Review DateN/A

Key ActionContractors must accept enrollment data in the EOHHS format and enroll members effective the first day of the following month, mailing enrollment notices within 10 calendar days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks in this window (0-19)

Table of contentsTOC present

Jul 1, 2023amendment date

10,000

AE membership threshold

10 daysenrollment notice timing

Coverage-related index and high-level obligations

Index of coverage-related sections

The table of contents indexes where coverage-related sections appear elsewhere in the Agreement (e.g., service accessibility, enrollment, payments, compliance).

TOC entries point readers to coverage-related sections including: Service Accessibility Standards (2.09), Member Services (2.10), Provider Services (2.11), Medical Management and Quality Assurance (2.12), Payments to and from Plans (2.15), Compliance (2.18).

Informational definition references

Definitions in Article I provide informational context used by coverage sections elsewhere in the Agreement.

CCBHC: must provide or contract for nine types of behavioral health services with emphasis on 24-hour crisis care, evidence-based practices, and care coordination with primary care and hospitals (definition provides context for behavioral health coverage).

Comprehensive Risk Contract: a contract that covers inpatient hospital services and includes EPSDT among listed service types (definition identifies EPSDT as part of comprehensive coverage).

Deemed Newborn Eligibility: newborns of Medicaid-eligible pregnant RI residents are deemed eligible from birth and remain eligible for one year, with retroactive coverage available (context for newborn coverage/enrollment processes).

Contractor operational and programmatic requirements

Operational requirements in ARTICLE II set Contractor obligations that affect coverage delivery and program administration.

Contractor must provide or arrange for the full scope of Covered Services across the State and assure all contract activities are carried out regardless of subcontracting (legal responsibility to EOHHS).

Contractor must incorporate and support value-based purchasing and accountable care arrangements, meeting APM percentage targets and implementing AE programs per EOHHS guidance; APM/subcontracting oversight and monitoring requirements apply.

Contractor must maintain sufficient administrative staff and organizational components, including required functions and qualified personnel; functions may be combined or subcontracted subject to subcontractor conditions.

EOHHS will conduct a Readiness Review (including at least one on-site review) prior to marketing and enrollment; no enrollment until readiness is demonstrated, and EOHHS may postpone start date or terminate contract if deficiencies are not remedied.

Contractor must correct readiness deficiencies identified by EOHHS and provide requested corrections prior to Contract Operational Start Date; failure may result in postponement or termination.

Contractor coverage and enrollment criteria

Enrollment and coverage obligations related to RIte Care are specified in Article II and affect who must be enrolled and when benefits begin.

Contractor must maintain administrative components and staff appropriate to its enrollment size and include specific program functions (e.g., Medical Director, Member Services, Provider Services, Medical Management, Grievance and Appeals, Claims, MIS).

EOHHS will perform a Readiness Review prior to enrollment; no members enrolled until EOHHS determines the Contractor is ready and able to perform obligations.

RIte Care consists of five base eligible groups (eligibility based on family composition, income, insurance status, pregnancy status); scope of benefits and enrollment procedures vary by aid category.

Following 90 days after initial enrollment, RIte Care members are locked into their Health Plan until the next open enrollment period unless valid disenrollment reasons apply (Health Plan lock-in).

Contractor must make the full scope of benefits available immediately upon member enrollment (services effective immediately).

Eligibility and guarantees

Eligibility rules and limited guarantees for specific populations are described in the enrollment provisions.

Rhody Health Partners eligibility: age >= 21; categorically eligible for Medicaid; not covered by other third-party insurance (including Medicare); Rhode Island resident; not institutionalized >30 days; enrollment based on EOHHS sole determination.

ACA Expansion adults: ages 19–64, income at or below FPL using MAGI, not pregnant, not otherwise eligible for Medicaid, and not eligible for Medicare.

Pregnancy-based guaranteed eligibility: individuals who attain eligibility due to pregnancy are guaranteed comprehensive services through two months postpartum (or post loss) and then eligible for Extended Family Planning benefits up to an additional 24 months.

There are no general eligibility guarantees for RIte Care members (no guaranteed eligibility).

Marketing and communications

Marketing and member communications must meet EOHHS standards and be pre-approved; materials requirements affect member outreach and informed enrollment.

All marketing and member materials must be submitted to EOHHS for review and written approval before distribution; materials must comply with 42 C.F.R. §438.104 and Rhode Island guidelines.

All written informational materials must be at no higher than a sixth-grade reading level, available in alternative formats (e.g., audio, large print), and available in alternate languages for LEP members.

Potential enrollee materials must include taglines in 15 specified non-English languages and provide the toll-free number for choice counseling; auxiliary aids (TTY/TDY, ASL) must be available free of charge.

Contractor may not distribute marketing materials without EOHHS approval, may not engage in door-to-door or unsolicited cold-call marketing, and must ensure electronic materials are readily accessible, printable, consistent with content/language requirements, and paper copies provided within five business days upon request.

Enrollment operations

Enrollment operations specify data flows, effective dates, and newborn enrollment procedures the Contractor must follow.

EOHHS will supply lists of newly enrolled members: daily for RIte Care and monthly for Rhody Health Partners and ACA Expansion; Contractor must accept enrollment information in the data format submitted by EOHHS.

Contractor must enroll members effective the first day of the following month after receiving notification from EOHHS and mail notification of enrollment (including effective date and how to access care) within ten (10) calendar days after receiving notification.

Contractor must have written policies and procedures to enroll newborns of RIte Care and Rhody Health Partners members effective to the time of birth and adhere to the Managed Care Newborn File Discrepancy Policy; EOHHS will make reasonable efforts to enter newborns into eligibility/MMIS and pay capitation retroactive to date of birth.

Coverage and enrollment criteria

Certain populations and enrollment types must be enrolled or offered coverage immediately upon notification; the Contractor must implement specified policies.

Newborn enrollment: Contractor must enroll newborns of RIte Care, Rhody Health Partners, and adult expansion members effective to the time of birth and adhere to Managed Care Newborn File Discrepancy Policy; Contractor will provide necessary files for enrollment and EOHHS will attempt timely entry and retroactive capitation payment.

Extended Family Planning: Contractor must offer an Extended Family Planning program for women up to 250% FPL as notified by EOHHS and have written policies to inform eligible members of the benefit.

Uninsured children conversion (Related Group): Contractor must make coverage available to uninsured children under age 18 with incomes above 250% FPL at a monthly premium not to exceed the community-rated non-group premium, may restrict enrollment by open enrollment and prior insurance rules, and must offer a conversion option for those who lose eligibility.

Services effective immediately: Contractor must make the full scope of benefits available immediately upon member enrollment.

Citations, attachments and code references

Inventory placeholder: no codesmixed

No codes listed

Not applicable in this excerptmixed

No codes listed

Attachments listingmixed

No codes listed

CCBHC referencemixed

Certified Community Behavioral Health Clinic (CCBHC) definition and service expectations; must provide or contract for nine types of services with emphasis on 24-hour crisis care, evidence-based practices, care coordination and integration with physical health care.

Comprehensive risk contract componentsmixed

Service components that may be included in a comprehensive risk contract (examples: outpatient hospital services; rural health clinic services; FQHC services; laboratory and X-ray services; nursing facility services; EPSDT services; family planning services; physician services; home health services).

EPSDT statutory referencemixed

No codes listed

Regulatory citation (definition cross-ref)mixed

No codes listed

Regulatory/statutory referencesmixed

42 C.F.R. §438.14	Regulatory citation referenced in definitions for 'Indian' and related terms.
25 U.S.C. §1603	Statutory citation referenced for Indian Health Care Improvement Act definitions (I/T/U).

Cited federal regulationsmixed

42 C.F.R. §438.2	Cited in definitions of non-risk payment and overpayment and related terms.
42 C.F.R. §438.114	Cited in definition of post-stabilization care services (emergency-related services).

Regulatory references (definitions)mixed

No codes listed

Regulatory citations for treatment limitationsmixed

42 C.F.R. §438.910(d)(2)	Illustrative list of nonquantitative treatment limitations referenced in definition of Treatment Limitations.
42 C.F.R. §438.900	Citation referenced in definition of Treatment Limitations.

Not applicable (no procedure/diagnosis codes)mixed

No specific procedure or diagnosis codes present in this segment; enrollment and notification timing guidance only.

inv-22: None specified — coding placeholder

Coding placeholderNone specified in this excerpt

Source noteTOC indicates coding sections exist elsewhere but no codes listed here

ActionRefer to full contract Attachments for actual code lists (not included in this window)

inv-23: Children with special health care needs enrollment

Provider responsibilities, authorization and operational obligations

Documentation Required

Maintain complete clinical and administrative documentation

Contract requires providers and contractors to maintain documentation supporting enrollee care and program compliance, including prior authorization records, concurrent review and discharge planning notes, retrospective review findings, and evidence of medical necessity determinations.

Medical Management Function must include prior authorization, concurrent review/discharge planning, and retrospective medical review (Contractor responsibility).
Pre-authorization is defined as the health plan's determination that a proposed service, drug, or DME is medically necessary (providers must submit necessary documentation).
Contractor must maintain written policies/procedures for enrolling members and for managing enrollment-related documentation.

Note

Follow enrollment and PCP assignment procedures in TOC sections

Table of contents headings indicate provider responsibilities for enrollment, assignment of PCPs, changes in status, new member orientation, and services for new members — contractors and network providers must follow these enrollment and PCP assignment procedures.

Terms and definitions shown in excerpt

inv-45: EPSDT

TermEPSDT (Early and Periodic Screening, Diagnosis and Treatment)

Statutory referenceDefined in accordance with 42 U.S.C. §1396d(r)

ScopeComprehensive set of services provided to all Medicaid-eligible children under age 21

inv-46: Contract terms / TOC headings

Document componentTable of Contents listing multiple contract terms and headings (definitions, enrollment, program standards, attachments)

Amendment dateAmended July 1, 2023 (header)

TOC usage

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyRhode Island EPSDT periodicity schedule (table of contents excerpt)

Policy CodePolicy N/A

Change TypeAdministrative update (TOC/header) — no material coverage changes

Effective DateJul 1, 2023

Last ReviewJul 1, 2023

Next Review DateN/A

Key ActionContractors must accept enrollment data in the EOHHS format and enroll members effective the first day of the following month, mailing enrollment notices within 10 calendar days.

SourceLink

On This Page

Children with special health care needs: children with complex health conditions enrolled in managed care

Eligibility contextIncluded among five RIte Care base eligible groups (see RIte Care eligibility sections)

Enrollment implicationContractor must enroll and provide benefits immediately upon member enrollment

inv-24: APM payment threshold for adjusting payment

Withhold amount0.5% of monthly capitation amounts (effective July 1, 2018)

Repayment conditionWithheld amounts repaid as quarterly adjusting payments contingent on Contractor achieving APM threshold values for the reporting period

Reporting basisQuarterly submissions using the 'Alternative Payment Methodology Reporting Template' and EOHHS review

inv-25: Contractor membership threshold for AE obligations

Membership trigger (single AE)Contractor must subcontract with at least one EOHHS-certified Accountable Entity once total RI Medicaid membership reaches 10,000 beneficiaries

AE minimum attributed livesEach subcontracted AE must have at least 2,000 attributed lives

Expanded requirement at 25,000When membership reaches 25,000, Contractor must subcontract with two AEs covering at least 10,000 lives

Effective timingConditionally effective provisions become effective next July 1 after thresholds met

inv-26: Enrollment notification timing

Notification timingMembers must be mailed notification of enrollment, including effective date and how to access care, within ten (10) calendar days after Contractor receives EOHHS enrollment notice

Enrollment effective dateContractor enrolls members effective the first day of the following month after notification

Data feed cadenceEOHHS supplies daily lists for RIte Care and monthly for Rhody Health Partners and ACA expansion; Contractor must accept EOHHS data format

EOHHS supplies daily (RIte Care) or monthly enrollment files; Contractor must accept EOHHS data format and enroll members effective the first day of the following month.
Sections include Assignment of Primary Care Providers (PCPs), Changing PCPs, New Member Orientation, Services for New Members, and Enrollment/Disenrollment Updates.
Member materials and orientation requirements (e.g., sixth-grade reading level) are listed under member enrollment sections.

Note

Refer to EPSDT periodicity schedule attachment for screening guidance

The Table of Contents lists 'RHODE ISLAND EPSDT PERIODICITY SCHEDULE' as an attachment; providers should reference that schedule for EPSDT screening periodicity and services, but no authorization rules are included in the extract.

EPSDT is referenced as an attachment (RHODE ISLAND EPSDT PERIODICITY SCHEDULE).
Medical necessity definition explicitly includes EPSDT services for members under 21 (see Medical Necessity definition).
No explicit prior-authorization rules for EPSDT appear in the listed attachment entry in this extract.

Denial Risk

Authorization requests may lead to an Adverse Benefit Determination

An Adverse Benefit Determination includes denial, limited authorization, reduction, suspension, termination, denial of payment, untimely provision of services, failure to meet grievance/appeal timeframes, denial of out-of-network requests for rural members, and denial of disputes about financial liability — providers' authorization requests may result in such determinations.

Denial or limited authorization based on type/level of service, medical necessity, appropriateness, setting, or effectiveness.
Reduction, suspension, or termination of previously authorized services or denial of payment are adverse determinations.
Failure to act within required timeframes or denial of dispute over financial liability are also Adverse Benefit Determinations.

Note

Provide or contract for required CCBHC services including 24‑hour crisis care

CCBHCs must directly provide or contract for nine types of behavioral health services, emphasize 24-hour crisis care, use evidence-based practices, and coordinate/integrate care with primary care and hospitals — providers delivering CCBHC services must meet these service obligations.

CCBHCs are EOHHS-certified entities required to provide (or contract for) nine service types.
Emphasis on provision of twenty-four (24) hour crisis care and evidence-based practices.
Care coordination with local primary care and hospital partners and integration with physical health care required.

Prior Authorization

Do not require prior authorization for emergency services meeting federal definition

Emergency medical conditions and emergency services are defined per 42 C.F.R. §438.114; emergency services needed to evaluate or stabilize an emergency medical condition do not require prior authorization.

Emergency medical condition: acute symptoms where a prudent layperson could expect serious jeopardy to health, serious impairment of bodily functions, or serious dysfunction of any bodily organ.
Emergency services: covered inpatient and outpatient services furnished by a qualified provider needed to evaluate or stabilize an emergency medical condition.
Contract member materials must explain after‑hours and emergency coverage and note that emergency services procedures (including authorization exceptions) are described in member materials.

Documentation Required

Ensure state authorization/licensure for Health Care Provider status

Health Care Provider is defined to include a physician (M.D. or D.O.) authorized by the State and any other person the Secretary determines capable of providing health care services — providers must meet applicable state authorization/licensure.

Definition cites 29 CFR §825.125: a doctor of medicine or osteopathy authorized to practice in the State is a Health Care Provider.
Also includes any other person determined by the Secretary to be capable of providing health care services.

Note

Recognize Indian Healthcare Provider status and applicability

An Indian Healthcare Provider is a health care program operated by IHS or by an Indian Tribe, Tribal Organization, or Urban Indian Organization (I/T/U) per 42 C.F.R. §438.14 and 25 U.S.C. §1603 — providers designated as I/T/Us have specific applicability under the contract.

Definition references 42 C.F.R. §438.14 and 25 U.S.C. §1603.
Indian Healthcare Provider means programs operated by IHS or an I/T/U.

Documentation Required

Document medical necessity; include EPSDT standards for under‑21 members

Medical necessity includes EPSDT for members under 21; services are medically necessary when they prevent, diagnose, cure, or treat conditions and meet any of seven listed situations (e.g., life‑threatening conditions, achieving age‑appropriate growth and development). Providers must document how requested services meet these criteria.

For members under 21, medical necessity includes services necessary to correct or ameliorate defects or conditions discovered through EPSDT screenings (42 U.S.C. §1396d(r) reference in EPSDT definition).
Seven situations define medically necessary services (life‑threatening, treat injury/illness, achieve function per community standards, maternity care, prevention, prevent impairment, achieve/maintain/regain functional capacity/growth).
Providers must show documentation that services meet medical necessity criteria when seeking authorization.

Prior Authorization

Submit clinical evidence to obtain pre‑authorization

Pre-authorization (prior authorization/precertification) is the health plan's determination that a proposed service, treatment plan, prescription drug, or durable medical equipment is medically necessary — providers must submit sufficient information to support medical necessity determinations.

Pre-authorization is required where the health plan's medical necessity determination is applicable.
Providers must provide clinical information supporting the proposed service, drug, or DME to obtain authorization.

Documentation Required

Adhere to PCP credentialing and access-control responsibilities

PCPs may control member access to other plan services and must meet Contractor credentialing criteria; PCPs may designate other participating clinicians to provide or authorize care — contractors and providers must follow PCP role and delegation rules.

PCPs serve as principal coordinator of care and may control access to diagnostic testing and specialist visits.
PCPs must meet credentialing criteria established by the Contractor and approved by EOHHS; NCQA PCMHs are included as PCPs.
Primary Care Providers may designate other participating clinicians who can provide or authorize a member's care.

Note

Treat delegated entities as subcontractors only when contractually defined

A Subcontractor is any entity with a contract relating to performance of obligations under the State contract; network providers are not subcontractors solely by virtue of network agreements — providers acting under subcontract must be managed under subcontractor rules.

Definition consistent with 42 C.F.R. §438.2.
Clarifies that a network provider is not a subcontractor simply because of a network agreement.

Documentation Required

Do not accept prohibited delegations under APMs; ensure oversight for delegated functions

When using Alternative Payment Models, contractors may not delegate network contracting, provider payment, claims processing, member services, or grievance and appeals without EOHHS written consent; for other delegated functions the Contractor must assess subcontractor capability and maintain written oversight and monitoring plans.

APM contracts may not delegate network contracting, provider payment, claims processes, member services, or grievance and appeals without EOHHS consent.
For delegated functions (e.g., care management), Contractor must assess subcontractor capability and establish oversight policies/procedures and a written monitoring plan.
Contractor must submit its monitoring and oversight plan for APM subcontractors to EOHHS upon request.

Billing Rule

Support Contractor APM reporting to secure capitation adjusting payments

EOHHS withholds 0.5% of monthly capitation (effective July 1, 2018) and repays withheld amounts as quarterly adjusting payments only if the Contractor demonstrates achievement of required APM thresholds per reporting templates — providers involved in APMs must support plan reporting and performance targets to enable receipt of withheld funds.

Withhold rate: 0.5% of monthly capitation, effective July 1, 2018.
Repayment as quarterly adjusting payments contingent on Contractor demonstrating achievement of threshold values in APM payments via the Alternative Payment Methodology Reporting Template.
EOHHS will review reports within 30 days and process adjusting payments within 45 days of receipt if criteria met.

Documentation Required

Comply with Medical Management Function activities and information requests

Contractors must operate a Medical Management Function that includes prior authorization, concurrent review/discharge planning, and retrospective medical review — providers must interact with and supply required information to these functions.

Medical Management Function required components: prior authorization, concurrent review/discharge planning, retrospective medical review.
Providers must supply documentation and cooperate with utilization management activities conducted by the Contractor.

Billing Rule

Process EOHHS enrollment files and mail member notices within 10 days

Contractor must accept EOHHS enrollment data (daily for RIte Care; monthly for Rhody/ACA), enroll members effective the first day of the following month after notification, and mail members enrollment notices within ten calendar days — providers should expect members to be active per these timelines.

EOHHS supplies enrollment lists (daily for RIte Care; monthly for Rhody Health Partners and ACA Expansion).
Contractor must accept EOHHS data format and enroll members effective the first day of the following month after notification.
Members must be mailed notification of enrollment (including effective date and how to access care) within ten (10) calendar days after Contractor receives notification.

Note

Support auto-assignment and re-assignment rules; accept re‑enrollments within 60 days

EOHHS may automatically assign members using an algorithm; members who regain eligibility within 60 days may choose plan or will be re-enrolled into their previous Health Plan; members without selection after 60 days will be auto-assigned per EOHHS algorithm.

EOHHS uses an algorithm to assign eligible members who do not choose a plan, considering quality metrics and performance.
Members disenrolled who regain eligibility within 60 days may select a plan; otherwise they are auto-re-enrolled into their previous Health Plan.
If more than 60 days have elapsed and member does not choose, EOHHS will auto‑assign based on its algorithm.

Note

Provide emergency care without prior authorization and document emergency status

Contractor procedures for obtaining benefits must include authorization processes and explicitly state that prior authorization is not required for emergency services as defined by federal regulation; providers should deliver emergency care without prior authorization and document the emergency.

Member handbook must describe procedures for obtaining benefits, including authorization requirements.
Prior authorization is not required for emergency services that evaluate or stabilize an emergency medical condition (42 C.F.R. §438.114).
Providers rendering emergency services should ensure documentation supports the emergency nature of the care for retrospective review and payment.

Indexes where full contract sections (e.g., Eligibility, Enrollment, Member Services) are located

inv-47: TABLE OF CONTENTS — EOHHS contract materials (amended July 1, 2023)

Document tableTable of Contents for EOHHS contract materials amended July 1, 2023

CoverageTOC enumerates Articles I–II and many subsections including definitions and enrollment rules

Attachment notedIncludes Attachment: RHODE ISLAND EPSDT PERIODICITY SCHEDULE

inv-48: ABUSE

TermABUSE

Definition summaryProvider practices inconsistent with sound fiscal, business, or medical practices resulting in unnecessary cost to Medicaid or reimbursement for services not medically necessary

Regulatory citationIn accordance with 42 C.F.R. §438.2 (citing 42 C.F.R. §455.2)

inv-49: ACCOUNTABLE ENTITY

TermACCOUNTABLE ENTITY (AE)

DefinitionAn integrated, interdisciplinary provider network financially accountable for member cost, quality, and health outcomes for Medicaid populations within value-based arrangements

Program roleAE participation tied to membership thresholds and APM/TCOC initiatives in Agreement

inv-50: Abuse

TermAbuse (alternate entry)

NoteSame definition as 'ABUSE' referencing provider or beneficiary practices causing unnecessary Medicaid cost

SourceArticle I: Definitions (EOHHS contract)

inv-51: Accountable Entity (duplicate)

TermAccountable Entity (alternate entry)

NoteDescribed as an integrated interdisciplinary provider organization financially accountable under value-based payment arrangements

Related sectionsAPMs, TCOC, and AE subcontracting requirements (Article II) reference this term

inv-52: Active Contract Management (ACM)

TermActive Contract Management (ACM)

DefinitionSet of strategies using frequent data and targeted agency-provider interactions to detect/respond to problems, improve performance, and identify reengineering opportunities

PurposeUsed by EOHHS to monitor and manage Contractor performance under the Agreement

inv_53: Actuary

TermActuary

QualificationIndividual meeting American Academy of Actuaries standards and Actuarial Standards Board practice standards

FunctionActs on behalf of State in developing and certifying capitation rates

inv-54: Advanced Directive

TermAdvanced Directive

DefinitionA written instruction (e.g., living will, durable power of attorney) recognized under State law about health care when an individual is incapacitated

Legal basisRecognized under State statutory or case law

inv-55: Advanced Practice Practitioners

TermAdvanced Practice Practitioners (APPs)

IncludesPhysician assistants, certified nurse practitioners, and certified nurse midwives subject to Rhode Island laws and regulations

ScopeMay not exceed authority permitted by State regulations

inv-56: Adverse Benefit Determination

TermAdverse Benefit Determination

DefinitionDenial or limited authorization of requested services; reduction/suspension/termination of previously authorized services; denial of payment; failure to provide timely services; failure to meet grievance/appeal timeframes; and related items per 42 C.F.R. §438.400

ImplicationTies to appeals and provider grievance processes described elsewhere in Agreement

inv-57: Affiliate

TermAffiliate

DefinitionEntity that directly or indirectly controls, is controlled by, or is under common control with the Contractor

Contract implicationAffiliates subject to contract provisions where applicable

inv-58: Affordable Care Act (ACA)

TermAffordable Care Act (ACA)

DefinitionPatient Protection and Affordable Care Act and related legislation; described with its effects such as expanding coverage and prohibiting denial for pre-existing conditions

Related populationsACA Expansion eligibles defined in Agreement

inv-59: Affordable Care Act Eligibles

TermAffordable Care Act Eligibles

DefinitionAdults age 19 or older and under 65 in the Expansion population under ACA provisions

Enrollment noteIncluded among populations EOHHS may enroll under contract provisions

inv-60: Agreement or Contract

TermAgreement or Contract

DefinitionThis document, referred to as the Agreement or Contract between EOHHS and the Contractor

ScopeSets terms governing Contractor obligations, definitions, and program standards

inv-61: Alternative Payment Method (APM)

TermAlternative Payment Method (APM)

DefinitionPayment approach providing added incentive payments to promote high-quality, cost-efficient care for conditions, episodes, or populations

Contract linkAPM thresholds tied to withhold/adjusting payments and reporting requirements

inv-62: Appeal

TermAppeal

DefinitionReview by an MCO, PIHP, or PAHP of an adverse benefit determination in accordance with 42 C.F.R. §438.400

Process tie-inPart of Grievance and Appeals System defined in Agreement

inv-63: Capitation Payment

TermCapitation Payment

DefinitionPeriodic payment made by the State to a contractor on behalf of each enrolled beneficiary based on an actuarially sound capitation rate

NoteWithhold arrangements may apply to capitation payments per Agreement

inv-64: Care Coordination

TermCare Coordination

DefinitionOrganized delivery of member care activities among two or more participants to facilitate appropriate delivery of health care services

ScopeInvolves marshaling personnel and information exchange to meet member needs

inv-65: Care Management

TermCare Management

DefinitionPerson-centered, goal-oriented steps to ensure members receive needed services emphasizing prevention, continuity and coordination; includes health risk assessment and intensive care management when appropriate

ProvidersProvided by licensed Program Coordinators or Care Managers as specified

inv-66: Care Transformation Collaborative of Rhode Island (CTC-RI)

TermCare Transformation Collaborative of Rhode Island (CTC-RI)

DefinitionOrganization promoting the PCMH model statewide and coordinating stakeholders to improve care and lower costs

RelationReferenced in TOC and definitions to support primary care transformation efforts