CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

LTSS approval requirement for home care beyond Preventive level

This notice governs approval requirements for home care hours beyond preventive-level homemaker/personal care for members enrolled in the INTEGRITY (MMP) line of business and affects providers delivering home care services to those members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyLTSS approval requirement for home care beyond Preventive level

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document EOHHS LTSS approval before delivering home care hours beyond Preventive limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 hrs/wkPreventive per single member

10 hrs/wkPreventive per household (≥2)

INTEGRITY (MMP)Line of business

Coverage criteria for long-term home care services

Coverage for long-term home care services

Covered beyond Preventive levels when ALL of the following are met

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyLTSS approval requirement for home care beyond Preventive level

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document EOHHS LTSS approval before delivering home care hours beyond Preventive limits.

SourceLink

On This Page

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Coding and preventive service limits

No codes listedmixed

No codes listed

Preventive homemaker/personal care limits (thresholds)

Single-member preventive limitUp to 6 hours per week of homemaker and/or personal care services for a single member.

Household preventive limit (≥2 members)Up to 10 hours per week of homemaker and/or personal care services for a household with two or more members.

ApplicabilityThese limits define 'Preventive services' and apply to short‑duration homemaker and personal care as described in the policy.

Provider actions, documentation, and authorization requirements

Denial Risk

LTSS approval required to avoid denial

Members in the INTEGRITY (MMP) line of business must have approval for Long-Term Services and Supports (LTSS) through the Rhode Island Executive Office of Health and Human Services (EOHHS) to receive home care hours beyond Preventive services. Services delivered beyond the Preventive level will be disallowed and may be denied without EOHHS LTSS approval.

Applies to INTEGRITY (MMP) members receiving home care beyond Preventive limits
Preventive services: up to 6 hours/week for a single member or 10 hours/week for a household with 2+ members

Documentation Required

Document EOHHS LTSS approval

Providers should confirm whether the member has EOHHS approval of LTSS-HCBS waiver before delivering home care hours beyond Preventive limits. Document the member’s EOHHS LTSS approval in the medical record and include evidence of the approved LTSS-HCBS waiver application when submitting claims or authorization requests.

Document EOHHS LTSS-HCBS waiver approval in the member’s medical record
Include proof of LTSS approval with authorizations or claim documentation to avoid denials

Prior Authorization

Provider impact — confirm and coordinate LTSS approvals

Neighborhood's Care Management team can assist members with completing the LTSS-HCBS waiver application. Providers should direct members to the EOHHS LTSS application resources and coordinate with Care Management as needed to secure approval prior to providing long-term home care services.

Refer members to EOHHS LTSS application resources
Contact Neighborhood Care Management for assistance with LTSS applications
Provider Services: 1-800-963-1001 for questions

Definitions

Preventive services (definition)

Preventive service definitionPreventive services include up to six (6) hours of homemaker and/or personal care services per week for a single member or ten (10) hours per week for a household with two (2) or more members.

ScopeThese hours represent the maximum allowed without LTSS approval for ongoing long‑term services.

Reference locationNeighborhood News ~ July 2025; Home Care Services Clinical Medical Policy language quoted in the notice.

LTSS‑HCBS waiver application (EOHHS approval)

RequirementSuccessful completion and approval of a LTSS‑HCBS waiver application through the state Executive Office of Health and Human Services (EOHHS) is required to receive more than Preventive services on a long‑term basis.

How to applyMembers can visit the EOHHS website to complete a LTSS‑HCBS waiver application; Neighborhood's Care Management team can assist with applications.

Affected membersApplies to members enrolled in the INTEGRITY (MMP) line of business seeking home care hours beyond the Preventive limits.

OpenPayer

LTSS approval requirement for home care beyond Preventive level

Coverage criteria for long-term home care services

Coding and preventive service limits

Provider actions, documentation, and authorization requirements

Background

Definitions