Rhode Island Medicaid LTSS Application Packet

RHODE ISLAND MEDICAID LTSS APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Letter to EOHHS / DHS
2. Applicant and Household Information
3. Program and Eligibility Pathway Selected
4. Income Statement and Worksheet
5. Resource (Asset) Statement and Worksheet
6. Primary Residence and Real Property Disclosure
7. 60-Month Transfer / Look-Back Disclosure
8. Spousal Impoverishment Worksheet (if married)
9. Medically Needy Spend-Down Election
10. Authorized Representative Designation
11. Verifications Checklist
12. Applicant Certification and Signature
13. Rhode Island Practice Notes
14. Sources and References

1. COVER LETTER TO EOHHS / DHS

[DATE: __/__/____]

Rhode Island Executive Office of Health and Human Services
Medicaid Long-Term Services and Supports
3 West Road, Virks Building
Cranston, RI 02920

Rhode Island Department of Human Services
[DHS FIELD OFFICE — CRANSTON / PROVIDENCE / PAWTUCKET / WAKEFIELD / WOONSOCKET / WOONSOCKET]

Re: Application for Medicaid Long-Term Services and Supports
Applicant: [APPLICANT FULL LEGAL NAME]
Date of Birth: [__/__/____]
Social Security No.: [XXX-XX-____] (last four)
Medicare HICN/MBI: [________________________________]
Setting: ☐ Nursing Facility ☐ Assisted Living ☐ HCBS Waiver ☐ PACE ☐ Shared Living

To whom it may concern:

Enclosed please find a complete application for Rhode Island Medicaid Long-Term Services and Supports on behalf of the above-named applicant, together with all required verifications listed in Section 11 of this packet. The applicant requests a determination under:

☐ Categorical (SSI-related, 300% FBR income cap) eligibility — 210-RICR-50-00-3
☐ Medically Needy eligibility with Flex-Test / spend-down — 210-RICR-50-00-2
☐ Spousal impoverishment treatment — 42 U.S.C. § 1396r-5

The applicant requests that the eligibility date relate back to the first day of the month of admission / application, [__/__/____], in accordance with 210-RICR-50-00-1 and 42 C.F.R. § 435.915 (three-month retroactive coverage).

Please direct correspondence to the authorized representative identified in Section 10.

Respectfully,

[AUTHORIZED REPRESENTATIVE NAME]
[ADDRESS]
[PHONE] | [EMAIL]

2. APPLICANT AND HOUSEHOLD INFORMATION

3. PROGRAM AND ELIGIBILITY PATHWAY SELECTED

☐ Institutional / Nursing Facility (continuous stay 30+ days)
☐ Home and Community-Based Services (HCBS) Waiver — Global Consumer Choice Compact §1115 demonstration
☐ Program of All-Inclusive Care for the Elderly (PACE)
☐ Assisted Living (Medicaid SHARED LIVING / SAFL — State Assisted Living Program)
☐ Shared Living / Adult Foster Care

Level of Care attestation: A separate clinical assessment (Highest, High, or Preventive Level of Care) has been or will be requested through the EOHHS Office of Community Programs. Date requested: [__/__/____].

4. INCOME STATEMENT AND WORKSHEET

Categorical income cap (300% FBR), 2026: approximately $2,982/month for a single LTSS applicant. CONFIRM current cap with EOHHS at filing.

☐ Applicant income is at or below the categorical cap — proceed under 210-RICR-50-00-3.
☐ Applicant income exceeds the categorical cap — proceed under Medically Needy pathway, Section 9.

5. RESOURCE (ASSET) STATEMENT AND WORKSHEET

Single-applicant resource limit (2026): $4,000 countable. CONFIRM before filing.

6. PRIMARY RESIDENCE AND REAL PROPERTY DISCLOSURE

Estate recovery notice: Pursuant to R.I. Gen. Laws § 40-8-15 and 42 U.S.C. § 1396p(b), Rhode Island will pursue recovery from the estate of any Medicaid recipient age 55 or older for LTSS expenditures, including against the residence after the death of the recipient (and any surviving spouse, minor or disabled child). Applicant has been advised of estate recovery.

Applicant initial: [____]

7. 60-MONTH TRANSFER / LOOK-BACK DISCLOSURE

For the period [__/__/____] (60 months before application) through [__/__/____] (date of application), the applicant and spouse disclose ALL transfers of assets for less than fair market value:

☐ No transfers for less than FMV occurred during the 60-month look-back.

Transfer-penalty calculation (per 210-RICR-50-00-6 and 42 U.S.C. § 1396p(c)):

Exempt transfers asserted (cite each):
☐ Spouse — 42 U.S.C. § 1396p(c)(2)(B)(i)
☐ Disabled or blind child — 42 U.S.C. § 1396p(c)(2)(B)(iii)–(iv)
☐ Caretaker child of homestead (2+ years) — 42 U.S.C. § 1396p(c)(2)(A)(iv)
☐ Sibling with equity interest residing 1+ year in homestead — 42 U.S.C. § 1396p(c)(2)(A)(iii)
☐ Special-needs trust (d)(4)(A)/(d)(4)(C)) — 42 U.S.C. § 1396p(d)(4)
☐ Solely for purpose other than to qualify; rebuttal — 42 U.S.C. § 1396p(c)(2)(C)
☐ Undue hardship — 42 U.S.C. § 1396p(c)(2)(D)

8. SPOUSAL IMPOVERISHMENT WORKSHEET (if married)

Fair-hearing rights: Either spouse may request a fair hearing to increase the CSRA or MMMNA upon a showing of exceptional circumstances or insufficient income. R.I. Gen. Laws § 40-8-9; 42 U.S.C. § 1396r-5(e).

9. MEDICALLY NEEDY SPEND-DOWN ELECTION

Pursuant to 210-RICR-50-00-2, applicant elects evaluation under the Medically Needy LTSS pathway:

☐ Applicant's countable income exceeds the categorical (300% FBR) cap.
☐ Applicant's countable income does not exceed the projected private-pay cost of the LTSS setting requested (Flex-Test).
☐ Applicant agrees to apply income to cost of care (post-eligibility patient pay amount) less the personal needs allowance ($[______]) and any allowable spousal/family allowance.

Personal Needs Allowance (PNA), Rhode Island NF (2025–2026): $50/month (institutional). CONFIRM current PNA. Resident Personal Needs Funds are governed by 210-RICR-50-05-2.

10. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT NAME], hereby designate the following person as my Authorized Representative for purposes of this Medicaid application, redeterminations, fair hearings, and all related communications, pursuant to 42 C.F.R. § 435.923:

Applicant signature: [________________________________] Date: [__/__/____]

11. VERIFICATIONS CHECKLIST

☐ Photo ID / driver's license / RI ID
☐ Social Security card
☐ Birth certificate
☐ Proof of citizenship/immigration status
☐ Marriage certificate / divorce decree / death certificate of spouse
☐ Medicare card
☐ Other health insurance cards and policies
☐ 60 months of statements for ALL bank, brokerage, retirement, and HSA accounts (applicant AND spouse)
☐ Deeds for all real property; current municipal assessment or appraisal
☐ Vehicle title(s) and current NADA value
☐ Life insurance policies — face value AND in-force ledger showing cash value
☐ Burial / funeral / cemetery contracts
☐ Trust instruments (full trust + amendments)
☐ Annuity contracts and disclosure of RI as remainder beneficiary
☐ Pension / annuity / 1099-R
☐ Last 3 federal tax returns
☐ Documentation of every transfer disclosed in Section 7
☐ Power of Attorney / guardianship orders
☐ DD-214 (if veteran)
☐ Level of Care assessment request / approval
☐ Notice of admission to facility (if institutionalized)

12. APPLICANT CERTIFICATION AND SIGNATURE

I certify under penalty of perjury under the laws of the United States and the State of Rhode Island that the information provided in this application and all attachments is true, correct, and complete to the best of my knowledge. I understand that:

• Knowingly providing false information is a violation of 42 U.S.C. § 1320a-7b and R.I. Gen. Laws § 40-8-13 and may result in denial, recoupment, civil penalties, and criminal prosecution.
• Medicaid is the payer of last resort. I assign to the State of Rhode Island all rights to recover from any third party (including health insurers, tortfeasors, and other liable parties) the cost of medical assistance paid on my behalf, pursuant to 42 U.S.C. § 1396a(a)(25) and R.I. Gen. Laws § 40-6-9.
• The State will recover from my probate estate (and, if applicable, certain non-probate assets) for LTSS paid on my behalf at or after age 55, pursuant to 42 U.S.C. § 1396p(b) and R.I. Gen. Laws § 40-8-15.
• I must report any change in income, resources, household composition, or living arrangement within ten (10) days.

Applicant signature: [________________________________]
Print name: [________________________________]
Date: [__/__/____]

Authorized representative signature (if applicable): [________________________________]
Date: [__/__/____]

13. RHODE ISLAND PRACTICE NOTES

1. Annuities. A Medicaid-compliant annuity must be irrevocable, non-assignable, actuarially sound, and name the State of Rhode Island as the primary remainder beneficiary up to the amount of Medicaid paid (or secondary to a community spouse / minor / disabled child). 42 U.S.C. § 1396p(c)(1)(F). Verify current EOHHS form for State remainder designation.

2. Promissory notes / loans. Must be actuarially sound, with equal payments and no balloon, and non-cancelable on death. 42 U.S.C. § 1396p(c)(1)(I).

3. Caregiver agreements. Must be in writing, signed before services rendered, with reasonable hourly rate documented and contemporaneous logs. EOHHS scrutinizes intra-family agreements heavily.

4. Personal-injury settlements. A first-party special needs trust under 42 U.S.C. § 1396p(d)(4)(A) must be established before age 65 with State remainder. A pooled SNT under (d)(4)(C) may be established at any age but EOHHS treats post-age-65 transfers to a (d)(4)(C) trust as a transfer for less than FMV (national split — verify RI policy).

5. Estate recovery. Rhode Island recovers from probate estates only; jointly held property passing by operation of law and life-estate remainders are generally not recovered against, BUT the Deficit Reduction Act of 2005 (42 U.S.C. § 1396p(b)(4)) permits expanded recovery — verify current EOHHS policy.

6. Fair hearings. Denial, termination, or reduction may be appealed to EOHHS Appeals Office within 30 days (90 days for good cause). R.I. Gen. Laws § 40-8-9; 210-RICR-10-05-2.

7. Retroactive coverage. Up to three months of retroactive Medicaid is available if the applicant met all eligibility criteria during those months. 42 C.F.R. § 435.915.

8. Managed-care enrollment. Most LTSS members enroll in Rhody Health Options, Integrated Care Initiative (ICI), or Medicare-Medicaid Plan once eligible. PACE is an alternative for age 55+.

9. HealthSource RI portal. Online applications are submitted at healthyrhode.ri.gov. Paper applications go to a DHS field office. LTSS-specific applications are routed to EOHHS LTSS.

14. SOURCES AND REFERENCES

• Rhode Island EOHHS — Medicaid LTSS: https://eohhs.ri.gov/consumer/medicaid
• Rhode Island DHS — Apply for Medicaid: https://dhs.ri.gov/programs-and-services/medical-assistance-programs
• HealthSource RI — Online application portal: https://healthyrhode.ri.gov
• 210-RICR-50-00-1 (LTSS Overview): https://rules.sos.ri.gov/regulations/part/210-50-00-1
• 210-RICR-50-00-2 (Medically Needy): https://rules.sos.ri.gov/regulations/part/210-50-00-2
• 210-RICR-50-00-6 (Financial Eligibility / Transfer Penalty): https://rules.sos.ri.gov/regulations/part/210-50-00-6
• R.I. Gen. Laws Title 40 Ch. 8 (Medical Assistance): https://webserver.rilegislature.gov/Statutes/TITLE40/40-8/INDEX.htm
• 42 U.S.C. § 1396p (Federal transfer / estate-recovery rules): https://www.law.cornell.edu/uscode/text/42/1396p
• 42 U.S.C. § 1396r-5 (Spousal impoverishment): https://www.law.cornell.edu/uscode/text/42/1396r-5
• Rhode Island State Long-Term Care Ombudsman: https://alliancebltc.org/ombudsman-program
• 2026 federal LTSS limits (CMS SMD letter): https://www.medicaid.gov