Rhode Island General Laws Title 40. Human Services § 40-8.13-1. Definitions

(1) “ Beneficiary” means an individual who is eligible for medical assistance under the Rhode Island Medicaid state plan established in accordance with 42 U.S.C. § 1396, and includes individuals who are additionally eligible for benefits under the Medicare program ( 42 U.S.C. § 1395 et seq.) or other health plan.

(2) “ Duals Demonstration Project” means a demonstration project established pursuant to the financial alignment demonstration established under section 2602 of the Patient Protection and Affordable Care Act ( Pub. L. 111-148) [ 42 U.S.C. § 1315b], involving a three-way contract between Rhode Island, the Federal Centers for Medicare and Medicaid Services (“CMS”) and qualified health plans, and covering health care services provided to beneficiaries.

(3) “ EOHHS” means the Rhode Island executive office of health and human services.

(4) “ EOHHS level-of-care tool” refers to a set of criteria established by EOHHS and used in January, 2014 to determine the long-term care needs of a beneficiary as well as the appropriate setting for delivery of that care.

(5) “ Long-term care services and supports” means a spectrum of services covered by the Rhode Island Medicaid program and/or the Medicare program, that are required by individuals with functional impairments and/or chronic illness, and includes skilled or custodial nursing facility care, as well as various home- and community-based services.

(6) “ Managed long-term care arrangement” means any arrangement under which a managed care organization is granted some or all of the responsibility for providing and/or paying for long-term care services and supports that would otherwise be provided or paid under the Rhode Island Medicaid program. The term includes, but is not limited to, a duals demonstration project, and/or phase I and phase II of the integrated care initiative established by the executive office of health and human services.

(7) “ Managed care organization” means any health plan, health maintenance organization, managed care plan, or other person or entity that enters into a contract with the state under which it is granted the authority to arrange for the provision of, and/or payment for, long-term care supports and services to eligible beneficiaries under a managed long-term care arrangement.

(8) “ Plan of care” means a care plan established by a nursing facility in accordance with state and federal regulations and that identifies specific care and services provided to a beneficiary.