Rhode Island – EPSDT

In Rhode Island:

• As of July 1, 2011, there were 197,248 individuals enrolled in the state’s Medicaid program, known as Medical Assistance; 135,253 of these individuals were receiving physical or behavioral health benefits through a commercial or Medicaid-only managed care organization under the state’s managed care program, RIte Care.
• Dental services are provided through a prepaid ambulatory health plan (PAHP).
• All Medicaid- eligible children or adults without third party insurance are required to enroll in managed care. Rhode Island Medicaid’s aged, blind, and disabled populations are required to enroll in either a health plan or the state’s primary care case management (PCCM) program, Connect Care Choice.

As of 2013, 116,118 individuals were eligible for Rhode Island’s Early Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. According to 416 data from 2013, the state achieved an EPSDT screening ratio of 73% and a participant ratio of 57%. 49,319 children received dental services of any kind, with 43,096 receiving preventive dental services.

Last updated September 2014

Medical Necessity	Rhode Island’s Medicaid Provider Manual defines medical necessity to mean “medical, surgical or other health services for diagnosis, cure, or treatment, including preventing deterioration of the involved physical or mental condition. Such services must be provided in the most cost effective and appropriate setting and shall not be provided solely for the convenience of the recipient or the service provider.”
Initiatives to Improve Access	Performance Incentive Program Qualifying Medicaid managed care plans in Rhode Island can receive payments through the state’s performance incentive program for achieving benchmark standards for access and quality performance measures. For more information on this program, see the Reporting & Data Collection section.
Reporting & Data Collection	Performance Incentive Program Under the Rhode Island Performance Incentive Program, Medicaid managed care plans can earn payments above their capitation rates as incentives for meeting benchmark standards for quality and access performance measures. Plans are evaluated based on several HEDIS, CAHPS, and state-specific measures, such as: Children had well-child visits in the 3rd, 4th, 5th, & 6th years of life Children received immunizations by 2nd birthday Children received periodic PCP visits Lead screening in children Adolescent well-care visit Members 6 years of age and older get follow up by 30 days post discharge (behavioral health).
Behavioral Health
Support to Providers and Families	Support to Providers The Rhode Island Medicaid agency operates a Healthcare Portal through which providers can access eligibility, claim status, and file exchange. The state also hosts a Provider & Partners page that contains Medical provider manuals, billing & claims information, general program information, and Medicaid forms & applications.
Care Coordination	CEDARR Family Centers Rhode Island received CMS approval in 2011 to develop a Section 2703 Health Home focusing on children with special health care needs served by CEDARR Family Centers. Comprehensive Evaluation Diagnosis Assessment Referral Re-evaluation (CEDARR) centers provide a system for facilitating the assessment of and need for the provision of medically necessary services that may be available for Medicaid-eligible children based on federal EPSDT requirements. As part of the health home program, CEDARR centers will operate as a “designated provider” for health home services and will coordinate a beneficiary’s services across all health care providers. Chronic Care Sustainability Initiative (CSI-RI) Nearly 100% of payers and providers in Rhode Island participate in the Chronic Care Sustainability Initiative (CSI-RI), which launched multi-payer patient-centered medical homes across the state. Medicaid fee-for-service and Medicaid managed care organizations participate in this initiative. For more information on Rhode Island’s medical home efforts, visit NASHP’s medical homes map page.
Oral Health	RIte Smiles Medicaid-eligible children born after May 1, 2000 are required to enroll in Rhode Island’s mandatory managed oral health program, RIte Smiles. The state operates this program under the authority of a Section 1115 waiver. The goals of RIte Smiles are to increase access to dental services, promote the development of good oral health behaviors, decrease the need for restorative and emergency dental care, and decrease Medicaid expenditures for oral health care. Medicaid-eligible children born after May 1, 2000 receive dental benefits through traditional Medical Assistance.

– See more at: https://www.oldsite.nashp.org/epsdt/Rhode-Island#sthash.LSGQOrDo.dpuf