Provider & Community Partner FAQs

Under new federal law (H.R. 1), Rhode Island Medicaid will implement several policy and eligibility changes starting in late 2026:

• October 1, 2026: Changes to eligibility for certain non-citizens.
• January 1, 2027:
  • Work requirements for expansion adults.
  • 6-month renewal cycles for expansion adults (replacing annual renewals).
  • Reduction of retroactive Medicaid coverage from 3 months to 2 months.
• October 1, 2028: Cost-sharing/copayments for certain services for expansion adults with income above 100% of the Federal Poverty Level (FPL).

Medicaid expansion provides coverage for low-income adults ages 19 to 64. Individuals enrolled through the expansion program may know their coverage as Medicaid Expansion ACA, Obamacare, Neighborhood (NHP) TRUST, UnitedHealthcare Rhody Health Partners ACA Adult Expansion, or Tufts Health RI Together.

Encourage members to keep their HealthyRhode account up to date, including their contact information and address, and to report any changes in their circumstances. You can also direct them to StayCovered.RI.gov for resources, updates, and guidance to help them maintain their health coverage and understand changes that may affect them.

Providers can also help keep members informed by displaying and sharing materials in offices and waiting rooms. Visit the toolkit page for materials to share in your office or digitally with patients, and use the print portal to order flyers and posters.

The following populations will retain full Medicaid eligibility:

1. Lawful Permanent Residents (LPRs / Green Card holders) who have met the 5-year waiting period (if applicable).
2. Cuban / Haitian entrants.
3. COFA migrants (from Micronesia, the Marshall Islands, and Palau).
4. Children under age 19 regardless of immigration status.
5. Pregnant and postpartum individuals (through 12 months postpartum).

The following groups are exempt from the 5-year waiting period once they become lawful permanent residents: Refugees and victims of human trafficking, asylees, certain Ukrainian or Afghan parolees, people granted withholding of removal, Iraqi or Afghan Special Immigrant Visa (SIV) holders, Amerasian entrants, Veterans, active-duty service members, and their families, and certain American Indians born abroad. 

No. This rule does not impact Emergency Medicaid. Local hospitals are required by law to give emergency medical care for serious or life-threatening problems, no matter a person’s insurance or immigration status.

The State is notifying non-citizens who may be impacted by these changes through mailed notices, digital notices in HealthyRhode accounts, emails, and text messages. The timeline of notices sent to potentially impacted individuals is below.

• July 2026: Initial notices mailed/sent to potentially impacted members.
• August 2026: Additional Documentation Required (ADR) notice sent to some individuals.
• September 2026: Formal Benefits Decision Notices (BDN) issued.
• October 1, 2026: Benefits end for non-qualifying individuals.
• October 2026: An additional notice is sent to individuals no longer eligible for Medicaid. This notice includes information about other ways to get health insurance and health care. 

You can view samples of these notices on our website here: Sample Notices to Non-Citizens | Stay Covered Rhode Island

Work requirements apply strictly to the Medicaid expansion population. This includes adults ages 19–64 who are not pregnant, do not have Medicare, and do not qualify for an exemption. 

Adults who have Medicaid through the Parent/Caretaker pathway are not part of expansion and therefore will not be subject to work requirements. Additionally, anyone younger than 19 or older than 64 will not be subject to work requirements. 

An individual can meet work requirements by earning at least $580 in an applicable month before taxes. For seasonal workers, an average monthly income of at least $580 over the previous six months also qualifies. If an individual earns this amount and the State has sufficient information on file, their coverage will renew automatically. If additional information is needed, the State will ask the individual to provide documentation, such as a pay stub.

Members can also qualify by completing 80 hours in an applicable month of any combination of the following:

• Working a job
• Volunteering or performing community service at a public or nonprofit organization
• Participating in job training, a job skills program, or a workforce development program
• Attending school or a trade or vocational program 
  • Individuals enrolled in an educational program at least part-time will meet the requirement.
  • Individuals enrolled less than part-time may combine school attendance with work, volunteering, or job training to meet the 80-hour monthly requirement.

For new applicants, the State will look back to the month before the application to see if the individual has met Medicaid work requirements.

For a member’s first renewal in 2027, the State will look back to the member’s last renewal, up to 12 months prior. After that, the State will review the previous six months at each six-month renewal. During each lookback period, the member must have met the work requirement or qualified for an exemption for at least one month.

Renewal Example: A Medicaid expansion member is renewing in March 2027. Here’s how one month of compliance during each lookback period would apply to their first and future renewals.

March 2027 renewal: The State looks back to the member’s last renewal, March 2026 through February 2027. The member only needs to meet the requirement or qualify for an exemption in at least one month during that period.

Next renewal, September 2027: The State reviews the previous six months, March 2027 through August 2027. Again, the member only needs to meet the requirement or qualify for an exemption in at least one month during that period.

This online screener tool can help members determine whether they may be exempt.

Work requirements DO NOT apply to individuals who meet any of the following exemption categories:

Members may qualify for a short-term hardship exemption if they cannot meet the work requirements due to:

1. Inpatient Medical Care: Were recently or are currently admitted to a hospital or rehabilitation facility for inpatient care or receiving a similar level of care in a home or community-based setting. 
2. Medical Travel: Must travel outside their city/town for 10 or more days to get medical care for themselves or a dependent due to a serious or complex condition.
3. Disaster / Emergency: Living in a federally declared disaster or emergency area (State determines). 
4. Economic Factors: Living in an area with comparatively high unemployment (State determines; currently does not apply). 

The State uses automated data matching first to reduce administrative burdens. Verification methods are split into two categories:

A. Automated Data Matching (No Action Required by Member)

B. Member Self-Attestation (Member Actions)

If automated data matching does not confirm eligibility, or if data matching is not available, members will be asked to self-attest via their HealthyRhode account, phone, or paper forms. People may self-attest for the following:

NOTE: Because Rhode Island uses medical claims data to automatically exempt patients in a drug or alcohol treatment program, or patients with special medical or behavioral health needs, providers should submit accurate diagnostic coding on all medical claims. Timely claims submission may prevent patients from being subject to work requirements.

Rhode Island will use medical claims data to automatically identify some patients who may qualify for a medical exemption. Providers should use accurate diagnosis codes on all medical claims and document relevant conditions in the EHR. When appropriate, include the severity of the condition and any functional limitations. These factors may be used to determine whether a patient qualifies for an exemption in future years. 

However, beyond this routine practice, healthcare providers WILL NOT be asked to submit additional documentation in 2027 to support member self-attestations. This may change in 2028, depending on federal guidance. The State will communicate any changes in necessary documentation to providers in advance. 

Members will not be asked to provide additional documentation to support their self-attestations.

The State created a list of conditions and information available via claims that qualify for medical frailty under the federally defined categories. Claims data will be checked first to determine whether someone has a qualifying condition and whether its severity or functional level impacts their ability to work, volunteer, or attend school. If claims data are insufficient, individuals can self-attest to their condition and its impact. Over time, the State may incorporate additional data sources to rely less on self-attestation and more on automated matching.

Substance use disorder is treated somewhat differently. People with a substance use disorder who have been in recovery for less than five years may qualify for the Medical Frailty exemption when the available information indicates that the condition significantly impacts their ability to meet Medicaid Work Requirements. Those in stable recovery for five or more years do not qualify based on SUD alone.

Beginning in 2027, expansion adults must renew coverage every 6 months instead of every 12 months.

• Passive Renewal (no member action needed): If state databases confirm ongoing eligibility, coverage auto-renews for 6 months. A Benefits Decision Notice is sent, requiring no action.
• Active Renewal (member action needed): If data is missing, the member receives a yellow renewal notice and a white Additional Documentation Required (ADR) notice. The member must submit any requested documents before the deadline listed on the notice.

Retroactive coverage allows Medicaid to pay for certain medical bills from before a person is eligible for Medicaid. Today, federal rules allow coverage up to three months before the month of application. Starting in 2027, federal rules will limit coverage to up to two months before the month of application.

Retroactive coverage is currently available only for:

• Most people with disabilities
• Adults age 65 and older
• Most people applying for long-term services and supports (LTSS), including through the Katie Beckett pathway
• Pregnant people
• Infants under age 1

The Department of Human Services (DHS) reviews Medicaid applications and determines whether someone is eligible. DHS does not automatically evaluate new applications for retroactive coverage eligibility. The applicant will need to request retroactive coverage and provide information about unpaid bills on their application. To learn more, visit dhs.ri.gov/apply-now. 

The retroactive period is based on the first day of the month in which the State receives the application. To help avoid delays, applicants should still submit applications that are as complete as possible.

An application is considered submitted only when DHS can officially date‑stamp it as received. DHS stamps applications when they are received through:

• Email (timestamped when received by DHS)
• Customer Portal (system submission timestamp)
• Drop‑off at DHS regional offices or DHS mailboxes before 4 p.m. on a business day
• Delivery to the DHS Central Mailbox by the post office before 4 p.m.

If DHS cannot stamp the application—because it is missing required minimum information—it is not considered submitted.

An incomplete application can preserve the application date, but only if it meets DHS’s minimum requirements for acceptance. If it does not meet minimum requirements, DHS does not stamp it and returns it to the customer. 

A complete application includes:

• All required personal information
• All required income, residency, and citizenship/immigration details
• Any documents needed to verify eligibility, including:
  
  • If applicable, all required asset and resource information
  • If applicable, documents to support Clinical/Functional Eligibility, such as a PM1 form
• All signatures and attestations

If any required information is missing, the application is not complete.

Yes. A signature is required for DHS to accept and stamp an application. Unsigned applications are not considered received and are returned to the customer.

During the transition period, if an application is received by DHS on December 31, 2026, by 4 p.m., the three months of retroactive coverage will apply. If an application was mailed to DHS on December 31, 2026, and DHS receives it on January 2, 2027, the two months would apply for this application.

Yes—but with a critical message: Timing matters, but a complete application matters, too. When application assistance is requested, providers should help applicants submit an application that is both timely and complete. Application assistance is also available through Certified Application Counselors or community organizations like the Aging & Disability Resource Center.

Retroactive Medicaid only pays for Medicaid-covered expenses. This can include a range of medical expenses, including hospital stays, doctor visits, prescription medications, and long-term services and supports (if eligible). If the recipient is eligible for retroactive coverage, the provider will be reimbursed for eligible covered services under standard Medicaid payment procedures. 

No. The change applies only to new applicants and newly enrolled members starting in 2027.

No. CMS has not changed the federal reconsideration/reinstatement policy. CMS still allows a reconsideration period if a member returns their renewal paperwork within 90 days after their termination date. This 90-day period is measured in days, not months, and is separate from the retroactive coverage policy. The date renewal paperwork is received is considered the application date for retroactive coverage purposes, if the member is eligible for retroactive coverage. Reconsideration does not guarantee uninterrupted coverage.