Correct Rhode Island pregnancy Medicaid routing and postpartum coverage

changelog.d/fix-ri-pregnancy-medicaid-pathways.fixed.md

@@ -0,0 +1 @@
+Correct Rhode Island pregnancy Medicaid and CHIP routing for people with third-party health coverage, and preserve full postpartum Medicaid based on qualifying pregnancy eligibility through the last day of the month in which the 12-month postpartum period ends, including after income changes or another pregnancy. Fixes #10390.

policyengine_us/parameters/gov/hhs/medicaid/eligibility/categories/pregnant/income_limit.yaml

@@ -27,6 +27,16 @@ metadata:
       href: https://medicaid.nv.gov/Downloads/provider/web_announcement_3748_20251020.pdf
     - title: "West Virginia Medicaid State Plan Amendment WV-19-0004, approval letter and S14 Pregnant Women #page 3,14"
       href: https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/WV/WV-19-0004.pdf#page=3
+    - title: 210-RICR-30-00-1 § 1.6(A)(2)(a) (version effective August 17, 2025)
+      href: https://risos-apa-production-public.s3.amazonaws.com/EOHHS/REG_13314_20250728104245127.pdf#page=5
+    - title: "Rhode Island 1115 expenditure authorities (December 23, 2013 to December 31, 2018), Budget Population 6b"
+      href: https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ri/Comprehensive-Demonstration/ri-global-consumer-choice-compact-expnditure-auth-12232013-12312018.pdf#page=2
+    - title: "Rhode Island 1115 amendment approval (March 21, 2024; 2019 to 2024), Budget Population 6b"
+      href: https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ri-comphnsve-dmnstrtn-aprvl.pdf#page=11
+    - title: "Rhode Island 1115 temporary extension (December 12, 2024; through June 30, 2025), Budget Population 6b"
+      href: https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ri-comphnsve-dmnstrtn-tmp-extn-amndmnt.pdf#page=6
+    - title: "Rhode Island 1115 approval (November 28, 2025; 2026 to 2030), Budget Population 6b #page 3,15"
+      href: https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ri-comp-demo-appvl-11282025.pdf#page=3
 AK:
   2018-01-01: 2.05
   2024-02-01: 2.30
@@ -113,8 +123,12 @@ OR:
 PA:
   2018-01-01: 2.20
 RI:
+  # The higher Medicaid ceiling for insured pregnant people is applied in the
+  # financial-criteria formula using Rhode Island's CHIP pregnancy ceiling.
+  # The insured route rests on 1115 Budget Population 6b since 2013 (185-250%
+  # FPL before MAGI, 190-253% after) and on 210-RICR-30-00-1 § 1.6(A)(2)(a)(2)
+  # from August 17, 2025.
   2018-01-01: 1.95
-  2023-01-01: 2.58
 SC:
   2018-01-01: 1.99
 SD:

policyengine_us/parameters/gov/states/ri/eohhs/medicaid/postpartum_coverage_months.yaml

@@ -0,0 +1,13 @@
+description: Rhode Island provides full Medicaid through the last day of the month in which a postpartum period of this many months, beginning on the last day of pregnancy, ends, including when federal funding is unavailable.
+values:
+  0000-01-01: 0
+  2022-10-01: 12
+metadata:
+  unit: month
+  period: month
+  label: Rhode Island postpartum Medicaid continuation months
+  reference:
+    - title: R.I. Gen. Laws § 42-12.3-3(g)
+      href: https://webserver.rilegislature.gov/Statutes/TITLE42/42-12.3/42-12.3-3.htm
+    - title: Rhode Island Medicaid State Plan Amendment RI-22-0024, section B (12-month period begins on the last day of pregnancy)
+      href: https://www.medicaid.gov/medicaid/spa/downloads/RI-22-0024.pdf#page=7

policyengine_us/parameters/gov/states/ri/eohhs/medicaid/third_party_coverage.yaml

@@ -0,0 +1,22 @@
+description: Rhode Island uses these coverage sources as third-party liability insurance under the Medicaid program.
+values:
+  0000-01-01:
+    - has_esi
+    - has_marketplace_health_coverage_at_interview
+    - has_non_marketplace_direct_purchase_health_coverage_at_interview
+    - medicare_enrolled
+    - has_tricare_health_coverage_at_interview
+    - has_champva_health_coverage_at_interview
+metadata:
+  unit: list
+  period: year
+  label: Rhode Island Medicaid third-party liability coverage sources
+  reference:
+    - title: "210-RICR-30-00-1 §§ 1.6(A)(2)(a)(2), 1.9(B)(1) (version effective August 17, 2025) #page 5,19"
+      href: https://risos-apa-production-public.s3.amazonaws.com/EOHHS/REG_13314_20250728104245127.pdf#page=5
+    - title: Rhode Island EOHHS, Third Party Liability
+      href: https://eohhs.ri.gov/providers-partners/billing-and-claims/third-party-liability
+    - title: TRICARE, Other Health Insurance FAQ
+      href: https://tricare.mil/FAQs/General/GEN_OHI_TRICARE
+    - title: VA, CHAMPVA benefits
+      href: https://www.va.gov/resources/champva-care/

policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_standard_pregnant_person.yaml

@@ -788,3 +788,231 @@
         state_code: MO
   output:
     is_chip_eligible_standard_pregnant_person: false
+
+# 210-RICR-30-00-1 § 1.6(A)(2)(b)(1)-(2) requires the absence of
+# third-party insurance for standard pregnancy CHIP in Rhode Island.
+# https://risos-apa-production-public.s3.amazonaws.com/EOHHS/REG_13314_20250728104245127.pdf#page=5
+# Supply Medicaid ineligibility here to exercise the CHIP insurance gate
+# independently; the Medicaid integration cases test the insured pathway.
+- name: Case 28, Rhode Island standard pregnancy CHIP excludes third-party coverage independently of Medicaid eligibility.
+  period: 2024
+  input:
+    people:
+      person1:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        has_esi: true
+      person2:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        has_marketplace_health_coverage_at_interview: true
+      person3:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        has_non_marketplace_direct_purchase_health_coverage_at_interview: true
+      person4:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        medicare_enrolled: true
+      person5:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        has_tricare_health_coverage_at_interview: true
+      person6:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        has_champva_health_coverage_at_interview: true
+      person7:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        is_medicaid_eligible: false
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+    households:
+      household:
+        members: [person1, person2, person3, person4, person5, person6, person7]
+        state_code: RI
+  output:
+    is_chip_eligible_standard_pregnant_person: [false, false, false, false, false, false, true]
+
+# RI-22-0025 CS27 continues the separate CHIP program through the postpartum
+# period; the full Medicaid benefit scope does not create duplicate enrollment.
+# https://www.medicaid.gov/CHIP/Downloads/RI-22-0025.pdf#page=4
+# R.I. Gen. Laws § 42-12.3-3(g) preserves the entitlement "without regard to the
+# availability of federal financial participation".
+# https://webserver.rilegislature.gov/Statutes/TITLE42/42-12.3/42-12.3-3.htm
+- name: Case 29, Rhode Island retains pregnancy CHIP despite later income, insurance, pregnancy or immigration changes.
+  period: 2024
+  input:
+    people:
+      person1:
+        age: 30
+        is_pregnant: false
+        immigration_status: CITIZEN
+        has_esi: false
+        ri_pregnancy_coverage: CHIP
+        ri_pregnancy_end_date: "2023-03-07"
+        medicaid_household_size: 2
+        medicaid_income_level: 4
+      person2:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        has_esi: true
+        ri_pregnancy_coverage: CHIP
+        ri_pregnancy_end_date: "2023-03-07"
+        medicaid_household_size: 2
+        medicaid_income_level: 4
+      person3:
+        age: 30
+        is_pregnant: false
+        immigration_status: UNDOCUMENTED
+        has_esi: true
+        ri_pregnancy_coverage: CHIP
+        ri_pregnancy_end_date: "2023-03-07"
+        medicaid_household_size: 2
+        medicaid_income_level: 4
+      person4:
+        age: 30
+        is_pregnant: true
+        immigration_status: UNDOCUMENTED
+        has_esi: false
+        ri_pregnancy_coverage: CHIP
+        ri_pregnancy_end_date: "2023-03-07"
+        medicaid_household_size: 2
+        medicaid_income_level: 4
+      person5:
+        age: 30
+        is_pregnant: false
+        immigration_status: CITIZEN
+        has_esi: false
+        ri_pregnancy_coverage: CHIP
+        ri_pregnancy_end_date: "2022-11-27"
+        medicaid_household_size: 2
+        medicaid_income_level: 4
+    households:
+      household:
+        members: [person1, person2, person3, person4, person5]
+        state_code: RI
+  output:
+    is_chip_eligible_standard_pregnant_person: [true, true, true, true, false]
+    medicaid_enrolled: [false, false, false, false, false]
+    chip_enrolled: [true, true, true, true, false]
+
+# 210-RICR-30-00-1 § 1.6(A)(2)(b)(1) and (c) place a new pregnancy in the
+# CHIP band in CHIP, and 42 U.S.C. 1397jj(b)(1)(C) bars CHIP only for people
+# eligible under Title XIX, which the state-funded continuation is not.
+# https://risos-apa-production-public.s3.amazonaws.com/EOHHS/REG_13314_20250728104245127.pdf#page=5
+# https://www.law.cornell.edu/uscode/text/42/1397jj#b_1_C
+- name: Case 30, a new Rhode Island pregnancy in the CHIP band moves a state-funded continuation to CHIP.
+  period: 2024
+  input:
+    people:
+      person1:
+        age: 30
+        immigration_status: CITIZEN
+        is_pregnant: true
+        ri_pregnancy_coverage: RITE_START
+        ri_pregnancy_end_date: "2023-03-07"
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        takes_up_chip_if_eligible: true
+      person2:
+        age: 30
+        immigration_status: UNDOCUMENTED
+        is_pregnant: true
+        ri_pregnancy_coverage: FCEP
+        ri_pregnancy_end_date: "2023-03-07"
+        medicaid_household_size: 2
+        medicaid_income_level: 2.0
+        takes_up_chip_if_eligible: true
+      person3:
+        age: 30
+        immigration_status: CITIZEN
+        is_pregnant: true
+        ri_pregnancy_coverage: RITE_START
+        ri_pregnancy_end_date: "2023-03-07"
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        takes_up_chip_if_eligible: false
+      person4:
+        age: 30
+        immigration_status: CITIZEN
+        is_pregnant: true
+        ri_pregnancy_coverage: MEDICAID
+        ri_pregnancy_end_date: "2023-03-07"
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        takes_up_chip_if_eligible: true
+    households:
+      household:
+        members: [person1, person2, person3, person4]
+        state_code: RI
+  output:
+    is_medicaid_eligible: [false, false, true, true]
+    is_chip_eligible_standard_pregnant_person: [true, false, false, false]
+    is_chip_fcep_eligible_person: [true, true, false, false]
+    chip_enrolled: [true, true, false, false]
+
+# 210-RICR-30-00-1 § 1.6(A)(2)(a)(2) and (b)(1) pair the routes: Medicaid with
+# third-party insurance, CHIP without it. VA coverage, other means-tested
+# coverage and the aggregate other-coverage flag are not on Rhode Island's
+# third-party list, so these applicants stay in standard CHIP.
+# https://risos-apa-production-public.s3.amazonaws.com/EOHHS/REG_13314_20250728104245127.pdf#page=5
+- name: Case 31, Rhode Island pregnant applicants whose only coverage is outside the third-party list stay in standard CHIP.
+  period: 2024
+  input:
+    people:
+      person1:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        has_va_health_coverage_at_interview: true
+      person2:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        has_other_means_tested_health_coverage_at_interview: true
+      person3:
+        age: 30
+        is_pregnant: true
+        immigration_status: CITIZEN
+        medicaid_household_size: 2
+        medicaid_income_level: 2.3
+        has_health_coverage_other_than_chip: true
+    households:
+      household:
+        members: [person1, person2, person3]
+        state_code: RI
+  output:
+    is_medicaid_eligible: [false, false, false]
+    is_chip_eligible_standard_pregnant_person: [true, true, true]