Official State of Rhode Island website

The Executive Office of Health and Human Services State of Rhode Island

Assisted Living

Provider Representative: Fidelia Williams-Edward   Tel. (401) 648-3759 email: fidelia.williams@gainwelltechnologies.com

Reference Guide

Updates

Assisted Living Facilities (ALF) Providers: 2025 Room and Board (R&B) and Cost of Care (COC) Updates

Effective January 1, 2025, the monthly Room and Board (R&B) Rate for all Medicaid LTSS Assisted Living participants with income below $2901 or 300% of the Federal Benefit Rate (FBR) will be $1299 to reflect the Year 2025 Federal Benefit Rate (FBR).   

Residents with income above the 300% FBR will be $2901 and adjusted accordingly based on single or double room occupancy. 

Cost of Care (COC) may also change to reflect the 2025 COLA for customers who are receiving SSA benefits and other income with annual COLA increases. 

For customers with income below $1299, their R&B may be less as such we encourage providers to help them apply for Category D to support their Room and Board. 

For assistance, questions, or concerns, please contact the DHS Assisted Living provider Email: DHS.AssistedLivingIntakes@dhs.ri.gov. 
 

New Explanation of Benefit (EOB) Codes
Beginning in the remittance advice 10/28/2022, provides will see three new Explanation of Benefit (EOB) codes post to their paid claims:

EOB 1003 – Claim used Tier A
EOB 1004 – Claim used Tier B
EOB 1005 – Claim used Tier C

These EOB’s will post to the notify the provider which tier was used to determine the per diem rate for pricing the claim. Additionally, there will be two new Error Status Codes (ESC) aka Edits:

Edit 150 – Provider assisted living level not on file - Claim will suspend with this ESC when the provider’s tier level is not on the provider’s profile.
Edit 151 – Recipient assisted living level not on file - Claim will suspend with this ESC when the recipient’s tier level is not on file. Recipient tier’s can be verified on the Healthcare Portal.

The 2 edits above will deny with EOB 249 – No rate on file for date of service billed.

For questions, please contact Provider Representative: Fidelia Williams-Edward at fidelia.williams@gainwelltechnologies.com or (401) 648-3759.

 

Billing Split Tiers and Patient Share
If a recipient changes their tier level during the month, the charges will need to be billed as 2 separate claims. This is different from past billing procedures.

For example:
Recipient has Tier A from 11/1/2022 – 11/15/2022 and Tier B from 11/16/2022-11/30/2022.
This would require 2 claims split to match the dates of service and units/days in each tier.

Additionally, it is important to check patient share on the Healthcare Portal to ensure that the share is entered to match the split in the tier level. If the share is not split and you bill two (2) claims for the month the share will be decremented twice.

If you do not see the patient share split you will need to contact Fidelia Williams-Edward of Gainwell Technologies at fidelia.williams@gainwelltechnologies.com or (401) 648-3759.