High vs Highest Level of Care in Rhode Island Medicaid: What Each Means

Most states have a single Medicaid level-of-care determination: you either qualify for long-term care services or you don't. Rhode Island is different. The state splits its clinical eligibility into two distinct tiers — "High" and "Highest" — and which one your parent receives determines not just whether they get services, but where they can receive them.

What "High" Level of Care Means

A "High" clinical designation means your parent has moderate functional deficits in their Activities of Daily Living. The DHS Clinical Team's assessment determines that without home and community-based services, your parent would deteriorate to the point of requiring institutional care.

People assessed at the "High" level can receive Medicaid LTSS services in community-based settings:

• Their own home (through the Personal Choice Program or agency-based home care)
• A shared living arrangement (RIte@Home)
• A licensed assisted living residence (through the Community Supportive Living Program)
• Adult day health programs

The critical restriction: "High" does not qualify your parent for Medicaid-funded nursing home placement. Even if the family believes a nursing home is the right setting, Medicaid will not cover it at this clinical level. The state's position is that if someone can be safely served in the community, that's where the services should be delivered.

What "Highest" Level of Care Means

A "Highest" designation means your parent has severe, unstable physical or cognitive impairments. The clinical determination requires evidence of at least one of these:

• Daily skilled nursing interventions — not just medication management, but active clinical care like wound treatment, catheter care, or IV therapy
• Comprehensive physical assistance requiring hands-on help from two or more people for transfers, mobility, or repositioning
• Cognitive behaviors posing imminent risk — wandering into traffic, physical aggression, inability to recognize danger

People assessed at the "Highest" level have complete freedom of choice. They can:

• Enter a licensed skilled nursing facility with full Medicaid coverage
• Choose to stay home or in assisted living and receive comprehensive, equivalent medical and personal services through the Medicaid HCBS waiver

This freedom-of-choice provision is significant. A "Highest" determination doesn't force nursing home placement — it simply opens that option. Many families with a "Highest" designation still choose community-based care because the person prefers it or because the family can supplement with their own oversight.

How the Assessment Works

The clinical level-of-care determination is conducted by the DHS Clinical Team (formerly called the Medicaid Office of Medical Review). The process requires two key forms:

Form GW-OMR-PM-1 (Provider Medical Statement): Your parent's physician completes this form documenting diagnoses, medications, functional limitations, and clinical needs. The physician's input carries significant weight — a vague or incomplete PM-1 can result in a lower classification than your parent's actual condition warrants.

Form AP-70.1 (Social Work Evaluation): A DHS social worker conducts an in-home assessment evaluating your parent's living environment, daily functioning, safety risks, and support network. This is the assessment that measures ADL performance, cognitive status, and behavioral indicators.

The Clinical Team reviews both forms together, along with any supporting medical records, and assigns the High or Highest determination. The process typically takes 30 to 60 days from the initial intake, though it can be faster if your parent is being discharged from a hospital.

What to Do If You Disagree

If your parent receives a "High" classification but their needs clearly warrant "Highest" — say they need two-person transfers that aren't safe to deliver at home, or they have dementia behaviors that an assisted living facility can't manage — you have options.

Request a reassessment. Clinical needs change, and Rhode Island allows reassessment requests at any time. If your parent's condition has worsened since the original evaluation, submit updated medical documentation and request a new determination.

Appeal the decision. If DHS denies, reduces, or terminates Medicaid LTSS services, the applicant has 35 days from the date on the Benefit Decision Notice to request a state fair hearing through EOHHS. During the appeal, your parent can continue receiving their current level of services.

Strengthen the medical documentation. The PM-1 form is where many families lose ground. If your parent's physician documented their condition vaguely — "needs help with daily activities" rather than "requires two-person assist for all transfers, incontinent, unable to manage medications independently" — the clinical team may underrate the severity. Ask the physician to be specific about functional limitations, fall frequency, and the level of skilled care required.

Why This Matters for Your Planning

The High/Highest distinction drives your family's entire care strategy:

• A "High" parent who truly needs a nursing home will be paying privately until their condition deteriorates enough to be reassessed at "Highest"
• A "Highest" parent who wants to stay home has stronger leverage to demand comprehensive home-based services — the state can't argue they don't qualify for intensive support

The Rhode Island Care Decision Guide covers the complete clinical assessment process, including how to prepare for the AP-70.1 home visit, what to ask your parent's physician to document on the PM-1, and the step-by-step appeal process if the determination doesn't match your parent's actual needs.

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