Alabama Administrative Code
Title 560 - ALABAMA MEDICAID AGENCY
Chapter 560-X-53 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)
Section 560-X-53-.04 - Participant Enrollment
Universal Citation: AL Admin Code R 560-X-53-.04
Current through Register Vol. 43, No. 02, November 27, 2024
(A) Enrollment Process
(1) Intake Process. Intake
is an intensive process during which PACE staff members make one or more visits
to a potential participant's place of residence and the potential participant
may make one or more visits to the PACE center. At a minimum, the intake
process must include the following activities:
(a) The PACE staff must explain to the
potential participant and his or her representative or caregiver the following
information:
(i) The PACE program, using a
copy of the enrollment agreement, specifically references the elements of the
agreement, including but not limited to
42 CFR §§
460.154(e), (i) through (m), and
(r);
(ii) The requirement that the PACE
organization would be the participant's sole service provider and clarification
that the PACE organization guarantees access to services, but not to a specific
provider;
(iii) A list of the
employees of the PACE organization who furnish care and the most current list
of contracted health care providers;
(iv) Monthly premiums, if any;
(v) Any Medicaid spenddown obligations;
and
(vi) Post-eligibility treatment
of income.
(b) The
potential participant must sign a release to allow the PACE organization to
obtain his or her medical and financial information and eligibility status for
Medicare and Medicaid.
(c) All
services provided to a Medicaid recipient must be medically necessary in order
to receive reimbursement.
(d) The
Alabama Medicaid Agency must assess the potential participant, including any
individual who is not eligible for Medicaid, to ensure that he or she meets the
nursing facility level of care as set forth in Rule No.
560-X-10-.10.
(e) The PACE staff must assess the potential
participant to ensure that he or she can be cared for appropriately in a
community setting and that he or she meets all requirements for PACE
eligibility as specified in 42 CFR §§
460.150 -
460.172.
(2) Denial of Enrollment. When an enrollment
is denied because his or her health or safety would be jeopardized by living in
a community setting, the PACE organization is required to complete the
following steps:
(a) Notify the individual in
writing of the reason for enrollment denial and their appeal rights;
(b) Refer the individual to alternative
services as appropriate;
(c)
Maintain supporting documentation of the reason for the denial; and
(d) Notify CMS and the Alabama Medicaid
Agency and make the documentation available for review.
(B) Enrollment Agreement and Procedures.
(1) The enrollment agreement
must, at a minimum, contain the information required by
42 CFR §
460.154, as may be amended.
(2) After the participant signs the
enrollment agreement, the PACE organization must give the participant the
following:
(a) A copy of the enrollment
agreement;
(b) A PACE membership
card;
(c) Emergency information to
be posted in his or her home identifying the individual as a PACE participant
and explaining how to access emergency services; and
(d) Stickers for the participant's Medicare
and Medicaid cards, as applicable, which indicate that he or she is a PACE
participant and which include the phone number of the PACE
organization.
(3) The
PACE organization must submit participant information to CMS and AMA in
accordance with established procedures.
(4) If there are changes in the enrollment
agreement information at any time during the participant's enrollment, the PACE
organization must meet the following requirements:
(a) Give an updated copy of the information
to the participant; and
(b) Explain
the changes to the participant and his or her representative or caregiver in a
manner they understand.
(5) If the prospective PACE enrollee meets
the eligibility requirements and signs the PACE enrollment agreement, the
effective date of enrollment in the PACE program is on the first day of the
calendar month following the date the PACE organization receives the
participant's signed enrollment agreement.
(C) Continuation of Enrollment
(1) Duration of enrollment. Enrollment
continues until the participant's death, regardless of changes in health
status, unless either of the following actions occur:
(a) The participant voluntarily
disenrolls.
(b) The participant is
involuntarily disenrolled, as described in Rule No. 560-X-53.05.
(c) Annual recertification requirement. At
least annually, the Alabama Medicaid Agency must reevaluate whether a
participant meets the nursing facility level of care as set forth in Rule No.
560-X-10-.10 and all services
provided to a Medicaid recipient must be medically necessary in order to
receive reimbursement.
(2) Continued Eligibility
(a) Deemed continued eligibility. If the
Alabama Medicaid Agency determines that a PACE participant no longer meets the
Alabama Medicaid Agency nursing facility level of care requirements, the
participant may be deemed to continue to be eligible for the PACE program until
the next annual reevaluation, if, in the absence of continued coverage under
this program, the participant reasonably would be expected to meet the nursing
facility level of care requirement within the next 6 months.
(b) Continued eligibility criteria.
(i) The Alabama Medicaid Agency must
establish criteria to use in making the determination of "deemed continued
eligibility." The Alabama Medicaid Agency, in consultation with the PACE
organization, makes a determination of deemed continued eligibility based on a
review of the participant's medical record and plan of care. These criteria
must be applied in reviewing the participant's medical record and plan of
care.
(ii) The criteria used to
make the determination of continued eligibility must be specified in the
program agreement.
Author: Linda Lackey, Medicaid Administrator, LTC Project Development Unit.
Statutory Authority: State Plan, Attachment 2.2-A, Attachment 3.1-A and Supplement 3; 42 CFR 460 Subpart I.
Disclaimer: These regulations may not be the most recent version. Alabama may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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