Current through Register Vol. 50, No. 9, September 20, 2024
A. In order to be
eligible for services from a PACE site an applicant must:
1. be 55 years of age or older;
2. be determined by the state administering
agency to meet nursing facility level of care, as established by the Department
of Health;
3. reside in the service
area of the PACE organization; and
4. at the time of enrollment, an individual
must be able to live in a community setting without jeopardizing his or her
health or safety.
B.
Eligibility to enroll in a PACE program is not restricted to an individual who
is either a Medicare beneficiary or Medicaid participant. A potential
participant may be, but is not required to be, any or all of the following:
1. entitled to Medicare Part A;
2. enrolled under Medicare Part B;
or
3. eligible for
Medicaid.
C. The
determination whether a potential participant can be cared for in the community
at the time of enrollment without jeopardizing his or her safety is based on
the PACE organization's evaluation of the potential participant. The following
are issues to consider when making this determination.
1. The potential participant does not have
the capability to call for emergency assistance or does not have the capability
to determine when emergency assistance is needed.
2. A physician, familiar with the potential
participant's health and social history, has documented a condition for the
potential participant that requires 24-hour/7-days per week of skilled
care.
3. The potential
participant's residence:
a. has been
condemned; or
b. has been
determined unsafe by habitation by PACE provider (detailed documentation of
specifics required); or
c. poses a
threat to PACE program staff due to:
i.
physical condition and integrity of dwelling; or
ii. evidence of abuse and/or neglect from
other household members; or
iii.
criminal activities or behavior; or
iv. illegal drug use; or
v. brandishing of weapons; or
vi. dangerous pets/animals.
4. The potential
participant exhibits health concerns that involve dangerous behavior(s) which
would pose a threat to him/her, other PACE participants, or PACE program
staff.
5. The potential participant
whose current medical treatment or regimen requires 24-hour supervision and
whose care is more appropriately provided in an institutional setting (hospital
or skilled nursing facility).
6.
Repealed.
D. If the PACE
organization determines that an applicant's health and safety cannot be ensured
with the services that PACE can provide, the PACE organization shall submit the
following within five working days to the Office of Aging and Adult Services
(OAAS):
1. justification for the determination
that health and safety cannot be ensured; and
2. any and all assessments and medical
records use to make the determination;
E. If OAAS agrees with the PACE organization,
OAAS will provide documentation to the PACE organization in writing
acknowledging the health and safety concern.
1. - 2. Repealed.
F. If the potential participant is denied
enrollment because the potential participant's health or safety would be
jeopardized by living in a community setting, the PACE organization must meet
the following requirements:
1. notify the
potential participant in writing of the reason for denial with notification of
appeal rights through the state fair hearing process;
2. refer the potential participant to
alternative services, as appropriate;
3. maintain supporting documentation of the
reason for denial; and
4. notify
CMS and OAAS in the form and manner specified by CMS and make the documentation
available for review.
G.
If OAAS disagrees with the PACE organization, OAAS will provide the PACE
organization with specific information as to why OAAS believes that with PACE
services in place, a plan of care can be developed that is adequate to ensure
the participant's health, social, and welfare needs. In addition, OAAS will
provide suggestions for services that would be beneficial to the
participant.
H. A PACE organization
shall 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.
I. Reevaluation of Eligibility
1. LDH shall annually reevaluate whether the
participant continues to meet level of care for nursing facility services. LDH
may permanently waive the annual recertification of level of care requirements
for a participant if it determines that there is no reasonable expectation of
improvement or significant change in the participant's condition because of the
severity of a chronic condition or the degree of impairment of functional
capacity.
2. LDH may determine that
a PACE participant who no longer meets the state Medicaid nursing facility
level of care requirements 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 six
months.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254, Title XIX of the Social Security Act,
and 42 CFR 460 et seq.
