Current through all regulations passed and filed through September 16, 2024
(A)
A person is
eligible for PACE only if the person meets all the following
requirements:
(1)
The person is at least fifty-five years of
age.
(2)
The person resides within a PACE organization's service
area.
(3)
The person has an intermediate or skilled level of care
in accordance with rule
5160-3-08 of the Administrative
Code.
(4)
ODA or its designee determine the person can live in a
community setting without jeopardizing his or her health and
safety.
(5)
The person, who may be enrolled as a medicaid or a
non-medicaid enrollee, is responsible for payment to the PACE organization as
follows:
(a)
If
a person is applying for, or enrolled in, PACE through the medicaid program,
the person maintains medicaid eligibility either under the financial
eligibility standard or under a needs allowance if the person has moved from an
institutional setting to a non-institutional setting, or pays the premiums and
any post-eligibility treatment of income (i.e., patient liability or share of
cost) ODM may require in rule
5160:1-6-07.1 of the
Administrative Code.
(b)
If a person is applying for, or enrolled in, PACE as a
non-medicaid enrollee, the person may remain eligible for PACE if the person
pays the premiums and incurred while using PACE. (For more information, see
rule 173-50-05 of the Administrative
Code and
42 C.F.R.
460.150 and
460.160.)
(6)
The
person agrees to obtain medicaid services, if any, or medicare services, if
any, only through the PACE organization during the period of enrollment in
PACE.
(7)
At the time of initial enrollment, the person meets the
following;
(a)
The person is not enrolled in one or more of the following
(or will discontinue being enrolled in one or more of the following upon
enrollment in PACE):
(i)
A medicaid managed-care program other than
PACE.
(ii)
A hospice program.
(iii)
The primary
alternative care and treatment (PACT) program.
(iv)
A medicaid
waiver program (e.g., PASSPORT or assisted living).
(v)
The residential
state supplement (RSS) program.
(vi)
A nursing
facility certified by medicaid while medicaid is covering the person's nursing
facility expenses.
(b)
The person
resides in a non-institutional setting (e.g., house,
apartment).
(B)
42 C.F.R.
460.160 requires ODA to assess, at least once
per year, whether each participant continues to require an intermediate or
skilled level of care in accordance with rule
5160-3-08 of the Administrative
Code. ODA may permanently waive the annual assessment if ODA does not
reasonably expect the participant's health to improve or significantly
change.
(C)
At any time and for any reason listed under paragraph
(A) of rule
173-50-05 of the Administrative
Code, the PACE organization may use the process in that rule for involuntary
disenrollment.
