Current through all regulations passed and filed through December 16, 2024
(A)
Oversight:
(1)
ODA manages the
enrollment for PACE.
(2)
ODA determines if a slot is available in
PACE.
(3)
ODA may restrict enrollment based upon funding for
PACE.
(4)
ODA may increase or decrease the maximum number of PACE
slots.
(B)
Intake process:
(1)
A person may
apply for PACE through either ODM's administrative agency or a PACE
organization. The two agencies coordinate intake with ODA.
(2)
The PACE
organization is responsible for completing its intake duties under
42 C.F.R.
460.152 and notifying ODA of any applicant
and its determination under 42 C.F.R.
460.152(a)(4). The PACE
organization may help the applicant apply for medicaid, unless the applicant is
already enrolled in medicaid.
(3)
ODM's
administrative agency is responsible for determining whether the applicant
meets all financial eligibility requirements for medicaid in Chapters 5160:1-1
to 5160:1-6 of the Administrative Code, notifying ODA, the PACE organization,
and the applicant (or the applicant's representative) of its determination,
and, if the applicant does not meet all financial eligibility requirements,
notifying the applicant (or the applicant's authorized representative) of the
denial and appeal rights under section
5101.35 of the Revised Code and
division 5101:6 of the Administrative Code. An applicant who is denied medicaid
may still enroll in PACE if the applicant is willing to privately pay the
premium that would have been covered by medicaid.
(4)
ODA is
responsible for the level-of-care assessment under
42 C.F.R.
460.152(a)(3) and rule
5160-3-08 of the Administrative
Code. ODA, in its discretion, may delegate this responsibility.
(C)
Enrollment: If ODA determines that an applicant meets all
eligibility requirements in rule
173-50-02 of the Administrative
Code, then the following apply:
(1)
ODA notifies the PACE organization of its
determination.
(2)
The PACE organization is responsible for notifying the
applicant of the opportunity to proceed with the process of enrolling into
PACE, providing the applicant with the enrollment agreement under
42 C.F.R.
460.154, and completing the enrollment
procedures in 42 C.F.R.
460.156 if the applicant signs the enrollment
agreement.
(3)
42
C.F.R. 460.158 determines the effective date
of the applicant's enrollment into PACE.
(D)
Denial: If the
PACE organization determines that an applicant does not meet all eligibility
requirements, then the PACE organization shall notify CMS and ODA of its
determination and need to notify the applicant of the denial and appeal rights
under section 5101.35 of the Revised Code and
division 5101:6 of the Administrative Code.
(E)
No available
slot: If a slot is not available in PACE, the PACE organization shall enroll
the applicant when a slot becomes available (if the individual continues to
meet the eligibility requirements) by one of the following two means:
(1)
Unified waiting
list: If the applicant meets the non-financial eligibility requirements for
enrollment into PACE, but a slot in the program is not available, the PACE
organization shall place the applicant on the unified waiting list under rule
173-44-04 of the Administrative
Code.
(2)
Home first: If the applicant meets all requirements for
the home first component of PACE in section
173.501 of the Revised Code, the
PACE organization shall enroll the applicant in PACE before enrolling any
applicant from the unified waiting list in PACE.
(F)
Initial
comprehensive assessment: The PACE organization's IDT is responsible for
completing the initial in-person comprehensive assessment of the participant
under 42 C.F.R.
460.104.
(G)
Plan of
care:
(1)
The
PACE organization's IDT is responsible for the initial in-person assessment and
in-person semi-annual reassessment under
42 C.F.R.
460.104.
(2)
In addition to
the semi-annual reassessments, the IDT may conduct an unscheduled reassessment
under under 42 C.F.R.
460.104 in person.
(3)
The IDT is
responsible for the comprehensive plan of care under
42 C.F.R.
460.106 based on the assessments in
paragraphs (G)(1) and (G)(2) of this rule.
(H)
Continued
enrollment: Continued enrollment is dependent upon the annual recertification
requirements in 42 C.F.R.
460.160.
(I)
An authorized
representative may represent an applicant in the enrollment process and a
participant in the reevaluation processes.
Replaces: 173-50-03