Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-36 - Program of All-Inclusive Care for the Elderly (PACE)
Section 5160-36-06 - Program of all-inclusive care for the elderly (PACE): organization reimbursement
Current through all regulations passed and filed through September 16, 2024
(A) PACE is a full-risk program in which the PACE organization assumes all financial risk for the cost of the medical care and services provided to participants.
(B) PACE organizations shall receive a monthly capitated payment from the Ohio department of medicaid (ODM) for each PACE participant enrolled in the medicaid program including individuals enrolled in both medicaid and medicare.
(C) The amount of the capitated payment shall be established in the PACE agreement.
(D) The amount paid in accordance with paragraph (B) of this rule represents the total maximum payment obligation of the state administering agency to the PACE organization for the cost of medical care and services provided to participants enrolled in medicaid including those participants enrolled in both medicaid and medicare.
(E) The PACE organization shall accept the capitation payment amount as payment in full for medicaid participants and shall not bill, charge, collect, or receive any other form of payment from ODM or from, or on behalf of, the participant, except as permitted under 42 C.F.R. Part 460.182(c) as in effect on October 1, 2019.
