Current through March 25, 2025
1.13.1
Overview
PACE provides a managed plan of coordinated Medicare and
Medicaid covered services from across the care continuum to certain
beneficiaries age fifty-five (55) and older. The operations of PACE are bound
by a three (3) way agreement between EOHHS, CMS, and the PACE provider to
integrate the full range of Medicare (if eligible) and Medicaid services
(primary care, acute care, specialty care, behavioral health care, and LTSS)
for PACE participants.
1.13.2
EOHHS Responsibilities
EOHHS is responsible for the eligibility and enrollment
functions set forth in §1.13.4 of this Part, establishing PACE provider
standards, and oversight and monitoring of all aspects of the PACE
program.
1.13.3
PACE
Provider Responsibilities
A. The PACE
provider is responsible for:
1. Point of entry
identification;
2. Submitting all
necessary documentation for initial determinations and reevaluations of a level
of need and referral to EOHHS for a determination of financial
eligibility;
3. Verifying PACE
enrollment prior to service delivery;
4. Verifying and collecting required
beneficiary liability (cost-share amount);
5. Providing and coordinating all integrated
services;
6. Reporting changes to
the PACE-eligibility status of participants; and
7. Adhering to all PACE provider requirements
as outlined in the PACE Program Agreement between EOHHS and CMS, and to all
credentialing standards required by EOHHS including data submission.
1.13.4
PACE
Participation Criteria
A. To qualify as
a Medicaid-eligible PACE participant, an individual must:
1. Be fifty-five (55) years of age or
older;
2. Meet the criteria for a
high or the highest need for a nursing facility level of care in accordance
with Part 50-00-5 of this Title; and
3. Meet all other financial and non-financial
requirements for Medicaid LTSS such as, but not limited to, citizenship,
residency, resources, income, and transfer of assets.
B. Medicaid-eligible PACE participants may
be, but are not required to be, enrolled in Medicare.
1.13.5
PACE Disenrollment
A. Reasons for PACE Disenrollment - Reasons
for disenrollment from PACE include but are not limited to:
2. Loss of Medicaid eligibility;
4. Placement in an out-of-State residential
hospital;
6. Change of State
residence;
7. Loss of functional
level of care; and
8. Voluntary
opt-out to Medicaid FFS.
B. The PACE provider may also request in
writing that a member be disenrolled on the grounds that the member's continued
enrollment seriously impairs the entity's capacity to furnish services to
either the particular member or other members. In such instances, EOHHS will
notify the PACE provider about its decision to approve or disapprove the
disenrollment request within fifteen (15) days from the date EOHHS has received
all information needed for a decision. Upon EOHHS approval of the disenrollment
request, the PACE provider must, within three (3) business days, forward copies
of a completed Disenrollment Request Form to EOHHS and to the Medicare
enrollment agency (when appropriate). The PACE provider must also send written
notification to the member that includes:
1. A
statement that the PACE provider intends to disenroll the member;
2. The reason(s) for the intended
disenrollment; and
3. A statement
about the member's right to challenge the decision to disenroll and how to
grieve or appeal such decision.
C. Disenrollment Requests Not Allowed. EOHHS
does not permit disenrollment requests based on:
1. An adverse change in the member's health
status;
2. The member's utilization
of medical services; or
3.
Uncooperative behavior resulting from the member's special needs.
D. Voluntary Disenrollment - PACE
participants may voluntarily disenroll from PACE at any time. A voluntary
disenrollment from PACE will become effective at midnight of the last day of
the month in which the disenrollment is requested.
E. Disenrollment Process. Regardless of the
reason for disenrollment, EOHHS is responsible for completing all disenrollment
actions. Disenrollments requested by the PACE provider on the grounds that the
member's continued enrollment seriously impairs the entity's capacity to
furnish services to either the particular member or other members are subject
to EOHHS approval. Beneficiaries who are disenrolled from PACE but retain
Medicaid eligibility will be enrolled in Medicaid fee-for-service and may
subsequently choose or be enrolled in an alternative service delivery if they
qualify. Beneficiaries have the right to appeal EOHHS's disenrollment action
(see Part 10-05-2 of this Title).
F. Disenrollment Effective Date. Regardless
of the reason for disenrollment, all disenrollments from PACE will become
effective at midnight of the last day of the month in which the disenrollment
is requested.
1.13.6
Disenrollment Appeal
If the member files a written appeal of the disenrollment
within ten (10) days of the decision to disenroll, the disenrollment shall be
delayed until the appeal is resolved.
1.13.7
Re-enrollment and Transition Out
of PACE
All re-enrollments will be treated as new enrollments
except when a participant re-enrolls within two (2) months after losing
Medicaid eligibility. In this situation, the participant's re-enrollment will
not be treated as a new enrollment. The PACE provider shall assist participants
whose enrollment ceased for any reason in obtaining necessary transitional care
through appropriate referrals, by making medical records available to the
participant's new service providers, and (if applicable), by working with EOHHS
to reinstate the participant's benefits.
