Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 270 - CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)
Section 270.12 - Client Eligibility Criteria
Universal Citation: 26 TX Admin Code ยง 270.12
Current through Reg. 49, No. 38; September 20, 2024
(a) To be eligible for participation the applicant must:
(1) be 55 years old or older;
(2) meet the medical necessity criteria for
nursing facility care in accordance with §19.2401
of this title (relating to General Qualifications for Medical Necessity
Determinations);
(3) live in a
Programs of All-Inclusive Care for the Elderly (PACE) service area;
and
(4) be determined by the PACE
Interdisciplinary Team (IDT) as able to be safely served in the
community.
(b) To be eligible for Medicaid capitated payment the applicant must be eligible for full Medicaid benefits through one of the following methods:
(1) be eligible for Supplemental Security
Income (SSI) benefits;
(2) have
been eligible for and received SSI benefits, and continue to be eligible for
Medicaid as a result of coverage mandated by federal law; or
(3) be eligible for Medicaid benefits, if
institutionalized.
(c) To obtain and maintain eligibility, the client must agree to accept the provider agency and its contractors as the client's only service provider.
(d) If the provider agency denies enrollment because the IDT determines that the applicant cannot be served safely in the community, the agency must:
(1) notify the
applicant in writing of the reason for the denial;
(2) refer the individual to alternative
services, as appropriate;
(3)
maintain supporting documentation for the denial; and
(4) notify the Centers for Medicare and
Medicaid Services and the Department of Aging and Disability Services of the
denial and make the supporting documentation available for
review.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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