Chapter 173-50 PACE Program

173-50-01 Introduction and definitions.

(A) Introduction: Chapter 173-50 of the Administrative Code regulates PACE. PACE is a managed-care program that provides its participants with all of their necessary health care, medical care, and ancillary services in acute, sub-acute, institutional, and community settings. Examples of PACE services are primary and specialty care, adult day services, personal care services, inpatient hospital stays, prescription drugs, occupational therapy, physical therapy, and nursing facility care.

(B) Definitions for this chapter:

(1) "Authorized representative" has the same meaning as in rule

(2) "CDJFS" means the "county department of job and family services."

(3) "CMS" means "the centers for medicare and medicaid services."

(4) "ODA" means "the Ohio department of aging."

(5) "ODM" means "the Ohio department of ."

(6) "PACE" means "the program of all-inclusive care for the elderly," which is established by 42 C.F.R. 460 (October 1, 2013 edition).

(7) "PACE organization" means an entity that provides services to participants under a PACE program agreement with CMS and ODA.

(8) "Participant" means a person who receives services through PACE.

Effective: 12/19/2013
R.C. 119.032 review dates: 02/17/2018
Promulgated Under: 119.03
Statutory Authority: 173.01 , 173.02 , 173.50
Rule Amplifies: 173.50 ; 42 C.F.R. 460.6 (10/01/2013 edition)
Prior Effective Dates: 03/28/2009, 02/16/2012, 02/17/2013

173-50-02 Eligibility criteria.

(A) A person may enroll in PACE only if the person:

(1) Is at least fifty-five years of age;

(2) Resides within a PACE organization's service area;

(3) Requires intermediate level of care under rule 5101:3-3-05 of the Administrative Code or skilled level of care under rule 5101:3-3-06 of the Administrative Code;

(4) Resides in a non-institutional setting (e.g., house, apartment) without jeopardizing his/her health or safety;

(5) 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 for the premiums and patient-liability costs;

(6) Agrees to obtain medicaid services, if any, or medicare services, if any, only through the PACE organization during the period of enrollment in PACE; and,

(7) Is not enrolled in the following (or will discontinue enrollment in the following upon enrollment in PACE):

(a) A medicaid managed-care program other than PACE;

(b) A hospice program;

(c) The primary alternative care and treatment (PACT) program;

(d) A medicaid waiver program (e.g., PASSPORT, choices, or assisted living);

(e) The residential state supplement (RSS) program; or,

(f) A nursing facility that is certified by medicaid while medicaid is covering the person's nursing facility expenses.

(B) At least once per year, ODA shall assess whether each participant continues to require an intermediate level of care under rule 5101:3-3-05 of the Administrative Code or a skilled level of care under rule 5101:3-3-06 of the Administrative Code. ODA may permanently waive the requirement to perform the assessment if ODA does not reasonably expect the participant's health to improve or significantly change.

(C) If, at any time, a participant in PACE no longer meets the criteria in paragraph (A) of rule 173-50-05 of the Administrative Code, the PACE organization may use the process for involuntary disenrollment described in that rule. However, a participant who may no longer meet the financial eligibility criteria for medicaid may remain eligible for PACE as long as the participant pays the premiums and the patient-liability costs incurred while using PACE. (For more information see rule 173-50-05 of the Administrative Code ; 42 C.F.R. 460.150(d) and 42 C.F.R. 460.160(a) (October 1, 2011 edition).)

Effective: 02/17/2013
R.C. 119.032 review dates: 11/21/2012 and 02/17/2018
Promulgated Under: 119.03
Statutory Authority: 173.01 , 173.02 , 173.50
Rule Amplifies: 173.50 ; 42 C.F.R. 460.150 , 460.160 (10/01/2011 edition)
Prior Effective Dates: 03/28/2009

173-50-03 Enrollment process.

(A) Oversight:

(1) ODA manages the enrollment for PACE.

(2) ODA determines if a slot is available in PACE in which to enroll an applicant.

(3) ODA reserves the right to restrict enrollment based upon funding appropriated for PACE.

(4) ODA reserves the right to increase or decrease the maximum number of PACE slots.

(B) Enrollment process, in general:

(1) To begin the enrollment process, a person may apply through either a CDJFS or a PACE organization.

(2) The CDJFS and the PACE organization shall coordinate efforts regarding the enrollment process.

(C) Enrollment process when a person initially contacts a CDJFS to apply for enrollment into PACE:

(1) The applicant shall complete form JFS07200 and form JFS02398 (or, instead of form JFS02398, form JFS02399).

(2) After form JFS 07200 is completed, the CDJFS shall determine if the applicant meets the financial eligibility criteria for medicaid that are specified in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(3) If the CDJFS determines that the applicant does not meet the financial eligibility criteria, it shall send a notice of denial and appeal rights to the applicant (or the authorized representative), as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. It shall also send a notice of denial to ODA and the PACE organization.

(4) The CDJFS may help the applicant complete, or partially complete, form JFS02398 (or form JFS02399). Afterwards, it shall forward the form (or the information on the form) to the PACE organization.

(5) Once a PACE organization receives the form (or the information from the form), it shall contact the applicant to complete the form, if necessary, and to provide the applicant with an in-person assessment to determine eligibility for PACE.

(6) Once the in-person assessment is fully completed, the PACE organization shall forward the information from its assessment to ODA.

(7) After receiving the information, ODA shall determine if the applicant meets the eligibility criteria specified in rule 173-50-02 of the Administrative Code.

(8) If ODA determines that an applicant meets the eligibility criteria, then:

(a) ODA shall notify the PACE organization of its determination.

(b) Once the PACE organization receives the determination from ODA, it shall notify the applicant (or the authorized representative) of the approval of enrollment into PACE and provide the applicant (or the authorized representative) with an enrollment agreement to sign.

(c) In order to be enrolled into the program, the applicant shall sign the enrollment agreement and return it to the PACE organization.

(d) The applicant's enrollment into PACE is effective the first day of the month following the date that ODA determined that the applicant met the eligibility criteria and the PACE organization received the signed enrollment agreement.

(9) If ODA determines that an applicant does not meet the eligibility criteria, then:

(a) ODA shall notify the PACE organization of its determination.

(b) ODA shall provide the applicant (or the authorized representative) with a notice of denial and appeal rights, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

(D) Enrollment process when a person initially contacts a PACE organization to apply for PACE:

(1) The PACE organization shall provide the applicant with an in-person assessment to determine eligibility.

(2) The PACE organization may help the applicant apply for medicaid financial eligibility or may help the applicant complete form JFS07200 and may secure the applicant's signature (or authorized representative's signature) for form JFS02398 (or, instead of form JFS02398, form JFS02399). The PACE organization may submit the forms to the CDJFS on the applicant's behalf.

(3) After form JFS07200 is received, the CDJFS shall determine if the applicant meets the financial eligibility criteria for medicaid that are specified in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(4) If the CDJFS determines that the applicant does not meet the financial eligibility criteria, it shall send a notice of denial and appeal rights to the applicant (or the authorized representative), as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. It shall also send a notice of denial to ODA and the PACE organization.

(5) After completing the in-person assessment, the PACE organization shall submit the information from its assessment to ODA.

(6) After receiving the information, ODA shall determine if the applicant meets the eligibility criteria specified in rule 173-50-02 of the Administrative Code.

(7) If ODA determines that an applicant meets the eligibility criteria, then:

(a) ODA shall notify the PACE organization of its determination.

(b) Once the PACE organization receives the determination from ODA, it shall notify the applicant (or the authorized representative) of the approval of enrollment into PACE and provide the applicant (or the authorized representative) with an enrollment agreement to sign.

(c) In order to be enrolled into the program, the applicant shall sign the enrollment agreement and return it to the PACE organization.

(d) The applicant's enrollment into PACE is effective the first day of the month following the date that ODA determines the applicant meets the eligibility criteria and the PACE organization received the signed enrollment agreement.

(8) If ODA determines that an applicant does not meet the eligibility criteria, then:

(a) ODA shall notify the PACE organization of its determination.

(b) ODA shall provide the applicant (or the authorized representative) with a notice of denial and appeal rights, as specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

(E) No available slot: If a slot is not available in PACE, the PACE organization may enroll the eligible individual when a slot does become available by one of two means: the unified waiting list or the home-first component of PACE.

(1) Unified waiting list: If the applicant meets the non-financial eligibility criteria 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 the terms of rule 173-44-04 of the Administrative Code.

(2) Home first:

(a) The PACE organization shall enroll an eligible individual who qualifies for the home first component of PACE before any eligible individual on the unified waiting list.

(b) An eligible individual qualifies for the home first component of PACE if the eligible individual meets both of the following sets of criteria:

(i) The PACE organization has determined that the individual meets all the eligibility requirements in rule 173-50-02 of the Administrative Code.

(ii) The individual meets at least one of the following four sets of criteria:

(a) The individual resides in a nursing facility.

(b) A physician has determined and documented in writing that the individual has a medical condition that, unless ODA's designee or the PACE organization enrolls the individual into a home and community-based program such as PACE, the individual will require admission to a nursing facility in fewer than thirty days after the physician's determination.

(c) The individual has been hospitalized and a physician has determined and documented in writing that, unless the ODA's designee or the PACE organization enrolls the individual in a home and community-based program such as PACE, the individual is to be transported directly from the hospital to a nursing facility and admitted.

(d) Both of the following apply:

(i) The individual is the subject of a report made under section 5101.61 of the Revised Code regarding abuse, neglect, or exploitation or such a report referred to the CDJFS under section 5126.31 of the Revised Code or has made a request for adult protective services as defined in section 5101.60 of the Revised Code; and,

(ii) A CDJFS or ODA's designee have jointly documented in writing that, unless the ODA's designee or the PACE organization enrolls the individual into a home and community-based program such as PACE, the individual should be admitted to a nursing facility.

(F) Definitions for this rule:

(1) "JFS02398 (rev. 8/1999) 'Request for Program of All-Inclusive Care for the Elderly Services'" ("JFS 02398") means the form a CDJFS may use to refer an applicant to a PACE organization.

(2) "JFS02399 (rev. 1/2012) 'Home and Community Based Services Waiver Referral'" ("JFS 02399") means the form a CDJFS may use to refer an applicant to a PACE organization.

(3) "JFS07200 (rev. 12/2012) 'Request for Cash, Food, and Medical Assistance'" ("JFS 07200") means the form a CDJFS uses to determine if an applicant is eligible for medicaid.

Effective: 02/17/2013
R.C. 119.032 review dates: 11/21/2012 and 02/17/2018
Promulgated Under: 119.03
Statutory Authority: 173.01 , 173.02 , 173.404 , 173.50
Rule Amplifies: 173.404 , 173.50 , 173.501 ; 42 C.F.R. 460.152 , 460.154 , 460.156 (10/01/2011 edition)
Prior Effective Dates: 03/28/2009, 01/14/2010, 03/12/2011, 09/29/2011

173-50-04 Voluntary disenrollment.

(A) A participant may voluntarily disenroll from PACE at any time without cause.

(B) Process for voluntary disenrollment:

(1) A participant who wishes to voluntarily disenroll from PACE shall initiate the voluntary disenrollment process by informing the PACE organization orally or in writing.

(2) Once the PACE organization receives the participant's request, it shall provide the participant with a disenrollment form.

(3) Once the participant receives the disenrollment form, he or she shall sign the form and return it to the PACE organization.

(4) After the PACE organization receives the signed disenrollment form, it shall forward the form to ODA on the participant's behalf no later than one working day after receiving the form.

(5) Once ODA receives a signed disenrollment form, it shall chose a date of disenrollment that occurs no earlier than the date on which the signed disenrollement form was received by the PACE organization and no later than the first day of the month after the month during which the PACE organization forwards the disenrollment form to ODA.

(6) After ODA chooses a date of disenrollment, it shall notify the participant in writing.

(C) After a participant initiates a voluntary disenrollment, the PACE organization shall:

(1) Complete the mandates regarding the disenrollment form in paragraphs (B)(2)

and (B)(4) of this rule;

(2) Continue to furnish necessary services to the participant until the date of disenrollment;

(3) Create a discharge plan to help the participant obtain necessary transitional care through referrals to other medicaid or medicare service providers, preferably within the service area; and,

(4) Provide the medical records of the participant in a timely manner to any provider to whom a referral is made as part of the discharge plan.

(D) After the participant initiates a voluntary disenrollment, he or she shall:

(1) Complete the mandate regarding the disenrollment form in paragraph (B)(3) of this rule;

(2) Continue to obtain necessary services from the PACE organization until the date of disenrollment; and,

(3) Remain liable for any premium or patient-liability costs incurred for services rendered by the PACE organization for all dates before the date of disenrollment.

Effective: 02/17/2013
R.C. 119.032 review dates: 11/21/2012 and 02/17/2018
Promulgated Under: 119.03
Statutory Authority: 173.01 , 173.02 , 173.50
Rule Amplifies: 173.50 ; 42 C.F.R. 460.162 (10/01/2011 edition)
Prior Effective Dates: 03/28/2009

173-50-05 Involuntary disenrollment.

(A) Criteria for involuntary disenrollment of a participant from PACE:

(1) Failure to pay: The participant fails to pay (or satisfactorily arrange to pay) any premium or patient-liability cost owed to the PACE organization after a thirty-day grace period; and, the PACE organization has documentation that it made at least one attempt in writing to:

(a) Collect the unpaid costs;

(b) Warn that the non-payment of costs may lead to disenrollment; and,

(c) Explain that no right to file a grievance exists for a participant who is disenrolled because he or she did not pay patient-liability costs.

(2) Fraud: The participant commits medicaid fraud or medicaid eligibility fraud, as described in sections 2913.40 and 2913.401 of the Revised Code, and the PACE organization has a signed narrative of the events from the staff person who discovered the fraud;

(3) Abusive behavior: The participant engages in abusive behavior (e.g. threats with a weapon, physical abuse, or recurrent verbal abuse) that jeopardizes the participant's safety, other participants' safety, or the safety of employees of the PACE organization, an affiliate, or a subcontractor; and, the PACE organization has the following documentation of at least one incident:

(a) A signed statement from a witness or the provider; and,

(b) A police report or a security staff report.

(4) Geography: The participant's permanent residence is no longer located in the service area, the participant is outside the service area or is incarcerated for more than thirty consecutive days, unless the PACE organization authorizes a longer period of absence for extenuating circumstances;

(5) Physician-patient relationship: The participant fails to maintain a satisfactory physician-patient relationship (e.g., repeated non-compliance with medical advice or repeated failure to keep appointments);

(6) Care plan: The participant is not compliant with the interdisciplinary team's care plan; and:

(a) The participant is capable of making informed decisions;

(b) Non-compliance with the care plan may result in a negative health outcome; and,

(c) The PACE organization has documentation that it made at least two attempts in the past six months to educate the participant on the importance of following the care plan, the negative health consequences of not doing so, and a warning that not doing so may result in disenrollment. Medical records and copies of letters written to the participation are examples of acceptable documentation.

(7) Level of care: The participant is determined to no longer meet the level-of-care requirements and is not deemed eligible;

(8) Providers: The PACE organization is unable to offer healthcare services because of a loss of state licenses or contracts with outside providers; or,

(9) PACE agreement: The agreement between the PACE organization, ODA, and CMS is not renewed or is terminated.

(B) Process for involuntary disenrollment:

(1) If a PACE organization requests permission to disenroll a participant under this rule, it shall submit the request to ODA along with:

(a) Documentation supporting one or more criteria in paragraph (A) of this rule; and,

(b) The participant's utilization profile.

(2) In the time between the request and ODA's decision:

(a) The PACE organization shall continue to provide for the necessary services to the participant; and,

(b) The participant shall continue to obtain necessary services under medicaid only through the PACE organization.

(3) ODA shall approve or deny the request based upon the criteria in paragraph (A) of this rule, then notify the PACE organization and the participant.

(4) If ODA does not approve the request:

(a) The PACE organization shall continue to provide necessary services to the participant; and,

(b) The participant shall continue to obtain necessary services under medicaid only through the PACE organization.

(5) If ODA approves the request:

(a) It shall establish the last date of enrollment for the participant as:

(i) The last day of the month in which the request was made;

(ii) The date of death, if the participant dies before the last day of the month in which the request was made; or,

(iii) The date on which the PACE agreement terminates, if the date occurs before the last day of the month in which the request was made.

(b) The PACE organization shall notify the participant in writing of the last day of enrollment;

(c) The PACE organization shall continue to provide for the necessary services to the participant through the last day of enrollment;

(d) The participant shall continue to obtain necessary services under medicaid only through the PACE organization and shall continue to remain liable for any premiums or patient-liability costs incurred through the last day of enrollment; and,

(e) The PACE organization shall create a discharge plan for each participant who is involuntarily disenrolled, regardless of the reason for the disenrollment. In each discharge plan, it shall state how it plans to:

(i) Help the participant obtain necessary transitional care;

(ii) Provide medical records to new providers;

(iii) Initiate the process of returning the participant to a fee-for-service medicaid program if the participant was enrolled in a fee-for-service medicaid program before enrolling into PACE.

Effective: 02/17/2013
R.C. 119.032 review dates: 11/21/2012 and 02/17/2018
Promulgated Under: 119.03
Statutory Authority: 173.01 , 173.02 , 173.50
Rule Amplifies: 173.50 ; 42 C.F.R. 460.164 (10/01/2011 edition)
Prior Effective Dates: 03/28/2009