Chapter 173-50 PACE Program

173-50-01 PACE: 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:

"Authorized representative" has the same meaning as in rule 5160-36-01 of the Administrative Code.

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

"CMS" means "the centers for medicare and medicaid services."

"ODA" means "the Ohio department of aging."

"ODM" means "the Ohio department of medicaid."

"ODM's administrative agency" has the same meaning as "administrative agency" in rule 5160:1-1-01 of the Administrative Code.

"PACE" means "the program of all-inclusive care for the elderly," which is established by 42 C.F.R. Part 460 (October 1, 2015).

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

"Participant" means a person who receives services through PACE.

Effective: 8/1/2016
Five Year Review (FYR) Dates: 04/18/2016 and 08/01/2021
Promulgated Under: 119.03
Statutory Authority: 173.01, 173.02, 173.50
Rule Amplifies: 173.50 ; 42 C.F.R. 460.6 (October, 2015 edition)
Prior Effective Dates: 03/28/2009, 02/16/2012, 02/17/2013, 12/19/2013

173-50-02 PACE: eligibility requirements.

(A) A person may enroll in PACE only if the person meets all the following requirements:

(1) The person is at least fifty-five years of age.

(2) The person resides within a PACE organization's service area.

(3) The person requires intermediate level of care under rule 5160-3-05 of the Administrative Code or skilled level of care under rule 5160-3-08 of the Administrative Code.

(4) At the time of initial enrollment, the person resides in a non-institutional setting (e.g., house, apartment) without jeopardizing his or her health or safety.

(5) The person 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 the premiums and any post-eligibility treatment of income ( i.e., patient liability or share of cost) ODM may require in rule 5160:1-6-07.1 of the Administrative Code.

(6) The person agrees to obtain medicaid services, if any, or medicare services, if any, only through the PACE organization during the period of enrollment in PACE.

(7) The person is not enrolled in one or more of the following (or will discontinue being enrolled in one or more of 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 or assisted living).

(e) The residential state supplement (RSS) program.

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

(B) 42 C.F.R. 460.160 requires ODA to assess, at least once per year, whether each participant continues to require an intermediate level of care under rule 5160-3-05 of the Administrative Code or a skilled level of care under rule 5160-3-06 of the Administrative Code. ODA may permanently waive the requirement to perform this 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 requirements 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 no longer meets the financial eligibility requirements for medicaid may remain eligible for PACE as long as the participant pays the premiums and 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) .)

Effective: 11/1/2018
Five Year Review (FYR) Dates: 8/14/2018 and 11/01/2023
Promulgated Under: 119.03
Statutory Authority: 173.01, 173.02, 173.50
Rule Amplifies: 173.50 ; 42 C.F.R. 460.150, 460.160
Prior Effective Dates: 03/28/2009, 02/17/2013, 08/01/2016

173-50-03 PACE: enrollment process.

(A) Oversight:

(1) ODA manages the enrollment for PACE.

(2) ODA determines if a slot is available in PACE .

(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 ODM's administrative agency or a PACE organization.

(2) ODM's administrative agency and the PACE organization shall coordinate efforts regarding the enrollment process.

(C) Enrollment process when a person initially contacts ODM's administrative agency to apply for enrollment into PACE:

(1) The applicant shall apply for medicaid (unless already enrolled in medicaid) with the assistance of ODM's administrative agency.

(2) After the applicant applies, ODM's administrative agency shall determine if the applicant meets all financial eligibility requirements for medicaid in Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(3) If ODM's administrative agency determines the applicant does not meet all financial eligibility requirements, it shall send a notice of denial and appeal rights to the applicant (or the authorized representative) according to 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) ODM's administrative agency may help the applicant apply, or partially apply for PACE and notify the PACE organization of the application.

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

(6) Once the in-person assessment is 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 all eligibility requirements in rule 173-50-02 of the Administrative Code.

(8) If ODA determines an applicant meets all eligibility requirements, 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 day ODA determined the applicant met all eligibility requirements and the PACE organization received the signed enrollment agreement.

(9) If ODA determines an applicant does not meet all eligibility requirements, 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 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 if the applicant meets the non-financial eligibility requirements for PACE.

(2) The PACE organization may help the applicant apply for medicaid (unless the applicant is already enrolled in medicaid) and PACE.

(3) After the application is received, ODM's administrative agency shall determine if the applicant meets all financial eligibility requirements for medicaid in Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(4) If ODM's administrative agency determines the applicant does not meet all financial eligibility requirements, it shall send a notice of denial and appeal rights to the applicant (or the authorized representative) 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 all eligibility requirements in rule 173-50-02 of the Administrative Code.

(7) If ODA determines an applicant meets all eligibility requirements, 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 day ODA determines the applicant meets all eligibility requirements and the PACE organization received the signed enrollment agreement.

(8) If ODA determines an applicant does not meet all eligibility requirements, 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 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 shall enroll the applicant when a slot does become available (if the individual continues to meet the eligibility requirements for PACE to want to enroll in the PACE) 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 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 the terms of 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.

Effective: 11/1/2018
Five Year Review (FYR) Dates: 8/14/2018 and 11/01/2023
Promulgated Under: 119.03
Statutory Authority: 173.01, 173.02, 173.50
Rule Amplifies: 173.50 , 460.160, 460.156, 460.154, 173.55 ; 42 C.F.R. 460.152, 173.501
Prior Effective Dates: 03/28/2009, 01/14/2010, 03/12/2011, 09/29/2011, 02/17/2013, 08/01/2016

173-50-04 PACE: 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 occurring 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 provide 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: 8/1/2016
Five Year Review (FYR) Dates: 04/18/2016 and 08/01/2021
Promulgated Under: 119.03
Statutory Authority: 173.01, 173.02, 173.50
Rule Amplifies: 173.50 , 173.55 ; 42 C.F.R. 460.152, 460.154, 460.156 (October, 2015 edition)
Prior Effective Dates: 03/28/2009, 02/17/2013

173-50-05 PACE: involuntary disenrollment.

(A) The PACE organization shall involuntarily disenroll a participant from PACE for one or more of the following reasons:

(1) Failure to pay: The PACE organization shall involuntarily disenroll a participant after a thirty-day grace period for not paying (or satisfactorily arranging to pay) any premium or patient-liability costs owed to the PACE organization if the PACE organization documented at least one attempt it made in writing to the participant containing all the following components:

(a) The PACE organization requested all unpaid costs.

(b) The PACE organization warned the participant that disenrollment may result from non-payment .

(c) The PACE organization explained 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 PACE organization shall involuntarily disenroll a participant who commits medicaid fraud or medicaid eligibility fraud, as described in sections 2913.40 and 2913.401 of the Revised Code, if the PACE organization has a signed narrative of the events from the staff person who discovered the fraud.

(3) Abusive behavior: The PACE organization shall involuntarily disenroll a participant who engages in abusive behavior (e.g. threats with a weapon, physical abuse, or recurrent verbal abuse) jeopardizing the participant's safety, other participants' safety, or the safety of employees of the PACE organization, an affiliate, or a subcontractor if the PACE organization has the following documentation retains one or both of the following records regarding at least one incident:

(a) A signed statement from a witness or the provider.

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

(4) Geography:

(a) The PACE organization shall involuntarily disenroll a participant whose permanent residence is no longer located in the service area.

(b) The PACE organization shall involuntarily disenroll a participant for remaining outside the service area for a period of more than thirty consecutive days, unless the PACE organization authorizes a longer period of absence for extenuating circumstances.

(5) Incarceration: The PACE organization shall involuntarily disenroll a participant for being incarcerated for a period of more than thirty consecutive days.

(6) Physician-patient relationship: The PACE organization shall involuntarily disenroll a participant for not maintaining a satisfactory physician-patient relationship (e.g., repeated non-compliance with medical advice or repeated failure to keep appointments).

(7) Care plan: The PACE organization shall involuntarily disenroll a participant for not complying with the interdisciplinary team's care plan if all the following apply:

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

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

(c) The PACE organization documented at least two attempts it made 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.

(8) Level of care: The PACE organization shall involuntarily disenroll a participant who no longer meets the level-of-care requirements and is not deemed eligible;.

(9) Providers: The PACE organization shall involuntarily disenroll a participant if the PACE organization is unable to offer healthcare services because of a loss of state licenses or contracts with outside providers.

(10) PACE agreement: The PACE organization shall involuntarily disenroll a participant if the agreement between the PACE organization, ODA, and CMS is not renewed or is terminated.

(B) Process to involuntarily disenroll a PACE participant:

(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 requirements 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 requirements 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: 8/1/2016
Five Year Review (FYR) Dates: 04/18/2016 and 08/01/2021
Promulgated Under: 119.03
Statutory Authority: 173.01, 173.02, 173.50
Rule Amplifies: 173.50 , 173.55 ; 42 C.F.R. 460.164 (October, 2015 edition)
Prior Effective Dates: 03/28/2009, 02/17/2013