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