(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 5160-3-06 of the Administrative Code .
(4) 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 for the premiums and patient-liability costs .
(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) At least once per year, ODA shall assess 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 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 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 may no longer meet the financial eligibility requirements 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, 2015).)
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. 460.150, 460.160 (October, 2015 edition)
Prior Effective Dates: 03/28/2009, 02/17/2013