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