Lawriter - OAC - 173-50-03 PACE: enrollment process.

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