5101:3-36-06 Program of all-inclusive care for the elderly (PACE) organization reimbursement.

(A) PACE is a full-risk program in which the PACE organization assumes all financial risk for the cost of the medical care and services provided to PACE participants.

(B) PACE organizations shall receive a monthly capitated payment from the Ohio department of job and family services (ODJFS) for each PACE participant enrolled in the medicaid program including individuals enrolled in both medicaid and medicare.

(C) The amount of the capitated payment shall be established in the PACE program agreement in rule 5101:3-36-02 of the Administrative Code.

(D) The amount paid in accordance with paragraph (B) of this rule represents the total maximum payment obligation of the state administering agency to the PACE organization for the cost of medical care and services provided to PACE participants enrolled in medicaid including those participants enrolled in both medicaid and medicare.

(E) The PACE organization shall accept the capitation payment amount as payment in full for medicaid participants and shall not bill, charge, collect, or receive any other form of payment from ODJFS or from, or on behalf of, the participant, except as permitted under 42 C.F.R. Part 460.182(c) as in effect on October 1, 2007.

Effective: 09/29/2011
R.C. 119.032 review dates: 03/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02, 5111.91, 173.50
Prior Effective Dates: 3/28/09, 7/1/11 (Emer.)