Chapter 5101:3-36 Program of All-Inclusive Care for the Elderly (PACE)
The purpose of this rule is to define the terms used in Chapter 5101:3-36 of the Administrative Code governing the medicaid funded portion of the program of all-inclusive care for the elderly (PACE).
(A) As used in this chapter:
(1) "Authorized representative" means a person, eighteen years of age or older, who stands in place of an individual who is applying for or receiving medical assistance including PACE enrollment and participation. The authorized representative may include a legal entity assisting in the application process, a family member, attorney, licensed social worker, or any other person chosen to act on the individual's behalf. In accordance with Chapter 5101:1-38 of the Administrative Code, the individual shall provide a written statement naming the authorized representative and the duties that the authorized representative may perform on the individual's behalf.
(2) "CMS" means the centers for medicare and medicaid services, a federal agency that is part of the U.S. department of health and human services and administers the medicaid program.
(3) "C.F.R." means the code of federal regulations.
(4) "CDJFS" means county department of job and family services.
(5) "Capitated payment" means the monthly payment paid to the PACE organization by ODJFS for medical care and services provided to medicaid recipients enrolled in the PACE program.
(6) "Individual" is the applicant for or recipient of a medical assistance program such as medicaid.
(7) "Involuntary disenrollment" means the disenrollment of a participant from the PACE program at the request of the PACE organization or a CDJFS.
(8) "ODA" means the Ohio department of aging.
(9) "ODJFS" means the Ohio department of job and family services.
(10) "PACE" means the 'program of all-inclusive care for the elderly' provided for in 42 U.S.C. 1396u-4 and 42 U.S.C. 42 C.F.R. Part 460 as in effect on October 1, 2007.
(11) "PACE center" means a facility operated by a PACE organization where primary care or other related services offered by the PACE program are furnished to participants.
(12) "PACE organization" means an entity that has a medicaid provider agreement and also has in effect a PACE program agreement with CMS and ODA.
(13) "PACE program agreement" means an agreement between a PACE organization, CMS, and ODA.
(14) "Participant" means a person enrolled in PACE and receiving services through the PACE program.
(15) "Private pay participant" means an individual who does not meet the medicaid eligibility criteria but chooses to participate in PACE and is responsible for payment of the PACE organization's private pay premium.
(16) "Service area" means the geographic area in which a PACE organization is approved by CMS and ODA to furnish services to PACE participants.
(17) "State administering agency" means the state agency responsible for administering the PACE program agreement. Pursuant to section 173.50 of the Revised Code ODA shall serve as the state administering agency for PACE in Ohio.
(18) "Voluntary disenrollment" means the disenrollment of a participant from the PACE program at the request of the participant or the participant's authorized representative.
(A) In accordance with section 173.50 of the Revised Code, the Ohio department of aging (ODA) shall serve as the designated state administering agency for the PACE program and shall adhere to and monitor the implementation of all applicable requirements for the program's administration as contained in 42 C.F.R Part 460 as in effect on October 1, 2007.
(B) In this capacity ODA shall:
(1) Facilitate the process in which prospective PACE organizations apply to the centers for medicare and medicaid services (CMS) for approval to provide PACE services;
(2) Enter into an agreement called the PACE program agreement with CMS and each PACE organization approved by CMS to provide PACE services to participants in Ohio who reside in the PACE organization's designated service area. The content and duration of that agreement shall conform to standards contained in 42 C.F.R. Part 460 as in effect on October 1, 2007.
(3) Ensure that PACE organizations providing PACE services have signed medicaid provider agreements.
(4) Work with PACE organizations to assist individuals seeking enrollment in the PACE program.
(5) Manage PACE enrollment.
(6) Allocate and as appropriate reallocate slots to PACE organizations for use by medicaid consumers. The allocation and reallocation of slots does not apply to medicare only or private pay patients.
(7) Adopt rules including, but not limited to, PACE participant eligibility, PACE participant enrollment, PACE participant voluntary disenrollment and PACE participant involuntary disenrollment.
(8) Confer as necessary and appropriate with the Ohio department of job and family services (ODJFS) on matters including but not limited to:
(a) PACE participant eligibility;
(b) PACE participant enrollment, disenrollment, and PACE program waiting list trends;
(c) Establishing the rates of reimbursement for PACE organizations operating in Ohio;
(d) Designating each PACE organization's service area;
(e) The enrollment and disenrollment of PACE organizations as providers of services through the PACE program; and
(f) The termination of PACE program agreements.
(C) Effective July 1, 2011, ODJFS shall be responsible for the capitated payments made to PACE organizations for medicaid services rendered to PACE program participants.
(A) To be eligible and maintain eligibility for the PACE program an individual shall meet the criteria for PACE participant eligibility in rule 173-50-02 of the Administrative Code.
(B) Individuals seeking enrollment in the PACE program through medicaid shall be determined by their county department of job and family services (CDJFS) to be eligible for Ohio medicaid in accordance with Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.
(C) If a PACE participant who is also enrolled in medicaid is institutionalized for a period of continuous institutionalization as defined in rule 5101:1-39-22 of the Administrative Code then that consumer's patient liability amount is to be recalculated by the appropriate CDJFS as directed in rule 5101:1-39-24 of the Administrative Code.
(D) Participants who fail or cease to meet the eligibility criteria contained in paragraph (A) of this rule shall be denied enrollment in PACE or involuntarily disenrolled pursuant to rule 5101:3-36-04 of the Administrative Code.
(E) If at any time an individual enrolled in the medicaid program fails or ceases to meet the medicaid eligibility criteria in paragraph (B) of this rule, the participant shall be denied entry in or disenrolled from the medicaid program. In such instances, the participant shall be notified by the appropriate CDJFS and granted all applicable hearing rights in accordance with Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.
(F) PACE participants who no longer meet the medicaid eligibility criteria shall be given the opportunity to remain enrolled in the PACE program as a medicare only or as a private pay participant.
(G) Participants who no longer meet the medicaid financial eligibility criteria but choose to remain enrolled in the PACE program through private resources shall be charged no less than the medicaid rate for services by the PACE organization.
(H) PACE participants who are no longer medicaid eligible and choose not to remain enrolled in PACE as a medicare only or private pay enrollee shall be disenrolled from the PACE program in accordance with rules adopted by the Ohio department of aging.
(A) Individuals eligible and seeking to enroll in the PACE program shall enroll in the manner established in rule 173-50-03 of the Administrative Code unless paragraph (B) of this rule applies.
(B) If the number of eligible individuals seeking enrollment in the PACE program exceeds the number of slots allocated by the Ohio department of aging (ODA), ODA may establish and maintain a waiting list for PACE enrollment.
(C) Should a waiting list for PACE enrollment be maintained by ODA, ODA shall, on a semiannual basis, provide the Ohio department of job and family services (ODJFS) with the number of individuals on the waiting list for PACE services, the service area in which they reside, and the average length of time consumers on the waiting list shall wait before enrolling in PACE.
(D) A PACE participant may choose to voluntarily disenroll from the PACE program at any time without cause if the participant or the participant's authorized representative informs the PACE organization orally or in writing.
(1) Should a PACE participant choose to voluntarily disenroll from PACE, ODA shall, prior to the participant's disenrollment, verify that the voluntary disenrollment was initiated by the consumer or the consumer's authorized representative.
(2) The voluntary disenrollment of a PACE participant shall occur in the manner prescribed in rule 173-50-04 of the Administrative Code.
(E) A PACE organization may initiate the involuntary disenrollment of a PACE participant if any of the following applies:
(1) The PACE participant no longer meets the eligibility criteria for the PACE program contained in rule 173-50-02 of the Administrative Code.
(2) The PACE participant meets the criteria for involuntary disenrollment in paragraph (A) of rule 173-50-05 of the Administrative Code.
(3) The involuntary disenrollment of a PACE participant shall occur in the manner prescribed in rule 173-50-05 of the Administrative Code.
(A) Each PACE organization shall establish and maintain at each PACE center an interdisciplinary team to assess the care and service needs of PACE participants. The composition of the interdisciplinary team shall be consistent with 42 C.F.R. Part 460 as in effect on October 1, 2007.
(B) The interdisciplinary team shall conduct a comprehensive assessment and develop a plan of care for each PACE participant.
(1) The plan of care developed for each PACE participant shall specify which services are needed to meet the participant's medical, physical, emotional, and social needs as identified in the comprehensive assessment, and will identify measurable outcomes to be achieved for the PACE participant.
(2) The interdisciplinary team shall implement, coordinate, and monitor the PACE participant's plan of care and modify the plan of care as appropriate.
(3) The interdisciplinary team shall at least semiannually, or more often if the participant's condition dictates or if requested by the participant or the participant's authorized representative, reassess each PACE participant and make changes as necessary to the plan of care.
(4) The PACE interdisciplinary team shall collaborate with the participant in the development of the participant's plan of care as well as with changes made to the plan of care.
(C) PACE organizations shall ensure that all PACE participants have access to all medically necessary services including, but not limited to, services covered by Ohio's medicaid program, in addition to those prescribed in 42 C.F.R. Part 460.92 as in effect on October 1, 2007 to 42 C.F.R. Part 460.96 as in effect on October 1, 2007.
(1) Services provided shall be sufficient in their amount, duration and scope to meet the participant's medical, physical, emotional, and social needs as identified in the comprehensive assessment to achieve the measurable outcomes identified in the participant's plan of care.
(2) Services provided shall be reflected in the participant's plan of care unless the services are an emergency service.
(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.