5101:3-36-03 Program of all-inclusive care for the elderly (PACE) eligibility.

(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.

Effective: 03/28/2009
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